Thursday, March 08, 2012

Hertfordshire Smokers and Obese Individuals No Longer Eligible for Routine Surgery, According to The Telegraph

According to an article in the The Telegraph, a ban on hip or knee replacement surgery for smokers and persons with a body mass index greater than 30 is being extended to cover all routine surgeries. Based on the article, the only exceptions are for "neurology, cardiac and cancer operations."

The article reports: "Data shows that more than a quarter of Primary Care Trusts in England have brought in new restrictions based on patients’ lifestyle criteria in the last year. It reveals that people are being denied IVF treatment, breast reductions and fat-loss operations based on their weight and whether they smoke. In the case of one trust, NHS Hertfordshire, a controversial ban imposed last year on knee and hip operations for anyone with a body mass index (BMI) over 30 as well as smokers, has been extended to cover all routine surgery. The new Hertfordshire policy, introduced in January, makes exceptions only for neurology, cardiac and cancer operations. ... Dr. Clare Gerada, head of the Royal College of GPs, said some of the restrictions, particularly for IVF, were “dreadful”. She added: “It’s becoming the deserving and the undeserving. I think it’s discriminatory and I find it astonishing.”"

The Rest of the Story

The first thing that readers need to understand is that while smoking and obesity do have adverse implications for healing after surgery and for outcomes in some types of surgery, there is no medical indication to withhold routine surgery from smokers or obese persons. Moreover, even for operations in which a patient might likely fare better if he or she quit smoking, such as knee replacement, there is no medical justification for withholding access to the treatment.

The only possible medical indications for withholding surgery would be if the smoking or obesity was the cause of the disease and the treatment would be unsuccessful or futile in the absence of smoking cessation or weight loss. For example, it wouldn't make medical sense to perform a liver transplant on an alcoholic with cirrhosis of the liver who refuses to quit drinking or enter an alcoholism treatment program. But to deny surgical treatment of a fracture to that person has no medical justification.

Another important factor to consider is that it is extremely dangerous to go down the road of withholding treatment to people because they engage in certain unhealthy behaviors that put them at increased risk of adverse health outcomes. The same reasoning being used to withhold surgery from smokers could be used to justify the withholding of treatment of chronic head injury for boxers or football players. It could justify withholding treatment for anorexia among people who refuse to eat a proper amount of food. It could justify withholding treatment of chronic tendonitis in tennis players or marathon runners. It could justify withholding treatment of hypertension for patients who eat extreme excesses of salt. This is definitely not a road that we want to go down.

A third important factor to consider is that the practice of medicine is based on the ethical principle that medical treatment decisions are based on serving the best interests of the patient, not on casting moral judgments on patient lifestyle choices. And medical treatments should not be made requisite on patient's making particular changes in their lifestyle unless there is a specific medical contraindication.

The reasoning being used by the Hertfordshire NHS would justify the refusal to provide anti-hypertension medication to any person with high blood pressure who does not successfully reduce his sodium intake to less than two grams per day. Any physician in the United States who did such a thing would not only be questioned for ethical reasoning, but he would most likely be sued successfully for malpractice.

I don't understand who the Hertfordshire authorities think they are who can decide which vices (i.e., what health-related behavioral or lifestyle choices) are permissible and which are not permissible in order to be eligible for routine surgery. This is not medically justified rationing. Instead, it is unethical discrimination, moralizing, and bigotry.

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