HEALTH : Refusal of Bypass for Smoker Has Britons Weighing Care, Cost

Britain’s medical Establishment has been roiled by an argument that has serious financial implications for the National Health Service, considered one of Europe’s best.

The controversy centers on the refusal by doctors in several British cities to perform heart bypass surgery for heavy smokers, unless they agree to quit smoking. The bypass procedure is medically perilous, time-consuming and extremely costly for the health agency, which covers the cost of the operation for qualified patients.

The argument over the propriety of the surgery for heavy smokers erupted earlier this month when Harry Elphick, 47, who sought a bypass in Manchester, was refused by a hospital cardiologist, Dr. Colin Bray, unless Elphick agreed to stop smoking.

Elphick had been referred to Bray for assessment after a February heart attack. Elphick was ordered to kick his 25-cigarette-a-day habit before receiving definitive tests for a bypass. He agreed, though he complained, “Why should doctors dictate to me how I should live my life?” He died Aug. 13, a week before doctors were to examine him at the hospital.

In defense of his judgment, Bray said that most hospitals have a policy of not treating heavy smokers as long as they are stable and not in emergency condition. “Patients who continue to smoke after surgery don’t have any survival benefits,” he explained. “They don’t live any longer than if they haven’t had an operation. Those are the hard facts.”

This view is in keeping with a stand taken earlier by doctors in other cities, decisions supported by Baroness Cumberlege, the government’s junior health minister who suggested that physicians should “play God” in deciding the priorities for treatment in the health service.

But Elphick’s wife and others responded that doctors had no right to “play God” and should treat everyone, regardless of personal lifestyle.

Bray and most of the medical community insisted that the hospital was taking a practical, rather than a moral stand. “We’re not saying that smoking is wicked and sinful,” Bray said. “We’re simply saying it’s bad for people’s health in the same way as we would be reluctant to treat the very fat, the people with very bad disease, where the surgical results are poor.

“In the real, live world,” he added, “if we operate on smokers, we do less operations in a year than if we operate on nonsmokers. Treating people who smoke increases the risks in the immediate postoperative period. We don’t have anything that’s as effective at reducing risk as simply stopping smoking.”

That view was supported by the British Medical Assn., which declared: “In cases of patients suffering from heart disease, any decision about a coronary artery bypass operation should be based on clinical grounds only. The possible complications following heart surgery on a heavy smoker--and the risks during surgery--are great. Experts consider that, frequently, the best possible management is to advise the individual to give up smoking and provide interim medical treatment. The patient would then be reassessed six to eight weeks after giving up smoking.”

But the British Cardiac Society seemed to differ and this week circulated guidelines to its members declaring it could not support a policy that “systematically denies the right of access to treatment for individuals on the basis of a specific risk factor, even if this is self-induced.”

Society officials, though, left critical decisions to doctors, adding they should “weigh up all aspects of patient care” including the risks of smoking. They concluded: “It is of paramount importance that physicians and surgeons should take every possible measure to encourage patients with coronary artery disease to avoid serious adverse risk factors, including smoking.”

Health department officials explained this week that the government does not issue directives to physicians on patient care but allows them to make their own decisions.

The government has, however, launched a massive campaign to get the British to stop smoking. It also has placed one of the heaviest taxes on tobacco products in the Western world.

National health officials point out that their budget is limited, and that apart from life-threatening emergencies, priorities must be established for the service’s free medical and surgical care.