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Sections in this issue outline (in order):
1. What they said. 2 The issue at a glance. 3 Background. 4 Internet information links. 5 and 6 Arguments for / against. 7 Further implications on this issue. 8 Newspaper items used in the compilation of the outline.
2004/12: Should smokers get reduced access to elective surgery?
What they said ...
'A doctor who did not provide a needed treatment to a smoker, on the grounds that he or she was a smoker, would be in violation of that person's fundamental human right to health care and their right not to be discriminated against because of a disability ... Taken to an extreme such an attitude would be akin to advocating capital punishment for smoking'
Medical ethicist, Nicholas Tonti-Filippini.
'Continued smoking in the face of elective surgery increases the risk to the individual and stretches the already stretched healthcare resources and expenditure unnecessarily . . . The extent of this evidence is such that it is no longer possible for surgeons and others in the healthcare system to ignore it . . . The community has to decide whether this waste is justified'
Dr Peters and his colleagues from Sydney's Concord Hospital
The issue at a glance
An editorial published on April 5 2004 in The Medical Journal of Australia argues that a wide range of elective surgical procedures should not be offered to smokers who do not try to give up the habit or who do not succeed in doing so.
The report was co-written by Matthew Peters, head of thoracic medicine at Concord Hospital, Sydney.
The views expressed in the editorial appear to have meet with support from the president of the Australia Medical Association (AMA), Dr Bill Glasson. Others, including both other surgeons and some medical ethicists, have expressed concerns about Dr Peters' proposition. They are concerned that smokers may be discriminated against and that other patients whose rate of recovery is also adversely affected by lifestyle-related factors, such as obesity, may also suffer discrimination in access to medical treatment.
Background
Smoking related deaths and healthcare costs in Australia
It is estimated by the Australian Medical Association that as of 2003 some 19,000 deaths a year were smoking-related. The AMA has also estimated that treating these tobacco related conditions cost the healthcare system some $12.7 billion annually.
Dr Matthew Peters and colleagues have now drawn attention to the strain placed on the healthcare system because of patients whose recovery is delayed from non-smoking related illnesses because of the impact of their smoking.
Federal Government expenditure on anti-smoking campaigns
Tobacco control was allocated $3.8 million in the 1998-99 Federal Budget. It has been claimed that relative to the health costs to which smoking contributes this government allocation is inadequate. Cigarette taxes and excise return to the Federal Government some $5 billion a year. Thus only a small proportion of the federal revenue gained from the import and sale of cigarettes was spent on programs to educate the public against the habit.
In 2000 the Federal Government spent $112 on anti-smoking measures for every death from tobacco-related diseases - a thousand times less than the $118,571 per death spent on anti-drugs campaigns. Anti-tobacco spending is also dwarfed, in terms of the number of deaths, by money devoted to the black-spot road safety program ($419, 619), AIDS control ($264,706), breast cancer ($20,172 ) and preventing falls ($1,438).
Internet information
'Smoking cessation and elective surgery: the cleanest cut' is an editorial published in the Medical Journal of Australia on April 5 2004. It was co-authored by Matthew J Peters, Lucy C Morgan and Laurence Gluch.
The editorial suggests that smokers be either denied access to certain forms of elective surgery or be put at the end of the waiting list.
The full text of the editorial van be read at http://www.mja.com.au/public/issues/180_07_050404/pet10839_fm.html
A media released produced by the Medical Journal of Australia gives a summary of the views presented in 'Smoking cessation and elective surgery: the cleanest cut' and some of the evidence upon which these views are based.
The full text of the media release can be found at http://www.ama.com.au/web.nsf/doc/WEEN-5XL798
ASH is an Australian anti-smoking lobby group. An ASH publication gives smoking rates in Australia as of 2000. This data can be found at http://www.aihw.gov.au/publications/phe/ndshs01df/ndshs01df-c04.pdf
It is a pdf file and requires Adobe Acrobat Reader in order to be read. This reader can be downloaded free from the Internet.
Intl-Tobacco is a post-only list distributing news clips, urgent actions, reports, testimony, updates and other information related to international tobacco and international tobacco control issues.
On June 27 2000 the site posted detailed information on the amount of money the Australian Government spends on anti-smoking campaigns. This sum was contrasted unfavourable with expenditure on other health risks that result in far fewer deaths.
This information can be found at http://lists.essential.org/pipermail/intl-tobacco/2000q2/000192.html
VicHealth Centre for Tobacco Control has published the revenues gained by the Fedral Government from tobacco taxes over the last three financial years. This information can be found at http://www.vctc.org.au/tc-res/latest.htm
The Vichealth Centre for Tobacco Control (VCTC) is based at the Cancer Control Research Institute (CCRI) of The Cancer Council Victoria. It commenced operations in January 2000, and was officially opened by the Minister of Health Hon. John Thwaites on 8th March 2000. The VCTC was awarded $500,000 per year over five years from the Victorian Health Promotion Foundation (VicHealth), to be one of its Centres of Research and Practice.
On October 9 2003 Now UC a student publication from Canberra University published an article titled 'Stubbing Out Smokers' Rights' by Isuru Neelagama .
Though the piece ultimately comes down in support of the rights of non-smokers it overviews a range of current developments that have made smokers feel marginalised and discriminated against.
The article can be found at http://www.ce.canberra.edu.au/nowuc/features/20031004002.htm
On February 2, 2002, the American smokers' lobby group publication, The United Pro Choice Smokers Rights Newsletter, published a report first printed in The Herald Sun on February 8, 2001. The news item is titled, 'Surgery ban on smokers' and it outlines the bans and limitations commonly imposed in a number of Melbourne's principal hospitals on smokers seeking surgical procedures.
The full text of the news item can be found at http://193.78.190.200/10/au.htm
Arguments in favour of smokers getting reduced access to elective surgery
1. Smokers have far higher post-operative complication rates
Chemicals in cigarettes, including nicotine, delay healing and so increase the risk of post-operative infection. The reasons for higher infection rates in smokers are unclear, but the authors of the Medical Journal of Australia article surmise that carbon monoxide (a by-product of cigarette smoke) decreases the supply of oxygen to body tissue, impairing the wound's capacity to heal. There are many other chemicals in cigarette smoke that could contribute to the adverse effects.
These concerns are not based on smoking-related diseases such as cardiac and respiratory conditions. The authors of the Medical Journal of Australia article cite numerous instances where infection rates are significantly higher in smokers.
Almost 8 per cent of breast reconstruction patients who smoke experience abdominal wall site necrosis, compared with 1 per cent of non-smokers.
A recent study of hip replacement patients found that 27 per cent of those who smoked ended up with wound infections, compared with none of the non-smokers. Where smokers quit even a matter of weeks before the operation, the rate of infection fell to zero.
Complications such as infection after surgery delay the discharge of the patient, inhibit recovery and consume hospital resources in terms of effective rehabilitation and the increased cost of hospital care.
It has been claimed that these delays in discharge and increased demand are not reasonable given the large strain hospitals are already under to meet the need for elective and other forms of surgery.
2. Surgery is a limited, much-sought form of medical treatment
An editorial published in the Australian on March 12, 2004, stressed the extent to which Australia's public health system was overstretched. The editorial stated, 'Ambulances queuing outside big city hospitals, stretchers lined up in corridors, and long waiting lists for elective surgery tell us the system is, if not broke, near to breaking point.'
A similar point was made by former Victorian premier Mr Jeff Kennett in an opinion piece published in The Age on March 28 2004. Mr Kennett stated, 'The health system is having great difficulty meeting the needs of the community - needs such as hospital services, health professionals, services for the chronically ill, and long-term planning and support for the ageing, to mention a few ... Hospitals in all states are under stress.'
It has been claimed that removing cigarette smokers from elective surgery lists or putting them to the end of the line would have a lot of appeal in these circumstances. The Age in an editorial published on April 6 2004 stated, 'Given the demands upon the hospital system, placing smokers at the end of the surgery queue is a tempting solution because they can take steps to improve their chances and shorten hospital stays.'
Dr Matthew Peters, head of thoracic medicine at Concord Hospital, has claimed, 'Public heath systems are faced with overwhelming demand and must generate the greatest benefit from limited resources. Continued smoking in the face of elective surgery increases the risk to the individual and stretches already stretched healthcare resources and expenditure unnecessarily. The community has to decide whether this is justified.'
A bladder surgery patient, Mr Ron McLean, believes smokers should be removed from elective surgery queues unless they quit. Mr McLean's views were reported in The Herald Sun on April 5, 2004.
Mr McLean stated, 'Something has to be done. I'm a non-smoker so why should I be pushed further back because someone can't quit?'
It has also been noted that treating smoking-related illnesses puts any even further strain on the health care system. The Australian Medical Association has claimed that about 19,000 Australians each year die from smoking-related illnesses, at a cost of $12.7 billion in healthcare and related costs.
3. Decisions are already being made as to who should be treated and how
It has been claimed that decisions are already made every day in hospitals, doctors' surgeries and on the side of the road at car accidents about who to treat - or not treat - and in what order.
It is said that there is nothing new in this approach to determining treatment priorities. Indeed, medical triage during mass casualty emergencies and in the busy emergency wards of hospitals is established practice around the world.
It has further been claimed that smokers are already debarred from some treatments. Smokers are currently not offered either lung or heart transplants. This is largely because their prospects of recovery would be very poor and so to offer them a transplant that they would then effectively abuse is seen as wasting a scarce resource.
Dr Peters has written, 'An essential part of a surgeon's role is to be selective in choosing who to operate on, and when, in line with current evidence. Policies and practices that flow from this may be regarded by the healthcare community as discriminating, but by smokers and the wider community as discriminatory.'
4. Only elective surgery would be affected
It has been noted that smokers' access to emergency surgery would not be affected. They would only be debarred from or required to wait longer for discretional surgery. It has been claimed that this would be no significant reduction in their right to medical treatment as their lives would not be put at risk by postponed surgery and when they had given up the habit they would be able to receive the treatment.
5. Smokers take up and continue the habit voluntarily
A bladder surgery patient, Mr Ron McLean, believes smokers should be bumped off elective surgery queues unless they quit. Mr McLean's views were reported in The Herald Sun on April 5, 2004.
Mr McLean has argued that each person has a responsibility to look after his or her health. The decision to smoke, it is claimed, is a free choice made by each smoker and one he or she can attempt to undo. Mr McLean has stated, 'No one is forcing them to smoke.'
Dr Peters has also stressed that the availability of treatment is at the discretion of the smoker. He has claimed 'Continuing smokers must accept that some risks are simply unacceptable given the intent of the surgery.' He has further written, 'If smokers, as a group, have a reversible factor that causes a longer hospital stay, incurs greater costs and leads to poorer outcomes, might it [not] be reasonable to allocate them a lower priority?'
Dr Peters emphasis throughout is that smoking as a risk factor is 'reversible' and therefore under the control of the potential patient. However, Dr Peters concludes by claiming that the medical community has a particular responsibility to inform patients of the need to quit smoking and to assist them in so doing.
Arguments opposing smokers getting reduced access to elective surgery
1. Restricting smokers' access to elective surgery is discriminatory
It has been claimed that all people should have equal access to health care services. The Age, in an editorial published on April 5 2004 encouraged readers to consider what it would be like if this principle were abandoned in favour of a more punitive approach.
The editorial opened, 'Imagine if the ambulance service instituted a policy at road accidents of deciding who they would transport to hospital first based on who was to blame for the collision. There would, quite properly, be a measure of public outrage.' Such a policy, the editorial goes on to argue, would be unjustifiably discriminatory.
The Victorian Government has a similar position. A spokesperson for the Victorian Health Minister Bronwyn Pike said a fundamental tenet of the health system was that everyone was treated equally.
The same point was made by The Herald Sun in an editorial published on April 5, 2004. The editorial states, 'By all means, encourage and help smokers to break the habit, but the over-riding consideration has to be that every patient, regardless of his or her personal history, has a right to the same standard of care.'
Professor Stephen Leeder, a professor of public health at the University of Sydney, has said the idea of limiting smokers' access to elective surgery was 'really problematic'.
'I think you can advise people to quit, but to make it a condition of medical care is really excessive,' Professor Leeder said. 'In a democratic society we don't mandate behaviours like that.'
Similarly, Associate Professor Stephen Gatt, program director of anaesthesia and intensive care for the Prince of Wales Hospital and the Children's Hospital at Randwick, New South Wales, has said: 'I think it is desirable people stop, but I don't think it's practical to tell people you will not operate on them if they don't. We can't discriminate against those who smoke.'
Medical ethicists and the anti-smoking lobby are also critical of precluding smokers from elective surgery. They claim such a measure would unfairly target the poor, as lower socio-economic groups have a far higher smoking rate. Studies have shown that not only does prevalence of smoking increase with socioeconomic disadvantage; the average number of cigarettes smoked per week also increases with disadvantage. Smokers in the most disadvantaged quintile smoked on average 122.4 cigarettes per week, compared with 86.6 cigarettes by those in the most advantaged quintile.
2. Other at-risk groups could be similarly treated
There are those who argue that a large number of conditions are in part caused by the lifestyle choices of those who suffer with them. The same lifestyle choices also reduce the rate or likelihood of a full recovery being made.
Dr Bill Glasson, the president of The Australian Medical Association has said it was a 'fair enough decision' for surgeons to tell patients that they could not have elective surgery unless they quit smoking. Dr Glasson has also argued that the debate could be broadened to other groups, such as those who are obese because of their lifestyle, or alcoholics needing a liver transplant.
However, other health authorities have claimed it would not be acceptable to preclude people from treatment because the manner in which they have led their lives has contributed to their diseases or reduced their likelihood of recovery. If this principle were ruthlessly applied there would be very few people who would be eligible for treatment.
A spokesperson for the Victorian Health Minister Bronwyn Pike has said, 'As soon as you start to discriminate in any form, according to things like smoking or drinking, then it really is the thin end of the wedge. Do you then stop giving people heart bypasses because they don't exercise and sit on the couch for too long?'
3. Smoking is a legal activity
Samantha Phillipe, president of the non-profit, US-based, smokers' rights organisation Smokers Club Inc, has claimed. 'Any legal product is just that, legal. If it becomes illegal, that's another story. It is illegal to drink and drive. It is not illegal to have a cigarette ...'
According to this line of argument it is not appropriate to penalise any patient for an activity that the laws of Australia allow that person to pursue.
4. Smoking is highly addictive
It has been noted that nicotine is a highly addictive substance and that it can be extremely difficult for an established smoker to relinquish the habit.
The federal Government has spent about $21 million on a national anti-tobacco campaign since 1997, a spokesperson for parliamentary secretary for health, Trish Worth, has claimed. 'Over this period,' the spokesperson noted, 'the level of smoking has fallen from 23.5 per cent in May 1997 to 19.8 per cent in November 2002.'
The fact that one in five Australians still smokes despite the efforts taken on a state and federal level to discourage the habit has been taken as a measure of how difficult it is to quit smoking.
The Quit program has assessed that between 75 and 80 per cent of smokers want to give up, but can't.
Professor Mac Christie, of the University of Sydney, has researched the pharmacology of nicotine addiction. His findings have indicated how addictive nicotine is.
Professor Christie has noted, "Research has emerged over the past decade that identified very clearly that nicotine is one of a small group of drugs that have a special kind of interaction with brain systems that serve compulsive behaviour. Those drugs include nicotine, heroin, cocaine and, more indirectly, alcohol.
We know now there's a group of nerve cells in the brain, we call them dopamine nerves, that, when they're stimulated, induce any mammal to repeat the behaviours that have led to that stimulation ...The brain changes in permanent ways as a result of that stimulation ... What needs to be understood is there really is a strong chemical change in the brain, and different individuals have different capacities to override that."
The head of the department of surgery at the University of Sydney, Professor John Fletcher, has noted, 'There is no doubt the risk of post-operative complications is higher in patients who smoke, and certainly the optimum would be for smokers to cease six weeks before surgery. But some patients, no matter how they try, just can't get off [cigarettes] completely and we have to take that into consideration. I think it would be unfair.'
5. Smokers pay high levels of taxation
In February 2004 the tax per cigarette was 22 cents. Federal budget figures indicate that in 2001-02 the Government received $4.84 billion in taxes or excise on cigarettes. In 2002-03 the figure was $5.14 billion and in 2003-04 it is estimated to be $5.09 billion.
Those speaking on behalf of smokers claim they are among the most highly taxed members of the community. It has also been pointed out that as their life expectancy is lower than that of the general community they are less likely to have the health care problems associated with old age. It is therefore claimed that it would be extremely unjust to debar them from health care services that they have helped to fund in most instances as PAYE taxpayers and also as smokers. This is especially the case, as it is not being proposed that they only be denied treatment for conditions that have been contributed to by their smoking. For example, one of the elective procedures that they might be debarred from is hip replacement surgery.
Further implications
Decisions about patient access to limited treatments are made on a variety of bases. It does not seriously appear that Dr Peters is attempting to punish smokers for self-inflicted ailments, though some of the arguments used to counter his position make it appear that this is the case. Rather, Dr Peters seems to be arguing that where prospects of a speedy recovery are limited by factors over which patients have some control then those patients should be denied elective surgery until they are willing and able to co-operate with those treating them.
Dr Peters has written, 'The extent to which doctors seek, and the wider community provides, permission for discrimination is an issue for serious community debate. An essential part of a surgeon's role is to be selective in choosing who to operate on, and when, in line with current evidence. Policies and practices that flow from this may be regarded by the healthcare community as discriminating, but by smokers and the wider community as discriminatory.'
Dr Peters' arguments are part of a debate that needs to be had. We know and accept that patients are prioritised for treatment in hospital emergency wards. However, in these circumstances there is usually no doubt that all will ultimately receive care. The principle is assumed to be that those in most need of attention receive treatment first. There are, however, very many other grounds on which patient access to treatment and the nature of the treatment they then receive can be determined. It is also far from inevitable that optimal treatment will be administered to all.
The principle of universal access to health care is probably more an ideal than a reality. Already we live in a society where access to certain important but non-emergency treatments, for example angiograms, is affected by whether the patient has private health insurance. Here, wealth and/or foresight appears to be the factor determining when or if an 'elective' procedure will be given. There are also significant grounds for believing that the health care afforded the elderly is sometimes of a quite different quality to that offered younger members of the community. It would appear that as one ages factors such as the prospect of full recovery and the quality of life which the patient, should he or she survive, would be able to enjoy, become particularly important in determining the vigour with which treatment is pursued. Despite the existence of ethics committees and codes of practice there is necessarily a significant element of adhockery about how these access-to-treatment decisions are taken. The folly for the general public is to believe they are not taken and that optimal health care is available to all.
Most of us will probably never be in a position to bring effective pressure to bear on how these access-to-treatment decisions are made. However, the more informed we are and the more widespread the public debate is on these issues, the greater the chance that these decisions are made according to a rationale of which the general public is aware and perhaps even approves.
Sources
The Age
13/1/04 page 4 news item by Kylie Walker, 'One in five Australians still refuses to butt out'
29/2/04 page 9 analysis by Sonia Harford, 'Quitter can't resist nicotine's lethal pull'
28/3/04 page 17 comment by Jeff Kennett, 'Condition critical'
5/4/04 page 3 news item by Carol Nader, 'Call for smokers to wait for surgery'
6/4/04 page 10 editorial, 'Smoking and surgery: an ethical dilemma'
The Australian
3/3/04 page 12 editorial, 'Bacon's words slice through the smoke'
12/3/04 page 12 editorial, 'Time to stop shifting blame on hospitals'
5/4/04 page 3 news item by Louise Milligan, 'Deny smokers surgery, says doctor'
The Herald Sun
5/4/04 page 5 news item by Paula Beauchamp, 'Ban smokers from surgery, say GPs'
5/4/04 page 5 news item, 'Non-smoker waits'
5/4/04 page 18 editorial, 'Health rights of smokers'
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