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FOCUS Doctor knows best

June 30, 2002
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by Dr. James ReadSmoking kills.

This is not news.

Smoking cigarettes causes the death of more than 400,000 Americans each year. It is responsible for more deaths than murder, suicide, drugs, AIDS, car accidents and alcohol combined. Secondhand smoke is linked with cancer, heart disease and crib death.

The details might be news, but the fact they illustrate–that smoking makes people sick and kills them–is not news.

People who stop smoking increase their chances of living longer. This is not news either.

So, why the hullabaloo when a physician uses these facts to give his smoker patients an ultimatum? Dr. Rick Ross is a family physician here in Winnipeg who decided last Christmas that he would send a message out to all his patients saying that if they were smokers and they hadn’t quit or entered a smoking cessation program by March 1 they would need to look for another doctor.

Dr. Ross reports that some of his tobacco-using patients, and many journalists, have taken exception to his new policy. In his words, he’s been vilified by the press. But he’s not caved in yet, and judging by the applause he received from medical colleagues at the ethics session where I heard him, he’s something of a hero among doctors. One defender asked, “Why are the ethics of this one physician questioned instead of the thousands who remain silent?”

Good question, but it presumes that we know what Dr. Ross’s ethics are. He says that his chief motivation is the health of his patients. As he wrote to one of them who complained, “You’re upset with me for taking this stand, but I don’t apologize because it’s in your best interests. You are making every excuse to avoid this issue. I really want you to quit smoking.”

Is this good medical ethics?

Dr. Ross’s critics have asked what he’s going to say to his overweight patients, or those who abuse alcohol, or skydive, mountain-climb, and risk their lives in extreme sports. If he’s going to be consistent (and an inconsistent ethic is no ethic at all), then he should cut off all his patients who are doing things that endanger their health, shouldn’t he? Since many diseases are connected with something we do or don’t do, one journalist joked that this would be a dream come true for insurance companies. They’d only have to pay for those who take care of their health so well that they don’t need a physician!

The question I asked him was whether the health of his patients really was his only, or his chief, motivation. I sensed a built-up frustration. Here he is, a man who has devoted himself to the hard discipline of medical science and medical skill, a man who works 80 or 90 hours a week, a man who carries a heavy patient load at a time when more physicians are retiring than entering the profession, and then he encounters patients who keep doing things that make themselves needlessly sick. Wouldn’t you be frustrated? Wouldn’t you think you had better things to do with your time?

Dr. Ross agreed that that’s a part of it. But is it unethical to draw a line and say you’re done with wasting your time and talent?

Less than a week after I heard Dr. Ross speak, I had a call from the administrator of a Salvation Army shelter for homeless women. She said she was wrestling with the shelter’s admission policy. Apparently they won’t let anyone in who has been drinking or taking drugs. She wondered if this was right. She could understand not admitting someone whose intoxication meant that they were a danger to other residents, but should we be saying “No entrance” to people for their own sake? There’s no question that the abuse of alcohol and drugs is a big part of what puts people on the street and keeps them there. And there’s no question that there are healthier options than continuing to abuse drugs and live without a home. Are we reinforcing irresponsibility if the Army simply throws the shelter doors open whether the applicant is drunk or not? Are we wasting valuable time and funders’ money if we never demand that residents help themselves as a condition for our care?

I honestly don’t know the answer. I can hear what Dr. Ross is saying. I can imagine the frustration he feels, caring more about his patients than they care for themselves. And yet, knowing the conditions he sets, would I want him as my family physician? Is he as hard on himself for his own irrationalities as he is on his patients’?

I wonder the same thing about the “tough love” policies of Salvation Army personnel. I can understand an Army shelter wanting to give an ultimatum to homeless people so that they’ll begin to take better care of themselves. I can even imagine a corps officer deciding she’s going to stop visiting the homes of people who foolishly reject the Gospel. But are these the kind of administrators and corps officers we want?

It’s not always easy knowing what Jesus would do. To the Twelve, he said: “If anyone will not welcome you…shake the dust off your feet when you leave that home” (Matt. 10:14). But it is also said of him that “we do not have a High Priest who is unable to sympathize with our weaknesses….He is able to deal gently with those who are ignorant and going astray” (Hebrews 4:15; 5:2).

e-mail Dr. Read at Ethics_Center@can.salvationarmy.org

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