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Allocation of Health Care to Smokers: Practice and Ethics

Institution: Stanford University
Investigator(s): Thomas Raffin, M.D.
Award Cycle: 1998 (Cycle 7) Grant #: 7IT-0129 Award: $113,598
Subject Area: Public Health, Public Policy, and Economics
Award Type: Inno Dev & Exp Awards (IDEAS)

Initial Award Abstract
Over the past decade, California has instituted a successful public health campaign to reduce the number of active smokers in the state. One result of that campaign has been the increasing stigmatization of the habit of smoking and of smokers themselves. Although the health benefits of a reduction in smoking are clear and non-controversial, there may be unintended social and ethical consequences to health messages which promote a cultural climate in which smoking is not only disapproved of but in which the smoker is held as morally or socially unacceptable. One such possible consequence is the effect that campaigns may have on the distribution of health care dollars and scarce resources such as organ transplants to smokers. Studies show that, often, there are sound medical reasons for the decision to limit care to smokers, but these studies also indicate that the characterization of smokers as somehow morally "less deserving" also plays a role. There is already evidence that implicit, i.e., unacknowledged, rationing to smokers does occur and strong arguments are being made for explicit rationing as well.

The difficulty lies in distinguishing appropriate, just ethical allocation of care to smokers that might include some limitations or denials of care from those allocation decisions that are based merely on a bias or prejudice. In addition, difficulty lies in balancing the substantial contributions of anti-smoking campaigns as well as other health promotion/disease prevention programs to the health of the people of the State of California as a whole with the possible detriment to targeted individuals (i.e., those who continue to smoke). A further challenge is in normalizing, at least to some extent, guidelines and policies so that decisions at the bedside or in an HMO clinical case management office are consistent and fair.

Addressing these critical ethical and policy dilemmas requires a combination of approaches. We propose first a program of empirical research to document the current status of rationing services to smokers. We need to know the attitudes and actual practices of clinicians, case managers and health care organizations throughout the state. In addition, we need to know the current climate of opinion among members of the general public and individuals who are chronically ill with smoking-related illnesses. However, data, no matter how carefully collected, will not answer the underlying ethical questions. Therefore, we also propose to create an ongoing Ethics Working Group. This group, composed of experts in health economics, health services research, philosophy, bioethics and health promotion, as well as lay representatives, will issue ethical guidelines to assist both health care providers and health care policy makers in determining appropriate care for those who have smoked or are currently smoking, and also to provide general ethical guideposts for caring for groups of individuals who are perceived as having contributed to, or caused, their own diseases.

Final Report
Over the past decade, California has instituted a successful public health campaign to reduce the number of active cigarette smokers (smokers) in the State. An unintended consequence of this effort might be the increasing stigmatization of smokers. The purpose of this planning study was to lay the groundwork for a more comprehensive research project to determine the effect that such campaigns and the consequent stigmatization may have on attitudes towards and practice of allocation of health care to smokers. The specific aims of the study were to develop and validate empiric research instruments, and set up an Ethics Advisory Panel to integrate empiric results to ethical analysis and policy development.

Three pilot surveys were conducted: 1) To document individual attitudes towards providing health care to smokers, a 125-item questionnaire was developed, pre-tested and distributed to 150 physicians, 90 physicians-in-training (trainees), and 100 patients at Stanford University Hospital and Clinics. Respondents’ willingness and rationale for providing health care to active smokers were queried both with general statements and hypothetical vignettes about specific treatment decisions and access to health care. Results show that willingness to recommend treatment to active smokers was highest for hysterectomy and lowest for lung transplant across all respondent groups. However, patients were more inclined than physicians and trainees to recommend liver transplant, coronary artery bypass graft and multiple ICU admissions. While the majority of all respondent groups believe everyone should have equal access to health care, a majority of physicians and trainees reject the idea that “an active smoker is entitled to the same access to health care that a non-smoker has.” Most popular reasons for these restrictions included: limited resources, personal responsibility and impact on long-term health. These results need to be replicated in a larger study. 2) To begin exploring existing practices of rationing, a structured interview guide was developed to cover a number of issues related to candidate screening and selection, and treatment eligibility criteria for smokers, focusing on organ transplantation, where explicit rationing to smokers currently occurs. This instrument was piloted by conducting a telephone survey of all multi-organ transplant (TX) centers in the State of California (n=14). Respondents included 12 TX coordinators at 9 hospitals, in charge of 18 TX programs (heart n=6, liver n=5, lung n=5 and heart-lung n=2). Results indicate that active smoking is an absolute exclusion for all lung, heart, and heart-lung TX programs surveyed, and for 3 out of 5 liver TX programs examined. The extent to which active smoking is becoming an exclusion in programs where smoking is not a recognized causal factor in the disease merits further study. 3) To analyze ethical justifications for providing or denying care to smokers, a structured interview guide was designed and pre-tested by conducting telephone interviews with a subset (10%) of respondents queried in the first survey. This survey helped validate and refine the questionnaire used in the first survey, but showed that in-depth understanding of the rationale underlying the decision-making process is required through less structured qualitative inquiry.

This planning study has shown that attitudes, practices and rationales for the provision of health care to smokers may differ among lay and professionals, depend on the type of care, and overall, are worth further investigation. We have now developed appropriate methods to pursue this project.