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Views And Reviews

Delaying surgery for obese patients or smokers is a bad idea

BMJ 2016; 355 doi: (Published 19 October 2016) Cite this as: BMJ 2016;355:i5594
  1. David Shaw, senior research fellow
  1. Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
  1. davidmartinshaw{at}

Targeting specific groups of patients is illogical and unethical, says David Shaw

It was recently reported that Vale of York Clinical Commissioning Group planned to delay all elective surgery for obese patients for a year until they lost 10% of their weight and to smokers for six months unless they stopped smoking for eight weeks.1 The overall rationale for this policy and the clinical rationale for targeting these particular groups are unclear.

The most obvious objection to the policy is that it is unfair to target specific groups of patients in this way. Why should obese people and smokers be singled out? The rationale cannot be clinical risk: though surgery is riskier for morbidly obese patients, and smoking is bad for your health in the long term, mildly obese patients and smokers are just as likely to recover well from surgery as slim non-smokers. The CCG seems to think that it is logical to target smokers and obese patients simply because patients who are very obese smokers are at greater clinical risk.

The effective ban on hip and knee replacements (for example) means that patients most in need will go without while patients who are healthier get priority. Fatter patients might not only be in more need of a new hip: obesity increases the risk of other health problems, and denying them the care they need just adds to this burden. Furthermore, many obese people have been trying to lose weight for years, and many smokers remain addicted to nicotine despite trying to quit; the CCG assumes that all patients in both groups have simply not tried to get healthier.

Policy would worsen health

The policy also treats patients within each group unjustly. BMI is notoriously unreliable for assessing individuals rather than populations; a heavily muscular person can be classed as obese despite being perfectly healthy. There is even less rationale for denying these healthy “obese” people surgery. And even if it were fair to single out these patient groups, the criteria by which they will later be deemed suitable for treatment are illogical. Why make obese patients wait a year? During that time the symptom that needs surgery will become worse and the patient will suffer as a result. Also, patients might become more obese because they are denied access to the surgery they need to become mobile again (such as a hip replacement). Smokers who fail to quit will also be less healthy when receiving the surgery, because they will have smoked more. The alternative to waiting is for a patient to try to quit smoking or to lose 10% of weight. This is also unfair, as it means that someone with a BMI of 31 would have to achieve a BMI well below the cut-off of 30. It also unfairly penalises very obese patients, who will have to lose several kilograms more than less obese patients.

The motivation seems to be neither public health nor clinical need but financial pressure

It is true that denying surgery may encourage behaviour change and benefit public health, but that cannot be used to justify denying surgery to patients in clinical need. In this case the motivation seems to be neither public health nor clinical need but financial pressure. It has correctly been pointed out that a blanket ban on surgery like the one proposed would be contrary to the NHS constitution, principle 2 of which states, “Access to NHS services is based on clinical need, not an individual’s ability to pay.” It should also not be based on a CCG’s ability to pay. After payment of incentives to CCGs for non-referral,2 this extreme attempt at rationing is another attempt to deny patients the services they need. Indeed, this policy will conveniently allow doctors to receive incentives for no referral for surgery.

NHS bosses moved swiftly to prevent this rationing policy being put into place,3 but it is a sign of what the NHS could become in the future: a health service where only the “deserving” receive treatment.


  • Competing interests: None declared.

  • A version of this article originally appeared as a BMJ blog (


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