NHS to Smoker With Fractured Ankle: Walk It Off

Jacob Sullum | September 20, 2007

Here's a story for anyone who imagines that government-run medicine will somehow do away with gatekeepers who deny suffering patients the treatment they need based on cold-hearted financial calculations: British doctors are refusing to perform surgery on a man with a multiply fractured ankle because he's a smoker. "Doctors at the Royal Cornwall Hospital in Truro have refused to operate," reports the Daily Mail, "because they say his heavy smoking would reduce the chance of healing, and there is a risk of complications which could lead to amputation." But at least they're willing to give him morphine for the agonizing pain caused by the injury they refuse to fix.

Michael Siegel explains the reasoning behind such decisions, quoting a commentary that appeared in the British Medical Journal:

Increased use of hospital beds and associated costs mean less opportunity to treat other patients. Based on these data, five non-smokers could be operated on for the cost and bed use of four smokers and the non-smokers' surgical outcomes would be better. A well informed smoker, unwilling or unable to quit, might assume an increased risk for himself, but the decision is not his alone when it can indirectly affect others. Then, the community must involve itself.

Siegel worries about the consequences of "community" involvement in every medical decision, and so do I. But while he calls for more compassionate, tolerant, and enlightened policies by health-care-dispensing bureaucrats, I'd like to avoid the centralization of such decisions, which inevitably leads to situations like this. Last April I attended a conference at Harvard that was supposed to explore the theme of "responsibility for health," and much of the discussion revolved around the question of how central planners should allocate scarce medical resources, including the issue of how much should be spent on fat people and smokers when the government can get more bang for its buck by focusing on skinny nonsmokers.

Scarce resources always have to be allocated one way or another, of course, and Michael Moore did not have to invent stories about getting screwed over by HMO gatekeepers. But there is an important difference when patients have some choice of providers and health plans. Some might deign to repair a smoker's fractured ankle, for example. There need not be one policy for the whole country regarding what is covered for whom. Giving the government a monopoly on dispensing health care only exacerbates the problems created by medical gatekeepers. 

More fundamentally, if people pay for medical care out of their own pockets, they are less likely to be viewed as public enemies when they fail to be as healthy as they can be. Those concerned about the totalitarian implications of treating every health-related decision as a matter of public policy should look for ways to expand competition and consumer choice in health care, not restrict it.

Comments

|9.20.07 @ 12:47PM|#

Huh. I had no idea that smoking was also responsible for broken bones.

Episiarch|9.20.07 @ 12:51PM|#

The NHS is really crazy about ankle/foot operations. They told me they wouldn't operate on mine because of the amputation danger, which would have left me a cripple. So they'd rather let me be an assured cripple than take a small chance of being a cripple. I told the doctor to go fuck himself.

Good thing I was an American with private health care.

|9.20.07 @ 12:52PM|#

...and we know that the doctors' statement about the surgery not working and causing greater problems is a cover for an anti-smoking agenda and an effort to control costs because...?

...well, becasue a guy with a blog who has never met the doctors, evaluated the patient, or even reviewed the patient's medical file "walks us through their thought process."

Close enough for anti-government work.

|9.20.07 @ 12:57PM|#

Health plans are ready for hillarycare, using lifestyle as a suitable excuse to disallow everything except childbirth (where the children will be taken from the mom for dangerous behaviors). More money and less treatment: health plans are gonna be rich(er)!

|9.20.07 @ 12:58PM|#

Sage, when one smokes, the oxygen levels in the blood are depressed.

When your circulatory system is stressed, this can be the difference between tissues healing and dying.

I remember a case where a man had his fingers reattached by an industrial accident. Everything was fine until the 7th day after the surgery when he smoked a cigarette. Gangreene set in, and he lost the fingers.

It is not unheard of for surgeons to refuse to operate on people because they smoke because they feel the surgery would be a waste of time and money. And as free people, every surgeon should have the right to refuse to perform any operation for whatever reason.

This being said, since the NHS doesn't have to face market competition, the doctors can turn away as much business as they want and not suffer economic harm. Thus the man will have a hard time finding someone willing to treat him. The fact hat he has been paying for medical care he is being denied for years makes this a moral crime, in my mind.

It's too bad that the fans of government paid medical care have so little trust in their schemes that they want to force people to pay into them at gunpoint.

|9.20.07 @ 1:03PM|#

Here's a story for anyone who imagines that government-run medicine will somehow do away with gatekeepers who deny suffering patients the treatment they need based on cold-hearted financial calculations

To be fair, this is only one system (NHS), which we seem to keep finding problems with.

Disclaimer(as though it were needed): I do not support government intervention in health care.

|9.20.07 @ 1:05PM|#

Interestingly selective quote from the BMJ, which covers elective procedures only and is mostly about the increased risk of infection.

According to the article, the guy would need to give up smoking for around four whole weeks to reduce his risk of post-surgical infection to that of a non-smoker.

Or he could pay for the operation out of his own pocket.

Paul|9.20.07 @ 1:06PM|#

tarran:

When your circulatory system is stressed, this can be the difference between tissues healing and dying.

All true.

My response: so what.

My father was 79 years old when he had quintuple bypass surgery. He was something like 72 when he had knee replacement.

It could be argued that both surgeries were unnecessary due to his age. I mean, really, how many years were we going to add to his life?

Episiarch|9.20.07 @ 1:09PM|#

well, becasue a guy with a blog who has never met the doctors, evaluated the patient, or even reviewed the patient's medical file "walks us through their thought process."

joe, there is no medical justification for not setting broken bones. The very fact that they have seen fit to give him morphine shows they realize how painful it is.

The anti-smoking agenda could be present, but who cares? The point is that it is being used as a justification for denying desperately needed medical service, to a person who has been paying into the system. If that doesn't indicate to you the dangers of single-payer gatekeepers, I guess nothing will.

|9.20.07 @ 1:12PM|#

Hillary will implement universal healthcare much better than the NHS has done.

|9.20.07 @ 1:14PM|#

This makes no sense. Yes, smoking a lot can decrease your recovery of surgery, but suddenly stopping smoking won't miraculously cure the damage you've already done your body. I don't think him suddenly stopping smoking would have done anything to help his recovery.

|9.20.07 @ 1:16PM|#

Wesley - from the selectively quoted BMJ article:

"A study of experimental sacral incisions of 12-18 mm found that infection occurred in 12% of smokers and 2% of non-smokers. Infection rates in smokers who had quit for four weeks were similar to those in non-smokers. In a study of wound and other complications after hip or knee arthroplasty, no smoker who quit developed a wound infection compared with 26% of ongoing smokers and 27% of those who simply reduced tobacco use. Overall complications were reduced to 10% in those who quit smoking compared with 44% in those who continued."

|9.20.07 @ 1:16PM|#

Episiarch,

Where'd you go to medical school? Would you say this fracture is worse than most that you've treated, or better?

They did set his bones - the put him in a cast. The doctors - the ones who evaluated him and know his condition - judged the benefits and risks from his surgery and made a medical judgement.

All the rest, about their supposed agenda, is made up. Imaginary. Incredibly convenient assumptions by people who are themselves pushing an agenda. Wholly without any supporting evidence.

Yeah, you're right - I don't find myself convinced by that type of "evidence."

ed|9.20.07 @ 1:16PM|#

It's ok. NHS has taken decades to get this fucked up. Hillary will last only 4-8 years if the End Times come and she's elected. That's about 10,000 times longer than the average American's attention span, and only twice as long as the next OJ trial. In other words, we'll have higher priorities.

|9.20.07 @ 1:18PM|#

This thread is amazing.

Socialist health system + smoker + procedure denied = too good to check.

Jennifer|9.20.07 @ 1:20PM|#

The doctors - the ones who evaluated him and know his condition - judged the benefits and risks from his surgery and made a medical judgement.

And even though the man is a grownup who pays taxes into that system, he cannot be trusted to make for himself the decision: "Is it worth the risk of surgical complications to get rid of the pain from my ankle?" How ridiculous to think the sufferer himself should have any say in this.

Jennifer|9.20.07 @ 1:23PM|#

I guess the doctors aren't too worried about the risks of the guy getting hooked on the painkillers he's taking in lieu of the surgery, though.

|9.20.07 @ 1:24PM|#

No, Jennifer.

People who pay taxes do not, as a matter of fact, have the knowledge to judge the chances of a medical intervention's success, or the likelihood of it causing greater problems.

|9.20.07 @ 1:24PM|#

I guess not.

|9.20.07 @ 1:25PM|#

Fair point, Jennifer. But insurance companies make decisions according to exactly the same logic...

|9.20.07 @ 1:25PM|#

Funny, just yesterday, someone was complaining about socialist health care leading patients to demand drugs and treatment when it isn't called for.

Anything for the cause.

Paul|9.20.07 @ 1:26PM|#

They did set his bones - the put him in a cast. The doctors - the ones who evaluated him and know his condition - judged the benefits and risks from his surgery and made a medical judgement.

joe, you are absolutely correct. But you're sidestepping the issue here. Choice. Once the public pays for all healthcare, the public chooses who to treat. The very reason that most libertarians abhor a fully publicly funded healthcare system is that we don't want to have to pay for our neighbors bad choices. I'm assuming that you read the article, and what becomes very clear, very fast is that this man could get the surgery he needs if he quits smoking long enough to satisfy the medical opinion of the doctors.

The rut that one gets into with publicly funded healthcare is that as a libertarian, when we do get our publicly funded system (and we will, believe you me) I'm going to be at the front of the crowd demanding limitations to care because I don't want to pay for your unhealthy choices. It's the natural outcome of anything publicly funded.

|9.20.07 @ 1:28PM|#

Most important, David S:

Doctors make exactly the same judgements based on medical criteria.

Do you have any idea, Jennifer, how often ER doctors have to deny people who really, really want antibiotics or some wonder drug they saw in an ad, because it isn't medically called for?

Look, I'm not a doctor, so I'm not going to second guess their medical judgement. But it's pretty freaking obvious that it was a MEDICAL JUDGEMENT. Even if you really hate socialized medicine and anti-smoking campaigns.

Just too good to check.

|9.20.07 @ 1:28PM|#

Paul - isn't it the natural outcome of any system for pooling risk - whether public or through a private insurance scheme?

|9.20.07 @ 1:29PM|#

Paul,

The doctors - not the public, not bureaucrats, the doctors who handled his case - decided who to treat, and how to treat him.

Sounds about right to me.

robc|9.20.07 @ 1:29PM|#

joe,

People who pay taxes do not, as a matter of fact, have the knowledge to judge the chances of a medical intervention's success, or the likelihood of it causing greater problems.

That is beside the point. It is a surgery on himself, it is his decision to make, even if he isnt qualified to judge. Now, in a free market health care system, he might not find a doctor to do it, so Im not dissing on doctors for saying no.

The point is that ALL systems have gatekeepers, most of us would prefer free market gatekeepers, not government gatekeepers.

Jennifer|9.20.07 @ 1:30PM|#

Fair point, Jennifer. But insurance companies make decisions according to exactly the same logic...

Refusing to pay premiums to an insurance company you don't like is, I'd guess, easier than refusing to pay taxes to a government-run healthcare program you don't like.

I wonder what other medical decisions will be based on lifestyle choices? Don't treat STDs in sexually promiscuous people, because they'll probably just get infected again? Don't waste precious blood transfusions on athletes, who are more likely to suffer injuries than more sedentary folk? Don't do heart surgery on fatties?

People who pay taxes do not, as a matter of fact, have the knowledge to judge the chances of a medical intervention's success, or the likelihood of it causing greater problems.

I never said they did; I said grownups should be allowed to decide for themselves whether or not they're willing to take that risk. But I am not surprised that you'd promote stifling individual freedom of choice in the name of "experts agree."

Russ 2000|9.20.07 @ 1:35PM|#

When you become a government doctor, the Bureaucratic Oath trumps the "To keep the good of the patient as the highest priority" portion of the Hippocratic oath.

|9.20.07 @ 1:36PM|#

Would a 57 year old ex-builder, unable to work because of smoking related chest problems, get better care with pure market provision?

Presumably, this guy would be looking to the state for his treatment in any developed country, including the US. And if the state didn't step in, he'd be completely screwed.

|9.20.07 @ 1:37PM|#

robc,

There is no - none, zero, zip, zilch - evidence that there WAS any government gatekeeping going on. The doctors used their medical judgement, and decided that the surgery would likely do him more harm than good.

The fevered imaginings of government gatekeeping going on in this post are wholly without support. They are ideological artifacts from people who got taken in because the story had a political angle.

Jennifer|9.20.07 @ 1:38PM|#

There is no - none, zero, zip, zilch - evidence that there WAS any government gatekeeping going on. The doctors used their medical judgement, and decided that the surgery would likely do him more harm than good.

So these were private doctors not on the government payroll?

|9.20.07 @ 1:38PM|#

Jennifer,

What caliber of pistol do you think we should hold to these doctors' heads when forcing them to violate their hippocrtic oath?

Don't lecture me on individual choice, when you are so plainly contemptuous of those who exercise it in a manner you disapprove of.

|9.20.07 @ 1:40PM|#

No reputable surgeon will treat an non-life threatening illness if there's a good chance that the patient will end up dead.

Episiarch|9.20.07 @ 1:40PM|#

joe, looks like being obnoxious isn't just a fluke from yesterday, but is now your modus operandi. Doesn't surprise me, as it's just the real you, but whatever.

You have a touching faith in elites and authority figures, including doctors. No wonder you are a collectivist and authoritarian.

But it doesn't change the fact that it's the guy's body and he should be able to risk amputation to relieve the pain. It's not like the doctors are refusing because he might die and they don't want his death on their hands.

And you might want to consider that the NHS may be calculating that if he does have an amputation, it will cost them tons for prosthetics and rehabilitation. Morphine is cheap.

|9.20.07 @ 1:41PM|#

Jennifer,

So these were private doctors not on the government payroll?

I love it when you write arguments that highlight their own indefensible underpinnings.

Because they work for the NHS, they can't possibly make medical decisions based on medical criteria.

As a matter of fact, Jennifer, they laid out their medical reasoning quite plainly. It is supported by medical facts that physicians are quite familiar with. None of that goes away because of whom the doctors work for.

|9.20.07 @ 1:42PM|#

There's a TV show about the Brookhaven obesity clinic. There are people there who need surgery but can't be operated on until they lose weight. They're willing to let a patient lose a leg before they'll let them die on the operating table.

Paul|9.20.07 @ 1:43PM|#

The doctors - not the public, not bureaucrats, the doctors who handled his case - decided who to treat, and how to treat him.

Sounds about right to me.

With all due respect, joe, I don't believe you. How many times have we here in the states been treated to cases of a doctors "decision" not to treat a patient where the follow-up investigation "proved" that it might have been because the patient had no insurance.

So this brings us to an interesting juncture. If a patient was turned away in an american hospital, and we got nine yards of sob-story from the media, it was the evil capitalist US healthcare system. If the NHS turns away a patient, and the British press prints nine yards of sob-story, it's just an overactive press strumming at our heartstrings?

|9.20.07 @ 1:43PM|#

Episiarch - so you phone up your insurance company and go "look, the doctors have told me procedure x is a bad idea, but I fancy having a go anyway... you'll pay for it, won't you?"?

Jennifer|9.20.07 @ 1:44PM|#

No reputable surgeon will treat an non-life threatening illness if there's a good chance that the patient will end up dead.

We're not talking about someone refusing to give a boob job to a person allergic to anesthesia. We're talking about doctors requiring a man to live in guaranteed pain because they can't absolutely guarantee a lack of surgical complications. By that standard, doctors should refuse to do any non-emergency surgery at all. After all, if you go under anesthesia there's a risk you'll never wake up.

Don't lecture me on individual choice, when you are so plainly contemptuous of those who exercise it in a manner you disapprove of.

No, what I disapprove of is an individual making the choice for another individual.

|9.20.07 @ 1:44PM|#

When I RTFA'd I couldn't get past the photos.

Party on, Garth!

|9.20.07 @ 1:45PM|#

Refusing to pay premiums to an insurance company you don't like is, I'd guess, easier than refusing to pay taxes to a government-run healthcare program you don't like.

Quoted simply to catalogue joe's being pwned.

What caliber of pistol do you think we should hold to these doctors' heads when forcing them

Oh the irony. Silly joe...the easy answer is a rifle...after all, that's what the government uses to force these doctors to work.

|9.20.07 @ 1:46PM|#

Quite whining, Episiarch. It just advertises that you can't hold up your end of the argument.

But it doesn't change the fact that it's the guy's body and he should be able to risk amputation to relieve the pain. And it's the physicians' bodies, and practices, and they should be able to treat patients according to their best medical judgement.

It's not like the doctors are refusing because he might die and they don't want his death on their hands. Actually, it is. It's exactly like that.

And you might want to consider that the NHS may be calculating that if he does have an amputation, it will cost them tons for prosthetics and rehabilitation. And you might want to consider that the political convenience of an argument doesn't make it true.

Do have anything - anything - to back up your gut feeling that there just hadda be something other than the doctors' medical judgement influencing their decision? Anything at all - other than "wouldn't it make my case well if...?"

No. You don't.

|9.20.07 @ 1:47PM|#

I can't wait for commie-socialist HillaryCare(tm) because then I can have all of the free recreational ankle surgeries that I want!

|9.20.07 @ 1:47PM|#

If a patient was turned away in an american hospital, and we got nine yards of sob-story from the media, it was the evil capitalist US healthcare system. If the NHS turns away a patient, and the British press prints nine yards of sob-story, it's just an overactive press strumming at our heartstrings?

Or, alternatively, if Michael Moore comes over all-simplistic about wonderful US capitalist health care, then that's an outrage... but if Reason does the same to the evil socialist system, then that's fighting the true fight...

Episiarch|9.20.07 @ 1:47PM|#

Episiarch - so you phone up your insurance company and go "look, the doctors have told me procedure x is a bad idea, but I fancy having a go anyway... you'll pay for it, won't you?"?

Actually, DavidS, I was in that exact situation. A NHS doctor told me flat out I would not be operated on if he had his way. I went back to the US, got the best doctor in NYC, and my insurance paid for it even though foot operations carry some risk. I chose to take that risk.

So to answer your question: YES.

|9.20.07 @ 1:47PM|#

Jennifer,

No, what I disapprove of is an individual making the choice for another individual.

You don't seem to disapprove of making the decision for these doctors.

|9.20.07 @ 1:49PM|#

Keep in mind that if the guy stopped smoking, they'd be willing to perform the operation.

In other words, he's getting sound medical advice that he refuses to follow. How this is the doctors' fault I have no idea.

So why doesn't he just stop smoking if the pain is so bad?

|9.20.07 @ 1:50PM|#

Not just the doctors' fault, Dan.

The bureaucrats who, er, um, don't seem to have played any role in the decision whatsoever.

ed|9.20.07 @ 1:51PM|#

I would pay American dollars to see joe and jennifer slug it out in a caged death match. My money is on the redhead. Unless joe also has red hair, then not.

Jennifer|9.20.07 @ 1:51PM|#

You don't seem to disapprove of making the decision for these doctors.

And of course, you see no difference in the two situations: individual choosing for himself whether to assume a risk, versus individual with a degree of authority choosing whether another invidiual may assume a risk. Exactly the same.

Russ 2000|9.20.07 @ 1:51PM|#

I may be a hateful prick, but even I wouldn't wish national health care on joe.

|9.20.07 @ 1:52PM|#

Lucky man, Episiarch. I am currently doing battle with an insurance company that doesn't want to pay for a treatment even though my doctor has recommended it.

Jennifer|9.20.07 @ 1:52PM|#

I would pay American dollars to see joe and jennifer slug it out in a caged death match. My money is on the redhead. Unless joe also has red hair, then not.

You'd be cheated out of good money. All he'd do is whine about my sex life and then demand an apology.

|9.20.07 @ 1:54PM|#

More fundamentally, if people pay for medical care out of their own pockets, they are less likely to be viewed as public enemies when they fail to be as healthy as they can be.

I dunno, the public is likely to feel some resentment at having to step over the cold, stiff bodies of those who came up a little short on ambulance fare every time they walk down the street...

Episiarch|9.20.07 @ 1:55PM|#

joe, you keep sucking the dicks of experts. I'd prefer to make my own decisions regarding my own body, especially if I have been forced to pay into the system that will perform the surgery and now want some service for my money.

Ever had broken bones grating against one another for hours, joe? It is fucking horrible. I can't even imagine years.

|9.20.07 @ 1:56PM|#

this is classic pro-capatalist propaganda. the idea that government restricts our choices and our individualism, the myth of a totalitarian style big brother government will result from entrusting the government with the public good.

of course the abuse of power is a looming threat. read Madison's federalist papers, this is exactly why there are internal controls on government. the idea that the free market is going to provide a better, more equitable service is just foolish. corporations have NO internal mechanisms of control. their only motivation is to increase profit in every fiscal quarter.

it is nothing but sheer misinformation and manipulation that has led to the idea that the free market and the private sector can better serve the public good. by demonizing the government in the public eye, big business has weakened the only institution in existence which can possibly hope curtail the rapid exploitation of the people and resources of our nation.

Paul|9.20.07 @ 1:56PM|#

but if Reason does the same to the evil socialist system, then that's fighting the true fight...

Michael Moore's style and Reason's reporting are miles apart. We can disagree with Reason on intellectual grounds. Michael Moore is a charlatan and a liar.

If you flatter and fawn upon your potential audience, I might add, you are patronizing them and insulting them. By the same token, if I write an article and I quote somebody and for space reasons put in an ellipsis like this (…), I swear on my children that I am not leaving out anything that, if quoted in full, would alter the original meaning or its significance. --Christopher Hitchens

|9.20.07 @ 1:57PM|#

What Dan said. If there's some paradise somewhere where this unemployed and unemployable man would get all the care he needs, it can only be a country that spends more of its GDP on a socialized health system than the UK does.

|9.20.07 @ 1:58PM|#

Ever had broken bones grating against one another for hours, joe? It is fucking horrible. I can't even imagine years.

But not so horrible that a guy would give up cigarettes, it seems.

|9.20.07 @ 1:58PM|#

The person in question can always go to a private doctor and pay the market price.

VM|9.20.07 @ 1:58PM|#

Doctors at the Royal Cornwall Hospital in Truro have refused to operate because they say his heavy smoking would reduce the chance of healing, and there is a risk of complications which could lead to amputation.

Mr Nuttall, of Newlyn, Cornwall, broke the ankle in a fall in 2005. Initially he refused surgery because he had caught MRSA at a different hospital four years earlier, and was terrified of history repeating itself.

However, the hospital told Mr Nuttall, who no longer works because of smoking-related chest problems, that he would have to give up smoking before an operation could be carried out

What are the medical risks involved?

Why is he an inappropriate candidate for surgery now, when he wasn't earlier?

What particular role does smoking play in this (or what would change if he quit smoking - what are his "smoking-related chest problems"?)?

Could Frank_A help out hier with the medical issues, because there really isn't enough info about the medical decision making process really to offer an opinion either way...

Paul|9.20.07 @ 2:01PM|#

by demonizing the government in the public eye, big business has weakened the only institution in existence which can possibly hope curtail the rapid exploitation of the people and resources of our nation.

Crazy hippie:

You're absolutely right. It's called "public/private" partnerships, where governments control commerce and profit for the public good. As PJ O'Rourke said: When politicians control buying and selling, the first thing to be bought and sold are politicians.

Hey everyone, has anyone noticed that the www.nldc.org website is "under construction". Is that irony?

Paul|9.20.07 @ 2:02PM|#

The person in question can always go to a private doctor and pay the market price

Can they with the NHS? It's illegal to do so in Canada.

|9.20.07 @ 2:02PM|#

Michael Moore's style and Reason's reporting are miles apart. We can disagree with Reason on intellectual grounds. Michael Moore is a charlatan and a liar.

Reason is wonderful of course - but can be sloppy when, as Joe says, it chances upon a story that confirms everything it wants to believe about how benighted the rest of the world is.

The selective quote from the BMJ article is a good example of that.

BTW, just so I can disagree with everyone in this thread, Joe is quite wrong if he thinks money doesn't figure in a story like this one.

The NHS is supposed to run according to a weird mix of 'clinical and cost effectiveness'. It's a messy fudge, but find me a health system that isn't...

|9.20.07 @ 2:04PM|#

Yes

|9.20.07 @ 2:04PM|#

Yes, Brits can 'go private' and many do - lots of people have health insurance.

|9.20.07 @ 2:06PM|#

The doctors - not the public, not bureaucrats, the doctors who handled his case - decided who to treat, and how to treat him.

That is absolutely false.

joe you are very wrong on this one.

The doctors are required to follow the rules of the bureaucrats.

In this case, the doctors are doing a cost benefit analysis. That should not be their job. This is a burden that the system has placed on these doctors.

joe you seem to be arguing that the doctors believe that that the surgery isn't medically necessary. But that isn't the case at all.

The surgery is medically necessary, but because of his being a smoker, the doctors are getting into probability and statistics. There is a chance it might not heal, there is also a chance that it would.

Unless he was guaranteed to not have any chance at all of healing, then the patient should not be denied the treatment that is in fact medically necessary.

nobody|9.20.07 @ 2:06PM|#

I am currently doing battle with an insurance company that doesn't want to pay for a treatment even though my doctor has recommended it.

Translation: I have shitty insurance so I am in favor of universal shitty insurance.

VM|9.20.07 @ 2:07PM|#

but that (payment source) doesn't answer the question if the risks of surgery were so great that it wasn't indicated.

|9.20.07 @ 2:09PM|#

Insurance will only pay for what they consider customary and reasonable.

For instance, when I had my wisdom teeth removed, my insurance wouldn't pay for the anesthesia since they weren't impacted.

Jennifer|9.20.07 @ 2:09PM|#

I may be a hateful prick, but even I wouldn't wish national health care on joe.

He wishes it on you.

|9.20.07 @ 2:09PM|#

It's my impression that the number of people "going private" has increased over the last twenty of thirty years and that this is seen as a bad thing by some advocates for the NHS.

|9.20.07 @ 2:09PM|#

Unless he was guaranteed to not have any chance at all of healing, then the patient should not be denied the treatment that is in fact medically necessary.

Is that really how the US system works? Anyone has the right to any treatment that has a chance of being effective? Even unemployed and unemployable builders?

|9.20.07 @ 2:11PM|#

The surgery is medically necessary, but because of his being a smoker, the doctors are getting into probability and statistics. There is a chance it might not heal, there is also a chance that it would.

Unless he was guaranteed to not have any chance at all of healing, then the patient should not be denied the treatment that is in fact medically necessary.

What a bunch of crap - any doctor I hope would consider probablity of success when considering an operation, regardless of money. Wouldn't it be unethical to perform an operation that has a better chance of making a patient worse than making him better?

Paul|9.20.07 @ 2:11PM|#

The selective quote from the BMJ article is a good example of that.

DavidS. Ehh, that's a stretch. Reason links to original articles allowing those of us who care to read the original stuff in context.

And you're correct about your assessment of joe. I, libertarian to the core, believed the U.S. media stories in the eighties about Dr's decisions to "not treat" and move to another E.R. due to lack of insurance, even though it was still done under the guise of a medical decision (of course at least the person still got treatment, just delayed and possibly shoddy). So why would it be any bigger stretch to assume public monies don't account for anything here?

You know, I remember back in the late nineties there arose a minor kafuffle about grocery stores issuing 'club cards'. The theory was that with stores being able to track your purchases, we were on a slippery slope to the government (or insurance companies) using that data to limit treatment for people who weren't making healthy food choices. I thought it was a ridiculous reach at the time. Now? Not so much...

|9.20.07 @ 2:12PM|#

Unless and until it is illegal to sell tobacco products and to use them, and unless and until the British government denies ALL health care to smokers because they use an illegal product, British "subjects" (a telling term, is it not? No one would ever say American "subjects") should receive health care they pay for in taxes whether they smoke or not.

How is it medically "better" that the patient's broken bones are not treated, especially if the poor guy needs continual morphine sedation? If complications "might" demand amputation, they might not, right?

Dan T's snotty comments notwithstanding, Americans do not encounter "cold, stiff bodies of those who couldn't afford ambulence fare." Under our supposedly bad health care system, everyone gets "free" treatment in ERs, and EMT's don't ask for payment up front, or even if a person has insurance, before taking them there.

OD'ing heroin addicts receive treatment at American ERs. One wonders if they do in the UK, or whether tobacco use is now considered somehow worse. Anyone know?

|9.20.07 @ 2:12PM|#

It would be unethical and they'd have to face the wrath of their medical review board if the patient died. Doctors in the US routinely make these kinds of decisions.

Doctors are not like auto mechanics.

|9.20.07 @ 2:12PM|#

What caliber of pistol do you think we should hold to these doctors' heads when forcing them to violate their hippocrtic oath?

How many patients have died while undergoing expirimental or dangerous/risky surgery because there was a chance, even a slim one, that they might be better off having taken the risk?

Did all of those doctors violate their Hippocratic oath?

It seems you don't really understand the Hippocratic oath. It's about doing no harm, not "don't do anything that has any risks involved".

Every single time a surgeon operates there is a level of risk. This guy is no different except for the matter of degree.

Last time I checked, smokers all across the USA were going in for surgeries all the time, so the elevated risk factors obviously aren't that great on their own to prevent doctors from performing medically necessary procedures. That seems to indicate that there is something else at play here other than merely the doctors making a medical decision

VM|9.20.07 @ 2:14PM|#

Chicago Tom - how do you know?

there's not enough info about what was medically wrong to see how/if/where this case demonstrates failure.

we do not know what the guy has that all of a sudden makes the surgery, which he qualified for earlier, inappropriate.

|9.20.07 @ 2:14PM|#

How many patients have died while undergoing expirimental or dangerous/risky surgery because there was a chance, even a slim one, that they might be better off having taken the risk?

Only life threatening conditions.

Paul|9.20.07 @ 2:15PM|#

How many patients have died while undergoing expirimental or dangerous/risky surgery because there was a chance, even a slim one, that they might be better off having taken the risk?

Non-fda approved AIDS drugs, anyone?

|9.20.07 @ 2:17PM|#

AIDS is a life-threatening condition.

And Insurance doesn't pay for experimental treatments.

|9.20.07 @ 2:18PM|#

What a bunch of crap - any doctor I hope would consider probablity of success when considering an operation, regardless of money. Wouldn't it be unethical to perform an operation that has a better chance of making a patient worse than making him better?

Not at all, not if the patient knows the risks and decides to take the risk.

Of course doctors should consider the probability of success, but where does one draw the line and who decides it? What probability of success would you require before you allow treatment to go forward? 50%? 40%? 30%?
Shouldn't the person who has to live with any condition get a say? If I am willing to roll the dice after being told that I only have a 10% chance of success shouldn't I be allowed the opportunity if I want it?

Any procedure involves a level of risk. Any time you go under the knife you run the risk of infection and death on the operating table. That is for me to decide, not you or the doctor or the beurocrats.

The only thing the doctor should be deciding is what is an appropriate treatment and what is necessary to fix what ails me. The doctor should also be telling me about the risks involved and then allowing me to make an informed decision.

|9.20.07 @ 2:20PM|#

Does anyone seriously believe that this guy couldn't get the surgery done here in the States? That this is so obviously a bad risk that not one single physician, exercising independent judgment, would take it on?

joe seems to believe that this is an open and shut clinical case, that all doctors would agree. That just shows how many doctors joe knows, and how unacquainted he is with both (a) their egos and (b) their greed.

I guarantee you that I would not have to ask more than three orthopedic surgeons before I found one who would take this case, because (a) every surgeon is a genius who can beat the odds and (b) every surgeon has payments to make on both his own Mercedes, but also those of his wife, mistress, and ex-wife.

|9.20.07 @ 2:21PM|#

I guess a captial "L" Libertarian would allow any body (no medical license required) to perform surgery ?

You'd simply pick the person with the cheapest rates and maybe the best success rates to operate .

|9.20.07 @ 2:21PM|#

Jennifer,

And of course, you see no difference in the two situations: individual choosing for himself whether to assume a risk, versus individual with a degree of authority choosing whether another invidiual may assume a risk. Exactly the same.

The doctors are choosing whether this individual will assume that risk. They are choosing whether they, themselves, are going to perform the procedure.

Why don't you want doctors to decide what procedures to perform, Jennifer? Is is because you hate freedom?

Jennifer|9.20.07 @ 2:21PM|#

we do not know what the guy has that all of a sudden makes the surgery, which he qualified for earlier, inappropriate.

All the doctors said was that he needs to stop smoking: "his heavy smoking would reduce the chance of healing, and there is a risk of complications which could lead to amputation."
Though the article said nothing about similar conditions being imposed on him two years previous, when he first broke his ankle.

There is always "a risk" in any surgery. And almost anything will "reduce the chance of healing." I'm a little bit underweight; that will probably put me at greater risk than if I had a couple extra pounds on me. Nonetheless, I'd have a low opinion of a doctor who said "To increase the chance of success, we're going to refuse surgery and make you continue living in pain until you put on five pounds. And not with unhealthy foods, either. Eat an extra thousand calories' worth of vegetables every day, and come see us again when you've gained a couple of dress sizes."

Meanwhile, the woman who's five pounds overweight is at increased risk, too. So she has to live in pain until she loses those five pounds. And her husband needs to stop knocking back a beer every night when he comes home from work. And their son needs to give up his reckless skateboarding hobby. . . .

|9.20.07 @ 2:22PM|#

er, the doctors are NOT choosing whether he assumes that risk.

|9.20.07 @ 2:23PM|#

That is absolutely false.

joe you are very wrong on this one.

I was about to point out this wonderful little vacuum of a world in joe's head where these doctors seem to live, untouched by any contamination from the NHS, where their experiience is always one of pure medicine and none of a predisposed bias from lessons learned....

When ChicagoTom did it for me.

All the rest, about their supposed agenda, is made up. Imaginary. Incredibly convenient assumptions by people who are themselves pushing an agenda. Wholly without any supporting evidence.

Hmmm, it seemed to be a unique and outragous enought of a situation for it to be deemed news by the Daily Mail in merry ol'. Maybe they know something you don't?

|9.20.07 @ 2:23PM|#

we do not know what the guy has that all of a sudden makes the surgery, which he qualified for earlier, inappropriate.

VM,

the remedy never became inappropriate. There is a particular way to treat broken bones.

The only thing that changes are the probability of successful healing because of the patients smoking.

That doesn't mean that the treatment is inappropriate. Just that it might be less effective

|9.20.07 @ 2:23PM|#

Episiarch,

I'd prefer to make my own decisions regarding my own body

So would these physicians. They're not your slaves. They're not his slaves.

Jennifer|9.20.07 @ 2:23PM|#

Shouldn't the person who has to live with any condition get a say?

According to Joe's 2:21 post, no. Because that is antithetical to freedom.

Bill Pope|9.20.07 @ 2:25PM|#

The problem with private gatekeeping is that the profit motive will continue to deny "choice" to the chronically ill. Private insurers will not cover them unless forced to, and even then they have a big incentive to treat them poorly in the hope they will become someone else's problem. Health care is the ultimate market failure.

|9.20.07 @ 2:25PM|#

Jennifer, should anyone be allowed to be practice medicine ? That would be the ultimate freedom, right ?

|9.20.07 @ 2:26PM|#

Chicago Tom,

No, YOU are wrong. You wrongfully assume that the cost-benefit analysis the doctors are doing is based on finances, when in fact, it is based on medical considerations, as it should be: they consider the potential benefits and the likelihood of success, and the potential harms and the likelihood of failure.

You, and Sullum, and the blogger he links to, and everyone else imagining a financial calculus into this story are hallucinating. There is not the slightest whit of evidence that this was anything but a medical decision, and clear and defensible explaination of what went into that medical decision.

|9.20.07 @ 2:27PM|#

When I RTFA'd I couldn't get past the photos.

Party on, Garth!

You aren't kidding! I couldn't get past the photos of Nigella and her flimsy dress. :::sigh:::

|9.20.07 @ 2:27PM|#

Nobody still has addressed the fact that the patient here has chosen to not follow the medical advice of the doctors and stop smoking so the procedure can be done.

|9.20.07 @ 2:29PM|#

Unless he was guaranteed to not have any chance at all of healing, then the patient should not be denied the treatment that is in fact medically necessary.

That is not even remotely how physicians decide whether to perform a surgery. They weigh REWARDS AND RISKS.

Paul|9.20.07 @ 2:29PM|#

And Insurance doesn't pay for experimental treatments.

I know, Tim, my point was it doesn't stop a whole host of people clamouring for them to do so.

As we speak, there are a whole bunch of people that want insurance companies to provide treatments that don't do anything.

But I guess providing a treatment that can't do any harm [or good] is better than providing one that might...

)))|9.20.07 @ 2:30PM|#

hasn't this guy been paying extra taxes on his smokes because of smokers extra burden on the health care system. I know I've been paying extra taxes on my smokes for years for that reason. the extra cost issue has been dealt with and shouldn't be considered in the decision to treat or not treat.

Episiarch|9.20.07 @ 2:31PM|#

So would these physicians. They're not your slaves. They're not his slaves.

No, except he cannot go to another doctor within the system he has paid into. Even if there were other doctors within the sysem that would be willing to treat him, the NHS says no. He doesn't have the money to go to a non-NHS doctor, he paid into the NHS in good faith, and now he's fucked.

I love how liberals like you are for the poor until the poor run afoul of one of your "big ideas", and then they are just grist for the mill. They're getting in the way of progress, so fuck 'em.

|9.20.07 @ 2:33PM|#

No, YOU are wrong. You wrongfully assume that the cost-benefit analysis the doctors are doing is based on finances, when in fact, it is based on medical considerations, as it should be: they consider the potential benefits and the likelihood of success, and the potential harms and the likelihood of failure.

Bullshit joe.

How do you know that what I believe is wrong? Becuase it doesn't say so in the article?

It is not based solely on medical considerations. If it were, he would be getting the surgery because it is medically appropriate, regardless of the probability of success.

The doctor's medical considerations should be to tell the patient what treatments are available/necessary and what the risks are and let the patient decide for themselves what risks they want to assume.

But since they are denying him, either the doctors or someone from above is making considerations other than medical and imposing them on this person.

Paul|9.20.07 @ 2:33PM|#

Health care is the ultimate market failure.

Would that be one of those market failures where the market careens closer to failure the more government regulation and price controls are place upon it?

|9.20.07 @ 2:34PM|#

Chicago Tom,

How many patients have died while undergoing expirimental or dangerous/risky surgery because there was a chance, even a slim one, that they might be better off having taken the risk? Many. Almost all of them from the underlying fatal disease which is a prerequisite for doctors prescribing a dangerous, risky course of treatment. Once again, risk-reward analysis.

Did all of those doctors violate their Hippocratic oath? No, because giving a patient a chance of death instead of the certainty of death is not harming him. Risking a patients' death or amputation to solve a less serious problem, especially when there is a good chance it won't work anyway, is a violation of the Hippocratic Oath.

Episiarch|9.20.07 @ 2:35PM|#

As stated above, if this had been a US private HMO doing the refusing, you'd be screaming about the profit motive. But NHS bureaucrats? It's un-possible!

|9.20.07 @ 2:35PM|#

In this case the patient simply has to quit smoking. Same thing if he was morbidly obese or an alcoholic. Both of those conditions will also preclude treating non life threatening conditions.

|9.20.07 @ 2:37PM|#

That is not even remotely how physicians decide whether to perform a surgery. They weigh REWARDS AND RISKS.

joe is it your position that physicians do not perform risky surgeries with low chances of success despite the patient wanting it?

is it your position that the only one who gets to weigh risk / rewards are doctors and not the patient?

if either of these are your positions you couldn't be more wrong.

|9.20.07 @ 2:37PM|#

ChicagoTom,

Of course doctors should consider the probability of success, but where does one draw the line and who decides it? What probability of success would you require before you allow treatment to go forward? 50%? 40%? 30%?
Shouldn't the person who has to live with any condition get a say?

That is a reasonable position, but it is an argument against how doctors practice medicine, not a national health system. Doctors in the free market US applied the same risk/reward analysis when deciding whether to operations in the 1890s, too.

|9.20.07 @ 2:41PM|#

RC Dean,

joe seems to believe that this is an open and shut clinical case, that all doctors would agree. Actually, no, I don't. I said the doctors' decision was reasonable, defensible, and based on medical criteria. It might be the right medical decision, it might not. The only point I've argued is that they made it based on medical criteria, and the boogeymen of anti-smoking ideology and socialist rationing is wholly without evidence.

Maybe the guy could find a doctor in the US with a different medical opinion. Maybe he could find a different doctor in the UK. If he did, it would be one doctor making a medical judgement that contradicts another doctor's medical judgement.

I'm not the one passing judgement on the quality of their medical judgement here, or asserting that I know better than them what the right treatement is. That would be Jennifer.

|9.20.07 @ 2:42PM|#

No, because giving a patient a chance of death instead of the certainty of death is not harming him. Risking a patients' death or amputation to solve a less serious problem, especially when there is a good chance it won't work anyway, is a violation of the Hippocratic Oath.

joe, despite what you keep implying, the odds of this man healing and not healing are much higher than the odds of requiring an amputation. It's not merely it works or it gets amputated.

So if let's say I have a 40% chance of healing, and a 40% chance of not healing properly and a 20% chance of amputation, and I am willing to take that risk, shouldn't I be provided with the treatment? Shouldn't the patient have quite a bit of say over the amount of risk (s)he is willing to take on?

Why should the doctor make that decision for me? It's my life and my body, and I will decide when I will risk life and limb once I know all the facts. Why is that so abhorrent to you

Paul|9.20.07 @ 2:44PM|#

If it were, he would be getting the surgery because it is medically appropriate, regardless of the probability of success.

Have to agree with Chitown-Tom on this one, joe. You're conflating "medically appropriate" with "risky".

According to the article: John Nuttall, 57, needs surgery to set the ankle which he broke in three places two years ago because it did not mend naturally with a plaster cast.

Assuming the reporter who penned the article isn't lying, then the surgery is medically necessary. Risky? Yes, but medically necessary.

|9.20.07 @ 2:44PM|#

This whole debate is really kind of looney.

People seem to really be suggesting that there is a possible scenario where unemployed people with no money could be able to demand medically irresponsible procedures but yet not bother to follow the medical advice that would make the procedure doable. And that doctors would go along with it, somehow.

I mean, really, folks. Libertarians will take a few good ideas and stretch them to such absurd lengths it makes me think you don't really want them implemented. What would you do with your time if you didn't have a government program to blame everything on?

|9.20.07 @ 2:44PM|#

That is a reasonable position, but it is an argument against how doctors practice medicine, not a national health system.

joe you have me confused with other people.
I am not arguing either for or against a national system. I actually lean towards supporting a Single Payer system.

I am arguing against doctors taking liberties and not allowing me, as an adult, to make my own medical decisions once I have all the facts.

Episiarch|9.20.07 @ 2:45PM|#

Risking a patients' death or amputation to solve a less serious problem, especially when there is a good chance it won't work anyway, is a violation of the Hippocratic Oath.

You really have no idea what you are talking about. Pain is harm. Morphine (have you ever used it for pain, joe? I have) does not magically take pain away. It counters pain with pleasure. It is merely a counterbalance. The pain is still there, but masked enough to be bearable.

Pain stresses your body, even on morphine. It is very bad for you, and can make your life much more unbearable than losing a foot.

Keep digging your hole, joe.

|9.20.07 @ 2:45PM|#

JW,

Any time you can show me the slightest bit of evidence for your case, you just go right ahead.

But you can't, because there isn't any. You just assume that there must be, because wouldn't it be totally awesome if there was?

|9.20.07 @ 2:47PM|#

Assuming the reporter who penned the article isn't lying, then the surgery is medically necessary. Risky? Yes, but medically necessary.

Exactly. Once it has been deemed medically necessary, then the doctors "say" in the matter is done. It isn't up to the doctor to decide what kind of risks i am willing to take and whether I want to smoke during my rehab. His role is to tell me the risks and recommend action. Not to black male me into changing my lifestyle.

|9.20.07 @ 2:48PM|#

Conversation in a free-market system:
"Fred, you really should quit smoking. It's going to reduce the chances of recovering from this broken ankle."
"I'll try, doc. But I'd like to have the surgery, because this pain is killing me. I'll take my chances. And since I'm paying you, I'll elect to have the surgery."

Conversation under bureaucratic/socialized medicine:
"Fred, you smoke and so fuck it. That goes against the rules written by our masters that we have to follow. Here are a shitload of pills."
"Fuck you, Doc."
"No, fuck you, Fred. Smoker. Asshole."

|9.20.07 @ 2:50PM|#

Episiarch,

How do you know this guy is poor? Aw, don't worry about it, there isn't any content to that part of your comment anyway.

The first paragraph, on the other hand - the one with a subject beyond "joe is a bad person, because he's not a libertarian" - raises a good point about the inability to get a second opinion in the NHS. If it's true. But, regardless, that also has nothing to do with the unsupported, evidence-free, too-good-to-check assumption that the doctors did not make their decision bases on their best medical judgement.

|9.20.07 @ 2:51PM|#

His role is to tell me the risks and recommend action.

And his recommended action is to stop smoking.

|9.20.07 @ 2:52PM|#

Chicago Tom,

joe, despite what you keep implying, the odds of this man healing and not healing are much higher than the odds of requiring an amputation.

Um, excuse me, but how did you get hold of this gentleman's medical records? And do you, ChicagoTom, MD, feel that it's appropriate to make such a statement about a patient you've seen in person?

|9.20.07 @ 2:52PM|#

er, "never seen in person."

|9.20.07 @ 2:52PM|#

Maybe he could find a different doctor in the UK. If he did, it would be one doctor making a medical judgement that contradicts another doctor's medical judgement.

Except that in the UK all the doctors have to live by the same rules right?

I am gonna assume that the reason this episode is newsworthy is because this guy can't just go to another doctor in the UK at this point, is that a fair assumption??

There may not be a smoking gun here, but there is a lot of circumstantial evidence that the decision to deny him surgery is based on more than just "medical considerations"

ed|9.20.07 @ 2:52PM|#

As an aside, I believe American doctors do the same thing when choosing organ transplant recipients. If the guy in line for a liver is an alcoholic or simply refuses to stop drinking, they'll take him off the list. At least that's what happened on Scrubs.

|9.20.07 @ 2:54PM|#

Episiarch,

As stated above, if this had been a US private HMO doing the refusing, you'd be screaming about the profit motive. But NHS bureaucrats? It's un-possible!

I'm sure it makes you feel good to think so.

Tell me, what's harder - reading people's thoughts over the internet, or across the Atlantic? You should know; you've done both today.

|9.20.07 @ 2:54PM|#

Um, excuse me, but how did you get hold of this gentleman's medical records? And do you, ChicagoTom, MD, feel that it's appropriate to make such a statement about a patient you've seen in person?

Yes joe, I feel very confident in my medical diagnosis.

I have a doctor in my family as well as an orthopod who is a very good friend of mine and my wife. I also had this discussion with my orthopod when I had ACL replacement.

So fuck you joe and your "if you aren't a doctor, shut up" attitude.

the odds of "amputation" being required are very low.

Jennifer|9.20.07 @ 2:55PM|#

Interesting quote from Joe on a thread dated August 5, 2007 and titled "Yes, there was a GOP debate":I want everyone to have access to decent health care without having people go broke, and I'm not overly concerned with ideologically-based statements about why we musn't make that happen.

Providing access to decent health care should be quite simple and very affordable, if we redefine "decent" to mean "refusing ankle surgery to a man who is in agonizing pain and currently unable to walk without a cane."

|9.20.07 @ 2:55PM|#

Conversation in a free-market system:

"Fred, you really should quit smoking. It's going to reduce the chances of recovering from this broken ankle."

"I'll try, doc. But I'd like to have the surgery, because this pain is killing me. I'll take my chances. And since I'm paying you, I'll elect to have the surgery."

"Well, okay, I guess."

"By the way, Doc, I want this surgery done in my bedroom instead of the hospital. And I'd like to drink bourbon during the procedure."

"That sounds like a very dangerous idea. Operating in an unsterile environment carries many risks."

"Do you want to get paid or not? My body, my choice, fascist!"

|9.20.07 @ 2:55PM|#

CTom,

I know that what you say - that medical practice doesn't involve consideration of the risks of a course of treatment - is wrong, because I know doctors, and they have told me. They consider the risks all the time, and choose not to perform treatments they deem unjustified on those grounds, all the time.

|9.20.07 @ 2:57PM|#

Tom, you are wrong on the facts.

Do you know any doctors?

If you do, ask him.

You are incorrect.

|9.20.07 @ 2:57PM|#

I wish to fully support ChicagoTom's comments in this thread.

ChicagoJason

|9.20.07 @ 2:58PM|#

If there's one thing that will absolutely enrage a doctor is to tell them how to do their job.

If you don't like it. Go to Mexico and have a back alley operation.

|9.20.07 @ 2:58PM|#

They consider the risks all the time, and choose not to perform treatments they deem unjustified on those grounds, all the time.

That explains why there are no boob implants anymore. I was wondering why.

poco|9.20.07 @ 2:59PM|#

Yes, Brits can 'go private' and many do - lots of people have health insurance.

E.g., BUPA, and is often (usually?) paid for by employers.

From the hilarious, highly recommended early '80s novel Secret Diary of Adrian Mole Aged 13 3/4:

I have had a letter from the hospital to say that I have got to have my tonsils out on Tuesday the 27th. This has come as a complete shock to me! My father says I have been on the waiting list since I was five years old! So I have had to endure an annual bout of tonsillitis for nine years just because the NHS is starved of finance!...I will get a paper round [route] and go private... I am joining BUPA as soon as they'll have me.

|9.20.07 @ 2:59PM|#

You too, Episiarch. You are wrong on the facts. Doctors refuse treatement on the grounds of it doing more harm than good all the time.

You don't know what you're talking about. You're justing assuming incorrect facts in order to buttress your case.

This is the last comment I'm making on the subject.

|9.20.07 @ 3:00PM|#

I know that what you say - that medical practice doesn't involve consideration of the risks of a course of treatment - is wrong, because I know doctors, and they have told me. They consider the risks all the time, and choose not to perform treatments they deem unjustified on those grounds, all the time.

Are you purposely being obtuse?

I never said "that medical practice doesn't involve consideration of the risks of a course of treatment" so please stop wasting your time arguing against things I didn't say.

But it isn't only up to the doctor. if a patient knows the risks and is willing to take them, the system as a whole should not lock this person out of it.

Sure any doctor is free to opt out of doing a surgery for whatever reason they want. But that isn't what we are talking about. We are talking about a system that is refusing to let any doctor do the surgery because the system has deemed his lifestyle to risky.

Further

|9.20.07 @ 3:01PM|#

Tom, you are wrong on the facts.

Do you know any doctors?

If you do, ask him.

You are incorrect.>

Oh I can play this game too.

Joe, you are wrong on the facts.

Do you know any doctors?

If you do, ask him.

You are incorrect.

Episiarch|9.20.07 @ 3:01PM|#

Tell me, what's harder - reading people's thoughts over the internet, or across the Atlantic? You should know; you've done both today.

Yes, of course, my having been in nearly the identical situation as this man means I have no clue what is going on.

My having a foot operation and having the doctor explain the chances of amputation (which are very low) to mean means I have no insight into this situation.

My personal experience with the NHS for this exact same thing means I know nothing.

Yet you, who has refused to address every question I have posed to you regarding your experiences with surgery, morphine, etc. (which leads me to believe you ahve no experience) know that there is no money consideration.

It must be great to be you, joe. Knowing everything would be wonderful.

|9.20.07 @ 3:02PM|#

Why don't you ask your doctor friend how often he makes diagnoses on people he has never laid eyes on, ChicagoTom.

This man is not you, with our ACL situation. He is an individual patient with an individual set of circumstances. Doctors make their decisions on a case-by-case basis.

|9.20.07 @ 3:03PM|#

JW,

Any time you can show me the slightest bit of evidence for your case, you just go right ahead.

But you can't, because there isn't any. You just assume that there must be, because wouldn't it be totally awesome if there was?

Gosh joe, I wonder if there anything in the article that is proof that it wasn't based on the doctors' previous experience in deasling with the NHS that would lead them to that conclusion.

Hrrrmmm...reading....reading...nope. Nothing says that. Not at all.

Whaddya know. My complete lack of evidence is just as valid as your complete lack of evidence.

|9.20.07 @ 3:04PM|#

Jennifer,

I'll see your "walk with a cane," and raise you amputation. I win! I win

Why do you want this man to lose his leg, Jennifer? Why?

Retreat to appeals to emotion much?

|9.20.07 @ 3:05PM|#

Still...nobody has addressed the fact that the patient here has chosen to not follow the medical advice of the doctors and stop smoking so the procedure can be done.

The doctors are not refusing to help the patient, the patient is refusing the doctors' help.

Episiarch|9.20.07 @ 3:05PM|#

This is the last comment I'm making on the subject.

I was just about to post that I seriously doubted this. Looks like I was right!

Jennifer|9.20.07 @ 3:05PM|#

Consistency, thou art a jewel:

Joe on September 20, 2007, explaining why it's okay for doctors to refuse to provide surgery to a man who smokes: The doctors are choosing whether this individual will assume that risk. They are choosing whether they, themselves, are going to perform the procedure. Why don't you want doctors to decide what procedures to perform, Jennifer? Is is because you hate freedom?

Joe on February 8, 2007, explaining why it's NOT okay for doctors to refuse to prescribe contraceptives, give abortions, or euthanize patients who want it: I realize that the concept of public service isn't particularly honored 'round these parts, but when you choose to become a physician, like when you choose to become a Marine, you are agreeing to certain restrictions on your autonomy, restrictions that exist for the purpose of furthering important public policy objectives... Similarly, it is important for the medical profession to be a sphere in which doctors prioritize their patients' autonomy over their own preferences, however deeply held.

|9.20.07 @ 3:07PM|#

J sub D,

That explains why there are no boob implants anymore. I was wondering why.

The risk to a healty young woman from that surgery is very low, which makes the risk/reward analysis come out differently than the case of an old man who'se been smoking for decades, has poor circulation, and needs an operation on his extremeties.

Individual cases. Individual diagnoses. What's so difficult about this concept?

|9.20.07 @ 3:07PM|#

While I certainly don't have any evidence (don't yell at me joe!), it seems like this guy must have some special case because he can't be the first smoker that needed a foot operation and if they denied care as a matter of course, it would certainly have been heard of before now. So I would think his odds of amputation must be higher than the normal case. Still, as ChicagoTom says, it's his risk to take.

Episiarch|9.20.07 @ 3:08PM|#

joe, you were getting pwned in general, but Jennifer just totally and utterly pwned you.

|9.20.07 @ 3:08PM|#

"corporations have NO internal mechanisms of control"

But they sure have external mechanisms of control. It's called free market competition.

Jennifer|9.20.07 @ 3:09PM|#

Joe, when you said last February that doctors must "prioritize their patients' autonomy over their own preferences," exactly which definition of "autonomy" were you using?

|9.20.07 @ 3:09PM|#

I have asked doctors, ChicagoTom. That's why I'm so confident saying this.

Now go ask your doctor friend if doctors refuse to perform surgeries that patients want because they deem it too medically risky. Please. This is a very easy dispute to settle.

|9.20.07 @ 3:09PM|#

Doctors refuse treatement on the grounds of it doing more harm than good all the time.

Joe this happens a lot less than you are pretending. Most doctors will respect the wishes of their patient unless the case is pretty much hopeless.

Why don't you ask your doctor friend how often he makes diagnoses on people he has never laid eyes on, ChicagoTom.

Whatever joe, the guy has a broken ankle. It's a rather straightforward ailment.
Are you really gonna pretend like the only way to speak intelligently about this is to have examined this patient and his whole medical history. This isn't diagnosing a persistent vegetative state via video. It's discussing how to fix a broken ankle

spare us your bullshit.

|9.20.07 @ 3:10PM|#

Well, Episiarch's out.

When he can't argue his case, he talks about what a terrible person I am.

|9.20.07 @ 3:12PM|#

Jennifer, too.

Completely given up on making an argument.

Oh, look, I'm mad at joe, so I'll dig up a gotcha quote.

I win! I win!

|9.20.07 @ 3:12PM|#

Now go ask your doctor friend if doctors refuse to perform surgeries that patients want because they deem it too medically risky. Please. This is a very easy dispute to settle.

joe I have.

And they agree that unless there is a very high risk of severe damage and almost no chance for success or the procedure wasn't medically necessary or they felt that the patient didn't really understand the risks they would respect the wishes of the patient.

Jennifer|9.20.07 @ 3:12PM|#

Joe, saying "I win!" rather than answering a straightforward question might fool yourself, btut nobody else. Let me repeat my question: when you said last February that doctors must "prioritize their patients' autonomy over their own preferences," exactly which definition of "autonomy" were you using?

|9.20.07 @ 3:13PM|#

Jennifer,

Joe, when you said last February that doctors must "prioritize their patients' autonomy over their own preferences," exactly which definition of "autonomy" were you using?

The one that says they should not bring their moral judgements to their work.

Which is quite different than their medical judgements.

|9.20.07 @ 3:13PM|#

joe, you were getting pwned in general, but Jennifer just totally and utterly pwned you.

Not really, joe's first quote deals with a doctors' medical opinion, which is relevant.

His second quote deals with a doctor's moral opinion, which is not relevant if it has nothing to do with the patient's well-being.

|9.20.07 @ 3:15PM|#

There's really no need for to swear, C-Tom.

Whatever joe, the guy has a broken ankle. It's a rather straightforward ailment.

On a 70-something man with extremely poor circulation in his extremeties. That you don't even recognize this to be a relevant detail to consider when deciding on the best course of treatment is yet another example of you not knowing enough to make a quality judgement here.

|9.20.07 @ 3:16PM|#

I can name joe's argument in 7 words:

You can't read their minds. I can.

Jennifer|9.20.07 @ 3:17PM|#

The one that says they should not bring their moral judgements to their work. Which is quite different than their medical judgements.

Ah. So you'd be fine with a doctor who refused to prescribe birth control pills, so long as he claimed it was the increased blood-clot risk that inspired him, but you'd oppose a doctor refusing to prescribe them on religious grounds. And you'd be fine with a doctor who refused to give abortions so long as he said he was worried about breast cancer, but not if he refused on religious grounds. It's not what the doctor DOES that concerns you; it's what he says about what he does. Motivations, not results, are what matter, right?

|9.20.07 @ 3:17PM|#

ChicagoTom,

And they agree that unless there is a very high risk of severe damage and almost no chance for success...

OK, now we're getting somewhere. Finally, you've admitted that doctors do, in fact, refuse to perform treatments based on risk/reward analysis.

Well, that's pretty much the ballgame. We have the doctors who looked at him who made that decision vs. some people who couldn't pick him out of a lineup.

|9.20.07 @ 3:17PM|#

maybe we can all chip in and buy this guy a nicotine patch?

Episiarch|9.20.07 @ 3:17PM|#

Oh, look, I'm mad at joe, so I'll dig up a gotcha quote.

HAHAHAHAHAHAHA

Using your own words against you is giving up on the argument? It proves that your arguments are solely based on other considerations because you do not hold consistent views for similar situations. In fact (surprise surprise) it seems that your arguments are based on political considerations like universal health care and the abortion debate.

You are intellectually inconsistent, but you are utterly predictable.

|9.20.07 @ 3:18PM|#

Sage: "I remember a case where a man had his fingers reattached by an industrial accident."

Sorry, but I had to laugh about the industrial accident that re-attaches fingers rather than severing them.

|9.20.07 @ 3:18PM|#

Regarding Jennifer's post at 3:05, add joe to the list of flip-floppers that includes John Kerry, Hillary Clinton, and Mitt Romney.

|9.20.07 @ 3:18PM|#

JW,

I don't need to read their minds.

I have their words, and their words are plausible.

What have you got? A "I WANT to believe T-shirt?"

I haven't pwned a thread like this in some time.

|9.20.07 @ 3:18PM|#

joe,
Does your doctor recommend surgery for your ass, since it's getting kicked so hard? Or is the risk too great that it's going to get kicked again in this forum?

|9.20.07 @ 3:23PM|#

haven't pwned a thread like this in some time.

When's that? Never?

Dear god, your ass was sanded down with 150 grit and handed to you in a bag about a couple hours ago.

But go down swingin' old boy. Be nothing if not proud, if not just plain nuts.

|9.20.07 @ 3:24PM|#

Jennifer,

Nice use of the word "claimed" there. It adds nothing to dicussion, but almost steals a base by assuming that there could not possibly be a legitimate medical case.

To answer the question you would have asked if you weren't so defensive, dishonest, and desperate: doctors refuse to prescribe birth control pills to women with elevated risk of blood clots all the time. If a physician is just using this as an excuse to hide his religious objections, that would be deplorable.

|9.20.07 @ 3:24PM|#

Jennifer's not going to need any dinner tonight, she just ate joe's lunch.

Jennifer|9.20.07 @ 3:27PM|#

If a physician is just using this as an excuse to hide his religious objections, that would be deplorable.

But Joe, why would you to force doctors to do things they feel would be a bad idea? As some freedom-lover whose name escapes me asked earlier today: "[the doctors] are choosing whether they, themselves, are going to perform the procedure. Why don't you want doctors to decide what procedures to perform, Jennifer? Is is because you hate freedom?"

|9.20.07 @ 3:27PM|#

I love how Joe referred to Doctor Siegel (20 yrs experience in the public health/tobacco field) as "some blogger"... apparently because he doesn't like Siegel's opinion.

|9.20.07 @ 3:27PM|#

In countries with socialized medicine, decisions ARE made on the basis of cost analysis. For instance, in the US, doctors make every effort to save everybody they can. In countries with socialized medicine, premies are often aborted because it costs less money to abort them than it would to try to save them.

|9.20.07 @ 3:28PM|#

Simple fact, joe:
No American doctor would refuse surgery for broken bones to a person who smokes.
Deal with that fact, joe.
Let it sink into that fat head.

|9.20.07 @ 3:28PM|#

Episiarch,

I'm going to take this opportunity to teach you, because you plainly like to argue, and don't seem to have a good working knowledge of how to about it.

Using your own words against you is giving up on the argument? It is when the words in question have nothing to do with the subject under dispute - in this case, whether the doctors' refusal was based on medical or nonmedical criteria, and whether doctors should be allowed to refuse treatments that they deem medically unwise.

It's a factor called "relevance." Jennifer couldn't find any relevant arguments to use against me, so she decided to play "gotcha" on a different question.

And, oh, look, I answered the question after all.

I gotta admire the will to be victorious among y'all, but you've got to stop with the wishful thinking. It'll get you every time.

|9.20.07 @ 3:30PM|#

The risk to a healty young woman from that surgery is very low, which makes the risk/reward analysis come out differently than the case of an old man who'se been smoking for decades, has poor circulation, and needs an operation on his extremeties.

This CPR issue brief is based on the FDA's analyses of data collected by Mentor Corporation and Inamed Aesthetics. It is based on research, not opinion.

-Most women can expect at least one complication within the first 3 years.
-40% of reconstruction patients can expect to have additional surgery within the first 3 years.

More here.

This took minutes to find.

|9.20.07 @ 3:30PM|#

"There's really no need for to swear, C-Tom."

Joe - didn't you just call a guy a "bitch" yesterday on one of the comment threads?

Jennifer|9.20.07 @ 3:31PM|#

Joe - didn't you just call a guy a "bitch" yesterday on one of the comment threads?

Pointing out Joe's self-contradictions is not an honest debate tactic, but merely playing a "gotcha" game.

|9.20.07 @ 3:32PM|#

Aw, you all so wanted to believe that Jennifer's question was an argument ender. And then I have to go and spoil it for you.

Sorry, everyone. I feel your pain.

Episiarch|9.20.07 @ 3:33PM|#

I gotta admire the will to be victorious among y'all, but you've got to stop with the wishful thinking. It'll get you every time.

And the irony becomes so powerful that I can barely type "projection".

|9.20.07 @ 3:34PM|#

OK, now we're getting somewhere. Finally, you've admitted that doctors do, in fact, refuse to perform treatments based on risk/reward analysis.

joe what exactly did you prove?

Sure some doctors do and some don't-- and they all have different levels of risk they are willing to take. But the risk has to be SKY HIGH and the reward has to be real fucking close to 0. And even then many doctors will still respect the wishes of a patient who understands what the risks are. Doctors aren't a monolithic entity nor are they Gods. Yes they make life and death decisions, but usually that's after the patient has given them that right. And most patients have a right to override the doctor's recommendations (unless the patient has some kind of mental problem that doesn't allow them to make rational decisions).

So what?

Well, that's pretty much the ballgame. We have the doctors who looked at him who made that decision vs. some people who couldn't pick him out of a lineup.

Unless by "ballgame" you mean your being a smug prick focusing on silly tangents, then it is by no means the ball game.

Just because some doctors in the UK made a decision doesn't mean it was correct or proper and it doesn't at all mean that it wasn't affected by other non-medical considerations.

The fact that most doctors in the states would perform the surgery pretty much calls into question the validity of this medical decision.

Jennifer|9.20.07 @ 3:34PM|#

Deliberate double-post:

If a physician is just using this as an excuse to hide his religious objections, that would be deplorable.

But Joe, why would you to force doctors to do things they feel would be a bad idea? As some freedom-lover whose name escapes me asked earlier today: "[the doctors] are choosing whether they, themselves, are going to perform the procedure. Why don't you want doctors to decide what procedures to perform, Jennifer? Is is because you hate freedom?"

|9.20.07 @ 3:35PM|#

Jennifer,

But Joe, why would you to force doctors to do things they feel would be a bad idea?

I've answered this already. Doctors give up their autonomy in certain areas when they become doctors, but have to remain loyal to their oaths as doctors.

They have to work according to their best medical judgement. This imposes some boundaries on them - such as not refusing to provide the best treatment they can based on their personal beliefs - but not in the area of their medical judgement.

|9.20.07 @ 3:36PM|#

I see. I just needed to validate that, as sometimes I feel I'm passing through the looking glass as I follow the course of a joe-fueled argument.

Joe - Ari Fleischer has got nothing on you.
Take that as a compliment if you'd like.

|9.20.07 @ 3:36PM|#

The problem with Jennifer's "gotcha" technique is that the thread has stopped being about the subject at hand and became about "how can we make joe look bad".

This would be called "trolling" if anybody but Jennifer did it.

|9.20.07 @ 3:37PM|#

If you're a smoker, your bones are less likely to heal correctly. My wife, who is an orthopedic surgeon, is leery of doing total hips or knees on smokers, because their bone doesn't attach well to the artificial hip or knee.

Much as I despise Britain's NHS, they have a point here. And, the person in question has the option of going to a private doctor to get this procedure done. The problem is, due to the confiscatory taxes that support the NHS and the rest of Britain's welfare state, he might not be able to afford it. So, the net effect of the state robbing people of taxes to pay for this is poorer health care than if patients kept their taxes and made their own health purchasing choices.

My apologies if someone already made this point, but I just don't have the time to wade through hundreds of posts on a thread.

|9.20.07 @ 3:38PM|#

J sub D,

"Some complications" is a broad category. A fever is a complication. You need to go past the headlines.

Besides, what do you think the study you linked to proves? That doctors don't require absolute zero risk when they do their risk/reward analysis? No kidding. Who ever said they did?

|9.20.07 @ 3:41PM|#

No American doctor would refuse surgery for broken bones to a person who smokes.
Deal with that fact, joe.

This bears repeating. over and over and over.

This is why you are dead wrong joe.

no matter how hard you try and blunt this fact with the dishonest "well you don't know since you didn't examine him" tripe.


From the article:
A spokesman for the hospital trust said: "Smoking has a very big influence on the outcome of this type of surgery, and the healing process would be hindered significantly."

Even the spokesman is playing up the "it might not heal" angle rather than the "it might make things worse" or the "it might need amputation" angle? Why? because the odds of it being worse with surgery are very very slim.

There are very very few doctors who would refuse to perform a medically necessary procedure because the healing process might be significantly hindered.

So joe, please stop the bullshit. This "purely medical decision" is tainted regardless of your protestations.

|9.20.07 @ 3:42PM|#

Jennifer, I'm pwning several different people at the same time. If you can just be a little more patient, I'll get around to spanking you in turn.

As a matter of fact, I already did. This is twice now you've flattered yourself that you've put together a conversation ended, only to look silly when my answer to your first question comes up immediately thereafter.

Bad form, Old Bean.

|9.20.07 @ 3:43PM|#

I think Jamie Kelly has boiled this down to its essence.

|9.20.07 @ 3:44PM|#

I have to admire joe's chutzpah in all of this. If it doens't say so in the article, then it doesn't exist in nature:

-He knows that the doctors are making a purely medical decision. They are not mere mortals.
-He knows they have no bias against smoking and they're not just ass-covering 2 years into it as to why they havn't treated a patient in chronic pain.
-They live on an island without a past, without knowledge from personal experience. Nothing they have done before this has any influence on them.
-There is no history of rationing in the NHS
-They couldn't possibly have other influences acting upon them, because it doesn't say so in the article.
-That this story is news to begin with is not anything unusual and not significant at all.
-His knowledge of medical issues and his ability to conjecture on that is far supeiror to anyone else here, including those who have been in the same situation.
-It's OK for joe to comment on things not mentioned in the article, but not for anyone else to do so.

Have I left anything out?

|9.20.07 @ 3:45PM|#

I'm pwning several different people at the same time. If you can just be a little more patient, I'll get around to spanking you in turn.

that's funny. you haven't pwned anyone on this thread yet.

You have been intellectually dishonest, but you haven't pwned.

(Yes, to pretend that doing a procedure that might not take would be violating the "do no harm" oath is quite intellectually dishonest)

|9.20.07 @ 3:45PM|#

My point about the guy's refusal to stop smoking is probably the best one, since nobody can refute it.

|9.20.07 @ 3:46PM|#

Joe -

Just making an observation here, and I could be wrong, so, if I am, please forgive my ignorance, but...

When one actually "pwns" a thread, or someone, doesn't a third party actually have to validate that?
Saying you pwned someone or something is kinda bad form, isn't it?

Just sayin...

Jennifer|9.20.07 @ 3:47PM|#

So, since Joe thinks (or did in February) it would be wrong for doctors to refuse euthanasia to those with incurable pain, I'm guessing the breakdown works like this: if you are in pain and say "to make this pain go away I am willing to die," a doctor has the ethical obligation to end your pain by killing you. But if you say "to make this pain go away I am willing to take the small risk of death or amputation," the doctor is within his ethical rights to tell you to live with the pain.

|9.20.07 @ 3:48PM|#

Chicago Tom,

joe what exactly did you prove? That your statement "Doctors don't refuse treatment based on risk to the patient" is incorrect.

Which then proves that your statement "Therefore, those doctors in Britain could not have based their refusal to operate on the risk to the patient" is also incorrect.

Just because some doctors in the UK made a decision doesn't mean it was correct or proper Yes, as I've already said, they may have made the wrong medical decision, but a medical decision it was, based on all the evidence we have here.

and it doesn't at all mean that it wasn't affected by other non-medical considerations. It may have been. We just a) don't have any evidence of that and b) have a plausible, defensible alternative.

The fact that most doctors in the states would perform the surgery has not been established. This particular man with this particular problem has not been examined by any doctors in the state. We do not know what they would have decided to do about this particular case. The specific facts of the particular case need to enter into your thoughts somewhere.

Episiarch|9.20.07 @ 3:48PM|#

Dan, your attempts to get attention are cute, but joe is far more obnoxious than you. Now don't take that to mean you should become more obnoxious--you annoy others in...different ways. Your ways.

Alice Bowie|9.20.07 @ 3:50PM|#

People are assholes.

Read Obedience To Authority

|9.20.07 @ 3:51PM|#

Thank you, prolefeed.

ChicogoTom keeps yammering false facts about medical practice, and we appreciate your informed, not-pulled-out-of-your-ass, reality-based insights.

I love the fact that you had to be a prick in your incorrect, unsupported, indefensible, unevidenced assertion that I was wrong.

Instant karma's gonna get you, ChicagoTom. Someimes, in the form of prolefeed pwning you without even trying.

Jennifer|9.20.07 @ 3:52PM|#

Joe, yesterday you said that 'sucking up to commenters' is a sign one's losing an argument. Is that why you're doing to to prolefeed today?

Episiarch|9.20.07 @ 3:52PM|#

joe, the only person you have pwned is yourself. And honestly, that's nothing to be proud of. In fact, I would think it hurts. However, in my capacity as an internet doctor I have determined that you should not receive treatment on the grounds that you deserved it.

|9.20.07 @ 3:53PM|#

Jennifer,

Not even Dr. Kevorkian would say that euthenasia is an appropriate treatment for pain that can be cured just by having surgery and not smoking for a few weeks.

WLC|9.20.07 @ 3:54PM|#

Joe,

So "some blogger" (ie Dr. Siegel) doesn't know shit despite his 20 years in the tobacco control field?

|9.20.07 @ 3:55PM|#

Jennifer,

I'd change the subject, too, if I was trying to argue your position.

Does anyone have any arguments that relate to medical treatment, this case in England, and how doctors decide what procedures to use?

Or is "joe is a bad person" all you've got left?

|9.20.07 @ 3:55PM|#

WLC,

Some blogger who's never laid eyes on the patient or seen his medical record.

Jennifer|9.20.07 @ 3:56PM|#

Not even Dr. Kevorkian would say that euthenasia is an appropriate treatment for pain that can be cured just by having surgery and not smoking for a few weeks.

Hell, you don't even have to go that far. Just getting the surgery would cure the pain, except the doctors refuse to give it to him. However, you've decided that the doctors are not denying John Nuttall his autonomy in this instance.

|9.20.07 @ 3:58PM|#

That your statement "Doctors don't refuse treatment based on risk to the patient" is incorrect.

Except that I never said that.
So please find the quote where I said that or retract.

Which then proves that your statement "Therefore, those doctors in Britain could not have based their refusal to operate on the risk to the patient" is also incorrect.


Again, you haven't "proved" anything.
And I don't think I ever said what you put in quotes above either.

I believe I said "solely on the risk to the patient" which changes the meaning of the statement quite I bit. And I stand by that belief. This decision was not based merely on medical considerations. I believe there were other (financial and political) considerations involved, and anyone with half a brain can conclude the same based on the circumstances and a rudimentary knowledge of how medicine works. And no amount of your dishonesty is going to change that belief.

Jennifer|9.20.07 @ 3:59PM|#

Or is "joe is a bad person" all you've got left?

Seriously, Joe, you need to stop being so self-contradictory. I say the exact same thing to you that you said to me yesterday ... yet when you say it, you call it a brilliant tactic and when I say it, it becomes "is that all you've got left?"

You really need to stop calling others out for using the exact same techniques as you. Or at least wait more than 24 hours before doing so, in hopes that folks won't notice.

|9.20.07 @ 4:00PM|#

About the article:

what a horrible, horrible, precedent this sets.

Now what's all the fussy comments about?

|9.20.07 @ 4:01PM|#

Wishful thinking, folks. It'll get you every time.

You so wanted this to be a case study in the problems with National Health, and it just wasn't.

You so wanted to believe these doctors weren't deciding based on medical considerations, but you've got nothing to hang your hat on.

Of course there was no legitimate reason why his smoking could influence the outcome of the surgery, because wouldn't be great if that was true?

Of course doctors don't refuse to perform surgeries they consider unwise or uncalled for, because it would really undermine your position if they did.

Yeah, I'm gloating. I've been treated like absolute shit for writing truthful, logical, correct statements, just because you didn't want to hear them, or admit that your beloved morality tale was less than meets the eye.

Wishful thinking people. It doesn't make bones heal faster in areas of bad circulation. It doesn't make doctors slaves to their patients. And it doesn't make weak, unsupported assertions win an argument.

|9.20.07 @ 4:01PM|#

This has already been addressed, but I'll reiterate: DAN T: THERE IS NO SUCH THING AS AMBULANCE FARE. Yes, ambulance services charge, but we do so after the fact. And most ambulance services (the one I work for included) write off the charges on close to half their calls.
And never, under any circumstances whatsoever have we refused to take someone to the hospital because they can't pay. In fact, we don't even ask the question in most cases. The hospital usually provides us with billing info.
Suggesting that an ambulance would leave a patient because of a lack of "ambulance fare" is a good pay to get punched out by an EMT.

|9.20.07 @ 4:02PM|#

Having a rational discussion with joe is like trying to bob for apples that you have to get to by sticking your face in a metal fan.

|9.20.07 @ 4:02PM|#

Jennifer,

Just getting the surgery would cure the pain

Except it wouldn't. It would cause him to get gangrene in his leg and end up getting it sawed off - this, according to the two physicians who are familiar with his case.

|9.20.07 @ 4:04PM|#

Dan T., utterly fucking PWNED by Number 6.

|9.20.07 @ 4:05PM|#

ChicogoTom keeps yammering false facts about medical practice, and we appreciate your informed, not-pulled-out-of-your-ass, reality-based insights.

joe, again I don't see how I was pwned?

If you're a smoker, your bones are less likely to heal correctly. My wife, who is an orthopedic surgeon, is leery of doing total hips or knees on smokers, because their bone doesn't attach well to the artificial hip or knee.

he said his wife is "leery". Good for his wife. The real question is, despite prolefeed's wife being leery would she still do it if the patient requests it.

He didn't say she refuses to do it. And hip and knee replacement is much different animal then putting pins in broken bones to set them. Much more intrusive much more difficult.

So despite your smug condescension it didn't actually prove anything. I don't think anyone is arguing that it's better to not smoke than to smoke. What we are saying is the fact that you smoke shouldn't be a deal breaker in getting a needed surgery. And in the US it isn't. Sure doctors prefer you don't smoke and your risks increase, but not significantly enough to refuse you treatment.

|9.20.07 @ 4:05PM|#

Chicago Tom,

OK, here:

Unless he was guaranteed to not have any chance at all of healing, then the patient should not be denied the treatment that is in fact medically necessary.

stuartl|9.20.07 @ 4:06PM|#

joe, 'fess up. How much does Reason pay you to be this entertaining?

|9.20.07 @ 4:07PM|#

psssst joe...

Second medical opinion. Try it sometime. You might find that doctors don't always agree with other doctors' diagnoses and opinions.

|9.20.07 @ 4:09PM|#

Yeah, I'm gloating. I've been treated like absolute shit for writing truthful, logical, correct statements, just because you didn't want to hear them, or admit that your beloved morality tale was less than meets the eye.


Except that you haven't

You started from the position that the doctors decided they way to perform the surgery would put the patient at too high a risk of death and amputation. Both of these positions were wrong.

Now you have moved the goalposts and are pretending like your point was that smoking would make the surgery less likely to be successful.

Less likelihood of success is not a valid reason to not try to fix this man
The reality is that there is still no purely medical reason to deny this man his surgery

|9.20.07 @ 4:10PM|#

Unless he was guaranteed to not have any chance at all of healing, then the patient should not be denied the treatment that is in fact medically necessary.

Aww, joe, you big softie. And all this time you had this humanitarian instinct hidden in that head full of shit.
You want doctors to be the puppets at the end of the lines of bureacratic oddsmakers who must do anything to manage costs.
Libertarians want the patient and the doctor to be in charge.
You, sir, are a suck-ass boob Rotarian.

|9.20.07 @ 4:13PM|#

"Second medical opinion. Try it sometime. You might find that doctors don't always agree with other doctors' diagnoses and opinions."

There are no second opinions in countries with socialized medicine.

Jennifer|9.20.07 @ 4:14PM|#

It would cause him to get gangrene in his leg and end up getting it sawed off - this, according to the two physicians who are familiar with his case.

No, it MIGHT cause him to get gangrene in his leg. And aspirin MIGHT kill me--but it's up to me to decide whether I'm willing to take that risk to make my headache go away. Doctors must respect patient autonomy, remember? Except for when that forces you to rethink your theories.

|9.20.07 @ 4:14PM|#

JW,

I think this is the fourth time I've written this, so please don't keep repeating yourself:

I am not saying their medical decision was correct, just that is was a medical decision based on the facts of the case and their knowledge of medicine.

Maybe their medical judgement - that this guy needs to stop smoking before having the surgery, or it is too risky - is incorrect. I also wrote that if it is true that he cannot get a second opinion under the NHS, that's a major problem with the system.

|9.20.07 @ 4:16PM|#

Uhmm joe, this:

Unless he was guaranteed to not have any chance at all of healing, then the patient should not be denied the treatment that is in fact medically necessary.

is not at all the same as :

Doctors don't refuse treatment based on risk to the patient

This is where you are getting into trouble joe.

You keep improperly conflating probability of success with risk.

The fact that a surgery might succeed in fixing the ailment is not a risk to the patient's well being. And no amount of you wishing it were will make it so.

Furthermore, my stating how I think doctors should act is not really stating how they do act in reality.

Maybe instead of gloating you should work on reading comprehension?

|9.20.07 @ 4:17PM|#

This has already been addressed, but I'll reiterate: DAN T: THERE IS NO SUCH THING AS AMBULANCE FARE. Yes, ambulance services charge, but we do so after the fact. And most ambulance services (the one I work for included) write off the charges on close to half their calls.
And never, under any circumstances whatsoever have we refused to take someone to the hospital because they can't pay. In fact, we don't even ask the question in most cases. The hospital usually provides us with billing info.
Suggesting that an ambulance would leave a patient because of a lack of "ambulance fare" is a good pay to get punched out by an EMT.

Don't take that too literally, Number 6. The context of that remark was what might happen in a true free market for health care, not what might happen in America.

No offense intended towards EMTs.

|9.20.07 @ 4:17PM|#

Both of these positions were wrong.

Not on your say-so, boy.

The people with medical degrees who've been handling the patient's case say you're wrong, ChicagoTom, and I'm right.

And you have nothing but wishful thinking and political ideology to put up against that.

Now you have moved the goalposts and are pretending like your point was that smoking would make the surgery less likely to be successful. If you have unsuccessful surgery, and the wound doesn't heal, you get gangrene, Tom. It isn't just a missed chance - it's actual harm to the patient.

|9.20.07 @ 4:18PM|#

Besides, what do you think the study you linked to proves? That doctors don't require absolute zero risk when they do their risk/reward analysis? No kidding. Who ever said they did?

joe, what are the health rewards for a boob job? Using your risk/reward standard, that would be, ...let me think about this for a while... some risk for zero reward. Hippocratic oath, my ass!

I'm somewhat surprised that you would defend these profit driven manglers of women's breasts, though. I condemn them, but amazingly enough, don't want to outlaw/regulate them.

|9.20.07 @ 4:18PM|#

Dan, your attempts to get attention are cute, but joe is far more obnoxious than you. Now don't take that to mean you should become more obnoxious--you annoy others in...different ways. Your ways.

I tell you what, when you guys smell joe's blood there's no distracting you.

|9.20.07 @ 4:19PM|#

Oh, good, I pre-empted both Jennifer and ChicagoTom.

How out on a limb does one have to find one's self to argue that a failed surgery doesn't impose harm?

|9.20.07 @ 4:20PM|#

Don't worry, Jennifer.

I didn't expect you to understand the difference between medical judgements and moral judgements.

You excel at playing dumb when you're losing, and you are taking such a beating.

|9.20.07 @ 4:22PM|#

As a physician, I can easily imagine a scenario that includes a heavy smoker with a non-healing fracture. This patient would also very likely have a very low chance of healing after an operation because of poor blood flow to his foot.

As far as smoking goes, numerous studies have shown that smoking impairs healing, increases the risk of infection and causes blood vessels to constrict (bad for healing).

|9.20.07 @ 4:23PM|#

J sub D,

The rewards of a boob job are that they make the patient happier. Doctors consider the happiness and desires of a patient to be an important goal. They then weigh this goal against the risks.

|9.20.07 @ 4:24PM|#

I am not saying their medical decision was correct, just that is was a medical decision based on the facts of the case and their knowledge of medicine.

Have you spoken to these doctors? Have you seen transcripts of the examinations?

No? Then you are talking out of your ass as much as you have accused everyone else having done. You are assigning attributes to these doctors that you have no way of knowing whether they are true or not. They may very well be completely forthright and doing their very best or they may be malpractice magnets and just phoning it in. We have no way of knowing.

And it is competely dishonest to deny that the possibility of costs to the national system did not play a role in this decision. You have been consistent in that.

|9.20.07 @ 4:26PM|#

And another person who personal, professional knowledge comes in and backs me up.

I haven't seen a person with professional knowledge drop in and say, "No, that's crazy, doctors don't refuse to perform surgeries that patients want because they deem it too risky."

We keep seeing people saying exactly the opposite.

Why do you think that might be? Maybe because the argument that would best make the political case you want isn't...you know...TRUE?

|9.20.07 @ 4:28PM|#

As a physician, I can easily imagine a scenario that includes a heavy smoker with a non-healing fracture. This patient would also very likely have a very low chance of healing after an operation because of poor blood flow to his foot.

Is it better to let him live in pain for 2 years or to ultimately do the needed operation with a reduced risk of success and higher costs? Which is the greater harm?

A different question: Do unsuccessful procedures have a negative effect on NHS physcican perfromance reviews, assuming they have them?

|9.20.07 @ 4:28PM|#

The people with medical degrees who've been handling the patient's case say you're wrong, ChicagoTom, and I'm right.

Who? the doctors that are part of the NHS? Sorry those guys are tainted. The fact that most doctors in the US would do the surgery pretty much blows you and the British doctors out of the water.

You can say it all you want, but this decision, on purely medical grounds was wrong.


If you have unsuccessful surgery, and the wound doesn't heal, you get gangrene, Tom. It isn't just a missed chance - it's actual harm to the patient.

This is false. Where are you getting your medical information from? There is a chance that one MIGHT get gangrene. But it isnt guaranteed and the odds are rather low.

The most likely outcomes will be the bones set and heal or they don't set and the patient is right back where he started. Sure there is a small chance of gangrene, but that exists even with non-smokers.

How out on a limb does one have to find one's self to argue that a failed surgery doesn't impose harm?

Not very. Especially in orthopedics. Most unsuccessful surgeries do not harm the patient (well except financially)

|9.20.07 @ 4:28PM|#

JW,

No, I've read their statement about their motives, and the reasoning they gave for why this patient is in too much of a risk for surgery, unless he quits smoking.

But, hey, they've gotta be lying. Becasue wouldn't that be awesome?

Episiarch|9.20.07 @ 4:29PM|#

If you have unsuccessful surgery, and the wound doesn't heal, you get gangrene, Tom. It isn't just a missed chance - it's actual harm to the patient.

And this is where nothing you say makes sense, joe. Are you claiming that leaving an unset ankle fracture with tremendous pain isn't fucking harm?

You are either a total monster or lack any empathy or understanding for physical pain. Has it not occurred to you what kind of permanent damage not setting the bone may be doing? That he may eventually lose the foot anyway, but gets to endure years of terrible pain first? The harm of daily usage of morphine? The harm of the stress to his body? The harm to his mobility and life quality?

If you are actually so dense that you think "harm" only refers to a utilitarian definition of physical damage, I don't know what else I can say.

|9.20.07 @ 4:31PM|#

lack of direct evidence to support a claim =/= lack of a reasonable argument.

In other words, just because it does not explicitly say something in the article does not mean that it was not present in the real-world scenerio. As Dan T correctly points out to us frequently, we can not assume that all details of a situation are included in the article provided.

|9.20.07 @ 4:31PM|#

And another person who personal, professional knowledge comes in and backs me up.

I don't think anyone has disputed the fact that smoking reduces the effectiveness of healing from such a procedure. Can you point to someone who did?

All anyone here has questioned is the wisdom of denying a patient medical care in a national system without an ability to appeal such a decision and not allowing him to assume the risks, knowing what they are.

|9.20.07 @ 4:32PM|#

And another person who personal, professional knowledge comes in and backs me up.

I haven't seen a person with professional knowledge drop in and say, "No, that's crazy, doctors don't refuse to perform surgeries that patients want because they deem it too risky."

Not one person has truly backed you up. The only thing they are confirming is what everyone agrees on -- that smoking hinders the healing process. But NO ONE has said that the risks to the patient are so high that they shouldn't even try. No one is saying that GANGRENE WILL SET IN as you have said. No one has said that it is proper to refuse to treat patients who smoke because of the lowered probability successful healing.

|9.20.07 @ 4:32PM|#

Dan T-Fair enough. I'm not sure I agree with your conclusions about a free-market health care system, but I can say with certainty that no one will die because the ambulance wouldn't pick them up. Now if they get bounced from an ER....well, that's a different story. Technically, it should never happen, but the law only requires that a patient be "stable." Stable has varying definitions.
Typically, what happens here (the local hospital is part of a for-profit corporation) is that the patient is stabilized just enough to survive the transfer to a public or charity hospital. A paramedic-level ambulance crew usually runs those, and I've heard from more than one medic that the patient was anything but stable.

In short, the health-care system has some major, major problems. I don't pretend to have any solutions, only observations.

But I do know that the one component of the medical system that will pick you up, treat you, and transport you no matter who you are is EMS.

|9.20.07 @ 4:34PM|#

Sorry those guys are tainted. Of course they are. Why, they must be!

The fact that most doctors in the US would do the surgery has not been established, and has been contradicted by the doctors who've dropped in on the thread and made statements about the results.

The most likely outcomes will be the bones set and heal or they don't set and the patient is right back where he started. Not according to the medical professionals who examined him. Just according to you. While we're discussing taints, Dr. ChicagoTom, remind us of your political opinions about socialized health care.

Most unsuccessful surgeries do not harm the patient Most surgeries are not conducted on patients with very poor circulation in the area to be worked on. As the doctors who keep dropping in keep telling you. For a healthy person like you or I, a failed orthopedic surgery just means we heal up fine but the problem isn't solved. But it's the "heal up fine" part that seems to be the problem here. The specific facts of this patient's case, according to his doctors, create a high risk of amputation.

|9.20.07 @ 4:34PM|#

But, hey, they've gotta be lying telling the truth. Becasue wouldn't that be awesome?

Fixed that. Guess what? Just as valid.

You don't know, but that won't stop you from claiming that you do and that no one else does.

|9.20.07 @ 4:35PM|#

No, I've read their statement about their motives, and the reasoning they gave for why this patient is in too much of a risk for surgery, unless he quits smoking.

And no one ever has any motive other than their publicly stated ones.

Nor do people whose livelihood depend on a bureaucratic system go out and publicly defend the system they depend on regardless of their true beliefs.

NEVER! EVER!

Episiarch|9.20.07 @ 4:35PM|#

The rewards of a boob job are that they make the patient happier. Doctors consider the happiness and desires of a patient to be an important goal. They then weigh this goal against the risks.

And being freed from daily (literally) grinding pain isn't a happiness consideration?

Your personality trait of refusing to admit when you are wrong causes you to say completely contradictory things, yet you keep going, after repeated contradictions and logic errors.

That's an impressive stubborness, that'll you'll follow even after it makes you look like a fool.

|9.20.07 @ 4:36PM|#

Ok, long day here and maybe I'm dense but to summarize the topic again:

NHS Doctor(s) refuse to set man's broken leg due to fact that he is smoker and it may not heal correctly because of this (the smoking).

Ok, bear with me here... they refuse to set leg because it MIGHT NOT heal.
Ok, that said, if no one attempts to set THE BROKEN BONES, they have a, what ZERO CHANCE of healing correctly.

Some Chance vs. ZERO chance.

And Joe, you are arguing that this is not fucked up?

|9.20.07 @ 4:38PM|#

The rewards of a boob job are that they make the patient happier. Doctors consider the happiness and desires of a patient to be an important goal.

The question of the day, does joe support wirehead surgery.

Paul|9.20.07 @ 4:38PM|#

What would you do with your time if you didn't have a government program to blame everything on?

Be free.

|9.20.07 @ 4:38PM|#

joe thinks the government and its tangled web of regulations and bureaucratic rules are wonderful.
because joe makes his living telling other people what to do. isn't that right, mr. planner?
joe, go survive in the real world. where broken bones get fixed.

|9.20.07 @ 4:39PM|#

Episiarch,

Are you claiming that leaving an unset ankle fracture with tremendous pain isn't fucking harm? No, of course not. According to the doctors who have been handling the case, it just poses less harm than doing the surgery, if he won't stop smoking. Losing a leg is harm. Having a gangrenous ankle is extremely painful.

But here's another chance for you to learn something about argumentation: if you think your opponent's position stems from holding beliefs that only a monster would hold - for example, not caring about the pain someone is in from a broken ankle, or wanting Saddam Hussein to feed people into a plastic shredder feet first - you probably don't have a very good understading of the issue, your opponent's argument, or both.

|9.20.07 @ 4:39PM|#

Paul wins the thread.

|9.20.07 @ 4:41PM|#

So...why doesn't the guy just stop smoking?

|9.20.07 @ 4:42PM|#

Dan T.

Because he is in too much pain too - Plus the State won't let him smoke pot.

|9.20.07 @ 4:43PM|#

JW,

The difference being, the physicians explained their reasoning, and it is consistent with the best medical practice.

In other words, I'm not just basing my statement on the validity of their decision on what I want to be right, but on the fact that they have laid out a case, and a good one.

As opposed to my opponents, who have only been able to come up with a motive.

|9.20.07 @ 4:45PM|#

The difference being, the physicians explained their reasoning, and it is consistent with the best medical practice.

What year of med school did you learn that? You must have ROCKED that class.

joe, just keep repeating to yourself "it's not news, it's not news, it doesn't have any significance, it's just the whackjob libertarians...LALALALALALA"

Episiarch|9.20.07 @ 4:46PM|#

According to the doctors who have been handling the case, it just poses less harm than doing the surgery, if he won't stop smoking. Losing a leg is harm. Having a gangrenous ankle is extremely painful.

I cannot believe you are truly this dense--it has to be your inability to give up the ghost.

One more time: if they do nothing, the bones don't heal. That is non-ending harm.

Also, potentially losing a leg is potential harm, and terrible pain is constant harm. So the doctors get to decide which the patient prefers, and not the patient?

Every thread your totalitarian streak becomes more and more apparent. I pity anyone who has to work under you, live with you, or associate with you.

|9.20.07 @ 4:47PM|#

*AHEM*

lack of direct evidence to support a claim =/= lack of a reasonable argument.

In other words, just because it does not explicitly say something in the article does not mean that it was not present in the real-world scenerio. As Dan T correctly points out to us frequently, we can not assume that all details of a situation are included in the article provided.

|9.20.07 @ 4:47PM|#

Like ChicagoTom.

And no one ever has any motive other than their publicly stated ones.

Fine, you've described a motive for why doctors might have an interest in not doing the surgery. We have an equally strong motive for why they would base their decision on sound medical practice - because they're doctors and want to heal people; because their professional reputations depend on their practising medicine well; or because they don't want to get in trouble.

But there's more than just speculation about motives here - there's their reasoning, as they lay it out. They said they think the surgery is too risky, and could cause him greater pain, maybe even amputation, because it wouldn't heal up. And there appear to be very good reasons to think this is so.

This isn't "he said-she said." It's "he said and laid out solid logic and evidence-she said."

|9.20.07 @ 4:50PM|#

So...why doesn't the guy just stop smoking?

He needs to. But smoking is addictive and very difficult to quit.
That should not preclude him from excercising a viable option -- to take his chances on his ankle NOT healing.
Unless you're joe. And you live to rob people of choices. And tell them "fuck you" when they claim they have them.

|9.20.07 @ 4:51PM|#

But there's more than just speculation about motives here - there's their reasoning, as they lay it out. They said they think the surgery is too risky, and could cause him greater pain, maybe even amputation, because it wouldn't heal up. And there appear to be very good reasons to think this is so.

And the patient says : Ok I got -- Ill take my chances.

And he should be denied because????

|9.20.07 @ 4:51PM|#

Episiarch, I've already answered you. Right there at 4:39. Of course healing this guy's injury is a benefit that they considered.

Why don't you put a little more effort into reading the arguments you attempt to respond to, and a little less effort strutting for the audience. Maybe you'll get whacked on the head with a folder chair less often, Hulkster.

|9.20.07 @ 4:52PM|#

Jennifer, the argument that the risk this guy faces from surgery is equivalent to the risk you face taking an aspirin is too stupid for words.

So, right now, I am doing an interpretive dance around a short bus, just for you.

|9.20.07 @ 4:53PM|#

... and could cause him greater pain, maybe even amputation, because it wouldn't heal up.

Yeah, because a completely fucked-up and useless but intact foot and ankle is so much better than a missing foot, which can be replaced with a prosthetic.
How's the inside of your colon looking, joe?

|9.20.07 @ 4:54PM|#

so joe, you believe that if a patient says " You know what, I would prefer to risk living life as an amputee rather than be guaranteed to live life in chronic pain" he shouldn't have a right to make that decision?

|9.20.07 @ 4:55PM|#

Jamie does remind me of something I meant to say earlier.

This guy just needs to suck it up and deal with not smoking for a month. Not saying the docs shouldn't have operated, but he does have a hand in this.

|9.20.07 @ 4:55PM|#

tk,

The risk isn't just that the leg might not heal up correctly, but that it might rot so badly that they need to cut it off.

Make the guy agree to stop smoking for a few weeks vs. a serious chance of him losing his leg.

Are you seriously arguing that this situation so obviously argues for performing the surgery that it is not possible the doctors could have made this decision based on their best medical judgement?

Episiarch|9.20.07 @ 4:56PM|#

Maybe you'll get whacked on the head with a folder chair less often, Hulkster.

joe, after watching you defend a decision to leave a person in horrible pain because there might be complications, I feel sort of like I have been hit with a folding chair. I'm stunned.

And you do know that amputation stops the pain, I assume? That having a prosthetic foot is not death, and that for some, risking it might be preferable to bones grinding indefinitely?

The world gives thanks that you are not a doctor.

|9.20.07 @ 4:56PM|#

Jamie Kelly,

I haven't worked for the government in two years.

Which is almost as long as it's been since you posted a relevant or useful comment.

How much of this thread has been wated on "Bad joe! Bad joe!" comments?

Can't you people argue facts and logic?

|9.20.07 @ 4:57PM|#

"Episiarch, I've already answered you. Right there at 4:39. Of course healing this guy's injury is a benefit that they considered."

So in a nutshell then: The State (NHS) knows better than the individual what is best for the individual, and has the power to enforce it's will upon the individual, who has no remedy in the face of state power.

When I went to school, the called that fascism.

|9.20.07 @ 4:57PM|#

I haven't worked for the government in two years.

And you've learned nothing of the real world since, apparently.

|9.20.07 @ 4:59PM|#

ChicagoTom,

And he should be denied because????

As I've said repeatedly, I don't know that he should. But as you've already acknowledged, doctors work like that. They sometimes refuse to perform surgeries if they deem the risk too high, regardless of what the patient wants.

Maybe that's not the best way to practice medicine. Take it up with the AMA and BMA. Regardless, that is how medicine - not medical finance, medicine - is practiced.

Episiarch|9.20.07 @ 5:00PM|#

Make the guy agree to stop smoking for a few weeks

Of course, with joe, it's always about force. The guy isn't allowed to decide that he'd rather smoke and risk losing his leg--that is not acceptable to joe. He can suck up the pain until he decides to stop smoking.

Again with the totalitarianism.

|9.20.07 @ 5:00PM|#

We need not assume that the doctors made this judgment solely based on their best medical judgment. As in most cases, looking at incentive structures and motives is a useful tool in determining whether or not we should be skeptical. That resulting skeptical view is not necessarily any more or less true than the default view, as we do not know the absolute truth.

|9.20.07 @ 5:03PM|#

joe, after watching you defend a decision to leave a person in horrible pain because there might be complications...

You know, if I'd been beaten as badly as you've been, I'd lie about what just happened, too.

tk,

You replaced "Doctors" with "state." The doctors refused to do the surgery unless he stopped smoking. Are my arguments really so terrifying that you can't acknowledge what they are?

|9.20.07 @ 5:04PM|#

Of course with Episiarch, it's all about force.

Force the doctors to perform the surgery that they don't want to perform.

There is one person arguing for individual choice on this thread, me, and a whole bunch of you furious that these doctors aren't being forced to perform unwise surgery.

The doctors aren't your slaves, and they're not the patient's slaves, either. Stop trying to make them.

|9.20.07 @ 5:05PM|#

They sometimes refuse to perform surgeries if they deem the risk too high, regardless of what the patient wants.

Find me one instance of an American doctor refusing to set broken bones because the patient smokes.
One, you power-hungry little boy.

|9.20.07 @ 5:06PM|#

"tk,

The risk isn't just that the leg might not heal up correctly, but that it might rot so badly that they need to cut it off.

Make the guy agree to stop smoking for a few weeks vs. a serious chance of him losing his leg.

Are you seriously arguing that this situation so obviously argues for performing the surgery that it is not possible the doctors could have made this decision based on their best medical judgement?"

Side note here- - somebody please tell me how to italicize.

Joe -

As you and others have pointed out numerous times already, we don't know all the facts of the case, and that said, no matter what, the point of what the BEST care is is moot.

However, my concern is that, in the system this guy is stuck in, he has no remedy. Chicago Tom (right?) had the resources to tell the NHS to go fuck itself and have his procedure (which - Surprise! a US Doctor deemed ok and necessary) done here in the US. The patient who is the subject of the article has no choice - he is fucked. Socialized medicine forces rationing of medical care, and care-givers are forced to become bureacrats over healers.
I find that abhorrent, but that's just me.

|9.20.07 @ 5:06PM|#

And with that, I bid my defeated foes farewell.

Easiest victory I've ever had.

Never before have my opponents argued so poorly, with so little evidence, for such an indefensible position.

|9.20.07 @ 5:07PM|#

PS,

Jamie Kelly,

I love the fact that I make you so mad that you are incapable of doing anything but calling me names.

Episiarch|9.20.07 @ 5:07PM|#

joe, repeating that you are TEH WINNAR in every post might convince you, but it doesn't convince anyone else. I have dealt with people before who will never admit they are wrong, must have the last word, and are convinced they know everything.

You are not pleasant people to deal with. But I think you know that deep down.

|9.20.07 @ 5:08PM|#

It's like when Bush says "Mission Accomplished". Just because you say it, joe, don't make it so.

|9.20.07 @ 5:08PM|#

tk - remove the spaces inside the brackets:

< i > text < /i >

|9.20.07 @ 5:09PM|#

OK, last one.

tk, as I said already, if this guy can't go get a second opinion, or if he isn't allowed to pay for the surgery out of pocket, that's wrong.

|9.20.07 @ 5:09PM|#

joe:
Read this and apologize, you goddamned fascist.

http://www.belfasttelegraph.co.uk/health/article2974173.ece

|9.20.07 @ 5:10PM|#

What was that you said yesterday, joe? "legend in his own mind"

|9.20.07 @ 5:10PM|#

JW -

Thank You

Episiarch|9.20.07 @ 5:11PM|#

The doctors aren't your slaves, and they're not the patient's slaves, either. Stop trying to make them.

Unless the patient wants contraceptives, wherein it is important to make them. joe, Jennifer annihilated you on that one; maybe it slipped your mind amongst all the other pwnages.

Again, your stubborness makes you sloppy.

|9.20.07 @ 5:13PM|#

Well, that ended as so many threads do.
I had a good time reading it, anyway.

|9.20.07 @ 5:17PM|#

From Wiki:
http://en.wikipedia.org/wiki/National_Health_Service#Criticism

Please especially note Access Control and Waiting Lists

|9.20.07 @ 5:17PM|#

Well, that ended as so many threads do.
I had a good time reading it, anyway.

Whew! Changin' minds is hard work.

Good ol' joe. Our own moo-cow in the pirahnna tank.

|9.20.07 @ 5:20PM|#

joe, you're posting today is as ugly as yesterday. What exactly is your problem? PMS? Haven't gotten any lately? Air America sucks?

A friendly observation, perhaps this is not the best forum to work out your issues.

Episiarch|9.20.07 @ 5:20PM|#

Jamie, your link isn't working (it's not your fault, it's the Telegraph's slow site), so here's another link: http://www.voidstar.com/ukpoliblog/index.php/fid/1011

And joe, Jamie just destroyed you with this. Good thing you left, I guess.

|9.20.07 @ 5:20PM|#

JW

Sadly, some minds can never, ever be changed

|9.20.07 @ 5:24PM|#

Sadly, some minds can never, ever be changed

OH, I had no doubt that no minds were going to be changing. It's just the response that's so outright hilarious.

Steve Hartwell|9.20.07 @ 5:34PM|#

to anti-smokers:

IF 'you' needed a blood transfusion or would die without it, and the only blood available was from a smoker....

would you take the blood ?

steve

|9.20.07 @ 5:39PM|#

Enough with the name-calling and talk about who "owned" who. It's more fun if we pretend to be grown-ups.

teh|9.20.07 @ 5:46PM|#

I don't have time to read the thread again, but didn't the statistics someone cited earlier say that he had a 12% chance of complications instead of a 2% chance? So he is being denied surgery from a health service that he paid taxes to because the chance of success is 88% instead of 98%? Is 88% not good enough?

If these rules were imposed by contract when he got the insurance, then yeah, maybe it would be reasonable. But it isn't like he was properly warned here that if smoking marginally increased his chances of (non life-threatening) complications he would be denied needed health care.

(Please correct me if someone has numbers that somehow significantly change this.)

|9.20.07 @ 6:24PM|#

That's great link, showing that somebody is making a recommendatin that the NHS adopt a policy THAT IS NOT CURRENTLY IN PLACE for the treatment of smokers.

And complaining that the policy is not in place. And wishing it was. And expressing anger that it is not.

What it has to do with the medical decision these doctors made, under a set of policies so different from that Ulster doctor's recommendations that he is driven to anger, I'm not quite sure.

Except that is seems to make some people feel like they can salvage some dignity.

|9.20.07 @ 6:25PM|#

teh -

YES, BECAUSE THE STATE DEEMED IT SO.

BTW, I am THE STATE!

ALL HAIL, IL DUCE!

|9.20.07 @ 6:27PM|#

J sub D,

Oh, please. Go back through the thread. Look at Jennifer's "contribution." Look at Episiarch. Look at Jamie Kelly (did he make a single substantive point? Even one?) Look at JW.

Yeah, I'M the bad guy here. I'm the reason there are personal insults on this thread.

News flash: I'm not Jesus. Assholes launch personal attacks on me, guess what? I'm going to hit them back. Just try to make me feel guilty about that.

Jennifer|9.20.07 @ 6:35PM|#

he is being denied surgery from a health service that he paid taxes to because the chance of success is 88% instead of 98%? Is 88% not good enough?

Apparently not. Joe, what percent chance of success should be the cutoff for NHS doctors to refuse to treat smokers, do you think?

|9.20.07 @ 6:37PM|#

Joe - please see teh's post at 5:46 -

All heated rhetoric aside, do you truly believe it is ok that this guy with the broken leg, who paid into the system with his hard earned $$, is being denied, because of some state-derived calculation, an operation because it only has an 88% chance of success?

If you of all people were in this situation, YOU, Joe, the terror of the thread would meekly say "OK, that's cool" and try your chances elsewhere? Come on... seriously....

Btw, I'm done. I'm off to enjoy a cigar and play some had, contact sports, thanking my lucky stars that if I break my leg, I'll be ok...

|9.20.07 @ 6:39PM|#

This is maybe the strangest thread I've seen in a while. This seems to be what matters:

"Scarce resources always have to be allocated one way or another, of course, and Michael Moore did not have to invent stories about getting screwed over by HMO gatekeepers. But there is an important difference when patients have some choice of providers and health plans. Some might deign to repair a smoker's fractured ankle, for example. There need not be one policy for the whole country regarding what is covered for whom. Giving the government a monopoly on dispensing health care only exacerbates the problems created by medical gatekeepers."

|9.20.07 @ 6:53PM|#

Jennifer,

Why, the NHS shouldn't refuse to treat smokers. As a matter of fact, it doesn't refuse to treat smokers. It treats smokers all the time. It would even treat this smoker, if he would comply with the course of treatment necessary for the treatement to work.

Now, the question you would ask if you were an honest person would be, "How much of an increase in risk justifies denying treatment?"

And my answer is, beats me. You should ask a doctor.

|9.20.07 @ 6:59PM|#

tk,

The 88% chance isn't just that the surgery would work. Remember, the risk here isn't "we tried, it didn't work, he's just the same as he was before."

The 12% means the guy loses his leg. Amputation is horrible. Have you ever heard of "phantom pain?"

No, it is not obvious to me that doing the surgery is the best option. Certainly not obvious enough for me to proclaim that these doctors are engaging in deliberate malpractice in an effort to advance their careers and/or impose a political agenda.

|9.20.07 @ 7:08PM|#

J sub D,

Oh, please. Go back through the thread. Look at Jennifer's "contribution." Look at Episiarch. Look at Jamie Kelly (did he make a single substantive point? Even one?) Look at JW.

Yeah, I'M the bad guy here. I'm the reason there are personal insults on this thread.

News flash: I'm not Jesus. Assholes launch personal attacks on me, guess what? I'm going to hit them back. Just try to make me feel guilty about that.

joe, everybody's out to get you? Why do feel that way. Let's talk about your toilet training ...

|9.20.07 @ 7:18PM|#

No, not everybody.

I had an excellent discussion with ChicagoTom - heated, but not irresponsibly so.

Just as I had an excellent, civil discussion with fyodor yesterday.

|9.20.07 @ 7:44PM|#

No, not everybody.

I had an excellent discussion with ChicagoTom - heated, but not irresponsibly so.

Just as I had an excellent, civil discussion with fyodor yesterday.

So please explain to me your defense of boob jobs and the doctors who perform this often mutilating surgery. It makes the patient feel better, justifies prescribig morphine for the common cold, and you know that. And you know that the results of breast enhancement surgery are often detrimental to the patient. Doctor doesn't always know best, and you know that. So was you lame attempt to defend breast enhancement surgery thought out or just reflexive? Be honest.

Privatized medicine leads to people being denied treatment, all agree. Some people think that your health care is your own resposibility, not mine. Plus socialized medicine sucks.

BTW, are you still a gov't employee? Not that there's anything wrong with that. ;-)

ed|9.20.07 @ 7:47PM|#

Who's winning?

|9.20.07 @ 8:26PM|#

Look at JW.

Look at meeeeeeee!

joe, dear, go back through the thread and show me where I even insulted you once.

Unless disagreeing with you is insult enough. In which case, that would make most of us that comic dog hand puppet.

|9.20.07 @ 8:28PM|#

No, it is not obvious to me that doing the surgery is the best option. Certainly not obvious enough for me to proclaim that these doctors are engaging in deliberate malpractice in an effort to advance their careers and/or impose a political agenda.

There is no 'inference' in 'joe.'

'Course, he got no Elvis in him either.

|9.20.07 @ 8:41PM|#

If you're a smoker, your bones are less likely to heal correctly. My wife, who is an orthopedic surgeon, is leery of doing total hips or knees on smokers, because their bone doesn't attach well to the artificial hip or knee.

he said his wife is "leery". Good for his wife. The real question is, despite prolefeed's wife being leery would she still do it if the patient requests it.

He didn't say she refuses to do it. And hip and knee replacement is much different animal then putting pins in broken bones to set them. Much more intrusive much more difficult.

To clear things up: I'm not a doctor, my wife is. I certainly don't understand all the medical nuances in this particular situation. But, as I understand it, my wife most likely won't do elective surgery if its a slowly deteriorating condition, the pain is still manageable, and the patient refuses to give up smoking. If it's a life or death situation, or the pain is unmanageable, she would most likely operate despite the risk posed by the smoking. In short, she makes a medical decision about the risks, in consultation with the patient, though she might refuse to do what she deems an excessively risky surgery even if the patient wants to proceed. But, if so, the patient has the right and ability to go see a different doctor.

Under the NHS, however, the doctors make the decisions for the patient, and those decisions are final and are based at least in part upon budgets. The doctors may decide to not proceed with a surgery even though the benefits for the patient outweigh the potential complications, because with the limited money available they think someone else deserves those rationed dollars more.

As a libertarian, I'm appalled at the NHS, but I don't blame the doctors in the case in the article, I blame the socialized system. I sure as heck don't want HillaryCare or ObamaCare or EdwardsCare. (I also don't want the shredding of civil rights by the non-libertarian Republican candidates, but that's another thread, yeah?)

Paul|9.20.07 @ 8:51PM|#

JW:

'Course, he got no Elvis in him either.

Eeeeveryone's got a little Elvis in 'em. Only Michael J. Fox has no Elvis.

|9.20.07 @ 9:48PM|#

He should take his business elsewhere!

...Oh, wait.

-jcr

miche|9.20.07 @ 11:07PM|#

Funny, just yesterday, someone was complaining about socialist health care leading patients to demand drugs and treatment when it isn't called for.

Anything for the cause.

Actually, I said that is one of the things that drive up costs.

Sam Nettles|9.21.07 @ 12:18AM|#

Nothing to discuss. People have gone nuts. No common sense and no valid thought. Smoking bans have destroyed reason. Mind Control and junk science have proven how stupid the great majority of people are. Millions of old smokers prove how ignorant bans and the believers are. To argue about how to deal with the ignorance is to squirm around in a mixture of quicksand and cow manure.

Thomas Paine\'s Goiter|9.21.07 @ 1:46AM|#

This thread is awesome with Joe on ignore.

|9.21.07 @ 5:36AM|#

Talked with my wife, the orthopedic surgeon, about this case. She hasn't looked at the charts or met the patient, of course, but it appears that virtually all American orthopedic surgeons would have also refused to operate on a smoker in this situation because of the high risk of surgical complications. Basically, nicotine paralyzes the osteoblasts, the new bone growth, so the bone will heal poorly with an active smoker.

My wife says she avoids this problem by convincing virtually all her patients in similar situations to give up smoking for the three months or so needed for the bone to heal. If they want to resume smoking afterwards, that's their business, though of course she discourages that for all the other reasons smoking impairs health. If they prefer to remain addicted, they live with the pain of an unhealed bone. Most orthopedic surgeons feel the same way, that for medical (not cost) reasons, unless it's a life-or-death situation, you don't operate on patients who won't quit cigarettes. Broken hips you operate on, for example, because not operating will kill the patient.

If the patient refused to give up his "fags", as the British call cigarettes, even after the doctors explained why he needed to quit at least temporarily, then the suffering he's going through is basically self-inflicted.

There's plenty of reasons to hate socialized medicine -- my wife certainly doesn't want to have any part of that -- but this particular case isn't a good example of why socialized medicine sucks.

|9.21.07 @ 6:55AM|#

I think there might be an excess of ad hominem attacks (cough, joe), but I'm not really smart enough to tell.

|9.21.07 @ 8:37AM|#

Basically, nicotine paralyzes the osteoblasts, the new bone growth, so the bone will heal poorly with an active smoker.

prole--No one is disputing that issue. And yes, I think most of us agree: he should stop smoking. Note, that is a should, not a must.

Give the patient the information and the risk factors. Let him decide what he wants to do. Counsel him. Guide him. Let him decide.

Just don't turn it into an null-choice collectivist nightmare.

|9.21.07 @ 8:52AM|#

In countries with socialized medicine, the doctors answer to the government. They obey the government if they are mandated to cut costs at the expense of some patients getting proper medical care. It happens all the time in countries with socialized medicine. In the free market, patients are the customers. The customer is always right. If a patient wants a particular operation or treatment, the doctor is happy to oblige if the treatment or operation is needed and there is a chance of success.

|9.21.07 @ 9:16AM|#

In the free market, patients are the customers. The customer is always right. If a patient wants a particular operation or treatment, the doctor is happy to oblige if the treatment or operation is needed and there is a chance of success.

The argument here is that the doctor should oblige even if the treatment is not needed or there is no chance of success. The customer is always right, even when he's wrong.

|9.21.07 @ 9:24AM|#

"The argument here is that the doctor should oblige even if the treatment is not needed or there is no chance of success."

Forget this particular issue. I'm talking about socialized medicine vs. free market medicine in gerneral.

|9.21.07 @ 9:28AM|#

What's really ironic about this thread is that if the situation was the same except it was an American insurance company refusing the surgery (not that an unemployed poor person would have insurance in the first place, but never mind that), posters here would go on and on about how the smoker needs to take "personal responsibility" and drop the habit, which he undertakes of his own free will.

I've repeated it over and over, and at least a few others have mentioned it as well, but the patient has been told what he needs to do in order to facilitate a recovery. He refuses to do it!

Not to mention that there will never, ever, be a health care system anywhere where people can just show up in any sort of condition and demand that doctors perform whatever treatment they want. Why? Because that would be insane.

|9.21.07 @ 9:48AM|#

"(not that an unemployed poor person would have insurance in the first place,"

If he was poor enough he would be on Medicaid, otherwise, he could always be treated at a charity hospital.

|9.21.07 @ 11:08AM|#

Well good gravy. Did I just walk into a Fark thread? O_o

Didn't the guy say he's tried everything and only got down to 10 a week? That's pretty good for a dyed-in-the-wool smoker, isn't it?

I wonder if that's really not good enough to give it a shot.

Jennifer|9.21.07 @ 11:49AM|#

The argument here is that the doctor should oblige even if the treatment is not needed or there is no chance of success.

Wrong. It's not "no chance of success," it's "an 88 percent chance of success." And since the man can't walk without grinding (literally) agony, saying it's "not needed" makes you as callous as the prosecutors who imprisoned Richard Paey for taking drugs to make his incurable pain go away.

If you simply must troll, Dan, troll on the side of the annoying, not the purely evil.

|9.21.07 @ 1:16PM|#

Basically, nicotine paralyzes the osteoblasts, the new bone growth, so the bone will heal poorly with an active smoker.

prole--No one is disputing that issue. And yes, I think most of us agree: he should stop smoking. Note, that is a should, not a must.

Give the patient the information and the risk factors. Let him decide what he wants to do. Counsel him. Guide him. Let him decide.

Just don't turn it into an null-choice collectivist nightmare.

JW and others, I understand your POV, but you're forgetting that two people must consent in this situation -- the patient and the doctor. The patient must give his or her consent to the surgery, and the doctor must consent to perform the surgery. The "88 percent chance of success" appeared way too optimistic according to my wife.

Yes, the patient should have the option to shop around for a doctor who will agree to treat him or her, an option denied to them by the NHS by bureaucracy -- but in America, such a search would likely be futile because doctors took an oath to "first do no harm" -- and because should the case go badly, which is quite likely, the doctor would be sued for malpractice, and most likely lose, for operating in a non-emergency case with a patient whose refusal to temporarily quit smoking greatly increased the risks to what most medical professionals would consider an unacceptable level.

Again, unless you are an orthopedic surgeon and dispute my wife's professional judgment, I would advise arguing the general case against socialized medicine, but not arguing this particular case where an orthopedic surgeon with many years of experience has concluded that under no system of medicine, socialized or otherwise, would this patient be likely to find a doctor who would consent to perform a non-emergency operation on a non-compliant patient who won't even temporarily quit the cigarettes.

|9.21.07 @ 1:24PM|#

Jennifer -- yes, the patient is enduring great pain -- but it is great pain they have voluntarily chosen to endure rather than quit smoking for a few months. Remove the NHS, remove the lawyers and have an iron-clad assurance that the doctor will not get sued for operating, then in that very libertarian society completely unlike the one we have the patient might find someone willing to treat them. If that's the hypothetical you're arguing, then OK, you have a valid point, but you need to explain those assumptions upfront.

Jennifer|9.21.07 @ 1:38PM|#

Jennifer -- yes, the patient is enduring great pain -- but it is great pain they have voluntarily chosen to endure rather than quit smoking for a few months.

By that use of "voluntary," you could justify any oppression. Fat people voluntarily refuse to lose weight, so let's deny medical procedures to them if a skinny person has a better chance of recovery.

Remove the NHS, remove the lawyers and have an iron-clad assurance that the doctor will not get sued for operating, then in that very libertarian society completely unlike the one we have the patient might find someone willing to treat them. If that's the hypothetical you're arguing, then OK, you have a valid point, but you need to explain those assumptions upfront.

Speaking of explaining assumptions up front, maybe NHS should at least let taxpayers know beforehand that "if you are a smoker, you might not be allowed to have your broken bone set properly, or denied other forms of healthcare which you have a 'right' to under our system."

|9.21.07 @ 1:56PM|#

Jennifer -- I'm not advocating oppression of anyone. I'm saying that in a marketplace, sometimes a buyer can't strike a bargain on the terms they want if the terms they're offering are a raw deal for the seller. In the actual very unlibertarian world we're living in right now, the patient in the specific situation has the right to shop around for doctors, but because of statism they are unlikely to get what they think they want. In Britain, the patient has the right to go to a private, non-NHS doctor, but because the statist government has confiscated much of their income, in reality that's not a workable option for most. In the U.S., the patient has the right to shop around for doctors if the first (and second, and third) refuses to treat them, but due to statist lawyers suing them and statist-packed juries who will convict any doctor foolish enough to treat this patient, it's unlikely he or she will find a doctor to consent to perform the procedure.

In both societies, due to statist constraints, it's a really raw deal for the doctors if they perform the surgery (the NHS doctors lose their job if they operate, the US doctors lose a lot of money on average if they operate due to lawsuits), so they generally don't.

Argue that the statist constraints need to be removed, and I'm with you on this bad puppy.

;)

|9.21.07 @ 3:00PM|#

Dan: The argument here is that the doctor should oblige even if the treatment is not needed or there is no chance of success.

Jennifer: Wrong. It's not "no chance of success," it's "an 88 percent chance of success." And since the man can't walk without grinding (literally) agony, saying it's "not needed" makes you as callous as the prosecutors who imprisoned Richard Paey for taking drugs to make his incurable pain go away.

If you simply must troll, Dan, troll on the side of the annoying, not the purely evil.

Jennifer: "even if" is the operative phrase here. Hypothetically, according to your logic, doctors must grant the wishes of any patient, no matter how unreasonable.

|9.21.07 @ 3:30PM|#

Again, unless you are an orthopedic surgeon and dispute my wife's professional judgment, I would advise arguing the general case against socialized medicine, but not arguing this particular case where an orthopedic surgeon with many years of experience has concluded that under no system of medicine, socialized or otherwise, would this patient be likely to find a doctor who would consent to perform a non-emergency operation on a non-compliant patient who won't even temporarily quit the cigarettes.

prole--Not to take anything away from your very smart wife, but there is a reason why we have built second opinions into our insurance system.

On more than one occasion, I have had doctors treat me differetnly for the same condition. One instance was for painful razor bumps on my neck. One dermatologist cured me, the other didn't.

The one that didn't cure me had me using all sorts of steroidal creams, with little effect. The one that did cure me took one look at me and said "change the direction that you shave." Damned if it wasn't just that simple.

In another instance, many years ago, I awoke with acute pain in my right foot. So much so, I couldn't walk on it. I went to the county hospital emergancy room and after waiting many hours and an x-ray, they concluded it was gout. Probably.

I then went to a podiatrist recommended to me. He looked at my foot for about 2 minutes. Gave my foot a nerve block shot and that was that. 2 days later, no more pain from the pinched nerve.

Maybe these UK docs are right on the nose, but something about it stinks. Looking at the comments on the Daily Mail page, we're not alone in that suspicion.

|9.23.07 @ 4:03PM|#

Somebody, anybody please expain how "First, do no harm." justifies plastic surgery for vanities sake. Nose jobs, boob jobs, liposuction, tummy tucks, facelifts, penis lengthening and who knows what else! The AMA certainly isn't coming down on these doctors,are they? I detect NO movement from the medical profession to do away with this stuff. First, do no harm - I call bullshit.