Recent measures in the United Kingdom have proposed restricting access to elective surgery for smokers and people with obesity, with requirements for health optimization prior to intervention.

In a paper published in BMC Medical Ethics, experts suggest that government health authorities should avoid explicit statements regarding the clinical efficacy of these measures for improving public health, primarily due to ethical concerns, as well as the lack of clinical data supporting these measures.

At the end of 2016, the National Health Service (NHS) approved the Vale of York Clinical Commissioning Groups (CCG) policy, which requires obese patients to lose 10% of body weight or maintain attempted weight loss for 12 consecutive months before being referred to and approved for elective surgery. This method of health optimization prior to surgery is often approached via primary care and community interventions. In general, most policies like the CCG policy only apply to non-urgent elective surgical procedures, reducing the likelihood of adverse events in patients.

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Other surgical rationing programs are often less broad and more specific regarding the types of surgeries that can be performed following health optimization. The Rotherham CCG, for instance, mandates clinical threshold criteria that focus on restricting access to major joint surgery in obese individuals. Some CCGs are voluntary in nature rather than mandatory, with recommendations for smoking cessation or weight loss being preferred over forced interventions. These voluntary recommendations are aimed at increasing patient awareness and education, with the hope that this will facilitate lifestyle change.

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Financial benefits for CCGs and local NHS authorities in the United Kingdom are the primary justification for the enlistment of a mandatory restriction on elective surgery in smokers and people with obesity. The clinical benefits associated with smoking cessation and weight loss, including a reduced risk in cardiovascular disease and cancer, represent another driving force behind the rise in mandatory elective surgery rationing policies.

In addition, post-surgical complications are also generally lower in patients who are a healthy weight and do not smoke, resulting in greater justification for the programs. Despite these potential benefits, there is currently a gap in evidence and real-world data that proves these programs are clinically effective, safe, and ethical.

“In order to better defend the permissibility of rationing elective surgery for both smokers and the obese,” the investigators wrote, “closer attention must be paid to the clinical justification for the precise parameters of the restrictions — including justification of the length, focus, and nature of mandatory health optimization periods, as well as to the evidence demonstrating their financial consequences.”


Pillutla V, Maslen H, Savulescu J. Rationing elective surgery for smokers and obese patients: responsibility or prognosis? BMC Med Ethics. 2018;19(1):28.