What is Our Ethical Responsibility to Treat Smokers? Drawing a Line Between Physician and Patient

Affiliations: 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

Abstract: The practice of medicine is regarded as one of the most valued and principled professions in our society. A doctor is perceived by the public to be an ethical and learned individual who is able to heal and care for those in need. There is a contemporary twist that may undermine this luminous halo that appears to surround physicians in most societies: the conflict by which 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, abandonment, trust, addiction, smoking, ethics, comfort, palliative care.
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The history of tobacco use, especially cigarette smoking, is quite complex. It was not that long ago that smoking was readily accepted in society, 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 and healthcare professional and policy makers’ attitudes toward cigarette smoking in particular but tobacco use in all its forms. Concerns raised about the harmful health effects of smoking tobacco and second-hand smoking have led to policy changes that have gradually eliminated available public spaces to smoke and have made it more expensive (eg, taxes) and less accessible, especially to young people. In 2010, the American Pharmacists Association called on drug stores to stop selling tobacco products; and last year, the CVS Pharmacy—the second largest drugstore chain—made a public statement when it decided to answer their call.¹

Although tobacco smoking is legal, healthcare providers may struggle with the ethical issues of whether someone who “abuses” their body with smoking are worthy recipients of healthcare resources. For example, there have been individual physicians who feel strongly that it is their ethical duty to refuse care to patients who are smokers. Some patients may not be truthful about their smoking history, and in elderly patients who have been smoking for decades, discerning their smoking habits and convincing them to quit may not be easy.

Case Scenario

Below, let us consider the complexities of treating an elderly individual—Mr. X—who resides in a long-term care facility. 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 has multiple comorbidities, including diabetes and coronary artery disease for which he has had several angioplasties and may be required to undergo another one due to symptoms of myocardial ischemia with recurrent chest pain inadequately responsive to medication therapy. The patient has been provided with the gamut of pharmacological interventions in the past but cannot tolerate them due to side effects. He is an immigrant from a culture where smoking is central to social interaction—almost considered a mandatory practice that has profound environmental influence on personal habits. Do you, as the healthcare provider in this case, blame the patient for refusing to quit? Since genetics and the environment are beyond the control of the patient’s physician, one might interpret such resultant actions of humans beyond their personal choice alone. How do you approach the care of this patient? Do you recommend the patient proceed with the angioplasty even though the operation is not likely to significantly improve his health status if he continues to smoke?

To Treat or Not to Treat?

The refusal to treat smokers is evidence-based, as the medical evidence shows that smokers who undergo certain medical procedures experience poorer outcomes, such as respiratory and cardiac complications, as a group compared to 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.² In another study, after bypass operations, the arteries of smokers were more likely to become blocked again.³  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.

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 regardless of the clinical outcomes may be psychologically beneficial to patients and their families. 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 is 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 than continued chemotherapy that is no longer providing a clinical benefit. Is it reasonable to apply this same thinking to smoking patients undergoing an intervention in which significant health outcomes are unlikely but may result in psychological benefit that there is hope for improvement?

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 resources to treat conditions with interventions that may not be as effective as in non-smokers. But is it fair to single out smokers for poor return on healthcare costs? This thinking could imply that all patients with chronic illnesses caused by lifestyle choices, such as diet and participation in sports (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.”⁴ Therefore, if a physician refuses to treat a patient due to the habits that may endanger their 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.⁵ It important to realize that denying treatment to smokers might result in a slippery slope because individuals other than smokers whose illnesses may be self-induced might also experience negative effects because of decisions to curtail treatments because of lower efficacy or high costs.⁶

Is There a Slippery Slope? Making the Patient Not Responsible for Decisions

The question that can rightfully posed is: can smokers, who are often non-adherent patients, be held responsible for their smoking-related actions and their results on their health?

External Constraints

There are those who take the position that our behavior is a result of our decisions; our decisions are partially if not fully governed by our desires; and our desires are partially impacted upon by our character, which is greatly affected by our 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.⁷ Studies have also shown that genetics have as much as a 50% impact on the liability for nicotine dependence.⁸ The environment is responsible for shaping the values and beliefs of an individual in regards to the act of smoking.

Internal Constraints

Apart from external constrains, an individual may also have internal constraints, such as psychological conditions that can cause one to resort to tobacco usage. As individuals reach a certain 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. Such emotions can lead one to find themselves in a depressive state. When negative emotions fill one’s mind, they will resort to practices that provide temporary satisfaction. Let’s revisit the above-mentioned case of Mr. X with a different diagnosis: an elderly person in a retirement home with his personality may have had little in the way of life satisfaction. His prognosis may be further compromised due to a recent diagnosis of advanced cancer. His goal might be to enhance the quality of the life and decrease the burdens brought by his illnesses. Smoking is his only way to attain pleasure in his final 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. X want to be a good role model for his grandchildren, he is unable to refrain.        If he were not restricted to smoking outside or was not willing to follow the rule, he could potentially be affecting the health of other residents in the facility or put the facility at risk of a fire if he were to smoke in an unsafe way. Congregated environments in which older people live can lead to severe consequences if individual smoking cannot be curtailed.⁹ 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.

What About Patient and Physician Autonomy?

The concept of autonomy in contemporary medical ethics is a very powerful source of authority for how decisions are supposed be made for and on behalf of patients. In the basic foundational concepts of autonomy it was meant to be directed to and for patients. The idea of physician autonomy in many ways seems to contradict that of patient autonomy: physicians are not making clinical decisions for themselves. If they do, autonomy would play a role as it would with any patient. The idea that a physician can choose patients they will treat and what treatments they will offer is a very different question. There is nothing in the original construct of autonomy as described in the classic works on ethical principles 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. 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. There is a literature on the process of smoking cessation, and it clearly is not a simple process for many of those addicted to smoking.^7,8,10 As such, physicians cannot ethically deny medical treatment by simply stating that their choice had led to the outcome because their current state will not allow the patient to take care of themselves. 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. Abandoning a patient because they do not “follow” a physician’s advice is not considered in most jurisdictions to be professional behavior.

Consider, for instance, the prospect of withholding the treatment as part of the punishment. Would this make any moral sense at all? What could it possibly mean to say that the person deserves to have this treatment withheld? Would this person still be responsible for his actions? It seems far more likely that those who have been aware of this case would be indicted for negligence. Would it make any sense to all to deny surgery/treatment to the Mr.X as a punishment if we knew the smoking was proximate cause of his medical  issues? Of course not. The urge for retribution, therefore seems to depend upon our not seeing the underlying causes of human behavior.

Physician–Patient Relationship

The relationship between a patient and a physician is based on trust, for the patient is dependent on the expertise of their physician. A physician is then responsible to respect their patient’s autonomy, hold their information in confidence and promote their well-being. Regardless of the responsibilities on both sides, there is an imbalance in their 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 to be not-indicated because of very high risk, the discussion has to be focused on the risks and benefits, and other factors that may allow a high risk procedure or treatment to be carried out as long as everyone understands the stakes involved.

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. 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. If it becomes necessary to transfer the responsibility of patient care because 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. 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.

Conclusion

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.¹¹

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 appear to be so dismal that in good conscience a physician would have great difficulty with such a 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/she cares for and therefore must find ways in which they can provide care to those in need, and also address their personal values without compromising the primary concern which is the well-being of their patients. 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.

References

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9. Marin Armero A, Calleja ernandez MA, Perez-Vicente S, Martinez-Martinez F. Pharmaceutical care in smoking cessation. Patient Prefer Adherence. 2015;9:209-215.
10. Mackrael K, TT Ha. Resident’s cigarette suspected in Quebec seniors' home fire. The Globe and Mailwww.theglobeandmail.com/news/national/ice-frigid-conditions-slow-search-for-victims-in-quebec-seniors-home-fire/article16482953. Published January 24, 2014. Accessed February 19, 2015.
11. Shuttleworth A. A principle we cannot afford to lose. Prof Nurse. 1993;8(10):620.

Disclosures: The authors report no relevant financial relationships.

Address correspondence to: Michael Gordon, MD, MSc, FRCPC, Baycrest Geriatric Healthcare System, 3560 Bathurst Street, Room 1C24, Toronto, ON, M6A 2E1, Canada; m.gordon@baycrest.org

Acknowledgments: The authors would like to thank Shaira Wignarajah, BSc, York University, Toronto, Ontario, Canada, for her assistance with editing this manuscript.