There are others that agree that smokers should have the same rights as non- smokers to treatment. Shiu (1993) claims that from an economic point of view it is cheaper and thus a better allocation of resources to give patients CABG as the cost of multiple medications is expensive, this together with the fact that patients who do not receive the operation are unemployable due to a decreased exercise tolerance and debilitating symptoms and thus the state pays for them to receive sickness benefits6.
It has been claimed that no one with certainty can attribute smoking to coronary heart disease7 and in some cases it may not be the primary cause of lung cancer. There is evidence that suggests that some people have a genetic predisposition to coronary heart disease and this can be observed in families where the disease is prevalent. Therefore, refusing to treat patients’ as a priority on these grounds would not be fair if the aetiology of the disease is incorrect. This is also true for ex- smokers, whilst their coronary heart disease may be due to their years of smoking, it is probably not justified to delay treating them as they no longer smoke and have proved that they can abstain from smoking, thus making the procedure a valid use of resources as it is unlikely that the patient will smoke again.
Whilst this is acceptable, there are cases of patients who have no genetic risk factors and the only independent risk factor they have in the presence of coronary heart disease is smoking, thus leaving health professionals with little doubt about its cause5. Therefore, it would be feasible to hold these patients responsible for their disease. This is also true for patients who have a family history of CHD but choose to smoke as they are aware of the risks of smoking in relation to their family history yet they continue to smoke.
It has also been proved that non- smokers can develop lung cancer from years of passive smoking. Many of these patients could not avoid the smoke from others perhaps due to the environment in which they work or because their partners smoke and so their resulting lung cancer is through no fault of their own. So it would be fair to say that they should have a priority over a lung cancer patient who has smoked all of life. Yet this is not a factor that is taken into consideration when assessing how resources will be allocated.
Whilst all of the arguments that have been mentioned are valid, Higgs (1993) points out that regardless of the pros and cons for treating smokers, medical ethics predicts that justice is an essential aspect of resource allocation and a distinction between distributive and retributive justice must be made8. Health care professionals have the responsibility of ensuring that health care resources are distributed fairly. It is not their task to ‘prescribe punishment 8.’ By denying treatment on the basis of responsibility is exactly this, but doctors often have the same moral values as the rest of society and whilst it is not their job to judge people, they do not give up their beliefs when they go to work. This is illustrated in the case of liver transplantation in alcoholics.
Liver transplantation in alcoholic liver cirrhosis is considered in a different way to cigarette smoking related diseases. In this case the disease can be directly related to the patients’ alcoholism. Therefore, there can be no mistake about the cause of the disease, so it must established if patients are responsible for their illness. Alcoholism is considered to be a disease and therefore it can be argued that alcoholics have the right to receive treatment for it just like anybody who has a genetic disease for example. There are treatment services available, which the NHS provides. However, it is the responsibility of the alcoholic to seek treatment. Uble (1997) claims that ‘…alcoholics are responsible for their own illness’ but ‘factors beyond peoples’ control influence their chance of becoming an alcoholic….’7 Ubel (1997) also argues that whilst alcoholism is a disease it results from a choice that the person made with regards to drinking alcohol. Yet Moss and Siegler (cited in Ubel 1997)7 claim that alcoholics are not responsible for becoming alcoholics but they are responsible for not seeking help to treat their alcoholism. From these arguments it is not obvious where the responsibility of alcoholics’ lies but it can be said with confidence that they are in part responsible for aspects of their disease.
Taking this into account, leads to the question should alcoholics receive liver transplants? Whilst most would not admit to refuse to treat patients on the basis that they are responsible for their disease, it has been considered that doctor’s do except they claim that it is the perceived prognosis of the patient that leads to their refusal to transplant. It has been suggested that alcoholics who receive liver transplants do not do well post operatively and that their prognosis is poor7. Therefore, it seems reasonable that no matter how ill they are the liver would be a waste as it would not improve the patients’ quality of life but it may improve the life of somebody who has no history of alcoholism. Whilst this seems severe, the fact is the NHS needs to balance finance with moral duty. There would be a public outcry if an alcoholic received a liver transplant and died a year later, when there was a young patient suffering from liver cancer, who would live for many years following a transplant but did not receive it and they died too. Whilst this is unlikely to happen due to the QALY system it illustrates the need for such a cost versus benefit approach rather than relying on concepts of desert.
However, put aside the need of other patients and now concentrate on the issue of giving an organ to a patient who has created their own health problems. In the case of smokers, they often receive transplants and operations without having to abstain from smoking although some doctors ask them to try to give up after the operation once the treatment is complete; they are free to carry on with the behaviour that necessitated the treatment in the first instance. Alcoholics however, do not get the same unconditional access to treatment. They must show that they can refrain from drinking alcohol for a significant period of time before they will be considered for a transplant7. This could be because it must be considered whether or not the patient can abstain from alcohol following the transplant. It would be a waste of resources to remove an alcohol damaged liver and replace it with a healthy one only for that to become damaged too. It would also be unfair to patients on the transplant list who would look after the organ but surely this is also true for smokers on the CABG waiting list.
Taking that into consideration, there are patients who have abstained from drinking alcohol but do not receive transplants due to their poor prognosis. However, Ubel (1997) claims there is data to indicate that people who are carefully selected for liver transplantation actually have a good prognosis that is similar to that of a person who is receiving a liver transplant for other reasons7. Yet few of these patients receive transplants quickly if at all. It could be concluded that this is because doctors and transplant coordinators feel that an alcoholics health problems are their own fault and that the NHS should not be required to foot the bill and therefore, feel that retributive justice is appropriate.
Society could argue that they should not have to pay for these people to stop drinking as they choose to start. Yet the same argument is not applied to those people that smoke or who are obese and these people also chose to start smoking or eating excessively but few people appear to have a problem with spending vast amounts of money caring for them. Few doctors make it compulsory for patients to stop smoking before they will treat them. It is common for obese patients to be told to loose some weight before they can have an operation. However, this is because of the risks involved in certain surgical procedures; it is not to prove to their doctor that they no longer have a problem with food. They may indeed eat ‘normally’ once they have received the necessary treatment.
Obesity is not an independent marker for CHD but it is associated with many health risks such as high blood pressure and high cholesterol, which in turn can lead to coronary heart disease5, 9. Obesity is also associated with type II diabetes and various cancers such as colon cancer. These diseases cost the economy a large amount of money in terms of hospital stay, specialist care, number of days off work and the treatment they require10. This money could be used to treat other patients who can not be held responsible for their illness.
However, Campbell (2003)11 believes that a patient cannot be blamed for being obese as there are many psychological factors surrounding eating habits and it has been considered by some that obesity is indeed an eating disorder. There are also cases where obesity is the result of an underlying physiological condition such as hypothyroidism or a genetic condition such as Prader Willi syndrome. Whilst this is true, there are many psychological factors surrounding alcoholism but those patients are not treated in the same sympathetic manner. How are the two groups different? It has been suggested alcoholics choose to drink but the same could be said about obese people choosing to eat the wrong foods and not exercising. Many alcoholics try to stop drinking but cannot and many obese people diet some with little success.
This highlights that the two groups are not dissimilar but decisions to treat them are evaluated in different ways. I suggest that this is because health care professionals and society tend to place blame with patients who have displayed socially unacceptable behaviour that has lead to their disease and they are thus treated accordingly. Whilst egalitarians argue that all people are equal and therefore, they must all be treated equally regardless of what has lead them to need treatment this is not a reality within our society. This is further illustrated in cases of people with Down’s syndrome who need a heart transplant.
Congenital heart disease occurs in about 40% of people with Down’s syndrome causing many patients to need a heart or heart and lung transplant12. Yet the Down’s syndrome association (cited in Scott 2000)13 claim that only one person with Down’s has ever been put on the NHS waiting list for a transplant. This is quite surprising given the fact that Down’s babies are at greater risk for congenital heart defects in comparison to babies without Down’s.
Not all people with heart defects require transplants, as many children receive corrective cardiac surgery, which is enough to treat them but there are some children for whom this does not work. There are also some young adults with Down’s who now have pulmonary vascular disease as they did not receive corrective surgery as children due to peoples’ attitude towards Down’s Syndrome and the fact that people with Down’s had a life expectancy of about 40 years12.
It is claimed that the reasons for this include that the outcome of a transplant is uncertain as specialists are unsure about how patients will react to the anti rejection and immunosuppressant drugs. This is due to the fact that people with Down’s Syndrome have an altered immune system which results in a high incidence of infections. This has been shown when treating Down’s patients who have leukaemia. It was found that there was a high incidence of infections and early mortality following bone marrow transplants12. This is certainly a plausible reason for not carrying out such a procedure, based on this evidence it would appear that the risks far outweigh the benefits and the cost that would be incurred would not only be financial; as the heart used in the transplant could have been given to an otherwise healthy individual to improve their quality of life.
It is still the view in some areas of society that people with Down’s Syndrome do not live long and have a poor quality of life and therefore, tax payers money should not be spent on giving them expensive life saving treatment. This view is illustrated by Dr. Savulescu (cited in Coats 2001) who said that ‘no one would offer a transplant to a severely mentally retarded or chronically institutionalize and incurable psychiatric patient because greater enhancement of life quality could be obtained by giving it to a young, otherwise healthy and productive member of society.’14
Whilst everybody is entitled to their opinion it must considered that there has been no published research to date to establish if theories regarding post operative complications are correct. Until heart transplantation in Down’s people is properly researched, there is no definitive answer and therefore, this group could be denied treatment on false grounds. Scott (2000) claims that in the United States there have been successful heart transplants carried out in Down’s Syndrome people13. Should this be the case, it would seem that there are prejudices operating within society and the NHS towards this group and these are well illustrated by Dr. Savulescu’s comments.
The fact is that many people with Down’s Syndrome now live well in to their 60’s and as with any syndrome, Down’s has varying degrees and a great many people have very active and fulfilled lives and aside from their heart defects people have a high quality of life. Dr. Savulescu’s comments highlight that there is unequal access to treatment as Coats (2001) points out that ‘it is their other conditions that affects our judgment as to whether they should be prioritised over others.’14 Whilst this should be considered in the context of how they will respond to treatment, it should not be the sole reason for denying treatment. Although, Dr. Savulescu’s argument does have some merits as it mentions treatment for ‘severely mentally retarded’ people, in this case offering a transplant would not improve quality of life. However, it must be made clear what is meant by severely retarded. In this context my definition is that of a person who is unaware of their surroundings, does not appear to get any pleasure out of life and is unable to understand communication from others at any level. Obviously this definition does not rely on IQ scores, which do have a role in indicating the potential of an individual but cannot quantify what a person gains from life and therefore cannot be used in an assessment of quality of life.
It is in these circumstances the QALY system fails, as it recognises disabilities as being less than 1 (which is considered to be healthy)1, therefore, when adjusting for quality of life years after the procedure, people with any kind of disability will be shown to have a low QALY score. In addition to this, the quality of life a person is perceived to have is very subjective and open to interpretation and one person’s idea of a poor quality of life could be another person’s idea of the perfect life. Therefore, by operating this system to decide who receives health care this group of people will always miss out; as they are not starting from the same point as other people due to their already existing disability that is constantly viewed in a negative light and can never be treated. This could communicate to this group that they do not have the same rights and thus access to health care, creating the idea that their lives are of less value in society than those who do not have a disability.
So how can this group improve their situation? There are no life style changes they can make to prove that they can benefit from the treatment, there is no counseling they can go to in order to improve their health; instead according to this system they must deteriorate.
The National Health Service and society as a whole seem to believe that it is better to treat people that have created their own disease as long as it is socially acceptable rather than treating people who have an illness that they cannot be held responsible for. Whilst health care professionals have a duty to care for patients regardless of how it came to be that they required medical treatment, with only finite resources surely it would be fair to treat those who are the most deserving. People who smoke had a choice when they started and they have a choice about giving up. Those people who are obese (not as a symptom of a metabolic or genetic disease) are aware of the health risks and whilst there is debate about whether obesity is an eating disorder for some, it is not the case for everybody and so valuable resources are used to treat those who have indulged themselves. Then there is the case of those people with Down’s who are considered to have a poor quality of life and are therefore, less deserving of treatment. However, taking all things as being equal then those with Down’s have a good quality of life it is just different to others and therefore, not grounds to deny people the chance to carry on living life.
I appreciate that once treated people that smoke or are obese are more productive members of society than those with Down’s Syndrome, however, if they did not smoke or over indulge this would not be an issue as they would not require treatment and those who were not in anyway responsible for their disease would always get priority. Whilst we cannot force people to give up bad habits, we should not reward them either.
The NHS cannot adopt a retributive care system; however it could treat patients more equally. It has already been mentioned that in order for alcoholics to be considered for transplantation they need to abstain from alcohol for a period of time, this notion should be adopted for smokers and those suffering from obesity. Should patients from any of these groups satisfy that criteria, then treatment should be carried out but those who are unwilling to help themselves or do not have the will power should not be given access to procedures such as CABG when there are people more deserving of finite resources.
References
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