Advances in pharmacological therapies have expanded the options available to clinicians and patients, offering meaningful benefits in appropriate cases. These developments mark important progress in recognising obesity as a chronic condition that can be managed with evidence-based medical interventions.

At the same time, these therapies are often costly, highly visible, and not equally accessible. In South Africa, these realities are particularly important. Prescribing decisions in this context are no longer purely technical, they also involve questions of indication, fairness, and professional responsibility.

Obesity is a complex, multifactorial condition with metabolic, behavioural, environmental, and social determinants. Effective pharmacotherapy can play an important role in treatment, particularly where there is a clear clinical indication. However, acknowledging obesity as a disease does not mean that every request for pharmacological intervention is automatically justified.

Recent ethics literature has highlighted that modern weight-loss pharmacotherapies raise broader concerns around distributive justice, affordability, stigma, and public health priorities. Similarly, broader ethical reviews emphasise the tension between individual patient benefit and societal considerations.

In other words, the question is no longer only whether a medicine works, but who should receive it, when, and on what grounds. This includes guarding against two opposite risks: Undertreating obesity because of stigma; and over medicalising body dissatisfaction in response to social pressure.

Autonomy matters, but it does not replace clinical judgment

Patients may present with strong preferences for pharmacological weight-loss interventions. These preferences are often shaped by personal experience, health concerns, and broader social influences, including media exposure and peer narratives.

Respect for patient autonomy requires that these views be taken seriously. However, autonomy does not replace clinical judgment. The clinician’s role remains to assess whether a requested intervention is medically indicated, likely to provide meaningful benefit, and appropriate in light of potential risks and constraints.

In practice, this involves balancing well-established ethical principles:

• Beneficence: Is the intervention likely to improve health outcomes?
• Non-maleficence: Do the benefits outweigh the risks and burdens?
• Justice: Is the decision fair, particularly in a context of unequal access?

Recent discussions in bioethics have framed this tension as one between individual autonomy and broader societal beneficence, particularly where high-cost therapies may not be equally accessible.

A helpful practical distinction is between treating chronic disease and responding to lifestyle-driven demand. While this distinction is not always clear-cut, it remains clinically and ethically important.

South African guidance generally supports pharmacotherapy for patients with higher body mass index (BMI) thresholds or those with obesity-related comorbidities, alongside lifestyle and behavioural interventions. That does not mean BMI should be used mechanically, but it does mean that departures from these norms may be appropriate, but they require careful justification.

Mini-case 1: When expectations are shaped by social pressure

A 34-year-old patient with a BMI in the overweight range, no significant comorbidities, and a strong desire for rapid weight loss requests pharmacological treatment. The patient is well-informed and able to afford therapy. This scenario is increasingly common. While the patient’s concerns should be acknowledged, the clinical indication may be limited. In such cases, the clinician’s role is to guide the patient toward an understanding of appropriate use, rather than simply fulfilling a request.

Mini-case 2: When pharmacotherapy supports chronic disease management

In contrast, a patient with obesity, associated comorbidities, and a history of unsuccessful structured interventions presents with a request for pharmacological support. Here, pharmacotherapy may form part of a comprehensive management plan aimed at reducing long-term health risks and improving quality of life. In such cases, ethical prescribing includes ensuring that the patient understands the potential benefits, limitations, costs, and need for ongoing follow-up. One of the recurring themes in the literature is that many pharmacological interventions for obesity may require sustained use to maintain benefit, raising important questions about long-term affordability and adherence.

Scarcity, cost and fairness in practice

The cost and duration of treatment are central ethical considerations. A treatment plan that cannot realistically be maintained may not ultimately benefit the patient. A patient who can afford several months of treatment, but not long-term continuation is not being ‘difficult’, the treatment plan itself may be unsustainable. Ethical prescribing therefore includes honest discussion about:

• Cost over time
• Expected duration of therapy
• Potential for weight regain after discontinuation
• The role of ongoing lifestyle or multidisciplinary support.

In South Africa, access to healthcare resources is uneven. Even in private practice, clinicians operate within a broader system marked by inequality. While individual patient care remains central, prescribing decisions may also have wider implications.

Ethical prescribing in this context involves thoughtful prioritisation. Clinical need, comorbidity burden, and expected benefit should guide decision-making more strongly than external pressures or ability to pay.

Mini-case 3: When access and indication intersect

A patient with a chronic metabolic condition reports difficulty accessing prescribed treatment, while another patient seeks pharmacological support primarily for weight management without significant comorbidity. This type of scenario highlights the importance of careful prioritisation.

Understanding the regulatory landscape

Clinicians should remain familiar with the regulatory status of medicines used in weight management. This includes understanding approved indications, as well as the principles governing off-label use.

Off-label prescribing is not inherently inappropriate, but it requires careful consideration. Decisions should be:

• Evidence-based
• Clearly explained to the patient
• Appropriately documented
• Supported by a plan for follow-up.

Guidance from regulatory authorities such as the South African Health Products Regulatory Authority (SAHPRA) emphasises that medicines should be prescribed within established regulatory frameworks, and that healthcare practitioners have a responsibility to ensure appropriate oversight and patient guidance.

Avoiding unsafe or unregulated treatment pathways

In environments where demand is high and access may be limited, there can be pressure to seek alternative routes to treatment. This may include products obtained outside formal healthcare systems. Regulatory authorities have raised concerns about unregistered, substandard, or falsified medicines being accessed through informal channels.

Clinicians play an important role in safeguarding patients against these risks. Encouraging the use of appropriately registered and regulated medicines helps ensure quality, safety, and accountability.

Ethical practice involves guiding patients toward safe and lawful treatment options, even when this requires careful and sometimes difficult conversations.

Ethical prescribing in a changing landscape

The expanding role of pharmacological therapies in obesity management represents a significant advancement in patient care. These treatments have the potential to improve health outcomes and quality of life for many patients.

At the same time, their use raises important ethical considerations. Clinicians are required to navigate patient expectations, clinical evidence, resource constraints, and regulatory requirements.

Ethical prescribing is not about restricting access, but about ensuring that care is appropriate, justified, and equitable. It involves maintaining professional independence, supporting informed decision-making, and prioritising patient well-being within the realities of the healthcare system. In a rapidly evolving therapeutic landscape, this remains the foundation of good clinical practice.

Dr Marietjie Botes is a lawyer and academic researcher specialising in biotechnology law, neuroethics, data governance, and intellectual property law. Currently an exchange scholar at the University of Texas (United States), she transitioned from a 20-year career as a practising attorney in health law and biotechnology to academia, where she focuses on interdisciplinary research at the intersection of science, technology, law, and ethics. She holds BProc, LLB, LLM (Intellectual Property Law), and a PhD in Biotechnology Law. Her research explores the regulation and ethics of gene therapies, gene and stem cell research, the use of big geospatial data during pandemics, and digital health technologies such as brain-computer interfaces. She has published widely, co-edits a Springer Nature digital ethics special edition, is an elected  Academy of Science of South Africa member, and contributed legal expertise to South Africa’s Covid-19 country reports.