BFP Magazine

Cardio-vascular Health

Coronary by-pass Surgery, Smoking

Don't put Coronary Bypass patients close to the Kitchen

By Dr. W. Gifford Jones

February 10, 1991

Should smokers who refuse to stop smoking be denied coronary by-pass surgery? Or placed at the end of the list? What does smoking do to the heart anyway? And should post-operative patients sue hospital staff for putting their beds too close to the kitchen?

There's overwhelming evidence that carbon monoxide generated by cigarette smoking has an adverse affect on the heart's muscle. Carbon monoxide is an odourless, invisible gas that attaches itself to red blood corpuscles decreasing the blood's ability to carry oxygen to tissues. This result can be lethal.

The brain dies when 50 to 80 per cent of hemoglobin becomes blocked by this gas. Dr. Thomas Dahms at the St. Louis School of Medicine reports that even a mere two per cent of carbon monoxide decreases the ability of angina patients to exercise. If the level reaches four per cent they are forced to stop a workout sooner than if they were breathing room air.

Despite these facts some patients with angina continue to smoke two packs of cigarettes a day. So does a doctor then have the right to say, "There's a limit to the extent I can be my brother's keeper. Why constrict my coronaries doing bypass surgery when you don't give a tinker's damn about your own?"

In 1989 Dr. Allan Taylor, chief of plastic surgery at The Ottawa Civic Hospital, wrote in The Canadian Medical Association Journal, "Insisting that patients stop smoking as a condition of their benefiting from our deluxe health care system is neither fundamentalism nor fascism. It's just plain old-fashioned horse sense in view of health care costs and impending shortages of services."

He added," I would not refuse to treat, beat into submission or deport smokers. I would simply assign them the low priority they deserve, at the bottom of the ever-increasing list for investigative procedures and elective surgery for smoking related diseases."

A spokesperson for The College of Physicians and Surgeons said," He could hardly believe that a doctor would actually have said this. It's the first time we've heard anything like this being said". But in 1986 I too wrote in this column that the medical lifeboat is sinking and people will be tossed overboard one way or another in time. It's happening even today.

The Mayo Clinic in the U.S. demands that patients stop smoking to be eligible for coronary by-pass operation. University Hospital in London, Ontario, has also taken a hard look at the overloaded lifeboat. The result? Patients there who have smoked or consumed alcohol for years and refuse to stop may be turned down for liver transplants.

Dr. Carlton Williams, a member of the ethics committee, was quoted in a Toronto Sun story that surgeons are reluctant to "waste their time" on such cases. This isn't an isolated, earth-shaking comment. It's the kind often heard in the privacy of the surgeons' lounge.

Is it unethical to be selective about which patients receive scarce transplant organs? Dr. Benjamin Freedman, clinical ethicist at The Jewish General in Montreal says a "hospital is not a courtroom". That if a doctor's decision to withhold an organ from a smoker results in that patient's death, he's acting as, "judge, jury and executioner."

Another problem always looms in this debate. As one cardiovascular surgeon recently said to me, "Some patients say they've given up smoking, but two weeks after the operation they're puffing away again. What can you do at that point? Take them back to surgery and remove the by-pass?"

The College of Physicians and Surgeons claims it won't take legal action against any doctor who places a smoker at the end of the surgical list unless the patient complains. The stand it should espouse, however, is that it's time that "responsibility and self-discipline" be an integral part of publicly funded health care.

"Hologram, The Canadian Journal for Health and Wellbeing" reveals how far society has gone in determining fault. A burglar in California fell through the skylight of a school and sued the school board for not warning him the skylight was unsafe. He won several hundred thousand dollars!

There's another story about a bypass patient who, following the operation, sneaked into the hospital kitchen, stuffed himself so much food that he ruptured his sutures. He then sued the nurses for putting him a room too close to the kitchen. He claimed they were aware he had an eating disorder!

It's a shame people can't see a bypass operation first-hand. Some would stop smoking immediately. Others would quickly realize that, although done frequently, this surgery is not like removing an appendix. And, who knows, it just might inject a sense of responsibility into some unthinking candidates. 

W. Gifford-Jones M.D is the pen name of Dr. Ken Walker graduate of The Harvard Medical School. He's been a ship's surgeon, hotel physician and family doctor and later trained in surgery at McGill in Montreal, University of Rochester N.Y. and Harvard. His medical column is published by 60 Canadian newspapers and several in the U.S. He is the author of seven books. Dr. Walker has a medical practice in Toronto. His Web site is: He can be reached at

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