Denying Medical Care to Smokers

Since Health care is in the news, here's something from a few weeks ago I never got around to posting, partly because the write-up at the end never seemed quite right (oh well, here it is anyway). In Britain, there's a debate over whether smokers should be denied medical care [yes, no] on the grounds that it's more efficient to treat non-smokers. The primary care trusts mentioned in the article are responsible for delivering health care and health improvements to their local areas. They are part of the National Health Service but have their own budgets and set their own priorities within within broad guidelines:

Should smokers be refused surgery?, EurekAlert: Last year a primary care trust announced it would take smokers off waiting lists for surgery in an attempt to contain costs. In this week's BMJ, two experts go head to head over whether smokers should be refused surgery.

Denying operations is justified for specific conditions, argues Professor Matthew Peters from the Concord Repatriation General Hospital in Australia. Professor Peters says that smoking up to the time of any surgery increases cardiac and pulmonary complications, impairs tissue healing, and is associated with more infections.

These effects increase the costs of care and also mean less opportunity to treat other patients, he writes. In healthcare systems with finite resources, preferring non-smokers over smokers for a limited number of procedures will therefore deliver greater clinical benefit to individuals and the community.

He believes that, 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 procedures.

But Professor Leonard Glantz from Boston University School of Public Health believes it is unacceptable discrimination. "It is astounding that doctors would question whether they should treat smokers," he says.

"Doctors should certainly inform patients that they might reduce their risks of post-surgical complications if they stop smoking before the procedure. But should the price of not following the doctor's advice be the denial of beneficial surgery?"

Cost arguments are made to support the discriminatory non-treatment of smokers. But why focus our cost saving concerns on smokers? Patients are not required to visit fitness clubs, lose 25 pounds, or take drugs to lower blood pressure before surgery. And many non-smokers cost society large sums of money in health care because of activities they choose to take part in.

Discriminating against smokers has become an acceptable norm, he writes. It is shameful for doctors to be willing to treat everybody but smokers in a society that is supposed to be pluralistic and tolerant. Depriving smokers of surgery that would clearly enhance their wellbeing is not just wrong – it is mean, he concludes.

It's possible to predict the success of particular treatments according to a broad array of voluntary behaviors, and also according to genetic factors.

What I'm curious about is how illnesses from factors an individual has no control over ought to be treated. Under a system of private insurance, do you think insurers should be able to exclude people from coverage due to genetic predisposition to high-cost illnesses which, unlike smoking, do not come from behaviors individuals choose (or effectively exclude them through high premiums)? I don't - denying or limiting coverage for conditions people can't prevent seems cruel. I think the health risks that come with the genetic make up we are born with are risks that ought to be pooled across the entire population. Thus, my choice would be to not allow screening on this basis. After all, there but for a mistake of the Intelligent Designer go I.

Comments

[supersaurus]

because I prefer single-payer universal healthcare, I sidestep your question. one major purpose of insurance is risk pooling: private insurors prefer exclusion which gives rise to the question, but with universal coverage it needn't be asked.

the question about deliberate behavior could still be discussed though. should a 30 year smoker with lung cancer be allowed to stand in the same line for a transplant as someone who got lung cancer due to inadvertant environmental exposure or due to unknown causes?

[Meh]

I can see why you didn't post this before. You're basically confusing two separate questions in ethics.

One is the "hand we are dealt when we are born." My brother in law died of a heart condition "enlarged heart" that was with him from birth. It's fairly trivial to demonstrate to anyone who has a bit of empathy that this kind of risk should be spread across a large insurance pool. That's what insurance as a societal concept (rather than a business) is all about. Hedging risks that we are largely unable to control.

The argument of the doctors is that smoking is a different kind of risk, one we can control. Thus, we're back in the territory of moral hazard. Of course, moral hazard can be overdone as an argument, but it's certainly a different question to the other case.

[Ken Houghton]

The choice appears to be doing a surgery on someone with (top-of-head numbers, exaggerated for effect) a 20% chance of something going wrong or doing the same surgery on someone with a 10% chance of something going wrong.

If I drink heavily the night before a scheduled operation, is the surgeon still obligated to perform surgery that day?

As Meh notes, the question is best phrased as: You are performing an activity that increases the chance of this going wrong. Can you stop doing that for a finite period of time before the operation?

If the answer is no, then we must assume that the smoker prefers to smoke rather than have the operation, rather as if I went on a bender the night before a scheduled gastric bypass.

[callahan]

If you want to deny my health care, as a smoker, who pays one of the highest cigarette sin taxes in the nation (Michigan), I say if you will take my tax dollars from cigarettes, and if you will continue to let tobacco manufacturers coninue to manufacture cigarettes, and until you outlaw smoking in this country completely, then I say you can go straight to hell, or you can deny all of the overweight and obese people, and all of the boozers their health care.

[evagrius]

I'm in favor of denying health care to people based on inherited wealth. Those who inherit wealth over a certain amount, ( say $100K),and who haven't done a day's worth of valuable work, should not be allowed any
medical care.
That would take care of a lot of medical costs.

[ken melvin]

I assume under Professor Peter's plan the smokers get an equivalent discount on their taxes.

[save_the_rustbelt]

Replace "smoking" with "risky sex" and see what kind of political firestorm you get.

Or "obesity."

Or "high cholesterol."

Or "mental retardation."

Some people have too much idle time to develop dumb ideas.

In a partial defense of the concept, heavy smokers do not recover from some surgical procedures as easily as non-smokers, so maybe we are wasting surgical dollars on heavy smokers.

(Obese patients are often denied certain elective surgeries because of problems with emboli and recovery times.)

[yartrebo]

Considering that smoking is highly addictive, that most people start very young (something like 90% start before age 18), and that there is heavy marketing and marketing-induced peer pressure for kids to smoke, I don't think that the 'moral hazard' situation applies here.

If you want to reduce smoking and thus smoking related illnesses, go to the source - the tobacco companies.

[callahan]

To yartrebo, well said.

Let tobacco growers and makers get a real job, and if the gov'munt wants to continue to collect taxes from cigarettes, let them take over the tobacco industry and put all income into health care.

G.D. the Marlboro Man.

[anon]

The doctors I know say that they have the right to refuse a particular treatment when risks of failure, or of dangerous complications are too high. So, they consider it OK to refuse a smoker surgery for lung cnacer if the smoker cannot quit for the recommended number of days before lung cancer surgery. I think that is different from making a decsion based on a general rule on guesstimates about the cost-effectiveness of medical treatments in smokers vs non-smokers.

[dd]

"I think the health risks that come with the genetic make up we are born with are risks that ought to be pooled across the entire population."

What if nicotine addiction is part of the genetic make up?
See: http://www.yaledailynews.com/articles/view/19414

[billy]

MT,

I think the health risks that come with the genetic make up we are born with are risks that ought to be pooled across the entire population.

The idea of risk implies something unknown. Genetic and pre-natal tests will make the unknowns you talk about known. What then?

What is to stop the insurance industry from insisting that babies with "genetic make up" that create health risks should not aborted? Or to take it further, parents who are prone to have such babies should not even have kids? Or to take it even further, insist that even such parents should not be allowed to come to existence; some particular combination of people should even be discouraged from marrying?

[callahan]

How about an incentive to live a healthy life style?

Such as don't smoke, or over eat, or over booze, you'll be healthier, and you'll save a few bucks to help you eek out your existance.

[Bruce Webb]

I don't have any problem giving disincentive to smokers. Here in Washington State we tax the hell out of them and make them stand in the cold 28' from the door. Certainly my lungs are now a lot cleaner since the second hand smoke got banished to the back porch. And the fact that most people I know can no longer afford the top national brands is not particularly my problem either. I notice people no longer just let cigarettes burn unattended, too expensive.

But while I don't have problems sending people out into bitter cold to shiver while they take some quick drags on their off-brand cigarette, I think a strategy that essentially adds up to "Drop dead you smoking wanker" goes a little far.

[callahan]

Thanks Bruce Webb, I am one of those smoking wankers who stands in the cold in Michigan to smoke my off brand that I can ill afford.

Damn that Marlboror Man.

[gordon]

In Australia, where Prof. Peters and I both live, it is pretty well-known that the value of excise tax raised on tobacco products greatly exceeds the estimated cost of extra health care attributible to smoking. Prof. Peters' real problem is getting the money out of the Govt., not with smoking as such.

[Keith]

I do think the way this country treats smokers is evil. If a guy wants to allow smoking in his bar and you don't like it, don't go to his bar and don't work in his bar. That's what living in a free society is about. People who want to ban smoking in restaurants and bars are sick Stalinist freaks in my opinion.

I'd have no actual problem with denying treatment based on behavior, though. It seems fair, and it's more efficient that taxing every pack of cigarettes or every fatty burger. There are people who smoke the occasional butt or eat the occasional burger who don't impose costs on the health care system, so why should they pay extra taxes for those choices? I'd have no problem letting people know that the consequence of their behavior would mean they may not receive certain social insurance.

It just doesn't seem enforceable, though. How will you verify whether somebody smoked?

My view. Tax cigarettes, but at a rate that reflects the real external costs of smoking. Smokers cost a bit more in health care but cost less in Social Security, and even if you threw in secondhand smoking, you might get 50-75 cents per pack. If you want a higher tax rate, you'd better be prepared to argue for a paternalistic tax based on the assumption that smokers are hyperbolically discounting or something.

As for fat, we may want to see if there are some diseases that are so completely caused by obesity that we could choose not to treat them (maybe type 2 diabetes?). But that may not work.

But quit hating on the smokers. That's another reason I'm not enthusiastic about a large welfare state in the US; so many of our countrymen, both liberal and conservative, are creepily puritanical. That could translate into big problems if we have a larger powerful government.

I mean, if we have a government that continues to wage a war on drugs, do we want to put that government in charge of health care?

[cm]

evagrius: I don't think refusing healthcare to anybody would make a positive contribution to anything. And $100K is in no way an amount of money that you can live off of these days. Nothing under several millions will do the trick (assuming you are not planning to exhaust it within at most a few decades).

[BiJian Feng]

This is exactly what happens once government takes over, and is the perfect reason WHY WE SHOULD NOT HAVE A NATIONAL HEALTH CARE PROGRAM. Certain people will try to impose their values on others, I find that these people tend to be either from the extreme left or the extreme right. They will use the power of the government to force us to behave according to their morals. Soon, the "health advocates" out there will make the case that heart disease is the #1 killer in the U.S. and therefore costs us X billion dollars a year more. They will then say that people who do not choose to eat right should not be given medical treatment. Never mind that they paid for the national health care plan through their taxes already. No, everyone will be forced to conform. Get in line and get your government breakfast, lunch, and dinner, with the correct amount of fat, calories, and vitamins. Those who do not take their government meals will be denied the health care they paid for already with their taxes.

England is already going through this and it will happen to us if we nationalize health care. No way!

[ilsm]

I propose that smokers and other people 'acting out' in risky behaviors are either genetically predisposed toward addictive behavior or environmentally addicted to the addicitive behavior and have very little choice in the matter, about 1% more choice than a person born to any of the auto-immune diseases we see.

The hard question goes toward euthanasia.

I am a quit smoker and getting over that addiction is a real accomplishment.

The last conscious decision concerning tobacco smoke was the second butt consumed!

As to denying me service, if my fate is to die the Norns will cut my thread on the ordained time.

[reason]

I think the health risks that come with the genetic make up we are born with are risks that ought to be pooled across the entire population.

This argument obviously applies to race and gender.

[reason]

And isn't there an even bigger problem about what happens to people who already suffer from an expensive illness (say MS or diabetes).

[Real Person from the Real World]

My father smoked all his life, and died of prostate cancer at 93. While smoking may be associated with health risks, those same risks are affected even more by your DNA. We're all human beings with weaknesses, if you start punishing people for weaknesses, we would all be penalized in some way. Also, this brings to mind a parallel issue: Credit companies screaming about all the deadbeats, while pumping the mail with offerings to get the same "deadbeats" even more into debt. With things getting tight, everyone starts to look around to see who can be screwed instead, so they can go right on enjoying life. Bah! I think CEOs who make too much money ought to be barred from getting medical care. They have too many goodies as it is, so let's even the score!