The first official move to refuse surgery happened last month when a local health authority in Ipswich, northeast of London, announced that obese people would not be given hip and knee replacements --- Quote from the article.

I wonder if that thinking is coming to Canada?

[ 17 December 2005: Message edited by: audra trower williams ]

http://www.collegedowntime.com/media/movies.php?title=familyguyvideofatguys

Anyways i can see where they are comming from, as these surgeries take up time that can be used to more important surgeries that are not preventable. This i reckon will encourage people to loose weight.

[ 17 December 2005: Message edited by: kiwi_chick ]

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Originally posted by kiwi_chick:
Anyways i can see where they are comming from, as these surgeries take up time that can be used to more important surgeries that are not preventable. This i reckon will encourage people to loose weight.

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Oh, certainly, that will encourage them. But the question is, how do you propose they lose that weight if they need a knee or hip replacement? I mean, besides starving it off, which lowers the metabolism and encourages the body (regardless the intention of the person inhabiting the body) to pack the weight back on soon after they're finished?

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The surgery limit has also ignited debate on whether or not smokers suffering from lung ailments will be the next group to be denied treatment if they refuse to kick the habit, and whether this trend amounts to an attack on the poor, who have rates of both smoking and obesity much higher than middle- and upper-class Britons.

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"Rationing is a reality when funding is limited," Harrison said, adding responsible health-service providers have an obligation to taxpayers to get the most benefit out of the money they're given.

Harrison said the lower success rates for hip and knee replacements in obese patients cannot be ignored.

"Ability to benefit is a key criteria. It is a valid point. If chances of successful outcomes go down, you are wasting money."

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I don't like that talk of benefits and chances for successful outcomes, because it sounds like the yardstick for success is a return to a healthy life within certain medical norms. This line of thinking has severe implications for people with disabilities.

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Originally posted by vmichel:
This part troubles me:

[QUOTE]"Rationing is a reality when funding is limited," Harrison said, adding responsible health-service providers have an obligation to taxpayers to get the most benefit out of the money they're given.

Harrison said the lower success rates for hip and knee replacements in obese patients cannot be ignored.

"Ability to benefit is a key criteria. It is a valid point. If chances of successful outcomes go down, you are wasting money."

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The obese patient probably feels that the temporary alleviation of his suffering is a successful outcome for his knee replacement.[/QUOTE]

Word, vmichel. This is a disturbing development, although we know that discussions like this have been bubbling up here as well for a while.

Look back to that quotation from Mr Harrison (of "an independent London think tank" - aha), and the [il]logical leap from his first statement to the second.

All the first statement means is that funds are tight - doctors attempting to run a national health service are discovering that the government has not given them enough money to do that. Whenever and wherever that is true, more or less arbitrary measures are going to be applied to cut costs - first come first served, nepotism, are you fat?, do you smoke?, etc - in a sense, all those categories are similar in that they are arbitrary.

But Mr Harrison feels justified in leaping to the conclusion that treating a patient who isn't going to "get well" to his standards (which, as vmichel has pointed out, are questionable in and of themselves) is "wasting money." That's a circular argument. It's only a waste of money if you've defined funding that way in the first place, as something you are going to keep cutting back to a point where all procedures cannot be paid for and therefore arbitrary choices have to be made to stay within budget.

There are lots of questions like vmichel's to be raised about Tony Harrison's standards of "successful outcomes." The implications for everyone with any kind of disability are indeed severe. He seems to be implying, in response, that the triage we do will be based on moral criteria: if you caused your disability, we're not going to "waste" money on you. But medicine does not know much about the causation of many illnesses. Most of us are probably "causing" all kinds of bad things in our own bodies right now without knowing it.

Medicine has two creative and hopeful directions to pursue right now: better treatment for those diseases we can't cure yet (which doesn't always mean more expensive and fancy treatment - it often means just that we have to get more humanely smart), and speeding research into genomics and related fields, which will answer many of the puzzles we still face.

Even so, we are all still going to get sick and die, and that is almost always the most expensive part of medicine. We will not have a good medical system until an enlightened citizenry demand, absolutely demand that our politicians fund the system on that understanding, clearing away all the outrageous, inhumane moralizing with which we tear our society apart.

[ 18 December 2005: Message edited by: skdadl ]

In addition for total joints, they just do not work in obese patients.

You must see that there is some distance between your regretful - and pretty muted, I take it - response and the heavily moralizing political argument made by the think-tanker in the linked article?

I think there is some distance, anyway. I speak as someone who has accepted the news from an emergency-room physician that she will be delivering only "the most conservative" treatment, which was reasonable, I thought, under the circs. (It worked anyway. )

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There are lots of questions like vmichel's to be raised about Tony Harrison's standards of "successful outcomes." The implications for everyone with any kind of disability are indeed severe. He seems to be implying, in response, that the triage we do will be based on moral criteria: if you caused your disability, we're not going to "waste" money on you. But medicine does not know much about the causation of many illnesses. Most of us are probably "causing" all kinds of bad things in our own bodies right now without knowing it.

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That is the attitude that is taking root in the US as well. If its your fault - suffer and die. Who determines if its "your" fault? Why, we do, of course, your (take your pick): government bureacrat/insurance bean counter/so-called 'medical ethicist' on staff.

I saw it in the move toward mandatory seat belt laws in the US (where not wearing the belt can be the sole reason for the cops to stop you). The main argument was the amount of money spent on medical care for people who did not wear seat belts in an accident. We didn't want to spend that kind of money bceause people were stupid.

Seems reasonable, doesn't it?

I had a radio show at the time and said, ok, you want to hold people responsible for their stupidity, let's have this law: the next time the paramedics come upon an accident on the highway and it can be conclusively determined at the scene that the injured was not wearing seatbelts, then withhold treatment and watch them die in agony. Sounds crazy? Well, my mum has been obese (but not morbidly so) most of her adult life and has had two complete knee replacements and two back surgeries (she's 67).

Had she not had those surgeries she would have been wheelchair ridden at least 10 years ago with all the costs associated with that. She would have also been in a great deal of pain and quite possibly have had both legs amputated. The pain may have been so great, she may have wanted to die, its hard to say.

You know, though, the thing is, even though she's fat and it was probably her fault for not turning into a fitness fanatic after she had my sister and I, I still love her and want the best for her. I don't want to see her in pain and I want her to be as self-sufficient in her widowhood for as long as possible.

But perish forbid that a reasonably decent society should pay for that.

I can't wait until we triage all the smokers who contract lung cancer and we can watch them die in agony as we wag fingers and tell them that it was all their fault, after all, and why should we pay anything to treat them?

New Study Calls for Longer Needles for Fatter Backsides

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Fatter rear ends are causing many drug injections to miss their mark, requiring longer needles to reach buttock muscle, researchers said on Monday.

Standard-sized needles failed to reach the buttock muscle in 23 out of 25 women whose rears were examined after what was supposed to be an intramuscular injection of a drug.

Two-thirds of the 50 patients in the study did not receive the full dosage of the drug, which instead lodged in the fat tissue of their buttocks.
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Besides patients receiving less than the correct drug dosage, medications that remain lodged in fat can cause infection or irritation....

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It's my understanding that the joint operations, especially knee operations, have only become effective in the last fifteen years or so. Can anyone confirm that? BH?

I have known older people, including my mother, to live into their nineties - if in wheelchairs - with disabilities that now can be treated if they are treated in, say, one's fifties or sixties.

So we are encountering new expenses, not just personal sins. People my age can be treated for problems my mother had but could not be treated for, and that will be even more true, and on other fronts, for all you young whippersnappers.

But many of those treatments, ultra-expensive and ultra-high-tech, are being put into competition with more traditional end-of-life treatments. To me, the problem is the competition. Do we really want to allow this logic to run its course? We can't fund homecare because we're saving so many knees?

There is a mentality that with a universal healthcare system everything should be ready and waiting for you should you need it. I think our healthcare system should be revamped to focus on the preventative measures rather than fixing outcomes. It would be a cost saving as well as a quality of life measure.

After all they could have taken steps to be shorter.

I have three cats, they all eat the same amount have the same conditions in which to live and yet one is quite thin, almost scrawny, one is "average" and one is quite chunky ala garfield.

So many things contribute to wieght including poverty, abuse, inability to buy good food, it is rediculous that anyone would withhold medical treatment based on weight.

Why don't they just get straight to the point and say that only the rich, the truly productive members of society may have medical treatment.

Heck, I know one person here in Calgary who drank his whole life, full blown alcoholic and has now had several heart by-pass surgeries as well as other medical procedures.

Should the taxpayer get stuck with his bill even though the alcoholism is his own fault?

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Originally posted by abnormal:
Contarian,

Hip replacements weren't particularly new 20 years ago. My mother had her's replaced in 86 after a fall and a friend of mine's father was actually on his second hip replacement by that time - he'd actually broken the first one after about five years of use.

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The materials they use has changed over time; some sites say they used to give hip replacements to people over 60 because they were less active and so would strain the artificial hip less. But now materials are stronger so they can give them to younger people.

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Originally posted by FabFabian:
The more weight you carry on your body, the more stress you put on your joints. I wouldn't want anyone to be denied outright any procedure that would eleviate pain, but I think personal responsibility in regards to healthcare doesn't get addressed. It doesn't say in the article whether these patients were told to lose some weight first or not. With any surgery if weight is an issue, a doctor will tell the patient to lose weight in order for the procedure to be a success.

There is a mentality that with a universal healthcare system everything should be ready and waiting for you should you need it. I think our healthcare system should be revamped to focus on the preventative measures rather than fixing outcomes. It would be a cost saving as well as a quality of life measure.

Of course, we need the leadership in gov't to promote healthy lifestyles and reward those sectors of society that contribute to healthy living. I don't think axing Participaction or tax credits for hockey enrollment are the answer either.

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Y'see, here is the problem. FabFabian, you can start off saying that you don't want to see people denied treatment, but then you spin off immediately into moralizing generalities that are dangerous to all kinds of individuals who don't fit into your generalizations.

It has already been explained - in the article that was the original link, and in following posts - that obese people are unlikely to be able to lose significant amounts of weight before surgery, for good reason. So the assessment has to be based on some better criteria.

And if you think you know for sure what a "healthy lifestyle" is, then good for you. You're way ahead of medical science on that score, far as I can tell.

One of the reasons that the early hip replacements were only given to relatively old people was the simple fact that, in the early days of this type of surgery the medical establishment didn't know what the long term effects of implants like this would be on the human body. As a result, if you did a hip replacement on a 60 year old you were generally looking at 20-25 years max before the person died. If you did the same operation on a 20 year old you're looking at a much longer time frame. By starting with older patients they got to see what happened over a relatively short time frame before they did something irrevocable to a 20 year old.

I don't think I'm a wimpy person, but the pain has been enough to completely destroy my appetite.

And I was told I was very lucky that I was "lean" because every pound of surplus weight actually puts three extra pounds pressure on the healing implant.

It's also much harder to operate when there are layers of fat because the sutures don't hold... an acquaintance had months of problems after having her appendix removed because her added weight kept her sutures from holding the incision closed...

even so, NOBODY should be denied surgery. And we all need to write our letters and pressure the governments to give adequate funding to the medical services.

Not that this is of major consequence, but my family and I have worked in the healthcare systems of both the UK and Canada. I do have some practical knowledge of what I speak. A doctor is completely within their rights to tell an obese patient that they will not proceed with a surgery if they don't lose some weight. Hospitals don't have OR tables to accommodate an obese person. Also, it is more difficult for a surgeon to wade through all that flesh. The likelihood of a patient's survival after such surgery is dramatically reduced due to weight. It would be no different than a smoker wanting surgery, they would still be told to lay off the cigs. Medicine has advanced, but doctors are not miracle workers.

As far as science and weight goes, it is a fact that the more energy you put into your body, the more you have to expend to burn it.

The topic of what physicians and surgeons consider "medically futile" is an interesting one. I can believe that that term applies in a strictly medical context, as the logical conclusion of strictly medical assessments, and in fact I have some current experience in thinking through such judgements. It's interesting to me to see how contested they can be, how mistaken they can be, although I have learned to respect them as well.

But the opening link in this thread raised the issue of such judgements shading over into another context: that is, of a future in which "medically futile" might actually mean "we're on a tight budget, and we have to throw some people overboard."

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I'll bet the well-heeled have a doctor in every country, every Caribbean island and every Riviera winter place they choose to live 181 days of the year in order to avoid paying Canadian taxes. I hope none of them and theirs has over-indulged.

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Originally posted by skdadl:
But the opening link in this thread raised the issue of such judgements shading over into another context: that is, of a future in which "medically futile" might actually mean "we're on a tight budget, and we have to throw some people overboard."

That's the future I was speaking to.

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Before I write what I have to say on this, I'd like to qualify it with a couple of things:

1. The rise in obesity is a problem caused and fuelled by a raging, uncontrolled market-based society, and is much, much less an individual "problem", as such. Capitalism simply has no respect and no love for the human body - I think that's pretty obvious in so many ways, I won't even go into it right now.

2. My dearest cousin had a hip replacement in 2004; she was severely overweight and tried for months and months to lose weight (yes, how does a person lose weight when she can barely move ). Finally, her doctor gave in and scheduled surgery, warning her of the high complication rate and low success rate in overweight patients. Two weeks after surgery, she developed an infection, for which she received antibiotics. A few nights later, she developed a pulmonary embolism (blood clot in the lungs) and then died of heart failure on the way back to the hospital. It was a rapid-fire chain of events, and I'm still grieving her death. She was my favourite cousin - the funniest, wittiest, smartest and most successful person in my extended family. But she was also living with chronic, excruciating pain, and her quality of life was decreasing with every passing day. I'm not sure what else could have been done, and maybe she was simply very, very unlucky.

Medically futile though, I dunno. I do know that surgery in obese patients is always a higher risk for infection - partly because the operation takes longer, and because the extra layers of fat constitute more physical space for an infection to develop and take hold. Also, there is a risk in anesthesia: the patient's heart has to work harder over a longer period of time, and if the blood starts flowing sluggishly, there's more chance of developing embolisms (clots). There's also the post-surgical risks: more weight means longer recovery and the increased pressure on the new joint, as anne mentioned. It's not like replacing a part on a washing machine.

But: our society, that's to say, the people who run it and think it's a good idea that everything be decided by markets and economic laws, have created this problem, and it's awful, though predictable, that they would say "ok, sorry to all of you who don't 'fit' into the current medical model - just go away and live the rest of your lives in complete inactivity and constant pain. Here's a renewable prescription for Celebrex."

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Originally posted by FabFabian:
Hospitals don't have OR tables to accommodate an obese person. Also, it is more difficult for a surgeon to wade through all that flesh.

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I think we could put some great minds together and solve that problem of inadequate tables... we have the technology! It's a hard one, but I bet we could pull it off!

Seriously, I understand that obesity contributes to the risk in joint replacement operations, but it seems we have two options. We could deny the surgery to obese people. Or, we could work on improving outcomes of the surgery for obese people. Why not the second?

I also feel that the decision whether the benefits of a surgery warrant the risks is best made on an individual basis, and joint replacement is a good example of why. A bad outcome isn't set in stone for the obese patient, and some may feel that the benefit may warrant the risk as brebis noire eloquently described above. I am respectful of the complications that obesity can cause, but every individual presents unique risks and circumstances that need to be evaluated.

I can understand a doctor assessing an individual and recommending that surgery not be performed for reasons of weight. But the decision whether or not to perform the surgery should be an individual one, informed by medical opinion, rather than by accounting and broad risk assessments.

[ 20 December 2005: Message edited by: vmichel ]

[ 20 December 2005: Message edited by: vmichel ]

QUOTE]Originally posted by Tape_342:
Pardon me if that has already been addressed, but don't joint replacements require pretty intensive post-op physical therapy to do much good?

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Originally posted by Accidental Altruist:

Fidel was talking about affluent patients having a doctor at every port while so many Canadians go without a GP.

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Yes, exactly. Wealthy Canadian's can access health care in the U.S. ahead of tens of millions of American citizens who are without health insurance. They have plenty of empty beds in U.S. hospitals waiting for those who can pay several thousands of dollars to the hospital, incidental anaesthestist bills, hundreds of dollars for bandages and aspirins and painkillers available at whatever price tag down there. And if Dubya and his minions ever feel hawkish enough to privatize social security in that country, then even more hospital beds and other medical services will be freed-up for the world's wealthy people to support and prop-up with their generous donations and bursaries while millions cross their fingers and hope they don't get sick.