With the rise of adolescent obesity, metabolic and bariatric surgery (MBS) yields clear and durable improvements in weight and comorbidities; however, ethical decision-making, growth and development, and healthcare equity remain contested. We propose an “ethics-clinical integrated” framework: (1) anchor decisions in the four principles, operationalized as parental permission plus adolescent assent; (2) shift indications from BMI-only to phenotype- and risk-driven criteria, supported by multidisciplinary team (MDT) assessment and standardized perioperative management; (3) implement long-term surveillance plans for growth/bone health, nutrition, and psychological well-being, with predefined risk-mitigation strategies. We advocate early referral for evaluation when BMI ≥140% of the 95th percentile or when severe obesity-related complications are present, prioritizing sleeve gastrectomy or Roux-en-Y gastric bypass as preferred options where appropriate. To promote justice and access, we recommend standardized referral and payment pathways and active reduction of stigma and delays. This framework aims to maximize net benefit while ensuring safety, thereby enhancing the standardization and accessibility of MBS for adolescents.
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