No More Surgery For Patients with Unhealthy Behavior

I always look to the United Kingdom’s National Health Service (NHS) for our possible futures, at least concerning healthcare. CNN highlights an interesting development on the other side of the pond; elective surgery will be withheld from current smokers (no surprise there) and the obese as measured by a BMI of 30 or more (for a 5’10” male 210 pounds). And this ban is permanent. But before we go on, these decisions made by “general practitioners and public health doctors, with the best interests of the whole patient population of our area in mind,” have a means of absolution. Smokers who can stop smoking for eight weeks, proven by a breath taste can then have their surgery. And for those obese patients, you need only reduce your weight by 10 to 15% in 9 months (for our typical male that is 21 pounds). Now Jillian Michaels, one of America’s “experts” says that with diet and exercise you can lose a pound and a half per week, and so does Dr. Oz, so that nine-month timeframe is at least possible. And it is not that the NHS leaves these patients without help, “they will be supported … with the free weight-loss and stop-smoking advice sessions already on offer.”

It should come as no surprise that the surgeons thought this was a bad idea, after all, they have a conflict of interest on this issue. So we might as well ignore their feelings. Then, of course, there are those pesky ethicists, is it right to withhold care because of a patient’s unhealthy behavior? The new rule meets the ethical pillar of justice, as we are not “wasting resources” on these unhealthy people at the expense of others. But it does seem to violate another ethical pillar, to Do No Harm – at least for those patients that may benefit from surgery despite the fact of their weight or smoking behaviors. And this rule also brings concerns to economists. Withholding care, rationing by another name, does reduce short-term costs; as one physician warned  patients were “soft targets for NHS savings.” But in the long-term, will there not be other costs that exceed those savings? Who really knows?

There are so many interesting issues that this, by a local unit of the NHS, brings to mind. Consider the following:

• There is good evidence that stopping smoking before surgery reduces the peri-operative complications, I am all for it, but as a vascular surgeon who cared primarily for smokers, that was more of an aspirational guideline than a rule. But should we use surgery as a reward? And if we do, will the patients return to smoking at their earliest convenience?  Again, no one knows.
• How about that weight issue? It most frequently comes up concerning knee replacements because these prosthetic knee joints have a harder time lasting when their owners weight hundreds of pounds. Fair enough, but again what is to guarantee that the weight remains off? Many numbers are bandied about, at least one article says 20%. So still, we don’t know.
• These new rules were a decision by the local health administration. It affected about 1 million people, but similar decisions have been made by about 33% of the local health authorities. Talk about disparities in care. By what measure is a medical procedure denied based on where you live within the country? It is useful to keep your answer in mind when you discuss turning over defining essential health benefits to the states as the President has done with the changes to “Obamacare.”
• Smokers already pay a “sin tax.” The tax on a pack of cigarettes is nearly $6 in New York City. And the tax on sugary beverages, a charge meant to reduce obesity although there is no evidence of that effect, is gathering increasing interest from cash-poor states and municipalities. So how much punishment should be meted out to these healthcare sinners?

Enough ranting. Let me end with these thoughts. First, in the words of Robert West, a professor of health psychology at the University College of London, “Rationing treatment on the basis of unhealthy behaviors betrays an extraordinary naivety about what drives these behaviors.” Amen to that. Second, there is entirely no reason this type of thinking will not find a home here.