Surgery for Obesity and Related Diseases 11 (2015) 729–731
1989 Presidential address
Presidential address given before the Annual Meeting of the American Society for Bariatric Surgery, June, 1989, Nashville, TN Justification The purpose of a Presidential Address has never been entirely clear to me. Over the years I have heard a number of such orations presented at different societies. I have been able to divide the content into 3 different types of presentations. The first category is the scientific talk that deals with either the individual’s life work, or in the case of specialty societies, an overview of the current state of the art. The second type is the historic address that chronicles one or another aspect of the society’s growth. The third is the political address that describes the interaction of the particular society with the body politic and is usually a forecaster of doom and destruction. I wish to approach this occasion from a slightly different tact. I have been involved with this society since its inception and long before it took on the title of the American Society for Bariatric Surgery. I hope I have contributed in some small way to the application of bariatric surgery to the human disease state, morbid obesity. In the early years, I’m sure many of the members of this organization grew tired of my insistence that we back up opinion with data. This address will not change the climate that exists in the United States, but may give some of us a slightly different perspective in approaching our own problems and the problems of our patients. The title of this discussion has tentatively been offered as “Justification,” but at the completion of the remarks, you may find a more appropriate nomenclature to describe the concepts put forth. As recently as 60 years ago, there was a tremendous debate in the United States as to whether or not the world had been created in a day or had developed over eons. Intelligent, honest, hardworking people positioned themselves philosophically on one side or the other of the argument. People became entrenched and battlements were erected. Opinion was rigorously supported and facts denied. Scientific fact would suggest that ages before there were ages, matter existed. It was the simplest type of matter that had not even taken on the shape of elements. Physicists have researched and have detailed the basic composition of this
matter at its particulate level. While the circumstances surrounding its existence are not clear, it would appear that this matter came together and exerted such tremendous pressure that an explosion occurred of such enormous magnitude that the effects are still being experienced by the universe as we know it. At this point, time began. There was only physics and chemistry. Biology did not exist. Over the millennia since that critical point, nature has followed an orderly progression. Subatomic elemental particles driven into motion by thermal agitation sped through the cosmos. As time passed and as temperatures cooled, collisions occurred among particles. As collision and recoil occurred, nuclear forces developed. If attraction exceeded the momentum of recoil, adherence between particles occurred. The course of the union depended on the match of the particles or the strength of the mutual bond. Attractive interactions were favored. If ambient conditions were mild, more unstable alliances were tolerated. Stable compounds with a natural inherent harmony existed for longer periods of time than those held together under stress. Stable compounds were long lived, while substances under stress were short lived. In this prebiotic area, the building blocks of our biological world were produced. Structures became more and more complex as the milieu became more conductive to their existence. There was an increase in the diversity of the compounds produced as well as the versatility of the actions inherent in these compounds. Recurring themes unified the events and after millions of years of this travel, physical evolution and biologic evolution were both characterized by common descendants, random interactions, and natural selection. These all were an expression of symmetry. Assemblies occurred and reproduced themselves. The reproduction was dependent upon messengers. Messengers from one part of the cell traveled to another part, transmitting vital information for survival. The messengers of this biologic evolution were molecules of RNA. They carried information in a linear language using a genetic code of 4 recurring subunits. They in fact carried communication both within the cell, as well as from cell to cell. This ultimately produced a 3-dimensional language that orchestrated a broad range of
http://dx.doi.org/10.1016/j.soard.2014.12.026 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
730
J. P. O’Leary / Surgery for Obesity and Related Diseases 11 (2015) 729–731
biologic activity. These were much more complex messengers than the intermediaries of the subatomic particle belonging to the classes of inorganic chemistry. Just as there were messengers at the cellular level, like DNA and RNA, messengers evolved that orchestrated functions of organs as well as functions of the cell. These messengers were peptides, some of which became known as hormones. This same process can be extrapolated to messengers in society that are responsible for the assimilation of knowledge and the impartation of knowledge from one group to the next. As the organisms became more complex, biological life appeared on the surface of the globe. The concept of time rose out of chaos. Physical evolution led to biological evolution which led to cultural evolution. Now man has become so arrogant that he has positioned himself not simply as a messenger of evolution, but as a director of evolution. The messages that are being coded at the genetic level are being modified by man. Certain expressions are being emphasized while other genetic expressions are suppressed. These modified messengers are then allowed to have their effect on the target cell or organism. Humans have become active participants in the process of evolution. They make decisions about genetic disorders, when and where to cut out a defect, and how to repair a faulty gene. This brings for us new problems that are ethical, legal, environmental, medical, social, and economic. The epic of evolution has now become telescoped and we, who are active participants, must stand in awe of the next stage, which is immediately around the temporal corner. Physical evolution occurred over some 15 billion years, according to Edward Rubenstein, who is Associate Dean for Postgraduate Medical Education at Stanford University [1]. The biologic era of evolution that I alluded to above occurred in approximately 3 billion years. Cultural evolution has occurred in the past 500,000 years, and we are just beginning that phase of directed evolution where man has interdigitated himself into the process of development. Many of you may wonder what all of this has to do with the American Society for Bariatric Surgery. It in fact has all to do with what we are trying to accomplish. I need not tell anyone in the audience that morbid obesity is a disease that adversely impacts the individual’s life on all levels. However, others, with another agenda, deny it as a disease process and ascribe it to the end result of man’s sloth. Dr. Albert “Mickey” Stunkard has spent a substantial portion of his life studying obesity from his vantage point as a professor of psychiatry. He has detailed the genetic aspects of morbid obesity. Every individual is different. We are different on the basis of our specific genetic codon that is responsible for our height, color of hair (or lack of hair), skin complexion, athletic ability, and intellectual prowess, as well as how each individual cell in our body
works [2]. It is amazing to me that providers of healthcare can accept all of these different attributes as expressions of our genetic makeup, while denying that morbid obesity might in fact also have its basis in such a genetic parameter. As we understand better who we are, we will be on the threshold of a true understanding of the genetic mechanisms within ourselves. It is clear that all material things about us have their origins at the biochemical interaction between DNA, RNA, and the diverse metabolic pathways within the cytoplasm of our cells. It is possible that morbid obesity can be induced in certain susceptible individuals. The sequelae of the disease are no less real in this individual than it is in the individual who acquires morbid obesity through genetic pathways. In a position paper presented by Drs. Aratta, Cowan, and Fobi, they point out that insurance companies are willing to spend enormous sums of money to treat patients with diseases that are almost uniformly fatal [4]. Patients with esophageal or pancreatic carcinoma, certain types of birth defects, hepatoma, and a host of other diseases receive insurance endorsement after only cursory review. In each of these circumstances, either the duration of life or the quality of life is severely limited, making the cost/benefit ratio exorbitant. But there is no prejudice against the patient who develops a carcinoma of the esophagus, for he looks, acts, and is like the vast majority of other people in our population. For reasons that are difficult to understand, the morbidly obese patient is seen as different in our society. I am not sure why this occurred. It certainly wasn’t true in the days of Henry VIII, or in the days of Reuben, who painted his exquisite masterpieces of obese individuals. Society, for whatever reason, has arbitrarily decided to penalize obese individuals because they differ from the norm. This type of prejudice is not seen in individuals with atherosclerotic cardiovascular disease or even in patients with addiction, such as alcohol or tobacco. Darwin, on board the HMS Beagle, described similarities and differences among individuals of the same species. He then described how the environment selected the fittest to survive in certain geographic climates [3]. Why should it surprise us that there should be a wide range of variation among individuals of the human race and that this variability would involve a number of physical attributes, not the least of which could be weight. Before completing this essay on justification, we need to deal for a moment with ethics. It is as important for a profession to examine its ethics, as it is for the profession to have special talents that it applies to the welfare of its clientele. First, we must understand our terms. My definition of a profession is: “that group of individuals with special knowledge that is not held by the body politic; yet the specific knowledge which may significantly impact on the physical, mental and social wellbeing of the general public.” Laymen cannot be expected to be conversant in most aspects of medicine. By the same token, laymen
Editorial / Surgery for Obesity and Related Diseases 11 (2015) 729–731
cannot be expected to understand all the innuendos and nuances of the law. To protect the lay public, each of these specialties must have strong ethics that are applied to the profession, so that the lay population will not be disadvantaged. Without a strong sense of ethics, a profession sinks to the level of a trade or guild. It would appear that many of our colleagues in law now hold that their behavior is ethical as long as the outcome is financially favorable to both the lawyer’s client and, interestingly enough, the lawyer. It is my strong feeling that ethics are not related to financial solvency. Ethics has to do with what is right and true and just and we must all evaluate our performance using those criteria. We, in medicine, are not exempt. Many of our colleagues prescribe exhaustive therapeutic nonsurgical experiences for the morbidly obese that profit the physician with little chance of success from the patient’s standpoint. The New York Times bestseller list in the nonfiction category has been monopolized for the last 20 years by various and sundry diet chronicles. The most recent plague is the protein-sparing modified fast. The companies that make these special solutions, the institutions that advertise these services, and the physicians who are monitoring the patient’s progress, have made enormous profits, while the efficacy of these in treating morbid obesity is clearly unproven. Yet, third party players, HMOs, and various other funding agencies find no problem in providing these kinds of products and services. The lay public needs to be informed about the ravages of morbid obesity and of the types of treatment available. We
731
must police our own society along the guidelines established by the American College of Surgeons. I have watched this organization grow (started in 1989) and I believe, prosper. I believe that this organization has contributed significantly to the accumulation of information about the effects of operative intervention in morbid obesity. I also believe that substantial contributions to our understanding of morbid obesity have come from individuals in this organization. Many have used the American Society for Bariatric Surgery as their forum for the presentation of new data and the results of clinical trials. It has indeed been an honor and privilege to serve as President of this organization. James Patrick O’Leary, M.D., FACS Executive Associate Dean for Clinical Affairs, Assistant Vice President Strategic Planning, Florida International University Herbert Wertheim College of Medicine Miami, Florida References [1] Rubenstein E. Stages of evolution and their messengers. Sci Am 1989;260:132. [2] Stunkard AJ, Sorensen TI, Hanis C, et al. An adoption study of human obesity. N Engl J Med 1986;314:193–8. [3] Darwin C. On the origin of species by means of natural selection: Or the preservation of the favoured races in the struggle for life. London: John Murray, 1860. [4] M. Fobi. Personal communication. June 3, 1989.
1989 Presidential address
Presidential address given before the Annual Meeting of the American Society for Bariatric Surgery, June, 1989, Nashville, TN Justification The purpose of a Presidential Address has never been entirely clear to me. Over the years I have heard a number of such orations presented at different societies. I have been able to divide the content into 3 different types of presentations. The first category is the scientific talk that deals with either the individual’s life work, or in the case of specialty societies, an overview of the current state of the art. The second type is the historic address that chronicles one or another aspect of the society’s growth. The third is the political address that describes the interaction of the particular society with the body politic and is usually a forecaster of doom and destruction. I wish to approach this occasion from a slightly different tact. I have been involved with this society since its inception and long before it took on the title of the American Society for Bariatric Surgery. I hope I have contributed in some small way to the application of bariatric surgery to the human disease state, morbid obesity. In the early years, I’m sure many of the members of this organization grew tired of my insistence that we back up opinion with data. This address will not change the climate that exists in the United States, but may give some of us a slightly different perspective in approaching our own problems and the problems of our patients. The title of this discussion has tentatively been offered as “Justification,” but at the completion of the remarks, you may find a more appropriate nomenclature to describe the concepts put forth. As recently as 60 years ago, there was a tremendous debate in the United States as to whether or not the world had been created in a day or had developed over eons. Intelligent, honest, hardworking people positioned themselves philosophically on one side or the other of the argument. People became entrenched and battlements were erected. Opinion was rigorously supported and facts denied. Scientific fact would suggest that ages before there were ages, matter existed. It was the simplest type of matter that had not even taken on the shape of elements. Physicists have researched and have detailed the basic composition of this
matter at its particulate level. While the circumstances surrounding its existence are not clear, it would appear that this matter came together and exerted such tremendous pressure that an explosion occurred of such enormous magnitude that the effects are still being experienced by the universe as we know it. At this point, time began. There was only physics and chemistry. Biology did not exist. Over the millennia since that critical point, nature has followed an orderly progression. Subatomic elemental particles driven into motion by thermal agitation sped through the cosmos. As time passed and as temperatures cooled, collisions occurred among particles. As collision and recoil occurred, nuclear forces developed. If attraction exceeded the momentum of recoil, adherence between particles occurred. The course of the union depended on the match of the particles or the strength of the mutual bond. Attractive interactions were favored. If ambient conditions were mild, more unstable alliances were tolerated. Stable compounds with a natural inherent harmony existed for longer periods of time than those held together under stress. Stable compounds were long lived, while substances under stress were short lived. In this prebiotic area, the building blocks of our biological world were produced. Structures became more and more complex as the milieu became more conductive to their existence. There was an increase in the diversity of the compounds produced as well as the versatility of the actions inherent in these compounds. Recurring themes unified the events and after millions of years of this travel, physical evolution and biologic evolution were both characterized by common descendants, random interactions, and natural selection. These all were an expression of symmetry. Assemblies occurred and reproduced themselves. The reproduction was dependent upon messengers. Messengers from one part of the cell traveled to another part, transmitting vital information for survival. The messengers of this biologic evolution were molecules of RNA. They carried information in a linear language using a genetic code of 4 recurring subunits. They in fact carried communication both within the cell, as well as from cell to cell. This ultimately produced a 3-dimensional language that orchestrated a broad range of
http://dx.doi.org/10.1016/j.soard.2014.12.026 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
730
J. P. O’Leary / Surgery for Obesity and Related Diseases 11 (2015) 729–731
biologic activity. These were much more complex messengers than the intermediaries of the subatomic particle belonging to the classes of inorganic chemistry. Just as there were messengers at the cellular level, like DNA and RNA, messengers evolved that orchestrated functions of organs as well as functions of the cell. These messengers were peptides, some of which became known as hormones. This same process can be extrapolated to messengers in society that are responsible for the assimilation of knowledge and the impartation of knowledge from one group to the next. As the organisms became more complex, biological life appeared on the surface of the globe. The concept of time rose out of chaos. Physical evolution led to biological evolution which led to cultural evolution. Now man has become so arrogant that he has positioned himself not simply as a messenger of evolution, but as a director of evolution. The messages that are being coded at the genetic level are being modified by man. Certain expressions are being emphasized while other genetic expressions are suppressed. These modified messengers are then allowed to have their effect on the target cell or organism. Humans have become active participants in the process of evolution. They make decisions about genetic disorders, when and where to cut out a defect, and how to repair a faulty gene. This brings for us new problems that are ethical, legal, environmental, medical, social, and economic. The epic of evolution has now become telescoped and we, who are active participants, must stand in awe of the next stage, which is immediately around the temporal corner. Physical evolution occurred over some 15 billion years, according to Edward Rubenstein, who is Associate Dean for Postgraduate Medical Education at Stanford University [1]. The biologic era of evolution that I alluded to above occurred in approximately 3 billion years. Cultural evolution has occurred in the past 500,000 years, and we are just beginning that phase of directed evolution where man has interdigitated himself into the process of development. Many of you may wonder what all of this has to do with the American Society for Bariatric Surgery. It in fact has all to do with what we are trying to accomplish. I need not tell anyone in the audience that morbid obesity is a disease that adversely impacts the individual’s life on all levels. However, others, with another agenda, deny it as a disease process and ascribe it to the end result of man’s sloth. Dr. Albert “Mickey” Stunkard has spent a substantial portion of his life studying obesity from his vantage point as a professor of psychiatry. He has detailed the genetic aspects of morbid obesity. Every individual is different. We are different on the basis of our specific genetic codon that is responsible for our height, color of hair (or lack of hair), skin complexion, athletic ability, and intellectual prowess, as well as how each individual cell in our body
works [2]. It is amazing to me that providers of healthcare can accept all of these different attributes as expressions of our genetic makeup, while denying that morbid obesity might in fact also have its basis in such a genetic parameter. As we understand better who we are, we will be on the threshold of a true understanding of the genetic mechanisms within ourselves. It is clear that all material things about us have their origins at the biochemical interaction between DNA, RNA, and the diverse metabolic pathways within the cytoplasm of our cells. It is possible that morbid obesity can be induced in certain susceptible individuals. The sequelae of the disease are no less real in this individual than it is in the individual who acquires morbid obesity through genetic pathways. In a position paper presented by Drs. Aratta, Cowan, and Fobi, they point out that insurance companies are willing to spend enormous sums of money to treat patients with diseases that are almost uniformly fatal [4]. Patients with esophageal or pancreatic carcinoma, certain types of birth defects, hepatoma, and a host of other diseases receive insurance endorsement after only cursory review. In each of these circumstances, either the duration of life or the quality of life is severely limited, making the cost/benefit ratio exorbitant. But there is no prejudice against the patient who develops a carcinoma of the esophagus, for he looks, acts, and is like the vast majority of other people in our population. For reasons that are difficult to understand, the morbidly obese patient is seen as different in our society. I am not sure why this occurred. It certainly wasn’t true in the days of Henry VIII, or in the days of Reuben, who painted his exquisite masterpieces of obese individuals. Society, for whatever reason, has arbitrarily decided to penalize obese individuals because they differ from the norm. This type of prejudice is not seen in individuals with atherosclerotic cardiovascular disease or even in patients with addiction, such as alcohol or tobacco. Darwin, on board the HMS Beagle, described similarities and differences among individuals of the same species. He then described how the environment selected the fittest to survive in certain geographic climates [3]. Why should it surprise us that there should be a wide range of variation among individuals of the human race and that this variability would involve a number of physical attributes, not the least of which could be weight. Before completing this essay on justification, we need to deal for a moment with ethics. It is as important for a profession to examine its ethics, as it is for the profession to have special talents that it applies to the welfare of its clientele. First, we must understand our terms. My definition of a profession is: “that group of individuals with special knowledge that is not held by the body politic; yet the specific knowledge which may significantly impact on the physical, mental and social wellbeing of the general public.” Laymen cannot be expected to be conversant in most aspects of medicine. By the same token, laymen
Editorial / Surgery for Obesity and Related Diseases 11 (2015) 729–731
cannot be expected to understand all the innuendos and nuances of the law. To protect the lay public, each of these specialties must have strong ethics that are applied to the profession, so that the lay population will not be disadvantaged. Without a strong sense of ethics, a profession sinks to the level of a trade or guild. It would appear that many of our colleagues in law now hold that their behavior is ethical as long as the outcome is financially favorable to both the lawyer’s client and, interestingly enough, the lawyer. It is my strong feeling that ethics are not related to financial solvency. Ethics has to do with what is right and true and just and we must all evaluate our performance using those criteria. We, in medicine, are not exempt. Many of our colleagues prescribe exhaustive therapeutic nonsurgical experiences for the morbidly obese that profit the physician with little chance of success from the patient’s standpoint. The New York Times bestseller list in the nonfiction category has been monopolized for the last 20 years by various and sundry diet chronicles. The most recent plague is the protein-sparing modified fast. The companies that make these special solutions, the institutions that advertise these services, and the physicians who are monitoring the patient’s progress, have made enormous profits, while the efficacy of these in treating morbid obesity is clearly unproven. Yet, third party players, HMOs, and various other funding agencies find no problem in providing these kinds of products and services. The lay public needs to be informed about the ravages of morbid obesity and of the types of treatment available. We
731
must police our own society along the guidelines established by the American College of Surgeons. I have watched this organization grow (started in 1989) and I believe, prosper. I believe that this organization has contributed significantly to the accumulation of information about the effects of operative intervention in morbid obesity. I also believe that substantial contributions to our understanding of morbid obesity have come from individuals in this organization. Many have used the American Society for Bariatric Surgery as their forum for the presentation of new data and the results of clinical trials. It has indeed been an honor and privilege to serve as President of this organization. James Patrick O’Leary, M.D., FACS Executive Associate Dean for Clinical Affairs, Assistant Vice President Strategic Planning, Florida International University Herbert Wertheim College of Medicine Miami, Florida References [1] Rubenstein E. Stages of evolution and their messengers. Sci Am 1989;260:132. [2] Stunkard AJ, Sorensen TI, Hanis C, et al. An adoption study of human obesity. N Engl J Med 1986;314:193–8. [3] Darwin C. On the origin of species by means of natural selection: Or the preservation of the favoured races in the struggle for life. London: John Murray, 1860. [4] M. Fobi. Personal communication. June 3, 1989.
