Tuesday, April 15, 2008

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.

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