Annals of Long-Term Care: Clinical Care and Aging. 2015;23(12):37-41.
Baycrest Health Science
3560 Bathurst Street
Toronto, Ontario, Canada M6A 2E1
The authors report no relevant financial relationships.
1Palliative Care, Geriatrics, and Pain Medicine, Baycrest Geriatric Healthcare System, Toronto, Ontario, Canada.
2Department of Family and Community Medicine, Division of Palliative Care, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
3Division of Geriatrics, University of Toronto, Ontario, Canada.
The authors would like to thank Shaira Wignarajah, who is presently studying for her Bachelors of Science in Kinesiology at York University, Toronto, Ontario, Canada, for her assistance with editing this manuscript.
The practice of medicine is regarded as one of the most valued and principled professions in our society. Some physicians believe they may not be obligated within their professional duties to provide treatment to smokers who refuse to quit. This dilemma is having an impact in particular on older individuals who have a wide array of comorbidities. The potential denial of needed treatments to elderly smokers may compromise the quality of life for these individuals. The ethical conundrum facing physicians is whether there is any ethical rationale upon which they can refuse to provide treatment or, in some cases, any aspect of medical care, unless the patient is willing to forgo their tobacco use.
Key words: treatment adherence, treatment benefit, addiction, smoking, ethics, palliative care
The history of tobacco use, especially cigarette smoking, is quite complex. It was not long ago that smoking was a commonly accepted behavior in society and permitted in all public spaces, from restaurants and airplanes to hospitals and long-term care facilities. The past few decades have been witness to almost revolutionary change in societal attitudes as well as the attitudes of healthcare professionals and policy makers toward tobacco use in all its forms and cigarette smoking in particular. Concerns raised about the harmful health effects of smoking tobacco and inhaling second-hand smoke have led to policy changes that have gradually eliminated available public spaces to smoke, have made it more expensive to smoke (eg, through taxation), and have made cigarettes less accessible, especially to young people. In 2010, the American Pharmacists Association called on drug stores to stop selling tobacco products; and last year, CVS Pharmacy—the second largest pharmacy chain in the Unites States—made a public statement when it decided to answer this call.1
Although tobacco smoking is legal, healthcare providers may struggle with the ethical issues of whether someone who “abuses” their body with smoking is a worthwhile recipient of valuable healthcare system resources. For example, some physicians feel strongly that it is their ethical duty to refuse care to patients who are smokers. A group of physicians in England decided to withhold non-urgent heart bypass surgery from smokers who did not stop smoking, arguing that non-smokers and those who had quit smoking should have a greater opportunity to receive surgery because they may receive a greater benefit from it.2 In the Netherlands, one doctor stated that spending time on people who “willingly and knowingly damage their own and others’ health” was “wasted energy.”3
Many physicians may choose to follow this method of thinking because short-term cessation will most likely reduce harmful acute effects of nicotine and carbon monoxide on the cardiovascular system while lung function is improving (this process takes about 8 weeks).4 A systematic review found that smoking cessation was associated with a relative risk reduction of 41% for prevention of postoperative complications. It was also found that each week of cessation increased the magnitude effect by 19%. Trials of at least 4 weeks of smoking cessation had a significantly larger effect than shorter trials. Therefore, patients with longer periods of preoperative smoking cessation have lesser postoperative complications.5
Moreover, it has been found that smokers experience more complications during the induction of anesthesia, compared with non-smokers. 5.5% of smokers had experienced respiratory events such as re-intubation, laryngospasm, bronchospasm, aspiration, hypoventilation and hypoxemia while given anesthesia, compared to 3.3% of non-smokers.6 Aside from the complications associated with the initial steps of treatment, chronic smokers also require high dosages of analgesics because the act of smoking encourages liver microsomal enzymes, thus increasing the metabolism of drugs. Apart from higher doses, some patients may require more volatile anaesthetic agents such as pethidine, which may cause hepatic and renal failure, adding to the complications that they may have to endure after treatment. Therefore, smokers may have to face complications before initial treatment, and the steps taken to make sure they receive the treatment may also come with potential side effects.6
These factors raise the question of whether smokers should be receiving the same treatment as non-smokers. Some patients may not be truthful about their smoking history. Additionally, for elderly patients who have been smoking for decades, discerning their smoking habits and convincing them to quit may not be easy.
Case Scenario 1
Let us consider the complexities of treating an elderly individual—Mr. X—who resides in a long-term care facility and is suffering from a long-standing tobacco addiction. Despite the patient’s understanding of the impact of smoking on his previous and current health status, he has not been able to quit. He is an immigrant from a culture where smoking is central to social inter- action—almost considered a mandatory practice that has profound environmental in uence on personal hab- its. He has multiple comorbidities, including diabetes and coronary artery disease, for which he has had sev- eral angioplasties. He may be required to undergo an- other angioplasty due to symptoms of myocardial isch- emia with recurrent chest pain inadequately responsive to medication therapy. The patient has been provided with several pharmacological interventions in the past but can no longer tolerate them due to side effects.
How do you, as the healthcare provider in this case, approach the care of this patient? Do you recommend the patient proceed with the angioplasty though the op- eration is not likely to signi cantly improve his health status if he continues to smoke?
Inferior Outcomes for Smokers Versus Non-smokers
Some health care providers’ refusal to treat smokers is evidence-based: the medical evidence shows that smokers who undergo certain medical procedures experience poorer outcomes, such as respiratory and cardiac complications, compared with non-smokers. An editorial published in the Medical Journal of Australia stated that a wide range of surgical procedures should not be offered to smokers.7 The reasoning offered was that smokers who receive treatment receive a smaller benefit from treatment than do non-smokers. In one review of outcomes in breast reduction surgery in smokers versus non-smokers, smokers experienced a higher incidence of wound infection than non-smokers.8 In another study, after bypass operations, the arteries of smokers were more likely to become blocked again.9 Some physicians have therefore defined such treatments for smokers as potentially not beneficial or even harmful, as they fail to achieve the desired and optimal physiological outcome.
Although the evidence supporting the inferiority of treatment outcomes for smokers versus non-smokers is compelling, the question that must be addressed is this: how definitively are physicians able to determine the likelihood that a given treatment will not benefit a smoker compared to a non-smoker? The denial of specific treatments for all smokers puts those individuals who may benefit from treatment at a disadvantage, one that might be difficult to justify on ethical grounds, depending on which of the ethical principles is considered dominant in such a situation.
Moreover, on what basis is a treatment considered not beneficial? Many treatments may be psychologically beneficial to patients and their families, regardless of the clinical outcomes. For example, many older individuals with metastatic cancer who are not responsive to chemotherapy may decide to discontinue treatment, whereas other individuals may decide to continue with it because it provides some level of comfort and hope. This would be considered a psychological benefit. The conversation between the physician and patient about future chemotherapy is often complex and must take into account not just the potential benefits of further treatment but also the adverse effects and interference with proper palliative care interventions that might meet the physical and psychological needs of the patient more effectively. Is it reasonable to apply this same thinking to smoking patients undergoing an intervention in which significant health outcomes are unlikely but that may result in a psychological benefit?
The Relative Value of Providing Care to Smokers
Physicians my fall back on non-maleficence as justification for not providing what they deem to be potentially harmful medical treatments to smokers, but they may also consider the effects of presumably “wasting” financial and other healthcare system resources to treat conditions with interventions that may not be as effective as in non-smokers. For example, a study had found that the probability of a smoker getting a wound infection after a joint replacement surgery was 3.3–3.4 times higher compared with a non-smoker.8 Wound infections lead to delays in hospital discharge and increases in fees and costs for hospital care.10 Another study revealed that, in smokers who underwent bone reconstruction, the process of arteries becoming blocked occurred more quickly. The cost of an arthroplasty, for example, if unsuccessful or complicated by an infection, can be $50,000.
Such facts bring into question whether limited healthcare system resources and costly procedures should be allocated and offered to smokers. Should an individual be able to demand a surgery regardless of the associated financial burden on the healthcare system?11 In a study involving 200 general practitioners and 200 oncologists, a majority rejected the idea of allocating costly procedures to smokers and justified this rejection by stating that health system resources should be fairly distributed.12 Dr. Graham Jackson, who is a consultant cardiologist at Guy’s Hospital and the editor of the British Journal of Clinical Practice, cited a 10-year American study that reported a survival rate of 68% among smokers who underwent bypass surgery, compared with a survival rate of 84% among non-smokers who underwent the procedure. The author concluded, “The differences are not of sufficient scale to justify a ban on treating cigarette smokers.”13
There is a separate question of whether it fair to single out smokers for poor return on healthcare costs. One could make a similar argument that all patients with chronic illnesses influenced by lifestyle choices such as diet and exercise (eg, end-stage diabetes, debilitating injuries) are not worthy of ongoing medical interventions to manage their conditions.
Part of the ethical principle of autonomy is the individual patient’s right to refuse treatment, which, although arises from ethics, is translated into law as the need for consent for treatments to be undertaken on behalf of a patient. Immanuel Kant’s principle in ethics—the categorical imperative—says, “If one chooses an action, it then becomes universal law.”14 Therefore, if a physician refuses to treat a patient due to habits that may endanger his or her health, then it follows that the physician must also refuse to treat others with conditions or personal practices that put themselves at medical risk, which might include bungee jumping, extreme sports, overeating, or excessive alcohol intake, for example.15 It is important to realize that denying treatment to smokers might result in a slippery slope.9
The Role of Patient Responsibility
Can smokers, who are often non-adherent patients, be held responsible for their smoking-related actions and the results on their health? There are those who take the position that our behavior is a result of our decisions. However, our decisions are partially, if not fully, governed by our desires. In turn, our desires are partially influenced by our character, which is greatly affected by genetic make-up and many environmental factors.
Studies on twins and families have shown that more than one gene plays a role in developing a smoking addiction. These genes are in control of how fast nicotine is metabolized by an individual.16 Studies have also shown that genetics have as much as a 50% impact on the liability for nicotine dependence.17 The environment is responsible for shaping the values and beliefs of an individual in regards to the act of smoking.
An individual may also have internal constraints that influence their ability to quit smoking, such as psychological conditions that can cause one to resort to tobacco usage. When individuals reach an older age, they begin to reflect on their life, which may bring upon thoughts of regret and sorrow. The medical conditions faced by the elderly can also lead to negative emotions, which can lead to a depressive state. In such cases, practices such as smoking that provide temporary satisfaction become more appealing.
Regardless of how hard some older people with a life-long smoking habit try to refrain from smoking, even when there are rules to prevent it, with the known addictive power of tobacco it is sometimes the only way someone can attain relief for their mental and psychological conditions in the face of a strong addiction. This is a difficult challenge to overcome for those responsible for assuring not just the well-being of an individual who may have strong needs, but of a congregated community. Congregated environments in which older people live can lead to severe consequences if individual smoking cannot be curtailed.18 For example, smoking in the long-term care environment could potentially affect the health of other residents in the facility or put the facility at risk of a fire.19
Case Scenario 2
Mr. Y is an older man living in a retirement home. He has had little life satisfaction. His prognosis may be further compromised due to a recent diagnosis of ad- vanced cancer. His goal might be to enhance the quality of life and decrease the burdens brought by his illnesses. Smoking is his only way to attain pleasure in his nal days of life and also his way to interact with others and recall memories. Therefore, despite the dangers that in some ways have already manifested themselves, he is not ready to quit and jeopardize this activity that provides him with pleasure. Although Mr. Y wants to be a good role model for his grandchildren, he is unable to refrain.
The Role of Patient and Physician Autonomy
The concept of autonomy in contemporary medical ethics is a very powerful source of authority for how decisions are supposed to be made for and on behalf of patients. The idea of physician autonomy in many ways seems to contradict that of patient autonomy: physicians are making clinical decisions not for themselves but for others. However, a physician has the autonomy to choose what treatments they will offer. The autonomy to choose which patients they will treat is a very different question, however. There is nothing in the original construct of autonomy that allows for physicians to refuse to treat patients because of their personal qualities or because of their clinical decisions as long as the treatment being discussed is legally acceptable within the jurisdiction in which the physician is practicing.
“First do no harm” is a guiding principle for physicians to follow.18 This statement means that a physician should not feel forced to perform or provide treatment where there is believed to be more risk than benefit, for it is wrong from any point of view to recommend a procedure that stands to run great risks and reap few benefits.
In order for the autonomy of both the physician and patient to be respected, the patient must be given the opportunity to evaluate treatment options for themselves in the context of their own values and desires. The physician has the legal obligation to explain the treatments that are legally acceptable. A physician should explain all the risks associated with a treatment and make sure the patient is aware of the risk-benefit ratio. Nobody can predict with certainty the degree of benefit in the individual case, and one person may benefit from a procedure whereas another person may not. Therefore, the idea that a physician could potentially withhold treatment from a patient that fails to follow a physician’s medical recommendations would certainly not fit into the ethical framework of patient autonomy.
An individual who develops an addiction to tobacco has an illness, a medical problem that deserves medical treatment. Those addicted to substances may lose their autonomy not so much in their ability to make decisions but in their ability to decide to forgo smoking. They are therefore in need of treatment to regain their control of their smoking habit but may not be willing to accept the treatment. The literature on the process of smoking cessation is not a simple process for many of those addicted to smoking.9,16,20
As such, physicians cannot ethically deny medical treatment by simply stating that the patient’s choice led to the negative health outcome. The role of a physician is always to support the patient and as much as possible to restore autonomy and return control to their patients to the extent possible.
The relationship between a patient and a physician is based on trust; the patient is dependent on the expertise of their physician. A physician is then responsible for respecting their patient’s autonomy, holding their information in confidence, and promoting their well-being. Regardless of the responsibilities on both sides, there is an imbalance in the relationship. Physicians in most jurisdictions make a commitment to the public and the regulating bodies that the interests of their patients are held ahead of their own. The decision strategy should be to avoid the worst outcome when there is a conflict between the treatment and responsibility. If, for example, when treatment is decided against because of a very high level of risk, the discussion has to be focused on the risks and benefits and the factors that may allow a high-risk procedure or treatment to be carried out.
A physician might only refuse a treatment if it poses such a danger to the patient that it could not be defended under any circumstance. Still, the patient cannot be abandoned even if a treatment is denied on good medical grounds. Patient abandonment occurs when a physician withdraws from caring for a patient.21 In order for a patient to state that they have been abandoned by their physician, the patient must prove that: (1) the physician had unreasonably discontinued medical treatment; (2) this was done against the will of the patient; (3) this was done without arranging for a substitute physician; and (4) the physician has some reason to know that physical harm may result to the patient, and the patient in fact suffered physical harm as a result of the discontinued treatment.
If it becomes necessary to transfer the responsibility of patient care because of the gap between what is requested and the physician’s belief of what the treatment entails, it would be necessary to try and transfer their responsibilities and care to another qualified and willing physician with full communication with the patient or their substitute decision-makers. If there is no transfer available, the physician must give the patient a reasonable time frame of notice so that he or she can find another physician. It is important to note that if a replacement is not found, the physician must accept the patient and continue providing care.
Trust is key to a physician–patient relationship. If there were, for example, a clinical or even a medical policy decision that smokers who will not cease smoking will not receive a given treatment unless they stop their habit, they may attempt to hide the fact that they smoke. Hiding this essential fact may cause the doctor to provide treatment that may in fact lead to worse outcomes, since smoking is not factored in the equation. Denying treatment for smokers might potentially be interpreted as a form of discrimination, but if a policy or a decision-making protocol takes risks and benefits into the equation, it may be deemed to be justifiable within the healthcare structure in which the patients and physicians receive treatment and provide it.
It is vital to realize that the cost of smoking in regards to the health service, to industries in terms of lost working days, and the emotional toll it takes on individuals watching their loved ones suffer, is grand. Research has also shown that smokers are not only harming themselves, but also those around them when they smoke. As a result, there are many health education programs put in place to make individuals aware of the harm they are doing. Regardless, denying smokers the right to healthcare is not the solution, because this will destroy the professional and ethical relationship that underpins the practice of medicine.22
Individuals are shaped by their genetics and environment, and once they start smoking they may lose their ability to act truly autonomously as it relates to their addictive smoking habit. Therefore, doctors should continue to keep their patients’ interest in mind and deny treatments only when the outcomes are likely to be too poor to justify the treatment. In the situation where there are no possibilities of changing the medical trajectory, the remaining quality of life for the patient can be maximized by utilizing palliative care philosophy and approaches. Therefore, when a physician concludes that there is no other type of intervention that will benefit the patient, they are still responsible to advise the patient to seek alternative treatments that might include palliative approaches to care.
The medical profession must embody the qualities of trust, integrity, and duty in order to deserve the faith that individuals have in physicians. A physician has a duty and responsibility to maintain the trust and the lives of the patients that he or she cares for and, therefore, must find ways to provide care to those in need. The needs of their patients must always be their first priority. Physicians must provide treatments to all individuals and continue to hold the ethical code that each individual has the right to access healthcare and the privilege to have a quality of life regardless of their age, medical condition, or personal practices.