Monday, September 17, 2007

UK Doctors Refuse to Fix Man's Broken Ankle Unless He Quits Smoking

According to an article in the Daily Mail, doctors at the Royal Cornwall Hospital in Truro have refused to perform surgery necessary to fix a 57-year-old Cornwall resident's severely broken ankle because he is a smoker.

According to the article: "A man with a broken ankle is facing a lifetime of pain because a Health Service hospital has refused to treat him unless he gives up smoking. John Nuttall, 57, needs surgery to set the ankle which he broke in three places two years ago because it did not mend naturally with a plaster cast. Doctors at the Royal Cornwall Hospital in Truro have refused to operate because they say his heavy smoking would reduce the chance of healing, and there is a risk of complications which could lead to amputation. They have told him they will treat him only if he gives up smoking. But the former builder has been unable to break his habit and is now resigned to coping with the injury as he cannot afford private treatment."

"He is in constant pain from the grating of the broken bones against each other and has been prescribed daily doses of morphine. Mr Nuttall, of Newlyn, Cornwall, broke the ankle in a fall in 2005. Initially he refused surgery because he had caught MRSA at a different hospital four years earlier, and was terrified of history repeating itself. He hoped the fractured bones would knit together with a standard plaster cast to immobilise his ankle. But six months and three plaster casts later, it became clear that an operation to pin the bones was the only solution." ...

"A spokesman for the hospital trust said: 'Smoking has a very big influence on the outcome of this type of surgery, and the healing process would be hindered significantly.'"

The Rest of the Story

This is truly disturbing, and it makes me quite irate. The man obviously needs to have this surgery. The ankle is broken in three places. This is not elective surgery. Refusing to perform the surgery really is sentencing this poor man to a lifetime of chronic pain. The poor fellow is on morphine, for goodness sake!

And all of this is simply because smoking presents an increased risk of surgical complications?

How can you ethically, as a physician, prescribe this patient morphine, which is quickly going to turn him into an opiate addict, yet refuse him surgery that would most likely repair the ankle, simply because he happens to be addicted to nicotine?

The same rationale for refusing surgery for a broken ankle could be used to deny surgery to a patient who is obese or overweight. To be sure, excess weight impairs the healing process and increases the complication rate following surgery. In fact, in my experience, overweight is a far more important than smoking in terms of impaired wound healing and post-operative wound infection.

Are these physicians also going to deny surgery to overweight patients with broken ankles unless they lose weight?

This action by these physicians violates two tenets of the Hippocratic Oath. First, it violates the promise to do no harm to one's patients. By refusing to fix this poor man's broken ankle, the physicians and the hospital trust are undoubtedly doing him harm. The harm is pretty severe: he is being sentenced to chronic pain, so severe that he requires daily morphine injections.

Second, this action violates the provision of the Hippocratic Oath whereby physicians pledge to keep the good of the patient as the highest priority. Here, the good of the patient is being sacrificed in order to save the government money.

In a British Medical Journal commentary supporting the idea of refusing surgery to smokers, Dr Matthew J. Peters argued: "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."

Here is where I think the idea of refusing surgery to smokers becomes dangerous (and not merely callous). The community must involve itself in the individual medical decisions regarding individual patients? That is very scary.

Are we going to start imposing community decisions about whether to allow women to have abortions? Are we going to start refusing medical treatment to heroin abusers when they develop phlebitis from shooting up heroin with unclean needles? Are we going to refuse medical treatment to alcoholics who abuse alcohol and end up with liver disease or esophageal varices? Do we just let them bleed to death unless they promise to stop drinking?

If I may close by borrowing the opening words of the opposing BMJ commentary written by my colleague at Boston University - Professor Leonard Glantz: "One of the noblest things about the profession of medicine has been its single minded devotion to patients. Doctors routinely treat patients who are despised by the society in which they live—enemy troops, terrorists, murderers. Given this, it is astounding that doctors would question whether they should treat smokers. The issue for doctors is whether they will allow the current antismoking zeal in America, the United Kingdom, and western Europe to infect their practice and undermine the doctor-patient relationship."

I would extend that statement to say that the issue is whether the current antismoking zeal with infect anti-smoking groups. The easiest way to put a halt to this type of nonsense would be for the anti-smoking groups to speak out against it. I just don't see that happening.

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