Wheelchair ultimatum

Smoker facing quadriplegia told to quit or go without surgery

As prognoses go, Shayne Turner's is pretty grim.

Turner, 56, was diagnosed last year with severe spinal cord compression, a progressive condition.

The Heffley Creek resident is gradually losing function in his upper extremities - he has difficulty buttoning a shirt at the moment - and has been told by a doctor that he may become quadriplegic without urgent surgery.

"It obviously terrifies me, the idea of being quadriplegic," he said. "I've been active all my life."

Yet Turner has been handed what he feels is an unfair ultimatum by the Kamloops neurosurgeon, Dr. Michael Nikolakis. A smoker since age 14, Turner's been told he won't get the surgery unless he quits beforehand.

"He has promised me that he will quit smoking and I consider this to be a contract between him and myself," Nikolakis writes in a letter to Turner's family doctor. "Should he violate this contract, he will not be operated on."

Turner understands the surgeon's desire to have him quit smoking in order to allow for a better surgical result. He's tried a variety of quitting strategies - nicotine pills, patches, electronic and herbal cigarettes - without success. He knows it would be in his best interest to quit, but he can't.

"I can understand the desire to have me conquer the habit, but from where I stand, the idea of a contact is not the way to do it. His personal ethics are getting in the way of professional obligation."

He also admits to having a profound distrust of the medical profession, an outlook he acquired early in life when he endured repeated hospital visits due to a congenital defect - he was born with his trachea fused to his esophagus - that required correction.

There were other complications, such as contracting pneumonia and double pneumonia 27 times before age five, and getting run over by a drunk driver at age six, that soured his view of the medical profession.

His current predicament has only hardened his attitude. Turner has a friend who also smokes and who underwent similar surgery in Vernon, leading him to wonder if he's being singled out.

"I just feel like I'm this carcass that you are to a doctor," he said. "I don't mind if they look at you insensitively, I just think they have way too much power and too much arrogance."

Smokers have to expect to tangle horns with their physicians. Doctors have refused to take on patients who smoke. Doctors can refuse to perform a procedure if they believe a patient's behaviour - through smoking or poor diet, for example - would undermine results.

Dr. Nikolakis did not respond to requests for comment on the matter.

Susan Prins, communications director with the B.C. College of Physicians and Surgeons, said it is not uncommon for surgeons and anetheseologists to ask their patients to quit smoking.

"It would be the clinical judgment of the physicians involved in the treatment of this patient," she said.

While Prins couldn't speak specifically about Turner's situation, she indicated it would be "entirely appropriate" for a physician to make a request that a patient stop smoking if he or she had concerns the habit would adversely affect the outcome.

"I've had these questions before," she said. "It's only appropriate for physicians to make these kind of decisions in discussions with patients."

She said patients such as Turner can pursue complaints through the college, which offers him a possible recourse, but that would take time.

Sharon Shore, communications director with the B.C. Medical Association, deferred to the college for an official position on the matter.

"That being said, it's certainly not unusual for a surgeon to request that a patient quit smoking before surgery," Shore said. "Whether or not they can say they will not operate depends on the type of surgery being performed."

Is there a legal basis for a physician to take such a firm stand, denying treatment?

Micheal Vonn, a lawyer and policy director with B.C. Civil Liberties Association, said the association has no position on the matter because it has never been asked such a question.

However, Vonn did provide some legal and moral considerations.

She said the college, in giving its position on the matter, doesn't seem to be making a key distinction between a physician's advice and what appears to be, in this case, an ultimatum.

"Does a surgeon have a right to refuse care on the basis of some condition they impose? This is not a trivial matter," Vonn said. "This is one of quality of life, a physical impairment issue."

Vonn said the legal question is beyond her realm of expertise, but felt that the notion of a contract between Turner and his surgeon might be inappropriately stated.

"The whole notion of what's required to make a contract - you can't make a contract out of duress.

"It certainly raises all sorts of ethical questions," Vonn added. "Do you have the right to refuse treatment to a heli-skier?" she asked rhetorically, citing another risk-taking behaviour sanctioned by society.

Arthur Schafer, director of the University of Manitoba's Centre for Professional and Applied Ethics, said there is some degree of latitude within the surgeon's explanation. If a doctor were to offer a medical reason for refusing to perform the surgery, a reason related to continued smoking, that would be acceptable, he said.

Yet there is no medical rationale other than that continued smoking might result in a "sub-optimal" surgical outcome. If there is no reason, then the ultimatum crosses into moral territory, with the doctor assuming the role of priest or dictator.

"I think he meant more, 'my way or the highway' and that seems to amount to medical arrogance," Schafer said. "You've got to have a valid medical reason (to deny treatment).

"We don't want our doctors to be moral judges. Their duty is to provide the best advice and the best treatment in the circumstances."

Turner is taking a holiday in the meantime in Thailand, where he might consider trying another smoking cure.

"The only thing I haven't tried is acupuncture."

He wants people to know, though, that it's not his way to complain. He wonders how many others are up against the same wall.

"I'm young and basically in good health. My only sin is I smoke. You need to treat me, not question me because I'm a smoker."

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