Tuesday, August 12, 2008

Half of UK Fertility Experts Would Deny In-Vitro Fertilization to Smokers if They Do Not Quit Smoking; Some Hospitals Already Refusing IVF for Smokers

According to a survey reported by BBC News, about half of fertility experts (physicians) interviewed support the concept of denying in-vitro fertilization (IVF) treatment to smokers and obese persons unless they meet certain conditions for modification of their lifestyles.

According to the article: "Almost half of fertility experts say access to IVF should be conditional - and smokers or the obese could be denied treatment, a survey shows. The poll of international experts, most of whom work in the UK, found just 29% thought IVF should be offered to all. Obesity and smoking have been linked to fertility problems, so doctors say it is fair to ask patients to change their habits before they are given care. Patient groups said lifestyle advice should be based on medical evidence. The poll asked for doctors to agree or disagree with the statement 'access to IVF should be conditional on criteria based on lifestyle choices - eg denying access to smokers'."

According to an article in The Guardian, up to 46 primary care trusts in England and Wales are already denying IVF treatment to smokers and will not allow them access to IVF unless they quit smoking.

According to that article: "Hospitals have been accused of rationing IVF by denying the treatment to smokers, in a move that will reignite debate about the right to NHS care. Childless women, and in some cases their partners, too, are being asked to give up cigarettes before they can be considered for fertility treatment in up to 46 primary care trusts (PCTs) across England and Wales. Ministers have retreated on suggestions that smokers should be denied treatment for tobacco-related conditions such as heart disease. But a Department of Health survey released to Labour MP Sally Keeble last week, shows that, despite official recommendations that all infertile couples should get three cycles of treatment free, clinics are increasingly making free IVF treatment conditional on not smoking. While smoking can affect a couple's chance of conceiving and smoking in pregnancy can damage the unborn child, tobacco use is listed as a 'non-clinical access criteria' in the survey - meaning it is not a medical requirement for treatment to work, but one of a series of optional requirements such as being in a steady relationship. Other lifestyle choices known to reduce fertility, such as drinking alcohol, do not affect eligibility in the same way."

The Rest of the Story

I suppose one effective way of knocking smokers out of society is to make sure that they cannot reproduce. As far-fetched as it may sound, this is essentially what the primary care trusts are doing in denying IVF treatment for smokers.

It is telling that these fertility clinics do not require women to stop drinking alcohol as a condition for IVF treatment. Smoking is being singled out, I believe, because it is viewed as a socially unacceptable lifestyle decision.

It is truly scary to think that a medical procedure would be denied to individuals based on a judgment about what is an appropriate or socially acceptable lifestyle. When judgments about lifestyle enter the clinical decision-making arena, the door is opened to all kinds of unacceptable consequences, such as denying treatment to individuals based on their sexual orientation or the presence of a "suitable" partner.

The hallmark of the practice of medicine is that it is supposed to be non-judgmental. As physicians, we are to provide the treatment that is in the best interests of the patient, without casting judgment upon the individual's lifestyle choices. Sure, it is perfectly appropriate to inform our patients about the health impact of their lifestyle choices, but we are not to deny medical care or to make such care conditional upon our patients conforming their lifestyle to meet our desires.

There is one reasonable criterion for denying medical care (outside of absolute medical contraindications) and that is situations in which the behavior in question is the cause of the medical problem and the treatment in question is severely limited in availability. For example, if an alcoholic seeks a liver transplant, it is not unreasonable to deny treatment or place the individual much lower on the transplant list because the alcohol was the cause of the liver damage and there are a very limited number of livers available for transplant. Clearly, this is not the case with in-vitro fertilization.

The policy of denying IVF treatment to obese or overweight individuals, or making that treatment conditional upon them changing their lifestyle, is equally despicable. People should not be denied basic rights because of their weight. Neither should they be denied basic rights because of their lifestyle decisions.

There are a host of medical treatments that are not as successful when the patient continues to engage in certain behaviors. There is no question, for example, that drug treatment for type II diabetes is much more effective when the patient loses weight. There is no question that treatment for hypertension is more effective when the patient restricts his or her salt intake. Insulin treatment for diabetes is more effective when the patient modifies his or her diet.

What are we going to do? Start restricting treatment of diabetes and hypertension to patients who agree to alter their diet and lose weight?

I can see why smokers are feeling persecuted by society. Their rights are being taken away. This is a threat both to basic human rights and to the integrity of medicine. As physicians, we are supposed to provide treatment to all patients without casting judgment upon them.

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