Who deserves health care?

                                                                

Rebecca O’Donovan

        In today’s National Health Service, there are more patients than there are resources to treat them. Therefore, the treatment patients receive is on a priority basis and this is assessed according to the patients’ need, how ill they are, how they will respond to the treatment and how much their quality of life will be improved following the treatment. In effect the NHS adopts a utilitarian stance when treating patients as it aims to do the greatest good for the greatest number.

In order to do this each patient requiring expensive treatment is assessed according to a quality adjusted life years (QALY) score¹. This is an equation that measures all of the aforementioned criteria and is used to assess the cost versus benefit of a particular treatment. If a patients quality of life would improve greatly and the cost of the treatment is low then the QALY score will be high. However, if the benefit to quality of life is high but the treatment is expensive then the score will be low. This tool is useful to a degree in assisting doctors who are trying to decide how to allocate limited resources but it discriminates against certain groups. For instance those patients who are elderly and need a hip operation for example will have a low QALY score because they have fewer quality of life years left to live than somebody in their fifties needing a coronary artery bypass graft (CABG) operation. In this scenario the person needing the bypass operation is likely to be overweight and, or a smoker and could be considered to be responsible for their illness. Yet due to the improvement of quality life this person is likely to gain, they will have the operation instead of the elderly patient as they will achieve a higher QALY score. This seems rather unfair and raises the question should people who are responsible for their own illness get priority for treatment over those who are not regardless of their QALY score?

        

In order to answer this, let us first examine the effects of smoking on health. It has been well documented that smoking has many related health risks. It has been estimated that smokers are 10 times more likely to suffer from lung cancer than those who have never smoked and they have twice the risk of developing coronary heart disease (CHD) than non- smokers². There are many other health problems associated with smoking, such as respiratory problems, strokes and other cancers. All of these are unpleasant diseases and treatment or palliation of them could greatly improve quality of life for that patient.  However, for many years the risks associated with smoking have been made very public as public health campaigns have become more graphic and hard hitting. Yet people still choose to smoke, knowing the risks to their health. Which raises the question should smokers have the same access and priority to services as non- smokers?

        

Research has shown that cigarette smoking accelerates the progression of coronary artery disease thus leading to patients requiring coronary artery bypass grafting (CABG). This procedure relieves the symptoms of angina and increases the activity of patients thus improving their quality of life. However, these benefits are not so obvious in smokers in comparison to non- smokers3. This treatment is also particularly expensive for smokers as they have a longer stay in hospital and it carries a greater risk of complication such as vein graft occlusion and the need for re- operation. All of these factors lead Underwood and Bailey (1993) to conclude that smokers should not be offered CABG.³

This is slightly extreme, after all for residents of the United Kingdom everyone is entitled to health care. Although it would be fair to say that this treatment should not be offered to smokers as a first line treatment and smokers should not be made a priority for it.

However, it must also be considered that smoking is addictive and many people become addicted as children before they understand its harmful effects. During World War II smoking was positively encouraged and so perhaps the government should share some of the responsibility placed on to smokers4. Whilst this is partly true, once people have been made aware of the harmful effects of smoking it is their responsibility to seek help to overcome their addiction. Those who do not do this are responsible for the progression of their addiction and its resulting disease

There are many that would argue that smokers have paid for their own care anyway through the taxes that were deducted when they purchased their cigarettes. It was estimated in 1998 that the treasury earn £6.5 billion per annum from tobacco duty and that smoking related diseases cost the National Health Service £1.2 billion per annum so smokers have more than contributed for the care they receive and therefore, are entitled to get their smoking related diseases cured 5.

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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 ...

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