Eat badly, smoke and lose your right to health care

VICTORIA - Down in the U.S. companies are getting ready to fire smokers.
Over in England, overweight people are being told they won't get knee or hip replacements.
And here in B.C., the province's chief medical health officer has just warned that diabetes - largely preventable - is already a $1-billion annual cost to the health care system. Within a decade, that will double unless we change our ways.
All three stories point to the need to start a debate on just how we're going to handle self-inflicted illness and injury when it comes to allocating scarce treatment resources.
Provincial health officer Dr. Perry Kendall focused on diabetes in his annual report. About 220,000 British Columbians have been diagnosed with the disease, and the number is expected to reach 390,000 within 10 years. Its complications can be cruel - heart and kidney disease, amputations and death.
And the problems are, Kendall reported, largely preventable. About 90 per cent of the cases are Type 2 diabetes, and people can slash their risk - and the cost to us all - if they eat healthier diets, exercise and keep their weight down.
Which raises a question about individual responsibility and the how we allocate finite health care resources.
U.S. companies, facing a health cost crisis far greater than anything we've seen in Canada, have started to make choices, with smokers the first target. Some are increasing health care premiums for smokers, or offering incentives and support for people who quit.
And some are firing people who fail tests for tobacco use. Scotts Miracle-Gro has told its 5,400 employees they have until next fall to quit, or they'll get the chop. (About 30 states have laws protecting people from being fired for smoking.)
It's not a moral judgment that smokers are flawed. The decision is based on economics. Smokers cost too much.
The British National Institute for Health and Clinical Excellence has just reported on the right of people with self-inflicted medical problems to treatment, and taken a similar approach The influential institute looked at the hard practical questions. Is it right to make a child needing a liver transplant wait in the queue behind a person whose illness is caused by years of alcohol abuse?
It's a tough question. Alcoholism is a disease too.
The institute took a cautious approach. Patients shouldn't be penalized for making themselves sick, it said. But if their behaviour reduces the chance of a successful outcome, then treatment can legitimately be delayed or denied. Why spend scarce resources on a liver transplant for someone like alcoholic former footballer George Best, who kept drinking and died within three years?
In reality health care providers have made those kinds of decisions. British National Health Managers in East Suffolk needed to save money this year, and so have stopped doing knee and hip replacements for anyone with a Body Mass Index over 30. If you're five foot nine inches and weigh 205 lbs, for example, no replacement. The surgery is riskier, outcomes poorer and artificial joints don't last as long. Joint replacements for overweight people are an inefficient use of scarce dollars.
A similar approach is take by some doctors in B.C, openly or not.
It's a difficult issue, theoretically and practically.
Type 2 diabetes, for example, is not always linked to diet and exercise. And people do not always have control over their circumstances. B.C.'s welfare rates, according to a new study from the Dietitians of Canada, don't allow a nutritious diet. Children from families on welfare are at increased risk of diabetes, and most people wouldn't argue they should be denied treatment.
But we shouldn't dodge the questions. We're already rationing surgery, often in arbitrary and unreasonable ways.
Demand and treatment options are increasing, while resources are finite. Finding the fairest, most efficient way of allocating those resources means looking at all the factors - even ones that make people uncomfortable.
Footnote: The other obvious issue is prevention. Kendall says a 25-per-cent reduction in the diabetes rate would produce annual savings of $200 million. That justifies a large upfront investment to expand existing programs aimed at increasing our health, and reducing the risk of diabetes and other illness.