Under socialized medical systems, there are parameters under which patients may and may not get various medical treatments. I thought this was an interesting new twist. (To be perfectly honest, "rules" like this already exist under some US systems, too. Still interesting topic)
Hospitals may ban treatment for smokers and drinkers
By Nigel Hawkes, Health Editor
SMOKERS, drinkers and the seriously overweight may be denied medical treatment if their lifestyle makes it ineffective, the Governments treatment watchdog said yesterday.
The National Institute for Health and Clinical Excellence (NICE) said that doctors who considered that a particular treatment might not be effective, or cost-effective, because of the lifestyle of the patient, may be entitled to withhold it.
However, doctors should not discriminate on the ground that a disease was self-inflicted. Even those who had brought their problems on themselves deserved treatment.
It makes clear, to the delight of campaigners, that discrimination on the ground of age alone is equally unacceptable. However, when a patients age affects the chances that a treatment will work, it can be taken into account.
The new guidance seems certain to be cited in cases such as the recent ruling by three primary care trusts in East Suffolk that obese patients could not have hip or knee transplants. The trusts were widely criticised, but could now use the NICE guidance in their defence arguing that operations are less safe for the obese, and that for such patients hip and knee implants are less effective as they wear out sooner.
The guidance could also be cited when heavy drinkers seek liver transplants, or when smokers need heart bypass operations. In each case, the intervention would be rendered less effective by the habit.
The NICE guidance, which is still in draft form, was developed by its citizens council, a group of people who offer advice on a wide range of social issues. But it was finalised by the NICE board.
Vivienne Nathanson, the head of science and ethics at the British Medical Association, said that the guidance reinforced what had always been good medical practice. I am delighted that NICE has not proposed a blanket ban on some treatments for some groups of people, Dr Nathanson said. That would have been wholly unacceptable.
It would also be wrong if this guidance were to be used to ration healthcare.
The judgment should always be, Does this person need treatment? and Will this treatment be of benefit? Every case should be considerd on an individual basis.
The NICE report said that it could be difficult to determine whether someones illness was self-inflicted or not. There was no way of knowing, for example, whether smokers who had a heart attack would have suffered one had they not smoked.
As a result, it said, NICE should avoid discriminating against patients with conditions that are, or may be, self- inflicted.
But it added: A patients individual circumstances may only be taken into account when there will be an impact on the clinical and cost-effectiveness of the treatment.
The report, Social Value Judgments: Principles for the Development of NICE Guidance considered whether social background, age or lifestyle choices should ever influence the care provided by the NHS.
It concluded that clinical guidance should recommend a treatment for a particular age group only where there was clear evidence of a difference in the treatments effectiveness for that age group.
NICE has previously made judgments of this sort, for example recommending that drug treatment for flu should be available for the over-65s as they are a vulnerable group and likely to be more seriously affected by flu than younger people, or that IVF treatment should be avail-able to women aged 23-39 because it was most likely to be effective in that group.
Professor Sir Michael Rawlins, the NICE chairman, said: On age we are very clear our advisory groups should not make recommendations that depend on peoples ages when they are considering a particular treatment, unless there is clear evidence of a difference in its effectiveness for particular age groups. Even then, age should only be mentioned when it provides the only practical marker of risk or benefit. NICE values people, equally, at all ages.
In the NICE programme of work there are a number of guidelines and technology appraisals in progress that may be influenced by the report. They include appraisals of statins; of pharmaceuticals for treating drug addiction; of coronary artery stents; and of treatments for lung cancer, and of falls, a problem found mostly but not exclusively in the elderly.
Among guideliness that may be influenced are those in preparation on drug misuse, high blood presssure, obesity and osteoarthritis.
Steve Webb, the Liberal Democrat health spokesman, said: There is no excuse for cash-strapped hospitals denying treatment to people whose lifestyle they disapprove of.
Treatment decisions involving peoples lifestyle should be based on clinical reasons, not grounds of cost. The NHS is there to keep people healthy, not to sit in judgment.
Jonathan Ellis, policy manager of Help the Aged, said: This is a real U-turn for NICE, which previously, and rather carelessly, suggested that age, rather than individual need, should be used to determine a persons treatment.
Were pleased to see NICE has finally shown an understanding of the importance of tackling age discrimination within health care.
Barring the use of age as a criterion for developing guidelines on NHS treatment and care will now make it more difficult to make false assumptions about someones age to influence clinical decisions.
It will ensure a fairer deal all round for older people using the NHS.
A lifelong drinker destroys his liver and seeks a transplant, with no plans to give up drink. A surgeon could refuse to carry out the operation on the ground that liver transplants are of limited effectiveness in alcoholics. Most surgeons already do.
HOW GUIDANCE COULD APPLY
A heavy smoker develops heart disease, and seeks treatment. A surgeon might refuse a heart bypass, because smoking increases the risk of the operation, cutting the cost-effectiveness of the treatment. He might offer to do it if the smoker gave up, because promptly quitting reduces operation risks.
An obese patient is suffering osteoarthritis. Painkillers are appropriate, but an operation to replace hips or knees may not be. However, a surgeon may alternatively argue that the pain makes it hard to exercise and without exercise it is difficult to lose weight. An operation might therefore be justified both to treat the arthritis and the obesity.
The evidence may be the tricky factor. Few trials have ever sought to include smokers, drinkers or the obese; thus, demonstrating that a particular treatment works less well for them will not always be possible.