What ever happened to humane medicine?

Doctors in the UK, prompted by policy changes by government, are increasingly refusing to treat patients because they smoke, drink or weigh too much. Who the hell do they think they are?

In the latest example of this trend, health chiefs in Norfolk and Newcastle-under-Lyme have decided to refuse certain kinds of non-urgent surgery to smokers – including hip and knee replacements. Both NHS areas are in financial crisis and are looking for ways to save money – and the government’s relentless campaigning against our bad habits have made smokers, drinkers and the overweight an easy target for these bean-counters.

The head of the Norfolk primary care trust (PCT), Dr John Battersby, defended the decision: ‘There is increasing evidence that smokers have three times the number of complications as non-smokers. What we are proposing is that if someone who smokes is being referred for surgery, we would instead want them to be referred to a smoking cessation clinic and give them three months to stop smoking.’ (1) After the three months are up, those who have stopped will proceed to surgery, while those who still smoke will be considered on the basis of ‘clinical need’.

In November last year, East Suffolk PCT barred obese patients from having similar surgery until they tried to lose weight. The argument was that replacement joints are more likely to fail if the patient is heavier; although as Brian Keeble, the trust’s director of public health, admitted: ‘We cannot pretend that this [decision] wasn’t stimulated by the pressing financial problems of the NHS in East Suffolk.’ (2) In December 2005, a patient at Lincoln County hospital was refused treatment on the arteries in his leg until he gave up smoking. A spokesman for the hospital said: ‘To proceed with treatment while patients smoke gives the wrong message, as it condones the habit.’ (3)

All these decisions in turn rely on a change of policy by the government’s National Institute for Clinical Excellence (or, ironically, NICE for short) that allowed health authorities to take patient lifestyles into account when deciding whether a particular treatment would be effective. While there may be medical logic in not going ahead with a procedure if it would be doomed to failure (it is wrong to put a patient through unnecessary pain if such treatment would not ultimately help them) it is quite another to refuse it on the grounds that it would cost more. From this perspective, we could see a complete recalculation of waiting lists along strictly utilitarian lines, with younger, fitter patients, who lead the ‘right’ kind of lifestyle, prioritised over those who might be more expensive to treat.

Frankly, the doctors behind these various decisions should be struck off. Their thinking is in direct contradiction to the spirit of medicine going right back to Hippocrates. When the Greek physician swore to ‘prescribe regimens for the good of my patients according to my ability’ there was no rider along the lines of ‘unless I don’t approve of the way they live’.

It is not for doctors to judge their patients’ foibles but to give them the best treatment in the circumstances. As the microbiologist Rene Dubos noted in the 1960s: ‘In the words of a wise physician, it is part of the doctor’s function to make it possible for his patients to go on doing the pleasant things that are bad for them – smoking too much, eating and drinking too much – without killing themselves any sooner than is necessary.’ (4)

Whatever happened to humane medicine? It is one thing to advise a patient that giving up smoking or losing a few pounds will aid their recovery or increase the chances of success. It is quite another to refuse treatment altogether.

There is also the small matter of patient autonomy. While rationing of one form or another has been ever-present in the NHS, there has been the general principle that patients will be treated on a first come, first served basis, regardless of their income or lifestyle. Using access to public services to modify behaviour is something more closely associated with dictatorial regimes. The result is a peculiar form of torture. Those who require hip or knee replacement operations are clearly in pain, and usually severely hampered by their condition. This is coercion through healthcare, as surely as twisting someone’s arm. The defence of autonomy, our freedom to live as we choose rather than as our government or our doctors see fit, is far more important than balancing the books of a cash-strapped NHS.

It is bad enough that we should be harangued at every turn about the way we live to the point where our pleasures are ruined by guilt at every puff, sip and mouthful. To force people to live in pain till they fall into line should be a cause for national scandal. It is a measure of how browbeaten we have become in matters of health that it is not.

(1) Give up or we won’t operate, smokers told, Daily Mail, 23 October 2006

(2) NHS cash crisis bars knee and hip replacements for obese, Guardian, 23 November 2005

(3) Hospital refuses to treat smoker, BBC News, 19 December 2005

(4) The Mirage of Health, by Rene Dubos, quoted in The Tyranny of Health by Dr Michael Fitzpatrick