Last year a primary care trust announced it would take smokers off waiting lists for surgery in an attempt to contain costs. In this week's BMJ, two experts go head to head over whether smokers should be refused surgery. Denying operations is justified for specific conditions, argues Professor Matthew Peters from the Concord Repatriation General Hospital in Australia. Professor Peters says that smoking up to the time of any surgery increases cardiac and pulmonary complications, impairs tissue healing, and is associated with more infections. These effects increase the costs of care and also mean less opportunity to treat other patients, he writes. In healthcare systems with finite resources, preferring non-smokers over smokers for a limited number of procedures will therefore deliver greater clinical benefit to individuals and the community. He believes that, as long as everything is done to help patients to stop smoking, it is both responsible and ethical to implement a policy that those unwilling or unable to stop should have low priority for, or be excluded from, certain elective procedures. But Professor Leonard Glantz from Boston University School of Public Health believes it is unacceptable discrimination. "It is astounding that doctors would question whether they should treat smokers," he says. "Doctors should certainly inform patients that they might reduce their risks of post-surgical complications if they stop smoking before the procedure. But should the price of not following the doctor's advice be the denial of beneficial surgery?" Cost arguments are made to support the discriminatory non-treatment of smokers. But why focus our cost saving concerns on smokers? Patients are not required to visit fitness clubs, lose 25 pounds, or take drugs to lower blood pressure before surgery. And many non-smokers cost society large sums of money in health care because of activities they choose to take part in. Discriminating against smokers has become an acceptable norm, he writes. It is shameful for doctors to be willing to treat everybody but smokers in a society that is supposed to be pluralistic and tolerant. Depriving smokers of surgery that would clearly enhance their wellbeing is not just wrong - it is mean, he concludes. ### Contact: Catherine Binnie

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