Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Economic Fallacy
- Robert Feal-Martinez (5 January 2007)
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Ethical principles regarding treatment of smokers
- Arulkumaran Sellappah (5 January 2007)
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On the turning away......
- CL Andrews (6 January 2007)
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Does smoking pay for itself?
- Aaron Kian Wee Chai, Aaron Chai (6 January 2007)
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I personally refused....
- jasé taylor (7 January 2007)
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Quit smoking increase health care costs.
- Gianfranco Domenighetti, 6900 Lugano (CH ) (7 January 2007)
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life and morality
- Jan M Perkins (7 January 2007)
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Rights and responsibilites
- Amitava Banerjee (8 January 2007)
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The best time to die (to help fellow taxpayers)
- Robert A. Da Prato (8 January 2007)
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Visit fitness clubs...
- Andrew J Wilkinson (9 January 2007)
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Surgical Risks
- David W Starkie (9 January 2007)
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Rationing irrationally.
- L S Lewis (10 January 2007)
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Orthopaedic surgery can help smokers quit their habit
- Jaykar R. Panchmatia (11 January 2007)
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Smokers and NICE guidance
- Ruth McDonald (15 January 2007)
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Re: Smokers and NICE guidance
- L Sam Lewis (15 January 2007)
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Discrimination against smokers.
- Peter O'Loughlin, Beckenham BR3 3AT (23 January 2007)
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Address the mother of all problems - a case for comprehensive ban on tobacco.
- Pankaj Chaturvedi (2 February 2007)
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Taking responsibility or casting blame?
- Pamela J Schartau (12 April 2007)
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Robert Feal-Martinez, Motel Owner The Carpenters Arms SN3 4ST
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I am a life long never smoker but as leader of Freedom to Choose I have examined an abundance of science about smoking and passive smoking. The economic arguments frequently put forward do not stand up to even cursory examination. Smokers contribute £10billion a year to the exchequer, this means that based on the admitted £1.70billion on smoking related health care the smoker has more than paid their share, the same can be said of those who consume alcohol. Those who use the economic argument to support the health argument may well have point about the £5billion spent on treating the obese, as food is revenue neutral. However clinical judgements based on cost are not only unjustified they are immoral, and go completely against medical codes of ethics. Any doctor publically calling for this should be struck off. Competing interests: Leader of www.freedom2choose.co.uk a pro choice organisation. We do not support smoking just the right in a democracy to choose. |
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Arulkumaran Sellappah, MB BS, currently MSc student University of London
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The article "should smokers be refused surgery?" did not make any reference to fundamental ethical principles. According to basic medical ethics, principles of "non-maleficence", "beneficence", "autonomy" and "respect" for the patient could potentially be seriously violated by any kind of discriminatory approach to treatment. Smoking is a disease, and smokers- like all diseased persons- must be afforded the same rights as any patient; the treatment of the smoker as if universal and immutable ethical principles somehow applied differently to him creates the possibility of harm, contravening the basic Hippocratic Oath (primum non nocere). By regarding the argument from this fundamental ethical perspective, it becomes clear, that the debate is not simply a case of YES (smokers should be refused treatment) or NO (they shouldn't) as the article by Peters et al made out; rather, there is a middle ground solution, between the two extremes of yes and no, where neither side can be proven absolutely right or wrong (for such is the nature of ethics that it is "unprovable" as to who is right). It follows, that in the absence of certainty, one should proceed by the tried and tested ethics of the doctor: to help respect the patient's basic rights,which implies providing treatment. REFERENCE: PetersMJ, Glantz BMJ Jan 6 (2007). Competing interests: None declared |
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CL Andrews, RN QEH, SA 5022
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Those who advocate a refusal of surgery to smoker’s would do well to remember that at one time (quite recently actually) it was customary to 'pay' soldiers and other members of the armed forces in cigarettes. It could reasonably be argued that the government itself not only condoned but also promoted this addiction, and is therefore culpable. The choice presently faced is only an option because of the sacrifices of those before us, many of whom smoked. In addition, it is puzzling that legally refusal is an option, since smoking is not a criminal offence. Smokers tend to be of lower socio- economic class and a policy of refusal would disproportionately affect the poorest and most disadvantaged people in the country. It is disappointing that this policy is being made by some of the most advantaged, who have the wealth, education and social supports to facilitate their choice. A decision of refusal would be morally bankrupt. From a personal point of view, my father, who smoked heavily, arrested in 1993. He went on to make a good recovery, and has never smoked since, but I wonder, if those people who support this policy of refusal, have given any consideration to how that policy would affect their family? And what they would do if it was their elderly father being refused surgery? Or are they lucky enough to be able to pay? Competing interests: None declared |
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Aaron Kian Wee Chai, Dental Student CF24 4LJ, Aaron Chai
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A = Smokers’ contribution towards the NHS budget in terms of taxation from tobacco sales. B = the financial burden of smoking related diseases on the NHS. Conclusion: 1. If A > B smokers are paying for their own treatment and could be paying for medical treatment for other non smokers 2. If B >A smokers are a burden to the budget of the NHS N.B: This equation takes into consideration only smokers who consume more than one pack of cigarettes a week. Competing interests: None declared |
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jasé taylor, Orthopaedic Surgeon ..retired NA
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In the early 80s, thrust into the 'back business' in this area (no other orthopods were interested and I was breaking in, as it were; I was faced with the prospect of spinal fusions. It was early information then that smoking delayed all sorts of wound healing...but was notably a deterrent to healing in fusions. The result of fusions were (still are I guess) very dicey...it was a problematic procedure. I learned very quickly that these caveats actually did apply to my patients' outcomes. LOTs of complications in the smoking demographic. All smokers were encouraged to abstain - at least yearwise - and were given every help we could offer to quit. Some complied and I then put MY reputation and results on the line to do them. But, end of story...I was refusing smokers certain procedures in the 80s. And would quite comfortably do so today. Competing interests: None declared |
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Gianfranco Domenighetti, prof.health economics Universities of Lugano and Lausanne, 6900 Lugano (CH )
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Just remember to those who are used to look at the mankind only through economic glasses that,if all smokers quit, health care costs would be lower at first, but in the long run smoking cessation would increase health care costs due to the creation of new probabilities for (chronic) morbidity from other diseases in the years of life gained (1). The same is probably true also for obeses that have 10 to 15 years less life expectancy compared to people having an "ideal" weight. REFERENCE: Barendregt J, Bonneux L, Van der Maas P. The health care costs of smoking.New Engl.J.Med 1997;337:1052-7. Competing interests: I currently smoke three cigarillos a day. |
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Jan M Perkins, Assistant Professor CMU 49340
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As a person (temporarily) living in a society where access to care depends on financial worth, I watch with interest the various debates on depriving groups of health care for other reasons. It all bypasses a few critical points. The author of this piece was commendably careful in his wording. The assumption in popular discussion is that a longer life is "good." The assumption is also made that certain behaviours are "good" and should be rewarded, and that a longer life is a goal toward which we all should subscribe. The definition of which behaviours are good varies with each decade. Very often the argument is made that prevention will lower costs. How? I avert a particular cancer only to fracture a hip and then develop Alzheimer's 20 years down the line? This will be cheaper - or better? Should we not base our beliefs on care on something sounder - like the value of human life and related respect for it? The arguments are all unsupported by evidence, divorced from the messy day to day reality of care, and very often fly in the face of common sense. If people smoke multiple packs per day and die early as a result, does this cost money or save money in terms of later illnesses or support services? When did "being good" to live longer become a moral imperative? When did caring become dependent upon a narrow set of behaviours - leaving out 1660 and related events? I am a clinician who believes in caring for individuals - flawed or unflawed. Some will die early because of the way they lived, some will die early despite the way they lived. Some will die late despite the way they lived. I believe in care rather than judgement and evidence rather than Puritanical rhetoric. The argument would be better centered round what level of care is reasonable for society to provide rather than who "deserves" care. Having benefited from "good living" and "prevention practice," I am baffled as to why this should be perceived as being more worthy of reward than simply living. Competing interests: Recently had a surgery allowing me to live a longer life, not sure why everybody thought this such an event |
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Amitava Banerjee, SHO Medical Rotation Oxford OX3 9DY
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This debate involves three key issues:
Health has been recognised as crucial to development and to poverty alleviation in all countries (1). The right to health and therefore the right to healthcare are the inalienable entitlements of all citizens of countries that have signed up to the UN human rights treaties and conventions (2). However, in health systems with finite resources, these rights are weighed against other citizens exercising their rights to health, and so we require an ethical way to ration health care. In Rawls’ theory of "luck egalitarianism", individuals are not responsible for outcomes due to “brute luck”, but with “option luck”, there is control over risks, and so there is personal responsibility (3). Brute luck is the operation of factors over which there is no responsibility or choice (e.g. congenital disabilities). Option luck involves factors over which there is no responsibility, but there is choice (e.g. heart disease as a result of the active decision to smoke cigarettes). Advocates of personal responsibility might argue that if a person displayed risky behaviours, then they must take the blame for the outcome, possibly including drugs,medical and surgical treatment. If a person is conclusively responsible for their illness then perhaps they should be more accountable for its treatment than somebody who was just unlucky in becoming ill. This can be illustrated if we have two lung cancer patients- one who is continuing to smoke cigarettes and one who has never smoked. However, it is very difficult to apportion blame for an individual’s illness because a disease process occurs as a complex interaction of genetic and environmental factors. The environmental factors include parental input, education, information availability and socioeconomic status which may not be under an individual’s control, and may play a major role in causation of the disease process. In these cases, an individual cannot hold full responsibility (if any) for their disease and therefore for its treatment. The health of the public is a social good, valued as a worthy goal beyond our preference for it or the satisfaction we may get in achieving it, and improving access to healthcare is part of this social good. These goods imply a set of responsibilities and therefore duties, tasks, and actions. If we hold that health for communities and for society at large is a social good that has value beyond the fact of our desiring it, and if it is a value to which we have committed, then we assume a responsibility for it. We have, in other words, an obligation to take positive action for its actualization, whether at the level of government or as a broader social responsibility. Why should smokers be viewed differently to people who eat excessively (leading to obesity), those who use intravenous drugs or alcohol, or practise unsafe sex? As another respondent writes, the medical profession is governed by the principles of "beneficence, non-maleficence, autonomy and justice". If we withdraw treatment from smokers and not from obese patients (who put themselves at risk of diabetes, heart disease etc.) then our justice is inconsistent, which is unacceptable. My concern is that the driving force behind such ethical discussion is the need for politicians to shift blame away from governments and to remove their responsibility for health and health care. The driving force should be the welfare of our patients and the codes of practice required by all health practitioners. Use of isolated cost-effective analyses out of context should not endanger the existence and function of the NHS or any health system. There needs to be consistency in these cost- effectiveness analyses as well. For example, if we are going to look at the past, present and future expenditure as a result of smoking, then we should also look at the wasted expense of repeated NHS organisational changes by consecutive UK governments, or the cost-effectiveness of using external management consultancies to enact policy change. Sir Muir Gray called for evidence-based public health and evidence-based policymaking in this journal in 2004. The evidence presented is simply inadequate to stop operating on smokers. References 1. United Nations Millennium Development Goals. http://www.un.org/millenniumgoals/ 2. Making the Right to Health a Reality : Legal Strategies for Effective Implementation. Iain Byrne. Commonwealth Law Conference, London September 2005. www.interights.org/doc/health%20paper.doc 3. Daniels N. Just Health Care. Chapters 1-3 4. Muir Gray, J A. Editorial:Evidence based policy making. BMJ 2004;329:988-989 (30 October), Competing interests: None declared |
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Robert A. Da Prato, Physician Portland OR 97229
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Not too long ago an accountant told me that, from a financial perspective only, a patriotic citizen should die the moment he or she changes from a net taxpayer (a net tax asset of the state) to a net tax consumer (a net tax liability of the state). For many people this means one should drop dead on the way home from one's retirement party. A brother and sister acquaintance illustrate this quite well. The sister, a non-drinker, non-smoker, responsible eater lived to be 85. Since age 65 she received 20 years retirement as a government worker, 20 years social security payments, had Medicare paid pharmaceutical charges for almost two decades of diabetes, hypertension, and elevated cholesterol, outpatient office visits, and hospitalization costs for a pneumonia, fractured hip and sub endocardial infarction. Her brother, a heavy smoker and drinker, literally dropped dead at 60. Up to that point he paid for medical expenses out of his own pocket. One sibling cost the taxpayers probably close to a million dollars (far greater that she ever paid into the system), the other nothing (in fact it was a great financial gain since he had a high paying job and paid taxes for years.) When I am asked, the advice I give to smokers is this: "As a physician I can tell you that if you smoke you will probably die of heart disease or cancer. If you don't smoke you will probably die of heart disease or cancer, but usually some years later. During the extra time non-smoking gives you, you may develop the infirmities, disabilities, illnesses, and aches and pains which go along with old age, and then die. My overall recommendation is not to smoke, however, because it really does increase the risk of dying from emphysema which is a very unpleasant way to become deceased. As a taxpayer, however, I applaude your decision to smoke since you will probably be much less of a financial burden to taxpayers because you will die sooner. You might even be a financial asset to them if you time it right." Competing interests: None declared |
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Andrew J Wilkinson, LAT Orthopaedics and trauma Altnagelvin Hospital Northern Ireland BT47 6SB
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Currently patients do not feel a general obligation to "get healthy" as a condition of receiving treatment. Recommendations to patients with mild to moderate osteoarthritis of the knee are advice only, I am certain though that losing 25 pounds or attending a fitness club would help them a great deal. Following this advice may even save some of these people from ever requiring a total knee replacement. However, I am sure that many patients have been commenced on antihypertensive drugs with the precise intention of lowering their blood pressure prior to undergoing surgery! Competing interests: None declared |
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David W Starkie, General practitioner Kidderminster. UK
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Leonard Glantz tells us that we should not discriminate against smokers as we would not expect patients to lose weight or take medication for blood pressure prior to surgery. However, both of these appear to be common practice, the former particularly in orthopaedics. I would agree with him, that just because someone smokes should not be a bar to any treatment, indeed because smoking increases Cardiovascular risk smokers are more likely to receive statins etc. for prevention. The overall risks and the benefits of surgery may be shifted considerably by smoking and other risk factors, however, and I would suggest these must certainly be taken into account when any surgery is contemplated. Competing interests: None declared |
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L S Lewis, GP Surgery, Newport, Pembrokeshire SA42 0TJ
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Leonard Glantz asks - “Do patients have a general obligation to get healthy as a condition of receiving treatment? Patients are not required to visit fitness clubs for eight weeks, lose 25 pounds, or take drugs to lower blood pressure before surgery.” I’m afraid that in Pembrokeshire it has now become almost a necessity of anaesthetists’ ‘Pre-assessment Clinics’ to get onto hypotensives, lose 25 pounds, and go to fitness clubs, before one is allowed onto the operating table. The anaesthetist may argue his case with regard to risks to patient, and perhaps, risks of litigation to anaesthetist. But it functions admirably as a way of depleting waiting-lists and meeting targets. The patient is removed from the waiting-list, and only returned (to the back of the queue) after he loses weight, and gets his BP below target. Dr Sam Lewis Competing interests: My patients are still sick and tired of waiting |
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Jaykar R. Panchmatia, Specialist registrar in neurosurgery King's College Hospital, Denmark Hill, London, SE5 9RS.
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Editor- Both Peters and Glantz articulate their opposing views with great clarity. I think that it is important to realise that patients smoking is often a consequence of their underlying condition. Many patients that I have cared for with debilitating orthopaedic conditions such as osteoarthritis of the hip, rheumatoid arthritis, lower limb spasticity caused by multiple sclerosis and, back pain and sciatica smoke because of their unbearable symptoms. Clearly to withhold surgery from these patients would neither alleviate their symptoms nor help them cease smoking. As physicians it is our duty to ensure that we discuss the full range of treatment options with our patients and give our opinion if requested. It is also clear that we should inform patients if their lifestyle choices are placing them at an increased risk of complications such as wound infections. These actions are all fundamental to obtaining informed consent. However, we should not discriminate or judge individuals for the lifestyle choices that they have made. Competing interests: None declared |
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Ruth McDonald, Researcher University of Manchester
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It's not just maverick PCTs that are discriminating against smokers to save money. The Report 'Social Value Judgements' Principles for the Development of NICE guidance suggests (principle 10) that 'if self- inflicted causes....influence the clinical or cost effectiveness of an intervention it may be appropriate to take this into account'. Which sounds a lot like saying it's OK to deny treatment to smokers since the benefits of treatment may be lower and/or costs higher. This report is based on deliberations of the NICE Citizens Council, so nationally PCTs wanting to discriminate against smokers can claim public support for their view. However, the report is a 'living document' and 'the guidelines will be formally reviewed in 2007'(Where next for cost containment? Future topics include the 'rule-of-rescue' and the 'problem of comborbidity'), so perhaps opponents of the policy should start contacting NICE now to provide input to the review process. Competing interests: None declared |
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L Sam Lewis, GP Surgery, Newport, Pembrokeshire SA42 0TJ
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'if self- inflicted causes....influence the clinical or cost effectiveness of an intervention it may be appropriate to take this into account' can cut both ways ! NICE recommends Statin be offered to everyone with a 20% calculated CVD risk .. which means that SMOKERS are getting PREFERENTIALLY treated over Non-Smokers, all other risks being equal !! Competing interests: None declared |
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Peter O'Loughlin, Alcohol and drug addiction recovery The Eden Lodge Practice, Beckenham BR3 3AT
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Would those who wish to decline treament for smokers take the same stance about those who have alcohol or drug addiction,hepatitis HIV or aids associated with the latter, or pathological gambling? Is there any evidence that smokers who have an otherwise healthy life style including exercise and a well balanced diet, suffer any more diseases than non smokers who do not? of for that matter die earlier? Competing interests: None declared |
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Pankaj Chaturvedi, Associate Professor, Head and Neck Surgery Tata Memorial Hospital, Mumbai 400012
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How does one become a smoker? No body is a born smoker, circumstances initiate and promote this habit. Who makes the cigarettes and sells them ? Some of our people earn their livelihood by making and selling these downbeat products. Who supports cigarette companies (apart from buyers)? Some of our people, many insurance companies and several governments openly invest in tobacco companies because it is considered safe and profitable. Who allows the ciagarette companies to continue their business? Most of us do not object to their existence and all governments continue to recognize it as a legal industry. Who grows tobacco? Tobacco is considered as a “cash crop” and it is a source of revenue for several countries. Who is gaining by continuing tobacco addiction? Hospitals, doctors, counsellors, nicotine manufacturers, media, investors in tobacco companies ( including governments and insuarance companies), tobacco growers, tobacco companies and sellers. Is tobacco adiction a habit discorder or a disease? WHO classifies it as a disease. The medical science always believes in looking for a cause and prevention of exposure to that cause. For example, if there is an obvious source of infection – it mandates removal of the infection. It is considered illogical to offer antibiotics in presence of an obvious source of infection. What is the cause of tobacco addiction? Exposure to tobacco and free availabilty. How difficult is quitting ? Dismal rates of successful quitting makes the addicts slaves of the industry. What is the remedy ? A total ban on tobacco. How difficult it is to ban the tobacco? Some powerful nations have shown the ability to oust a powerful Iraqi dictator, defeat dreaded Talibanis and other militant outfits by forming cross border coalitions. A total ban on tobacco that kills many more people than war and act of terrorism, appears achievable. How many more debates ? How many more deaths? How many more disabilities? How long will we talk about tobacco control, harm reduction, cessation and health education? With decades of experience we know that it hasn’t delivered desired results. Why don’t we just ban the tobacco? If we had started a phased tobacco ban 10 years back, we would have created a safer world for our children? There is no economic, political or social argument that can justify it’s availablity in our society. For some strange reasons, there is no public outrage or a cross-border powerful demand for a ban on tobaco. What do we do when a serial killer is stalking the citizens? Is it logical to continue investing in public protection while the culprit is let loose? Tobacco companies continue to make more profits, people continue to die and we continue to have such debates – to treat or not to treat. Competing interests: I am a member of Action Council Against Tobacco-India.An NGO engaged in tobacco control in India. |
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Pamela J Schartau, project officer Macfarlane Burnet Institute for Public Health and Medical Research, Melbourne, VIC 3004, Australia
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The problem with refusing smokers surgery is that the individual is being blamed for what is really a public health problem. Why do people smoke? Why do people engage in unhealthy lifestyles" altogether? I do not believe that such choices are always rational. Rather, there are a number of risk factors that lead people to engage in activities harmful to their health in the first place. This is corroborated by simple demographics - unhealthy lifestyles are found predominantly in more disadvantaged groups of society. Factors which contribute to the uptake of smoking are, for example: poverty, emotional problems, abusive relationships, stress, peer pressure. If the ultimate aim is to have less people smoke (which I presume it is!), then government should take responsibility and give everybody equal chances to not take up or continue smoking, and to engage in healthy lifestyles in general. For example, it should ensure that: (1) all children have access to good schools, offering plentiful after-school activities so that the temptation to take up smoking is less; (2) all areas have the same number of recreational facilities, so that smoking out of boredom or in pubs (because pubs are the only "recreational" space on offer!) is reduced; (3) everybody has equal chances in education, training, and finding jobs. Finally, it is well known that punitive measures don’t usually work as a response to public health problems. E.g. countries with very harsh penalties for drug abuse do not have fewer drug users than other countries. In addition, their drug users suffer from much higher prevalence of HIV and other diseases. What is required is a harm reduction philosophy – recognising that harmful behaviours (such as smoking) do presently occur, and minimising the damage resulting, to individuals and community as a whole. This will require complex responses, which will take a lot of effort - but will ultimately yield much better results than the attempt of a quick fix by blaming individuals. Competing interests: None declared |
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