Action on Smoking and Health Suggests that Former Smokers Not Be Eligible for Heart Transplants

Responding to an article which reported that one in four heart transplant patients resume smoking after their operations, Action on Smoking and Health (ASH) has suggested that former smokers should be made ineligible for heart transplants.

In its press release, ASH wrote: "More than one in four heart transplant patients start smoking again after their operation, a move which slices their life expectancy, and is being called a 'disgrace' and 'selfish,' considering that half of those who need a heart replacement die while awaiting a donated transplant. Indeed, since many families of heart donors are 'very upset and disappointed' when former smoker donors 'waste' this gift of life by smoking again, perhaps they should begin to specify that hearts should go only to those who never smoked, or who gave it up many years ago, says Action on Smoking and Health (ASH)."

The Rest of the Story

This is an extremely dangerous position for an anti-smoking group to take. It is dangerous because it crosses the line into making medical treatments contingent upon an individual having a lifestyle that is acceptable to the family of the organ donor, or to certain medical authorities. The same reasoning could be used to deny heart transplants, or other medical procedures, to people of certain racial/ethnic or religious groups.

In other words, this position represents one of discrimination and bigotry. It needs to be condemned immediately by other anti-smoking groups throughout the country.

ASH actually puts forward the argument that denying heart transplants to former smokers is not analogous to denying the procedure to people of a certain race or religion: "Conditioning the gift of a heart upon a requirement that it not be largely wasted by being transplanted into someone very highly likely to smoke and risk a condition called graft coronary artery disease, where blood vessels connected to the new heart are damaged by the toxic chemicals in tobacco, is very different from trying to prevent a heart from being donated to someone because of his or her race, religion, or similar immutable characteristics, Banzhaf suggests."

However, this argument falls apart because being a former smoker is, in fact, an immutable characteristic. Once you have smoked, you are always a former smoker. There is no way to become a neversmoker once you have smoked. Thus, it is an immutable characteristic and denying a transplant from such a person is analogous to denying a transplant to a person on the basis of race, religion, or other immutable characteristics.

Just because ASH seems to despise smokers and former smokers is no valid reason to categorically deny heart transplants to every person who has ever smoked. Importantly, this is not a medical criterion. It is a personal value judgment.

To be a valid medical criterion, one would have to judge each individual separately based on his or her own personal situation. That's how medicine is practiced. We do not make assumptions about an individual's personal suitability for a procedure based solely on the category to which that person happens to belong.

Doing so, and following ASH's advice here, would lead to blatant and unacceptable discrimination.

For example, suppose that data showed that people who are poorer and less educated are more likely to resume smoking after a heart transplant. Using ASH's reasoning, we should deny heart transplants to people who are poor or uneducated. This would lead to a discriminatory system of transplantation, where only the upper socioeconomic classes would be eligible for these procedures. Transplants would be unavailable for the lower socioeconomic classes.

This is why in medicine we do not make assumptions about patients based solely on the groups to which they belong. We don't deny procedures to patients based on group membership unless that group membership automatically affects the medical appropriateness of the procedure.

What ASH is suggesting here would not only result in bigotry and discrimination in organ transplantation, it would also destroy the very heart and soul of medicine: the principle that individuals should be treated as individuals and that decisions should be made based on the best interest of that particular patient, not based on any group to which the patient belongs (unless that group membership directly affects the medical appropriateness of the treatment).

I have seen the effects of treating people categorically, and it is quite unfortunate. For example, I observed that physicians often assume that people who are poorer or people who are of color are more likely to abuse pain medication. Perhaps there is even some data out there supporting such an impression. However, the result of categorically denying adequate pain medication to people of color is a medical system in which these people are disproportionately suffering pain. It is discrimination and racism. And it is based on the very same thinking that ASH asks us to bring to the issue of eligibility for organ transplantation.

There is no place for discrimination and bigotry in the practice of medicine. And I hope other anti-smoking groups join me in speaking out against the position that ASH has advanced here.

Aberdeen City Council to Smokers: We Will Not Allow You to Adopt or Foster Children

According to an article on the STV web site, the Aberdeen City Council is poised to prohibit smokers from fostering or adopting children, regardless of whether they smoke in the home or promise not to smoke in the home once they adopt.

In fact, under the proposal, prospective foster or adoptive parents would have to prove that they have quit smoking for at least one full year before being eligible to have children placed in their care.

Furthermore, according to the article, "no child born in a non-smoking family would be placed in the care of a smoker." Although I'm not clear on the interpretation, it appears this means that if the biological parents were nonsmokers, a child would not be placed even with a former smoker.

According to the article: "Stephanie Stone, assistant director of Barnardo's Scotland, said: "If Aberdeen City Council adopt the recommendations they will be falling in with the majority of agencies and councils in Scotland. "There are a number of agencies who will of course have existing carers who smoke. In this situation we would do our best to encourage them to cease smoking and offer them support in doing so. "Local authorities are looking at the impact of smoking on young children. Unless we take proactive steps to stop smoking, local authorities, in theory, in the best interest of the child or young person, could withdraw the placement of the young person. We have to make carers aware that this is a live possibility."

The Rest of the Story

I have to question the priorities of the Aberdeen City Council. Is it more important that a child’s parents do not smoke or is more important that a child has parents? There are many children without parents who will be denied a loving family because of this policy, or who will at least experience a delay in the provision of a loving family. There is a widespread shortage of foster and adoptive parents and the demand, unfortunately, generally outpaces the supply. So this policy is tantamount to saying that the City Council would rather children remain parentless than that they enter a loving family if the prospective parents are smokers.

Health has nothing to do with this policy because the adoption ban is not restricted to smokers who fail to promise not to smoke in the presence of the children. The very fact that a parent is a smoker is apparently the problem, rather than exposure to secondhand smoke. This is reinforced by the fact that the policy requires a smoker to have quit smoking for a full year prior to adopting or fostering a child. If the issue were merely protecting children from secondhand smoke, then ex-smokers should be welcomed to adopt children as soon as they quit. And even current smokers should be welcomed to adopt children as long as they agree to smoke outside or outside the presence of the child.

While promoting not smoking or cessation of smoking is a laudable goal, there is no excuse for pursuing this goal at the expense of the welfare and well-being of children. We must always act in the best interests of these children. Their needs and interests should not be sacrificed or compromised because the Aberdeen City Council wants to make a statement about the evils of smoking.

The policy is clearly based not on the interest of protecting the children from secondhand smoke, but on protecting the children from having a parent who smokes. Why, then, is the Aberdeen City Council not also prohibiting overweight or obese individuals from being adoptive or foster parents? Why is the Council not prohibiting people who don’t exercise sufficiently from becoming adoptive or foster parents? What about parents who don’t regularly use seat belts?

The selective inclusion of smoking as the only unhealthy behavior which automatically disqualifies you from being an adoptive parent suggests that the real intent of the policy is to punish smokers and deny them the joy and fulfillment of parenthood. That is despicable enough, but that the policy punishes children to carry out this intent is unconscionable and unacceptable.