Smoking cessation and elective surgery: the cleanest cut

In reply: The rigid way in which Hodgkinson has addressed risk reduction in plastic surgery seems reasonable, as long as there is open disclosure and access to smoking-cessation services is assured.

It is an unfortunate fact that our healthcare system cannot provide everyone with what they want, or need, in a clinically appropriate timeframe. Resources are finite. In his own case example, and without considering the legal or ethical basis of his intervention, once Tonti-Filippini arranged for a patient at high risk of complications to have surgery, someone else was immediately prevented from having hospital care that was necessary for them. If complications developed, extending hospital stay, more than one patient might have been adversely affected.

Let me extend Tonti-Filippini’s case a little and imagine that a similar patient with peripheral vascular disease who was moved further down the vascular surgery waiting list as a result of the smoker’s surgery being expedited was an ex-smoker who had taken advice and ceased smoking to reduce risks and improve the surgical outcome. Then, in the period of surgical delay, the affected leg became acutely ischaemic and amputation (rather than vascular reconstruction) was required. Are there not ethical implications that follow? Reading more deeply into the Australian Medical Association’s Code of Ethics, one finds that we should work to increase standards and the quality of and access to medical services in the community, and make available our special knowledge and skills to assist those responsible for allocating healthcare resources. These are important obligations.

Most smokers are addicted, and this is a medical problem that needs to be consistently identified and addressed; the issue of smokers with mental illness was highlighted in the editorial. If a clinical decision is made not to perform surgery in the context of continued smoking, it is not made because the person is a smoker, or because they have an addiction, but because the ongoing smoking has major, adverse consequences that we are unwise to ignore. The distinction is subtle but important.