The rationing of medical treatment is really sick

According to the Observer, more than half of Britain’s doctors ‘support measures to deny treatment to smokers and the obese, according to a survey that has sparked a row over the NHS’s growing use of “lifestyle rationing”‘. That summary is actually a bit misleading, but it is certainly true that health bureaucrats and many doctors are now determined to tell us how to live, and to blackmail us by threatening to withdraw medical treatment if we don’t submit.

The Observer story comes from a survey on Doctors.net.uk, to which just over 1,000 of the website’s members responded, of whom 54 per cent agreed that doctors ‘should have the right to refuse non-emergency treatment to patients unless they lose weight or stop smoking’. The question asked did not, however, specify the basis on which doctors might refuse treatment. Since it isn’t hard to imagine a situation in which a doctor might refuse treatment on strictly clinical grounds – for example, if a patient were massively overweight, a hip replacement might not make much sense – the results don’t necessarily tell us that most doctors have become little lifestyle Hitlers. Yet.

The accompanying press release makes clear that this is a live debate among doctors. So one doctor, commenting on the Doctors.co.uk website, said he had ‘no grouse’ with the NHS refusing treatment under certain circumstances and ‘would expect an alcoholic or very obese person, who was having an elective liver transplant, to show some signs of modifying their behaviour before going ahead with the operation’.

Other doctors, however, can thankfully see the logical outcome of such an outlook. One said: ‘By extension, should we refuse treatment to those who do not exercise enough, do not eat their five a day, or drink alcohol? If a rugby player breaks their finger, should we refuse to treat them because they should not have taken the risk to play? People make lifestyle choices and who are we to withhold care as a result?’

While the debate continues amongst medics, the reality in primary-care trusts (PCTs) is that many patients are already refused treatment on the grounds that they smoke or are too fat. In March, another medical magazine, Pulse, published the results of 91 freedom-of-information (FOI) requests to primary-care trusts. Twenty-five of the trusts had some kind of lifestyle or bodyweight restrictions in place. Some of these were about eligibility guidelines, not lifestyle change. For example, Bury PCT in north-west England rations bariatric surgery (to reduce weight) to those who are very overweight. Such surgery will only be performed on patients with a body-mass index (BMI) of at least 45 – equivalent to being 10 stone overweight for a man of average height.

Other PCT measures are about strongly proposing lifestyle changes to patients in order to aid the efficacy of treatment. Smoking, for example, does seem to impact on the already-low success rate of IVF fertility treatment. Helping wannabe mums to stop smoking would seem sensible in such circumstances and, unsurprisingly, women in this position show real determination to quit. But quite why Nottinghamshire PCT insists that both partners should be non-smokers is hard to fathom on purely clinical grounds.

Other PCT measures sound like clinical guidelines but are no doubt motivated by a desire to find some excuse to ration treatment. Hampshire PCT will not perform hip and knee replacements on patients with a BMI over 35. That’s well into the ‘obese’ category, but it really isn’t that heavy at all. Such surgery would undoubtedly succeed in many such patients and substantially improve their quality of life, even if the success rate is lower than for lighter patients.

In other instances, however, it really does look like some health authorities in Britain are practising medical blackmail. In Hertfordshire, no elective surgery may take place if the patient has a BMI over 30 – that is, technically ‘obese’ but in reality just a bit chubby – or if the patient smokes. (The Pulse evidence says obese people in Hertfordshire are referred to a weight-management clinic, but it doesn’t say what happens to smokers.) In North Essex, all smokers must be referred to a smoking-cessation clinic on their first appointment for a range of treatments, including scar revision and breast surgery. What on earth has smoking got to do with clearing up scars?

The NHS was created with great fanfare in 1948 to ensure that healthcare would be ‘free at the point of use’ to everyone. This is clearly not true anymore. It is free to slim, non-smoking, moderate-drinking, junk-food-dodging people. But if you see fit to indulge in a habit that is not approved of by certain members of the medical elite, then you risk being refused care.

Some will argue that this is only right and proper. With NHS budgets apparently already stretched, indulging in habits that increase your risk of ill health, leading you to make a greater demand on NHS resources, is seen as immoral. But this argument doesn’t stack up. There is plenty of research to suggest that if obesity, smoking and the rest really do shorten your life, then you will end up costing the rest of society less than if you selfishly live to a ripe old age with all the demands that will place on the Treasury in terms of pensions, social care and healthcare.

Moreover, it is one thing to demand that people take responsibility for their health. It is another to deny them healthcare while taking their money regardless. When it comes to life insurance, for example, I can still get cover if I admit to smoking and drinking, but I will need to pay a bit extra. I would rather not pay more, but at least there is the choice.

But when it comes to the NHS, there isn’t a box I can tick to say: ‘I like to drink and smoke and eat the wrong foods, so I will withdraw from the NHS and pay for my own healthcare. Please send my refund by cheque to my home address. (Oh, and please include all that excise duty I paid, too. Thanks.)’ To charge someone for something, and then years later deny them the service in question because you have decided to change the rules arbitrarily, would provoke uproar in most areas of life. The BBC TV show Watchdog would be on the case in a jiffy, exposing the men responsible for this blatant fraud. But when it comes to ‘Our NHS’, as its supporters love to describe it, we are expected to kowtow.

This daylight robbery is justified by the health-policy wonks and campaigners who love to berate us for our bad habits, the kind of people who are already demanding that Something Must Be Done about smoking (bans, heavy taxation, plain packaging), drinking (more taxation, health warnings, minimum prices, ID checks), and obesity (fat taxes, endless lectures, school lunchbox inspections). It is hardly a huge leap from this endless busybodying to refusing healthcare to those who refuse to fall into line with the health mafia’s rules and regulations.

The proper role of the NHS is to allow us to live our lives as we choose and to treat us when we become sick or are injured. It is entirely reasonable for a doctor to advise a patient that smoking will make his or her bronchitis worse, or that they might want to cut back on the booze if they have liver problems. It is another thing entirely to insist on such things. The state has no business interfering in our lives in this manner. Effectively blackmailing sick people is repulsive.

Those members of the medical profession who feel the need to hold a metaphorical scalpel to our throats and impose their vision of the Good Life upon us need to be put in their place. And those members of the medical profession who still have some professional pride and sense of vocation could do worse than stand up and be counted, rather than allow the lie to continue that doctors are ‘united’ on the need to micromanage our lives.

Rob Lyons is deputy editor of spiked. His book, Panic on a Plate: How Society Developed an Eating Disorder, is published by Societas. (Buy this book from Amazon (UK).) Read his blog here.