Monday, December 05, 2005

Pandora and the NHS

I haven't much felt like blogging lately -- I blame it on a combination of excess turkey intake, too much work, and good old fashioned procrastination. While there are certainly a few posts percolating around the few remaining sulci in my frontal lobes, nothing has sprung forth in a frenzy of keystrokes (yet).

I did find something interesting recently while perusing the news, however. It is the kind of governmental decision that generates all sorts of interesting dilemmas, all under the guise of saving money and "doing what's right for patients." It will also generate rather intense debate, I suspect. Fortunately for those of us on the western side of the great Atlantic pond, this debate will be taking place in Great Britain. It seems that the National Health Service has issued a "guidance" to physicians permitting them to refuse to treat a patient if they judge that an illness is self-inflicted. It also appears that this directive has already been an undeclared policy for some NHS physicians:

The guidelines will be introduced as a poll shows that one in five doctors admits that he or she has already denied patients treatment because they drink heavily, smoke or are obese.
Wow. It seems that Pandora's box has been nicely untied and opened, not by the lovely Pandora herself, but by bureaucratic fiat!
Just as Pandora loosed a torrent of ills for humanity upon opening that crate, the potential ramifications of this decision may be quite far-reaching (and beyond the expectations of those who crafted it). To be sure, the obvious self-inflicted diseases can be, and frequently are, listed by any second grader:
  1. Smoking, with the potential sequelae of lung, oropharyngeal, and bladder cancer; COPD/emphysema; coronary artery disease; peripheral artery disease....
  2. Alcohol abuse, which may result in cirrhosis and liver failure; pancreatitis (acute or chronic....and eventual diabetes); alcohol-related accidents and injuries; withdrawal; depression.....
  3. Drug abuse, a culprit in hepatitis and liver failure; endocarditis; renal failure; severe dental problems (seen particularly in meth abusers)....
  4. Obesity, which can lead to diabetes; sleep apnea; heart disease; degenerative joint disease; depression; steatohepatitis;....
That's a laundry list of potential medical problems that some physicians may not feel bound to treat unless the patient chooses a different lifestyle. No one can argue that it is imperative for patients with these issues to take charge of their own health, quit smoking, stop drinking, lose weight, etc. It appears, however, that the real reason behind this decision is a bit less idealistic, and a bit more pecuniary in nature:
This weekend Sir Michael Rawlins, chairman of the National Institute for Health and Clinical Excellence (Nice) said the guidelines would ensure that the limited National Health Service budget was well spent.... He singled out alcoholics by saying the institute├é’s new social value judgments will make it clear that if patients continue to drink they will not be given a liver transplant....The Nice guidelines state that care cannot be denied simply on the grounds that a condition is self-inflicted. However, according to a draft of the code to be debated next week, the treatment can be withheld if the patient├é’s lifestyle affects the success or cost effectiveness of the operation.

I know that Sir Michael Rawlins must be in a difficult position, trying to help a nationalized health system be both a deliverer of good medical care and be fiscally responsible. Make no mistake, however --- this is health care rationing (which has always gone on in the British system), but it is doing so while singling out certain types of behavior which clearly cost the system a lot of cash.

One could easily argue that we in the US do this all the time --- the morbidly obese patient may be told to lose weight before having a total knee replacement, the smoker may be told to quit before the distal bypass can be done --- but it is hardly an official policy of our "system" as a whole. There is certainly no unanimity among American physicians about which patients should and should not receive certain types of therapies. Nor, I suspect, will there ever be.

Perhaps before the British (or we) embark on such a policy, it might be a good idea to expand the above laundry list, and look at a wider array of diseases that have a hefty self-inflicted component:

  1. Sexually transmitted disease from promiscuity -- including HIV, with all of its financial ramifications; HPV infection resulting in cervical cancer; STD induced infertility...
  2. Sporting activities --- leading to orthopedic injuries, head injuries, and later development of arthritic conditions requiring expensive joint replacement surgeries
  3. Tattoos and piercings --- associated with a higher risk of hepatitis
  4. Sun-worshippers and tanning salon users --- obviously risk development of skin cancers
  5. Loud music --- those who like to listen to "head banger heaven" on MTV are at a huge risk for hearing deficits in the future
  6. Political junkies --- risk mental illness and ulcer disease when their party leaders make boneheaded statements, and may get lund disease while inhaling the orations of political windbags

Yes, the last one was (a bit of) a joke. In the long run, it will be difficult to make such blanket decisions that affect only one type of self-inflicted disease. Those of you who are familiar with the legend of Pandora (ok, ok, I had to look it up!) will remember that she opened the box a second time, and released Hope. I would hope for a more market-based approach --- if patients are a bit more responsible for the financial costs of their health care, they may be more incentivized to change their behavior.

A few British reactions can be read at The Scotsman and at this pro-smokers' rights site.