Punishing the smoking patient

Following recent events I have been having a quick look at some of the literature on withdrawing treatment – part of the package of measures that is proposed by NHS Grampian.

I have discovered that I don't read very fast. There are abundant stories of people being refused treatment. Two pieces stand out. One, a principled piece by Canadian medical writer Douglas Waugh dating from 1988, states clearly that punishment is not the role of the medical practitioner, chiefly on the grounds of medical effectiveness, as a punitive approach is unlikely to have a positive effect on the patient's health.(That's what it's all about, isn't it?)

The other is more recent (2006). Dominic Lawson describes the death of an acquaintance hospitalised for a minor operation who was forced on admission to relinquish his tobacco and later suffered a fatal stroke. In medical terms he was a textbook case, aged just 68 and a heavy smoker, but it is a moot point whether sudden unwanted deprivation of tobacco at a critical time added to his mental and physical agitation. Lawson acknowledges there is no proof that removing this man's tobacco led to his death but regrets the cruelty involved in depriving him of tobacco without even the offer of a substitute.

He also describes a Radio Four debate in which a Dr Colebrook claimed that 'smokers take longer to recover from operations' ...and continues:

Well, it's obvious that NHS treatment is subject to rationing - that is inevitable with any good for which consumers are not individually charged; but given that we have such a system, it would seem more humane and also more in accordance with the Hippocratic Oath to treat people according to their clinical needs. Dr Colebrook, however, had come armed to the studio with what might without hyperbole be described as a "killer fact". Smokers, he declared, were six times more likely to suffer from "hospital-acquired infections" than non-smokers.

This is an observation to be savoured; it should be rolled around in the mouth like the bouquet from a fine cigar. What Norfolk PCT's Director of Clinical Services was saying is that he would rather not perform routine life-enhancing operations on smokers, because they are too liable to fall victim to the consequences of his staff's inability to maintain proper standards of hygiene. Or, put more bluntly: stop smoking, and we are less likely to kill you.

I agree that treatment should be on the basis of need: in general this should be the absolute priority, rather than the likelihood of a good outcome. The use of any form of triage should not be encouraged outside of emergency situations: the principle of not allowing patients who are too far gone to be treated in favour of those that have a better chance of survival is a difficult and senstive issue which should not be extended beyond emergency care.

Much of this is irrelevant to the situation proposed for NHS Grampian, which proposes (according to the Press and Journal) withholding care from people if they breach the rules. Even if the ban were legally enforceable outdoors, simply lighting up and refusing to stub out when requested has nothing to do with breaking doctor's orders. A patient who loses his or her right to treatment for breaching such a policy is not the subject of a clinical decision. It has nothing to do with doctors at all in fact as the order has come from the NHS trust. Many doctors will agree with this kind of totalitarian nonsense of course but clinical judgement has less relevance in this doctrinaire atmosphere.

I asked the Scotland Patients' Association for a comment tonight, pointing out the reversal of smoking policy in Derby described here. The reply came from Margaret Watt, the Chairperson: 'on this occasion we have to agree to disagree'. I don't think it's quite that easily resolved.