Doctors tackle lifestyle dilemma: Decisions to withhold treatment must be made on clinical grounds, ethics committee chief says

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The Independent Online
THE BRITISH Medical Association is to spell out when a patient's lifestyle can affect a decision to give treatment, against growing fears that doctors will be pressured into making moral judgements in the budget-driven NHS market.

Claims that a man who smoked was refused heart treatment and a young woman who was overweight was refused fertility treatment have fuelled concern that patients who deliberately put their health at risk will not get treated.

But Dr Stuart Horner, chairman of the association's ethics committee, said yesterday that decisions to treat must always be made on clinical and not moral grounds.

His committee is working on a statement of position on the issue of lifestyle and right to treatment which will be put to the full BMA council for its approval in January.

The council saw the draft from Dr Horner's committee at its September meeting and asked for a final version. Dr Horner said there was no disagreement with the draft. It says it is unethical to discriminate against a patient because of lifestyle; that the judgement of the individual doctor is paramount; and that treatment decisions should reflect benefit to the patient. The draft also says that when action by patients to change their habits would have a good effect on their treatment, the doctor should first help the patient to bring about the lifestyle change.

'We are not talking about life and death situations - a doctor must try to save a life. We are talking about situations in which a fat elderly lady needs a hip replacement but her weight means that the operation will not work,' Dr Horner said.

The BMA is concerned that as contracts between the health authorities which buy the treatment for patients and the hospitals which provide it become more sophisticated, the drive towards improved results will have an unlooked-for effect.

Contracts that write in a single measure of success for a treatment should be to the advantage of patients, but it could result in fewer patients being treated, or those least likely to respond not being given the chance of a cure. Dr Horner said that in the North-west, contracts exist for kidney stones based on making the patient pain-free, rather than on the total number of treatments paid for. 'The pressure on doctors is coming. Some patients need one treatment, others five or six. If you have to give a high number of treatments, it follows that you will treat fewer patients,' he said.

The purchasing contracts drawn up on the basis of patient results can have another effect. Doctors could be influenced by the need to achieve high levels of success with the minimum number of treatments per patient - and as a result select patients most likely to respond rapidly.

Land of the rising smoke, page 17