In last week’s issue of the British Medical Journal, two physicians argue about the merits of refusing to perform elective surgeries on smokers. The debate has been spurred by a primary care group in the UK who announced last year that it would take smokers off waiting lists for surgery in an attempt to contain costs. The proponent, Matthew Peters, argues that, for elective procedures such as plastic, reconstructive, and orthopedic surgeries, the rates of complications in smokers are so high that the increased costs and poor outcomes should make smokers ineligible for these surgeries. For example, the author cites a study of complications after hip or knee arthroplasty in which 26% of smokers developed wound infections, compared to no wound infections in smokers who quit. The author argues that the decreased costs and resources saved by excluding smokers will give physicians more opportunities to treat non-smokers, whose outcomes will be better. He does acknowledge that any decision to withhold surgery should be based on a consideration of risks and benefits and concedes that in some cases, performing surgery on a smoker may be an acceptable decision.
The opponent, Leonard Glantz, argues that denying surgery for smokers undermines the doctor-patient relationship, and that although smoking does increase surgical risks, the patient should be informed of these risks and, with the help of a physician, decide whether surgery is an appropriate choice. Using the example of sports-related injuries, he makes the argument that society routinely incurs large health care costs because of the activities people choose to do. Refusing surgery for smokers, he states, is discriminatory, and it would be “shameful” and “mean” to deprive smokers of surgeries that may be very beneficial.
What do you think? Should smokers be refused elective surgeries?
The essence of this argument comes down to the question of whether people who are knowingly doing things that may be harmful to their health are entitled to health care. Surgery is routinely performed on diabetics, who also are at risk of increased postoperative complications. If surgery can be denied to smokers, should we also refuse to operate on diabetics with poor glycemic control because they don’t comply with diet or medications? Refusing to operate on smokers would begin a fall down on a very slippery slope, eventually allowing surgeons to choose to operate only on low risk patients. Rather than to simply refuse to operate, it would be much more prudent for physicians to educate their patients about the risks of smoking (and other risk factors) prior to surgery and entitle patients to make an informed decision about their healthcare.