Are we doctors or judges?
Phil believes that patients’ health damaging lifestyles should be none of his business
Phil believes that patients' health damaging lifestyles should be none of his business
I was full of admiration. I hadn't seen this girl for 18 months, and if I hadn't had her name up on the screen I would not have recognised her. She was a shadow of her former self.
The last time I had seen her she was a human blimp. She had come to see me to ask for the famous mythical ‘slimming pill', and we had spent 20 minutes discussing why I thought weight loss was not to be found via a prescription pad. She had been disappointed, but not surprised. For once I had found a patient who agreed with me that she had to take control of the problem herself. And she had done it.
After making the appropriate congratulatory noises, I asked her what I could do for her. ‘Well doctor, it's this……' She undid her tightly-buttoned high-waisted trousers, and out fell about a yard of grotesque wrinkly redundant abdominal skin. She could have dropped the lot into a supermarket carrier bag and still had some left over.
I'm not usually a chap who reacts kindly to requests for cosmetic plastic surgery, but before the ridiculous pink mess had stopped swinging, I was already reaching for the dictaphone. ‘You want that lot taking off? I'll do my best!'
Three months later and here she is again, choking back tears. ‘He says he'll do it, but only if I give up smoking first. They're going to do a breath test to make sure.'
She hasn't had a cigarette in three weeks. Already she's put the best part of a stone back on. This always happens when you give up smoking. Everyone knows this and I'm sure the surgeon is no exception.
Currently, the newspapers are carrying the story of a bloke with a malunion of his ankle fracture who is being refused a corrective operation because, sinner that he is, he will not give up cigarettes. The reason he is being given is the same one being given to my patient: if you smoke, the operation is less likely to be successful and more likely to encounter complications.
I'm sure they are right, in both instances. And I'm sure it isn't, say, a cynical way of hitting targets and manipulating demand.
Where do we draw the line?
Why do we think we have the God-given right to dictate our patients' lifestyles? Who the hell do we think we are? And who decides where we draw the line?
Many, possibly most, of the illnesses suffered by our patients are self-inflicted. Fat people get diabetes and arthritis, athletes get sports injuries, drunks get wounds, doctors – for God's sake – get depressed and alcoholic. Smokers have their problems, myriad in number.
The fact that smoking is voluntary should have no bearing on our care for them.
That's not to say that we should be non-judgmental, that we should ignore the damaging life choices our patients make. We should comment, we should judge, we should advise. But we should not presume to withhold treatment based on our knowledge of any of this.
We work in the National Health Service; treatment, free for all, at the point of delivery. Too often I see stories in the press of operations denied to fat people or smokers or the delinquent or non-compliers. None of this should matter, because their treatment is covered by the concept of informed consent.
Explain the risks, talk about the alternatives, offer the treatment, and if necessary, deal with the fallout. It's our job to offer health care, not to dictate how people should conduct themselves. Let's leave arrogance and righteousness and hypocrisy to the politicians. They do it so much better.Phil Peverley