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Nailing Patients

Posted by Dr No on 19 December 2010

health_fascist.jpgStorms of protest have greeted recent ‘leaks’ that NHS trusts plan to shoo existing smokers and fatties off waiting lists, and ban new and returning entrants until they have done time in a get fit quick boot camp. Herr citizens who fail to comply vill be sent down ze salt mine, and the key (but not their matches and crisps) thrown away.

These variants of health fascism are in fact nothing new. IDS style poor law conservatism always reckons those who have fallen on hard times have somehow managed to pull a fast one, and health fascism is the natural sibling of poor law conservatism. Those who cannot work will not get benefits; and those who will not fix their habits will not get NHS health care. Scattered amongst the protest comments on blogs and in the media is more than enough serves-the-bastards-right why-should-we-pay-for-their-healthcare invective to make Dr No’s toes curl.

The health fascist’s arguments invariably rest on a double barrelled litany of righteous indignation. By the first barrel – bang! – gaspers and fatties have by lifestyle choice caused their illness, and thus are culpable, and so punishable; and by the second barrel – bang! – why should the righteous pay for the sins of the sick? Low-life scumbags! Bang-bang!

Now, as it happens, the righteous are unwittingly enclosed in an unseen glasshouse. With very few notable exceptions, most modern chronic illnesses are caused to a varying extent by lifestyle choices. Athletes wear out their joints. Sunbathers crisp their skin and grow cancers. Workaholics punch up the mercury, and pop cerebral arteries. The list is endless. And, as the saying goes, people in glasshouses shouldn’t throw stones, let alone blast away with both barrels at those less fortunate than themselves.

For one day, perhaps not too distant, they may discover that they too now find themselves staring down the barrel of the health fascist’s gun. Consider hormone replacement therapy. In the absence of medical indications, HRT is – all said and done – a lifestyle choice to mitigate the effects not of an illness, but of a natural process - the menopause. For some, the price of that oestrogen glow will be cancer; and in cause and effect Sarah with her HRT triggered breast cancer is inseparable from Susan with her smoking induced lung cancer. And so it must be that the health fascist who would exile Susan from the NHS must now also exclude Sarah.


Whilst I agree with the jist of your article and I wouldn't deny anyone treatment on the basis of their lifestyle, having sought some medical help for their disease-inducing lifestyle, people do have some responsibility for managing their lifestyle to minimise its damaging effect. There are plenty of people who refuse or unwilling to do this yet expect continuing treatment and complain when it doesn't work.

Our health system is simply preparing us for the fact universality and comprehensiveness will soon become things of the past - first they came for the fatties and smokers, and then the drinkers - of course, the temptation for the finger waggers to blame the poor for causing their own health problems will be almost impossible to resist?

Your point is well made. What infuriates me is how the health fascists refuse to accept that smokers and drinkers pay for their habit related health problems and contribute several more billions to the Exchequer. This is not a fact that can be disputed. Even if we take the British Heart Foundation research, that is costs the NHS £5 bn p.a. to treat smoking related diseases, the gaspers contribute about twice that amount a year in taxes. The righteous assume that if smokers were forced to give up their wicked ways they would not require the serves of the NHS. These saved sinners, so the theory goes, will require no health care during the rest of their long lives and will eventually drop dead at little or no cost to the public purse. They also forget that early deaths save further billions in pensions, freeing up capital, etc.. Drinkers make a similar contribution to the Exchequer. The fatties help out because they are quite likely to be smokers and drinkers, and they consume copious quantises VATed goodies. (This means that the “cause” of their death can appear on three sets of statistics and can be counted three times as a cost to the NHS.)

Here’s to the gaspers, boozers and fatties for their generous contributions to the NHS. Of course I would like them to contribute a little less and live a little longe - but what the hell.

As a one med (initiated mid-fifties) seldom (once every two years average) GP atendee - I can understand this current stance; for I smoke, (binge) drink once a week and my BMI would suggest that I eat like a pig! One thing I would like to ssk about this eating larky-malarkey is, although I don't eat like a bird - I certainly don't eat like a pig, so why does my friend who eats like a pig look like a matchstick?

As you rightly state, this attack on the miscreants of society is nothing new. All of our sins lead to the need for hip or knee replacements and we should be denied them. Obesity, alcohol and nicotine consumption definitely lead to the erosion of hip and knee joints - those who do not partake in these perilous habits are immune to them.

Dr Zorro highlighted a pertinent point that in the GMC Good Practice Guide, it states "You must not refuse or delay treatment because you believe that patient's actions contributed towards their conditions." So do these doctors think they are above good practice guidelines and deem themselves as holier than thou?

Visit JME: "The right to treatment for self inflicted conditions." In the conclusion it states that "it is clear that any serious list of people who share responsibility for their own adverse health would have to include a high proportion of the population."

Is routine surgery routine surgery or an indication of bad habits?

For doctors, the GMC guidance is, as usual, twisted in knots. As Dr Z points out in his post, it wimps out when the sh*t hits the fan. And how does shopping bad practice fit with being a cozy 'team player', such as we are all must be these days? And what about the medical director of the trust which has shooed the undesirables off its waiting lists: surprise, surprise, he will be your GMC Responsible Officer, with the gift of your continued registration in his/her hands...

No one so far as I know is saying doctors shouldn't advise smokers to stop and fatties to eat less/exercise more. The crunch here is culpability and punishment. The ethicists were bound to have a view, and - Dr No suspects - the familiar fault lines will open up between deontology (duty driven actions) and consequentalism (consequence driven actions). The deontological lot will tell the undesirables they have a duty to improve their health (and sod the consequences if they don't ie no surgery for you, pal); the consequentalists (most doctors) will urge the undesirables to better their ways (because of the consequences - better health, lees surgical risk).

Keith's well made fiscal point about who pays and how much is very pertinent here, for it also has an ethical dimension: where is the morality in hoovering vast revenues off undesirables, and then telling them to get lost when their ship comes in? Surely that is the sort of thing bankers, not doctors or governments, do?

What about the other lifestyle choices and health risks? Trauma care for motorcyclists? Rheumatology for athletes? Obstetric care? The line will be drawn where it's fashionable and where it suits the politicians of the day.

Renal - Absolutely. This is the problem. Given enough zeal, just about any illness or injury can be seen as self-imposed (your obstetric example is already half way there...) and so all patients must pay for all their treatment. This reductio ad absurdum (at least one hopes it is) shows the futility of any such moves. More worrying is any partial implementation. Who decides what is self-imposed? Who decides what the sanctions are against the guilty patients? At the end of the day it will always be a subjective moralistic series of value judgements. Any move to introduce a system based on 'good patients' and 'bad patients' is deeply sinister and, at least to Dr No, is quite unacceptable. He prefers to do what real doctors have always done: treat their patients, without worrying about the moral niceties of how they got to be patients in the first place (and before anyone suggests otherwise, note that ignoring moral niceties has nothing to do with attending to medical realities - if someone's lifestyle is killing them, Dr No would be the first to point that out - but as a medical reality, not a moral judgement).