Should Smokers and the Obese be Denied Coronary Artery Bypass Surgery – No

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There are four fundamental reasons why smokers and the obese should not – and must not - be denied coronary artery bypass surgery, or for that matter any other medical procedure assuming the same procedure is available to non-smokers and non-obese.

The first one is to to with scientific facts and can be called a non-sequitur. Smoking and obesity are epidemiological risk factors, are correlated with heart disease, not causes of it. This is statistically speaking. Overall, people who smoke and people who are obese are more likely to develop heart disease, but this is by no means a 100% correlation: not all people with heart disease are obese or smoke(d), and not all smokers or obese have (or will end up having) heart disease. If we cannot prove causality on a mass scale, we cannot prove causality in any individual. We have no idea whether a certain smoker or an obese person who develops heart disease would have not developed it had he or she not smoked and stayed healthy weight, and thus we cannot assume that his conditions was self inflicted.

Frankly, this one reason is enough. Unless we accept that it's morally permissible to sentence people to punishment on the basis of probability of guilt rather than require the guilt proven beyond reasonable doubt, no other reason is needed.

The second reason can be called slippery slope. If we deny treatment to people whose conditions are (or may be, or are likely to be) self-inflicted, then when this will end? Presumably anybody suffering an accident while engaged in sport should be denied treatment too? And so should all those that suffer from skin cancer, if there is any indication that they exposed themselves to the sun at any time after they turned eighteen? What about anybody that is infected with sexually transmitted disease? Should we send away those who suffer from a heroine overdose or a delirium tremens? What about a woman beaten up by her husband who had done it before, but now she has broken arm, should she be sent away without help as she had not left him in time? Should we refuse treatment to those who visited malaria destinations but didn't take the anti-malarial drugs and caught the disease? The list is endless. In fact, in most cases of medical problems, and especially in degenerative conditions of the old age, but by no means only those, there are some correlates with the lifestyle, behaviour or actions of the individual. Some of these are much stronger connections than connections between obesity and smoking and heart disease: we can be 100% sure that, had the person that broke their leg skiing not engaged in the sport, they almost certainly wouldn't have broken anything. And yet it would be unreasonable to deny treatment to the broken-legged skier.

Life is a risky activity, and at the end we all, sooner or later, die. We could spend all our waking hours trying to delay that final moment, or we could get out of our own backsides, take the eyes off the navels and go out there and do some living – which includes taking some risks. Some of the risks we are exposed to are totally or almost totally out of our control, but most we can, at least in theory, influence, either by taking some actions (leaving a stressful job, losing weight) or refraining from others (not skiing, not smoking)... One of the reasons we actually have such a thing as a health care system, and in most civilised countries in the world, a publicly funded health care system, is to insure us – in a manner of speaking – against such risks as we might reasonably take, while living. Denying treatment to people with self-inflicted conditions would be the first step on a road, which taken not-even-to-extreme would end denying treatment for most conditions to most people and contravene the whole idea of universal health care system in the first place.

The third reason has to do with fairness and equality. It assumes a certain value system in which notions of fundamental equality of all human beings and their equal right to life figure prominently.

Medical help cannot be – in principle, I know doctors make such judgements in practice - based on the judgements on who deserves to die and who deserves to live. Otherwise we could easily imagine extending the rule from denying treatment to those who supposedly brought heir illness on themselves (or anyway were likely to) to only providing life-saving treatment to those who are worthy of living. And then, we have to establish the criteria for being worthy of life. Are you sure that you yourself would be deserving enough? Fit enough? Pretty enough? Rich enough? White, black, Asian or Jewish enough? Male or female? Tall, intelligent, blond, slim and blue eyed enough? Bubbly and happy enough? Straight enough? Christian enough? Communist enough? This is indeed getting on the very dangerous territory here, and one that, after the experiences of eugenics and industrial genocide that the 20th century was so full of, we should be over-cautious about. If a procedure is available, it should be available to all, otherwise the doctors (or administrators) are starting to play gods.

And the final reason, and ultimately possibly as compelling as the first one, is to do with compassion. Medicine developed as a way of what was on some basic level, helping people who suffered, regardless of how “deserving” they were of help, or rather based on the idea that everybody deserves help, as much as on a moral plane, everybody deserves forgiveness and a second chance. The best doctors, nurses and healers helped all. The story of a Good Samaritan and the Hippocratic oath are time-honoured reminders of what helping – and medicine – should be about.


Incidentally, if you think it's all about money allocation, then I have another argument, which can be called no-double-taxation. Using the UK and smoking as an example, the tax revenue from tobacco is around three times as much as the cost of treating all smoking related illnesses - and we must remember not all cases of smoking-RELATED illnesses are CAUSED by smoking - on the British National Health Service (this doesn't take into account additional savings gained by the fact that smokers die earlier and thus generate less costs to the public purse in the extreme old age, from state pensions to nursing care and treatment of other geriatric conditions).

More about this author: Magda DH

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