Thursday, January 11, 2007

BMJ Article Urges that Smokers Be Denied Elective Surgery

An article in the current issue of BMJ argues that smokers should be refused elective surgery unless they quit smoking for at least one month because smoking impairs wound healing, increases the risk of infection, and imposes greater health care costs on a limited health care system.

Dr. Matthew J. Peters, a respiratory physician from Sydney, Australia, argues that: "Smoking up to the time of any surgery increases cardiac and pulmonary complications, impairs tissue healing, and is associated with more infections and other complications at the surgical site. These adverse effects compromise the intended procedural outcomes and increase the costs of care. Therefore, as long as everything is done to help patients to stop smoking, it is both responsible and ethical to implement a policy that those unwilling or unable to stop should have low priority for, or be excluded from, certain elective surgical procedures. Such a policy should be limited to procedures where the evidence of harm is strongest. These include plastic and reconstructive surgery and some orthopaedic surgery. ...

Increased use of hospital beds and associated costs mean less opportunity to treat other patients. Based on these data, five non-smokers could be operated on for the cost and bed use of four smokers and the non-smokers' surgical outcomes would be better. A well informed smoker, unwilling or unable to quit, might assume an increased risk for himself, but the decision is not his alone when it can indirectly affect others. Then, the community must involve itself. With surgery that is done for purely cosmetic purposes, the increase in the risk and consequences of wound infection or fat necrosis from smoking is unacceptable and surgery is illogical. In reconstructive surgery, whether breast reconstruction after mastectomy or as part of head and neck cancer surgery, smoking substantially increases the risk of wound infection, flap necrosis, and fat necrosis. If a patient wants breast reconstruction at the time of mastectomy, the development of wound infection or flap necrosis will delay adjuvant chemotherapy or radiotherapy. Therefore, unless reconstruction is required as part of essential surgery that cannot be delayed, it is good policy not to offer reconstruction until the patient has stopped smoking."

In a counterpoint response, Professor Leonard Glantz from my own Boston University School of Public Health argues that such a policy is overtly disriminatory, violates the most basic tenets of medicine, and would greatly distort the doctor-patient relationship. He counters the cost-effectiveness argument by noting that the same reasoning being used to support denying smokers surgery could equally be used to deny surgery to people who are obese or do not exercise.

Professor Glantz concludes: "Discriminating against smokers has become an acceptable norm. Indeed, at least one group of authors who believe smokers should be refused surgery blithely admits that it is "overtly discriminatory." The suggestion that we should deprive smokers of surgery indicates that the medical and public health communities have created an underclass of people against whom discrimination is not only tolerated but encouraged. When the World Health Organization announced that it would no longer employ anyone who smokes, public health and medical communities did not respond to this act of blatant bigotry. Similarly, it is shameful for doctors to be willing to treat everybody but smokers in a society that is supposed to be pluralistic and tolerant. Depriving smokers of surgery that would clearly enhance their wellbeing is not just wrong - —it is mean."

The Rest of the Story

It is disturbing to me that we have reached a point where the question of denying elective surgery to smokers would even be debated prominently in a premiere medical journal. The fact that this is even a consideration worthy of public debate in the medical community is quite troubling.

For the fourth straight day since I have returned from winter vacation, the most over-riding and striking aspect of this debate is the singling out of smoking as being the one behavior over which society should assert control in order to reduce health risks.

Could it not be equally well argued that patients who are obese should be required to lose weight before undergoing orthopedic surgery? Or that patients who do not exercise should be forced to start working out in the health club prior to surgery? There is convincing evidence that obesity impairs wound healing and that both obesity and lack of exercise are major impediments to recovery from surgery.

Refusing surgery to the fat and sedentary would save a tremendous amount of health care dollars and would greatly help to relieve the waiting line for elective surgeries for those who are "responsible" enough to control their weight and get enough exercise.

But we are not talking about denying elective surgery to fat people or those who fail to exercise. We are only talking about denying surgery to smokers. As Professor Glantz astutely points out: "The suggestion that we should deprive smokers of surgery indicates that the medical and public health communities have created an underclass of people against whom discrimination is not only tolerated but encouraged."

Professor Glantz' point about the distortion of the physician-patient relationship is also well-taken. Implementing the policy that Dr. Peters advocates would inevitably lead to smokers being afraid to admit to their doctors that they smoke. We might succeed in denying surgery to some smokers, but we would lose the trust in the doctor-patient relationship for a large percentage of the population, as well as the opportunity for physicians to appropriately diagnose and treat patients who have a major risk factor for a number of severe diseases.

Just as physicians should advise patients to improve their nutrition, lose weight, and exercise before surgery to promote the best possible outcome, they should also advise their patients to quit smoking. But it doesn't make sense for the consequences of the patient failing to lose weight, eat properly, or exercise to be having surgery offered anyway, but for the consequences of the patient failing to quit smoking to be being denied surgery.

Perhaps the most disturbing aspect of Dr. Peters' argument is that it would require physicians to act in a way that is often not in the best interests of their patients, violating a central and essential tenet of medical practice. If a smoker does not succeed in quitting smoking, then it is almost certainly in his or her best interest to have surgery anyway, especially for something like an orthopedic procedure where his or her quality of life will be greatly affected by the failure to perform the procedure and where the chances are still much greater than not that there will be no complications from the surgery due to continued smoking.

In these cases, the physician would be enforcing on her patient a decision that is not in the patient's best interest, but is mandated because of a societal judgment that smoking is the one behavioral choice that affects surgical risk that cannot be tolerated.

As Dr. William Cameron said so eloquently in his rapid response to the article: "The role of the physician whose proper client is his patient is to act in that individual person's best interests. Otherwise, the physician should confess the competing interest (like some notion of the public purse) to his patient, and if conflicted, refer the patient to an unbiased provider. If a person or his disease is distasteful to a physician, he should confess and refer, rather than construct arguments that rationalize, or worse impose the prejudice by policy in disfavouring one person for another. All persons should be considered equal in dignity and rights, and triage for access to limited resources should be according to need, not by social or any other lottery. If it is the mission of a well-meaning physician to 'fight smoking' then he should address smoking, not the smokers, and surely not in the face of illness and a need for care."

But I can't think of a more fitting closing comment than to share the rapid response offered by Dr. Patrick Silvestre, who wrote: "I really agree with this analysis of the surgical care in smoker's population. I propose also to study carefully the case of obese ones, who are guilty of their bad alimentation, of car or bike users, and their traffic injuries, or the pedestrian who would have to remain at home. Perhaps can we have productive thinking of cost effectiveness of care for the poor and unemployed or more simply, the other, the stranger? What a wonderful medicine, this medicine of the future! I am sorry, it's not mine."

How true. If, in our desire to cut medical costs, we abandon the most basic aspects of medicine - our willingness to provide treatment to people regardless of the circumstances that led to the need for treatment - we will end up causing much more harm than good.

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