Yes

by Jonathan Carney

Created on: February 17, 2008   Last Updated: February 18, 2008

Coronary artery bypass surgery is a surgical procedure carried out to relieve angina and reduce the risks of coronary artery disease. The term bypass refers to the fact that the surgeon bypasses, or creates a detour around, the sites of narrowing or blockage in the artery. To do this, arteries or veins from elsewhere in the patients body are grafted from the aorta to the coronary arteries. This improves blood supply to the coronary circulation supplying the heart muscle. Generally, the surgery reduces the risks of heart attacks, saving many lives. The cost however, is very great. One source claims that one bypass surgery operation can cost upwards of 13902, not including drugs and after care. Surely such a cost should not be funded for those who've brought about the situation themselves. By this I mean the obese and smokers.

Obesity invariably increases the need for coronary artery bypass surgery. Much of the food consumed is likely to contain cholesterol containing animal fats which build up and clog arteries. In turn the blood flow is restricted, causing an increase in blood pressure. This leads an increase in the need for surgery to prevent heart attacks and ultimately death.

Those who regularly smoke also pose a greater risk of developing the need for heart bypass surgery. A number of ingredients found within tobacco lead to the narrowing of blood vessels (Arteriosclerosis), and an increase in the likelihood of blockage. This dramatically increases the risks of heart attacks and strokes. According to a study by an international team of researchers, people under 40 are five times more likely to have a heart attack if they smoke. Other chemicals found within cigarette tobacco are known to lead to high blood pressure and cause damage to the inside of arteries.

The needs for operations such as heart bypass surgery are largely self-inflicted, and could have been easily avoided if they'd led a much healthier lifestyle. According to the British Medical Association News survey 40% of doctors agree. They state that obese patients, smokers, and heavy drinkers should be denied treatments. The poll of 225 doctors also found that 39% had agreed with the recent action carried to bar obese people from joint surgery to cut costs in Suffolk. Another 39% stated that policies should be widened to deny smokers and heavy drinkers from certain treatments. The conservative party also seems to agree. New proposals could lead to failing to allow free NHS treatment to those who don't lead healthy lifestyles. Patients would be given "NHS Health Miles Cards" allowing them to earn reward points for losing weight, giving up smoking, receiving immunisations or attending regular health screenings. Personally I think this could be a good idea, but would only lead to greater bureaucracy in the country, which could affect waiting times, costs etc. Ultimately these proposals would not help the situation.

On the other hand surely a large percentage of people who are obese cannot help it, as a result of genetics and external factors. Therefore are these people right to be denied treatment for something they can't avoid? Several genetic conditions that feature obesity have been identified (Prader-Willi syndrome, Bardet-Biedl syndrome, MOMO syndrome, leptin receptor mutations and melanocortin receptor mutations). However only 5% of obese individuals have been found with any of these conditions. It is important though to aknowledge that a large proportion of genes relating to obesity have yet to be discovered, and many cases of obesity will be as a result of interactions between multiple genes, rather than one single gene determining your entire bodily weight. Futhermore, different ethnic groups may be prone to obesity more than others. Clearly it would unreasonable and immoral to deny somebody treatment with the knowledge that they are suffering from a disease which gives them limited control over their weight. The question remains though, how and when will we be able to determine the causes of obesity for each and every individual patient? Personally I believe that until we can be certain of the exact causes of obesity within patients, surgery should remain for all, with the possible exception of smokers.

National Health Service managers say smokers and taking more time to recover from their surgery, blocking beds and ultimately costing more to treat. Rod Moore, assistant director of public health at Leicester City West Primary Care Trust, has said it should be the norm for all patients to quit smoking prior to their treatment. "If people give up smoking prior to planned operations it will improve their recovery," he says. "It would reduce heart and lung complications and wounds would heal faster. Our purpose is not to deny patients access to operations but to see if the outcomes can be improved". Most NHS managers agree with this statement, and now want patients to have not smoked any cigarettes for a month before their surgery. However, as most people can take up to two months to quit, operations could be in turn delayed by a further 3 months. Most of these schemes seem to be implemented to help save the National Health Service from its cripplying debt. Vast quantaties of the money saved could be spent on other services, such as transport and education. Further money could be invested in the NHS as well, helping to reduce waiting times and increase staff numbers. In turn a wealthier government could eqate to people living much healthier lifestyles, especially if we get richer. Facts now show that obesity is linked to poverty and occupation in Britain. A report from the National Statistics claims- 'Obesity is linked to social class, being more common among those in the routine or semi-routine occupational groups than the managerial and professional groups. The link is stronger among women. In 2001, 30 per cent of women in routine occupations were classified as obese compared with 16 per cent in higher managerial and professional occupations'. Denying Coronary artery bypass surgery could give way to solving many of Britain's problems in the long term.

In contrast, whilst denying smokers and the obese NHS treatment would save money, they have been giving their money to the NHS for most of their lives through taxing and vat. Being prevented having a life saving operation would be unfair to someone if they'd help pay for it their entire lives through tax. One man commenting on an online Daily Mail article bluntly wrote 'Isn't it against our human rights to deny us treatment? Presumably if we are not going to be treated then there is no point in us paying tax'. His points are reasonable, but surely if the obese and those who smoke are costing and delaying the NHS, then they are in a sense denying other peoples treatment.

Alternativ ely, such a radical new way of denying treatment to obese and smokers would surely encourage them to loose weight or quit smoking. And isn't this good for the individual? Perhaps yes, but many people would not have the time to loose weight or quit smoking before their condition can be treated- and their lives saved. It's clear however that the government has to create new policies to encourage people to lead healthier lifestyles, without forcing them and denying all treatments.

On top of being expensive to carry out Coronary artery bypass surgery on, obese patients are also at a much greater risk of dying during the operation. This can be highlighted by the effects of general anaesthetic upon them. For example obstructive sleep apnea (OSA) is a disorder which requires special care associated with anaesthetic. Many patients with OSA are obese, placing them in the category of increased risk for aspiration of acidic gastric fluid at the time of anaesthesia induction. Consequently obese patients have to receive medications to suppress this. Another challenge doctors have to carry out when undergoing surgery on obese patients is being able to obtain adequate intravenous access. This is highly significant because during Coronary artery bypass surgery veins from elsewhere in the patient's body are grafted from the aorta to the coronary arteries. If access cannot be gained to these arteries as a result of too much fat, patients will die. Patients with OSA (largely the obese) are also often sensitive to sedative medications, especially if the OSA is untreated. Obese patients as well as smokers, due to having reduced oxygen reserves, cannot tolerate a lack of ventilation for longer periods. This causes even more problems for surgeons to tackle. For these reasons, the NHS could be right to deny the obese and those who smoke coronary artery bypass surgery, as they'd stand a much better chance of survival if they weren't so obese or didn't smoke. This is only of help to the patients, with the exception of those who don't have the time to change their lifestyles before their lives are taken away.

In conclusion, I firmly believe that in some point during the future, obese and smoking patients should be denied treatment. In exception, once genetics are more advanced, if the patient has been found to carry a condition (s) which makes them overweight, they should still be given Coronary artery bypass surgery. Also, if the patient would be found to not have enough time to quit smoking, or loose weight prior to the operation due to risk of life (3 months), then surgery should also be given. Hopefully such new policies would encourage those who are obese and those who smoke to change their lifestyles, without forcing them with the predicament of death.

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