[ProCOR] Should Smokers be Refused Surgery?
In the 6 January 2007 issue of BMJ (2007; 334: 20-21), Matthew J. Peters,
associate professor, Department of Thoracic Medicine, Concord Repatriation
General Hospital, Concord, Australia, argued that denying surgery to smokers is
justified for specific conditions. His commentary responded to a 2006 announcement by a
primary care trust to take smokers off waiting lists for surgery in an attempt
to contain costs. Leonard Glantz, professor of health law, bioethics and human
rights, Boston University School of Public Health, Boston, USA, rebuts this
argument, believing that it is unacceptable discrimination.
Below are excerpts from both sides of the argument.
Juan Ramos
ProCOR Program Coordinator
Jramos3@partners.org
----
"Should smokers be refused surgery?"
BMJ 2007; 334: 20-21
Yes: http://www.bmj.com/cgi/content/full/334/7583/20
No: http://www.bmj.com/cgi/content/full/334/7583/21
----
Matthew J. Peters
Associate professor, Department of Thoracic Medicine
Concord Repatriation General Hospital
Concord, New South Wales, Australia
"In healthcare systems with finite resources, preferring non-smokers over
smokers for a limited number of procedures will deliver greater clinical benefit
to individuals and the community."
The adverse effects of smoking up to the time of surgery, such as increase in
cardiac and pulmonary complications and higher risk of infection, "compromise
the intended procedural outcomes and increase the costs of care...as long as
everything is done to help patients to stop smoking, it is both responsible and
ethical to implement a policy that those unwilling or unable to stop should have
low priority for, or be excluded from, certain elective surgical procedures."
"Such a policy should be limited to procedures where the evidence of harm is
strongest...A study of experimental sacral incisions of 12-18 mm found that
infection occurred in 12% of smokers and 2% of non-smokers...In a study of wound
and other complications after hip or knee arthroplasty, no smoker who had quit
developed a wound infection compared with 26% of ongoing smokers and 27% of
those who had simply reduced tobacco use."
"Increased use of hospital beds and associated costs mean less opportunity to
treat other patients...Well informed smokers, unwilling or unable to quit, might
assume an increased risk for themselves, but the decision is not theirs alone
when it can indirectly affect others."
"Smoking causes disease that may require surgery, but smoking as a cause of
disease is not the issue for debate. Individuals should be treated equitably
regardless of the cause of their disease. It is also true that smoking is rarely
the only risk factor for a poor outcome, and smoking should not be considered to
the exclusion of all others. Smoking is, however, unique in that its associated
risk can be reduced substantially within a short period."
"Therefore, it is not so much the principle that should be debated here but the
practical aspects of implementation and exceptions that might apply...A properly
implemented policy would require that non-smoking status be validated but, for
the potential benefits, this is justified."
----
Leonard Glantz
Professor of health law, bioethics and human rights
Boston University School of Public Health
Boston, Massachusetts, USA
"It is astounding that doctors would question whether they should treat
smokers...It is not without some irony that surgeons who refuse to perform
operations on patients unless they stop smoking make the same argument that
cigarette companies used [in lawsuits brought against them by diseased
smokers]-if smokers don't want to incur the adverse effects of smoking,
including refusal of surgery, they should quit."
"The idea of doctors treating all smokers the same way runs counter to the
practice of medicine...Evidence exists that smokers are at an increased risk of
postsurgical complications compared with non-smokers, and when smokers stop
smoking before surgery their risks of complications decrease. But those same
data show that most smokers who have surgery have no complications, and a policy
denying all smokers access to surgical procedures arbitrarily denies beneficial
treatment to those who would have had no complications."
Withholding surgery from smokers also distorts the modern doctor-patient
relationship...Doctors determine the risks and benefits of treatment and inform
the patients of these facts, and patients then decide whether to incur the risks
to gain the benefits."
"If the decision whether to take an increased risk is not left to patients, they
are likely to lie to their doctors about their smoking. This deception, of
course, will make us unable to help smokers who wish to stop but fear the
repercussions of disclosing their smoking to their doctors."
"Many non-smokers cost society large sums of money in health care because of
activities they choose to take part in. "Baby boomers" in the United States lost
488 million days of productivity in 2002 because of sports injuries...We could
reduce healthcare expenditure by simply refusing to pay for treating any
injuries related to voluntary participation in sports...But we don't even think
this let alone suggest it."
"The suggestion that we should deprive smokers of surgery indicates that the
medical and public health communities have created an underclass of people
against whom discrimination is not only tolerated but encouraged...Depriving
smokers of surgery that would clearly enhance their wellbeing is not just
wrong--it is mean."
associate professor, Department of Thoracic Medicine, Concord Repatriation
General Hospital, Concord, Australia, argued that denying surgery to smokers is
justified for specific conditions. His commentary responded to a 2006 announcement by a
primary care trust to take smokers off waiting lists for surgery in an attempt
to contain costs. Leonard Glantz, professor of health law, bioethics and human
rights, Boston University School of Public Health, Boston, USA, rebuts this
argument, believing that it is unacceptable discrimination.
Below are excerpts from both sides of the argument.
Juan Ramos
ProCOR Program Coordinator
Jramos3@partners.org
----
"Should smokers be refused surgery?"
BMJ 2007; 334: 20-21
Yes: http://www.bmj.com/cgi/content/full/334/7583/20
No: http://www.bmj.com/cgi/content/full/334/7583/21
----
Matthew J. Peters
Associate professor, Department of Thoracic Medicine
Concord Repatriation General Hospital
Concord, New South Wales, Australia
"In healthcare systems with finite resources, preferring non-smokers over
smokers for a limited number of procedures will deliver greater clinical benefit
to individuals and the community."
The adverse effects of smoking up to the time of surgery, such as increase in
cardiac and pulmonary complications and higher risk of infection, "compromise
the intended procedural outcomes and increase the costs of care...as long as
everything is done to help patients to stop smoking, it is both responsible and
ethical to implement a policy that those unwilling or unable to stop should have
low priority for, or be excluded from, certain elective surgical procedures."
"Such a policy should be limited to procedures where the evidence of harm is
strongest...A study of experimental sacral incisions of 12-18 mm found that
infection occurred in 12% of smokers and 2% of non-smokers...In a study of wound
and other complications after hip or knee arthroplasty, no smoker who had quit
developed a wound infection compared with 26% of ongoing smokers and 27% of
those who had simply reduced tobacco use."
"Increased use of hospital beds and associated costs mean less opportunity to
treat other patients...Well informed smokers, unwilling or unable to quit, might
assume an increased risk for themselves, but the decision is not theirs alone
when it can indirectly affect others."
"Smoking causes disease that may require surgery, but smoking as a cause of
disease is not the issue for debate. Individuals should be treated equitably
regardless of the cause of their disease. It is also true that smoking is rarely
the only risk factor for a poor outcome, and smoking should not be considered to
the exclusion of all others. Smoking is, however, unique in that its associated
risk can be reduced substantially within a short period."
"Therefore, it is not so much the principle that should be debated here but the
practical aspects of implementation and exceptions that might apply...A properly
implemented policy would require that non-smoking status be validated but, for
the potential benefits, this is justified."
----
Leonard Glantz
Professor of health law, bioethics and human rights
Boston University School of Public Health
Boston, Massachusetts, USA
"It is astounding that doctors would question whether they should treat
smokers...It is not without some irony that surgeons who refuse to perform
operations on patients unless they stop smoking make the same argument that
cigarette companies used [in lawsuits brought against them by diseased
smokers]-if smokers don't want to incur the adverse effects of smoking,
including refusal of surgery, they should quit."
"The idea of doctors treating all smokers the same way runs counter to the
practice of medicine...Evidence exists that smokers are at an increased risk of
postsurgical complications compared with non-smokers, and when smokers stop
smoking before surgery their risks of complications decrease. But those same
data show that most smokers who have surgery have no complications, and a policy
denying all smokers access to surgical procedures arbitrarily denies beneficial
treatment to those who would have had no complications."
Withholding surgery from smokers also distorts the modern doctor-patient
relationship...Doctors determine the risks and benefits of treatment and inform
the patients of these facts, and patients then decide whether to incur the risks
to gain the benefits."
"If the decision whether to take an increased risk is not left to patients, they
are likely to lie to their doctors about their smoking. This deception, of
course, will make us unable to help smokers who wish to stop but fear the
repercussions of disclosing their smoking to their doctors."
"Many non-smokers cost society large sums of money in health care because of
activities they choose to take part in. "Baby boomers" in the United States lost
488 million days of productivity in 2002 because of sports injuries...We could
reduce healthcare expenditure by simply refusing to pay for treating any
injuries related to voluntary participation in sports...But we don't even think
this let alone suggest it."
"The suggestion that we should deprive smokers of surgery indicates that the
medical and public health communities have created an underclass of people
against whom discrimination is not only tolerated but encouraged...Depriving
smokers of surgery that would clearly enhance their wellbeing is not just
wrong--it is mean."
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