U.K. Smoker Denied Surgery for Broken Ankle

Britain’s National Health Service had denied surgery for John Nuttall–the reason? He’s a smoker.

A man with a broken ankle is facing a lifetime of pain because a Health Service hospital has refused to treat him unless he gives up smoking.

John Nuttall, 57, needs surgery to set the ankle which he broke in three places two years ago because it did not mend naturally with a plaster cast.

Doctors at the Royal Cornwall Hospital in Truro have refused to operate because they say his heavy smoking would reduce the chance of healing, and there is a risk of complications which could lead to amputation.

They have told him they will treat him only if he gives up smoking. But the former builder has been unable to break his habit and is now resigned to coping with the injury as he cannot afford private treatment.

He is in constant pain from the grating of the broken bones against each other and has been prescribed daily doses of morphine.

I’m not a doctor, but I suspect that, given the NHS’s past statements on the matter, that this has very little to do with the actual risks of complications and more to do with the bottom line. After all, Mr. Nuttall risks a lot more with his limited mobility, not to mention the fact that the side effects of his daily morphine prescription–which can include respiratory depression and severe constipation–aren’t exactly trivial.

Now it may well be that the risks of surgery are substantial, but I’m not sure that they are so substantial that Mr. Nuttall deserves to live the rest of his life in constant pain.

Update (Steve Verdon): I have to say I find this story rather amusing in a grim fashion since it is often a story we’d hear from the advocates of universal health care; that a person is denied care because of the inability to pay. In a country where there is supposedly universal health care, care is denied to a patient who obviously needs it.

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Alex Knapp
About Alex Knapp
Alex Knapp is Associate Editor at Forbes for science and games. He was a longtime blogger elsewhere before joining the OTB team in June 2005 and contributed some 700 posts through January 2013. Follow him on Twitter @TheAlexKnapp.

Comments

  1. Scott_T says:

    Yes! Please lets have socialized medicine like Europe, it’ll solve all our woes.

    😛

  2. davod says:

    I can see the bottom of travel brochure*

    *Travellers are warned that those who need surgery while in the UK may be refused if you are one more of more of the following:
    Smoker, overweight, underweight, drinker of alcohol, coffee or sodas.

  3. Grewgills says:

    Always anecdotes. In any system anywhere there will be anecdotal evidence of failings of the system. Look at the medical care available to the poor in any inner city or poor rural area and you can find plenty of anecdotal evidence of the failings of our system. You need to look at the entire system and how it effects the entire population. Every study I have seen that does this ranks the care received as better in universal care countries and their costs less. Can you point to any studies by any non-partisan group that refutes these results?

    Now an anecdote from the other side. I am being visited by family in the Netherlands. One of them needed to see a doctor. We walked to the local health center and she was able to see a doctor, get tested, and receive her meds in about an hour and a half for 35 euro and no need to use her American insurance.

  4. Tano says:

    Steve,

    No one is so dumb as to not realize that limited resources need to be rationed. The question is – for health care – what is the rationing criterion, need or wealth?

    The case recounted here seems that it might possibly be an instance where a need-based system has failed to make a proper assessment. I am sure that there are avenues available for appeal – as a last resort one could appeal to ones legislator, given that the system is public, or the media – which might be what is going on here.

    I am sure you would concede the existence of many anectdotes of private insurance companies denying coverage for things that you and I would judge necessary. What is the recourse then?

    Maybe the good old marketplace will offer up another (better) insurance company that would be glad to pay for the expensive operation you need at the time of application!

    Or are y’all trying to claim that it is only public systems that would ever try to erect strict (or overly strict) criterea for expensive procedures?

  5. I suppose one could develop a theory of rationing that might preclude treatment for, say, emphysema for smokers, but a broken ankle? Yeah, I read the argument about smoking interefering with the healing process, but isn’t getting old a rather significant impediment to the healing process as well? Or is that a leap of faith we just know won’t be made?

  6. iftheshoefits says:

    Denying insurance coverage is not the same thing as denying treatment.

    Sure, if I can’t afford to pay for it myself, then the end result may effectively be the same. But that’s only if it’s impossible to find a facility that won’t provide some basic uninsured treatment.

    I’ll take my chances with a system wherein I know I can find a qualified emergency room to set my broken ankle, even if I may have to pay for the privilege.

  7. Smokey says:

    This situation sounds a bit over the top, but, nicotine does constrict blood vessels and screw up your circulation, especially in the extremities. The diabetics I know who smoke have the concentration of amputations and blindness compared to those who don’t. There may be some other complication that is not reported in the article, after all there is a reason the break did not heal right when set and treated before.

  8. Grewgills says:

    I’ll take my chances with a system wherein I know I can find a qualified emergency room to set my broken ankle, even if I may have to pay for the privilege.

    The emergency room is not the place to go to have your ankle that healed poorly be reset.
    If you have insurance you should have it done by appointment and deal with any regulations that your HMO may have. Perhaps they would not find the operation to re-brake and reset your ankle a necessary procedure. Perhaps your lucky and they approve it. Perhaps they must provide it because of some government regulation (bad, right?).
    If you do not have insurance it is not likely you can afford to have this procedure done in an ER, even if they would do it in that venue.
    As for having it done by doctor or hospital as an uninsured individual without guaranteed payment, good look getting that done. I am relatively certain that this is not a procedure that a hospital or doctor would be required to do for an indigent person. Correct me if I am wrong here.

    Keep in mind also we cannot see his medical chart. A few details were reported.
    I really do like how the crowd that constantly touts personal responsibility as the reason for not providing public services is using this case. A heavy smoker will not give up smoking prior to an operation in order to improve the chance of that operation being successful. All he has to do is quit smoking for a couple of months to get an operation that will prevent him what he calls daily agony. He either can not or will not give up cigarettes for a few months to get this operation.
    If cigarettes are really so addictive that he can not give them up to prevent daily agony, should they be legal when other far less addictive drugs are not?
    If he will not, what does that say about his priorities?

  9. Steve Verdon says:

    No one is so dumb as to not realize that limited resources need to be rationed. The question is – for health care – what is the rationing criterion, need or wealth?

    So you reject the notion of universal health care? Funny after all your defenses of it.

    The case recounted here seems that it might possibly be an instance where a need-based system has failed to make a proper assessment.

    And who makes such a determination? The electorate might decide that this is just fine…if enough of the electorate don’t smoke.

    I am sure you would concede the existence of many anectdotes of private insurance companies denying coverage for things that you and I would judge necessary. What is the recourse then?

    Moving of the goal posts duly noted. Denying coverage is one thing, denying care is another matter entirely. By law hospitals are required to render care irrespective of ability to pay.

    Maybe the good old marketplace will offer up another (better) insurance company that would be glad to pay for the expensive operation you need at the time of application!

    Insurance doesn’t work that you need an operation so you go sign up. No insurance company could ever be profitable.

    If you do not have insurance it is not likely you can afford to have this procedure done in an ER, even if they would do it in that venue.

    But they will do it, because that is the law.

    As for having it done by doctor or hospital as an uninsured individual without guaranteed payment, good look getting that done. I am relatively certain that this is not a procedure that a hospital or doctor would be required to do for an indigent person. Correct me if I am wrong here.

    Yes you are wrong. Going to the ER will get it done. You can get just about anything via the ER if you wait long enough and complain vociferously enough. This is one reason why health care in the U.S. is so expensive. To the extent that a government provided program reduces this kind of usage of ERs it will save money. But the increased demand due to increasing the number of people who have easier access to health care will raise costs.

    If he will not, what does that say about his priorities?

    What?!?!?! I’m shocked. You’d better be careful your good standing as a collectivist could be called into question here.

  10. Brian says:

    Man, this is great! I can’t wait til the US Government is controlling our health care.

  11. Tano says:

    “Denying coverage is one thing, denying care is another matter entirely.”

    First of all, in the real world the difference is not as clear as you may think. If the procedure would cost something on the order of a year of your salary (common for us peasants), then a denial of coverage = a denial of care.

    “By law hospitals are required to render care irrespective of ability to pay.”

    Thats malarky – in the context of this discussion. Hospitals are NOT required to do an expensive, possibly dangerous, elective surgery of the type that you describe in this post.

    “Insurance doesn’t work that you need an operation so you go sign up. No insurance company could ever be profitable.”

    I guess you are having a bit of a slow day, Steve. Yes, that is the point. If your insurance company wont pay for your surgery, then the private marketplace does not offer any recourse.

  12. Grewgills says:

    So you reject the notion of universal health care? Funny after all your defenses of it.

    Acknowledging that resources are not unlimited does not equal rejection of universal care as you well know despite the snark.

    And who makes such a determination?

    Ideally a doctor or doctors with the patient. Often though in the US the decision is made by a bureaucrat in an insurance company office dozens or hundreds of miles away. For the average American that has health insurance coverage is rationed by their HMO.

    I am sure you would concede the existence of many anectdotes of private insurance companies denying coverage for things that you and I would judge necessary. What is the recourse then?
    Moving of the goal posts duly

    No, clear parallel.

    By law hospitals are required to render care irrespective of ability to pay.

    You leave out one very important word. By law hospitals are required to render emergency care irrespective of ability to pay and then their requirement is to stabilize the patient. Some doctors and hospitals do offer charity care, but they are not required to provide non-emergency care to those unable to pay.
    I believe that EMTALA is the legislation that covers this. Maybe you should read it.

    Insurance doesn’t work that you need an operation so you go sign up. No insurance company could ever be profitable.

    So government insurance won’t do it equals bad, but private insurer won’t do it equals understandable because they need to make a profit?

    But they will do it, because that is the law.

    It is not emergency care so no.

    Yes you are wrong. Going to the ER will get it done. You can get just about anything via the ER if you wait long enough and complain vociferously enough.

    If you complain loudly enough may recieve what is referred to as charity care or uncompensated care (bad debt) but care is not legally mandated unless it is an emergency.

    This is one reason why health care in the U.S. is so expensive. To the extent that a government provided program reduces this kind of usage of ERs it will save money. But the increased demand due to increasing the number of people who have easier access to health care will raise costs.

    The indigent waiting until a medical situation becomes an emergency and only then seeking care at among the most expensive outlets (ERs) is one of the myriad reasons for the high price of American medical care. Universal care would allow care before the situation became an emergency when treatment is cheaper not only because the venue is different but because the situation is cheaper and easier to treat. Ex/ A child with an ear infection is far easier and cheaper to treat in the early stages than when it has progressed to the point that it is an emergency (pus or blood leaking from the ear, possible permanent hearing damage, etc.).

    If he will not, what does that say about his priorities?

    What?!?!?! I’m shocked. You’d better be careful your good standing as a collectivist could be called into question here.

    No real response, I’m shocked! He refuses to quit smoking for the four weeks prior to an operation to save him what he terms daily agony. He obviously wants the cigs more than he wants the pain to stop. He doesn’t even have to quit forever. He can pick up a pack and return to the habit that has created the “chest problem” that prevents him from working on his way home from the hospital.

    Denying coverage is one thing, denying care is another matter entirely.

    The man in the case you described was denied coverage that resulted in his not being able to afford care.

  13. I guess the old “first, do no harm” is the first thing to be thrown out with socialized medicine.

    Having had a massively broken ankle that required pins and plates, I find this story horrific. I cannot imagine having to have a doctor, someone there to heal me, tell me that.

  14. Paul says:

    I’m generally opposed to government subsidy of health care except perhaps for the poor, but I think some of the conservative sniping at this story misses the point — the guy is still allowed to go buy his own care inside the UK if he’d just pay up for it. So their critique is not actually that this is a fault of the UK in providing too much health care, but not enough, you want it for smokers too. God knows if we subsidize health care even more (Medicare along will already sink us) we’d better do something to discourage smoking, but I’d probably go with higher cigarette taxes rather than paying bumbling bureaucrats to manage cases like this story here.

  15. lunacy says:

    I’m supposing the guy has already paid for his health coverage through his taxes. If the UK gov’t is going to start segregating health care for smokers, will then they start taxing smokers less than non-smokers?

  16. TJIT says:

    Grewgills says,

    You need to look at the entire system and how it effects the entire population. Every study I have seen that does this ranks the care received as better in universal care countries and their costs less. Can you point to any studies by any non-partisan group that refutes these results?

    Sure, check out this link

    The “crippled and broken ” US health care system comes through again

    The researchers, whose report is published in the journal Annals of Oncology, found that Austria, France, Switzerland and the US were leaders in using new cancer drugs.

    The greatest differences in the uptake of drugs were noted for the new colorectal and lung cancer drugs.

    The proportion of colorectal cancer patients with access to the drug Avastin was 10 times higher in the US than it was in Europe, with the UK having a lower uptake than the European average.

  17. TJIT says:

    Another study showing the superiority of the US private healthcare system.

    Is American health care more productive?

    The proper way to measure the performance of health care is to measure the difference it makes in the quality of life of people who come for help…What we need to know is whether the higher level of spending means the United States is much less productive in health care than other countries.

    In an attempt to test the limits of knowledge here, we studied the treatment of four diseases — diabetes, cholelithiasis (gallstones), breast cancer, and lung cancer — in three countries: Germany, the United Kingdom, and the United States. These three countries were the only countries for which comparable data existed for these diseases, either nationwide or for large regions.

    The United States is more productive in all these diseases except for diabetes in the United Kingdom. [emphasis added] The reasons for this result can be traced directly to the huge differences in the way the health care sector is organized and governed across these three countries.

  18. Grewgills says:

    I’m supposing the guy has already paid for his health coverage through his taxes. If the UK gov’t is going to start segregating health care for smokers, will then they start taxing smokers less than non-smokers?

    American HMOs would never treat smokers differently would they? The wouldn’t dream of charging smokers more for care than non-smokers would they?
    You can get nailed with higher costs before or with less coverage later, but either way in either system you have to pay for this lifestyle choice when it comes to health care.
    It seems that cigarette taxes could be given to the health care system to defray or even pay the costs of tobacco on the system.

  19. TJIT says:

    Tano said,

    The case recounted here seems that it might possibly be an instance where a need-based system has failed to make a proper assessment. I am sure that there are avenues available for appeal – as a last resort one could appeal to ones legislator, given that the system is public, or the media

    I have noticed a few people responding to incidents like this with the idea that there must be some reasonable government authority who will help fix the mistake the other government bureaucracy made.

    Unfortunately this is not a reasonable assumption as the following link illustrates.

    Why I am a Small l Libertarian

    My wife and I wanted to put an addition on our house here in the City of Los Angeles. Our general contractor told us that the first thing we had to do was get up-to-date zoning and property information from the Building Pemits Department. He recommended that we hire a “fixer” who was used to dealing with the bureaucracy. That was 2 months ago.

    Today, we were informed by the City zoning department that they could not give us the necessary zoning information … because, according to zoning records, our house does not exist! On top of which, the zoning folks also had no record of the street on which we live.

    The rest of the gory details are presented at the link, it is well worth reading.

  20. Giacomo says:

    As an orthopaedic surgeon, perhaps I can shed a little light. Smokers develop both small and large vessel vascular disease. Such reduced blood supply to the extremity can be improved if it’s large vessel disease, but not if it’s small. The fact that this gentleman already failed to heal his fracture and now it’s two years later is a bad enough sign. He’s at very high risk of complications including failure of bone healing, skin breakdown, development of infection. His risks would be even higher if he were also overweight and/or diabetic.

    That said, if he’s at such high risk that fixing the fracture isn’t an option, particularly if he keeps smoking, then they could at least offer him an amputation, which would be likely to solve the pain issue and leave him ambulatory.

  21. Smokey says:

    Amazing – everyone here seems to be ignoring that there may be a medical reason indicated for the denial of service. The article suggested that the smoking would impare healing. If he was asked to give up heroin because of a danger of conflict with the anestetic would people be reacting the same?

    No wonder there is no intelligent political discussion in this country, everyone on both sides just trys to make a point despite what the facts might really be.

    What are the FACTS of this case – anyone care?

  22. Grewgills says:

    TJIT,
    The first study you mention has some bad things to say about the UK system relative to other EU universal systems. Most of the anecdotes that seem to be floated by people in opposition to universal care do seem to come out of the UK. The UK is not the model that most are looking to emulate. That one universal health care system and one of the lower performing ones at that has problems is hardly a cogent argument against universal health care.
    This study only peripherally mentions US health care and then only in relation to the delivery of one drug. This is a long way from a full comparison of any universal health care system to the US system.
    The second article you point to is a blog posting and has no independent corroboration for its conclusions.

    Giacomo,
    Thanks for offering a medically informed addition to the conversation.