From the Toronto Star

By: LESLIE PAPP
FEATURE WRITER

Fed up with patients who won't quit tobacco, a Northern Ontario surgeon is refusing to operate on smokers — even if it could save their lives.

And other doctors in the province have the right to do the same thing, says Ontario's medical watchdog, the College of Physicians and Surgeons.

Ethicists label such refusals unfair. Smoking, they point out, is an addiction, and many in its grip don't have the power to quit. They warn that targeting smokers is discriminatory, since lifestyle choices such as eating fatty food play a big role in other diseases, from heart problems to diabetes.

But Dr. Alberto de la Rocha, a chest surgeon who does all lung cancer operations in Timmins, has taken a stand. "Nobody goes under the knife without having quit smoking," he says, tapping his desk with a forefinger.

It's not known how many doctors reject tobacco users. A Winnipeg family physician, Dr. Frederick Ross, made headlines last year when he gave his patients three months to stop smoking or find another doctor.

And surgeons in Melbourne, Australia, have refused to give smokers heart or lung transplants, or life-saving bypass surgery, citing medical and moral grounds.

De la Rocha says that about one in five smokers coming to him are denied surgery; they're unwilling, or unable, to give up tobacco.

Some are outraged by the very suggestion that they butt out. De la Rocha says angry patients have answered him with a one-finger salute and slammed his door so hard, the diplomas on his wall rattled.

"I've had people where I thought, `My God, is this guy going to jump across the desk?'"

Others quietly leave his office, promising to try quitting, and they don't come back.

De la Rocha requires smokers to abandon their habit three to six weeks before a procedure, and he cites sound medical reasons for that.

Studies show that smokers don't do as well as non-smokers on the operating table. Tobacco users are prone to risky complications, such as lung infections and blood clots, resulting in heart attack or stroke.

Smokers also consume valuable health-care resources, de la Rocha says. If society is going to spend thousands of dollars to treat them, it's only fair to ask that they "take the first step" and quit their risky habit.

And there's worry that bad outcomes, aggravated by smoking, could tarnish a surgeon's reputation, de la Rocha says. In the United States, there's extensive monitoring of surgeons' performance, with "report cards" separating the profession's stars from its screw-ups. A trend toward increased accountability is building here, too, making smokers less desirable to have as patients.

Performance report cards "are coming down the pipe," de la Rocha says, elaborating on why he has rejected smokers. "If my reputation is on the line, it stands to reason I would take that step."

According to the Ontario Medical Association, he is well within his rights.

The stop-smoking ultimatum "could be a reasonable thing to say," says Dr. Ted Boadway, executive director of health policy for the OMA and a family physician for 13 years. "You have to look at the risks involved, and every surgeon has to make a decision."

Boadway says he isn't aware of other Ontario doctors refusing to treat smokers, but he has personally dropped patients because they were addicted to drugs or alcohol.

Their problems were "insoluble as long as they continued their behaviour," he says. "You put a huge amount of effort into these folks. And every doctor has their breaking point."

Doctors are free to drop smokers from their patient list as long as they steer them toward appropriate care from some other source, says Dr. Graeme Cunningham, head of the College of Physicians and Surgeons of Ontario.

Doctors ending their relationship with a patient need to give the departing person "a menu of choices," he says. This could be as simple as a list of other doctors expert in treating a patient's particular disease, or hospitals where help is available.

There's no requirement to actually find another doctor for a patient who is sent away, and no policy on whether smokers should be denied treatment because of their addiction.

"We wouldn't take a specific position around smoking and smoking cessation, and people needing lung or heart operations," Cunningham says.

But ethicist Margaret Sommerville says refusing to treat smokers solely because of their addiction unfairly targets this population. It amounts to discrimination, "to the extent that an addiction is a physical and mental disability."

De la Rocha's reply: "I'd like to see that ethicist taking care of a patient in respiratory failure following surgery. That's all."

Doctors are clearly justified in refusing to do a procedure if they feel the risks of an operation outweigh the benefits. But undergoing surgery as a smoker doesn't appear to be riskier than being denied treatment.

"There's a risk in not getting the operation," says Sommerville, founding director of the McGill Centre for Medicine, Ethics and Law in Montreal.

"As well, the physician must make sure that the refusal to treat would be a last-ditch option, that all other ways of solving this situation — such as offering support and addiction treatment — have been explored."

De la Rocha says he tries to be flexible. He relies on family physicians to provide smoking-cessation services and to refer patients to other specialists. An emergency case is always treated. And sometimes, when a patient is a particularly heavy smoker and is desperately trying but unable to stop, he settles for a big drop in cigarette use — something like a 75 per cent reduction.

"That's a good chunk."

Those who fail to quit, or refuse, must find another surgeon. And that means going to Sudbury or Toronto.

"Can they find someone?" de la Rocha muses. "I have no idea. I don't follow them up."

Other doctors say they've been tempted to drop smokers.

"I have considered it," admits Dr. Gail Darling, a chest surgeon at Toronto General Hospital who has operated on more than 1,000 lung cancer patients. But she has decided to continue treating tobacco users even if they don't quit.

"Smoking is an addiction (and) addiction is a disease," she says. "It's a terrible thing."

Dr. Jon Irish, chief of surgical oncology at Toronto's University Health Network and Mount Sinai Hospital, says he has heard anecdotes about Ontario physicians refusing to treat smokers, adding he might have been sympathetic to such a policy early in his career.

Now, after years spent watching smokers suffer from their habit, he says denying care "is a pretty harsh line to take."

Irish specializes in cutting out head and neck cancers — diseases mainly caused by tobacco use.

About 90 per cent of his patients are smokers and Irish is "very adamant" in pushing them to quit. Almost 60 per cent of them do, he says, citing his own study, soon to be published in a medical journal.

But Irish doesn't deny treatment to patients who don't butt out. That would amount to punishing them for an addiction over which they have little control, he says. And they're being punished enough.

"If you have a cancer and I'm going to take out your tongue or take out your lung or take out your bladder, that's a pretty high price to pay," Irish says.

"That's a pretty good incentive to stop smoking. If you continue to smoke, that, to me, signifies addiction."