'Are smokers less deserving of expensive treatment? A randomised controlled trial that goes beyond official values'.
BACKGROUND
To investigate whether Swedish physicians, contrary to Swedish health care policy, employ considerations of patient responsibility for illness when rationing expensive treatments.


METHODS
A random sample of oncologists and pulmonologists made up the main study-group (n = 296). A random sample of GPs (n = 289) and participants from the general population (n = 513) was used as contrast group. The participants randomly received one version of a questionnaire containing a case description of a terminally ill lung cancer patient. The two versions differed in only one aspect: in one version the patient was a smoker and in the other a non-smoker. The main questions were whether to offer a novel, expensive and marginally life-prolonging treatment and whether the patient could be held responsible for her illness. The quantitative data was analysed using Chi2-tests and comments were analysed using content analysis.


RESULTS
Among oncologists and pulmonologists, 78% (95% CI: 72-85) would offer the treatment to the non-smoker and 66% (95% CI: 58-74) to the smoker (Chi-2 = 5.4, df = 1, p = 0.019). Among the GPs, 69% (95% CI: 61-76) would treat the non-smoker and 56% (95% CI: 48-64) the smoker (Chi-1 = 4.9, df = 1 and p = 0.026). Among the general population the corresponding proportions were 84% (95% CI: 79-88) and 69% (95% CI: 63-74).


CONCLUSIONS
This study indicates that applying an experimental design allowed us to go beyond the official norms and to show that, compared to a smoking patient, both the general population and physicians are more inclined to treat a non-smoking patient. This clearly runs counter to the official Swedish health care norms. It also seems to run counter to the fact that among the physicians studied, there was no association between finding the patient responsible for her disease and the inclination to treat her. We think these paradoxical findings merit further studies.
Karolinska Institutet, LIME, Stockholm Centre for Healthcare Ethics, Stockholm, Sweden. joar.bjork@gmail.com.|Department of Research and Development, Region Kronoberg, Sigfridsvägen 5, Box 1223, 351 12, VÄXJÖ, Kronoberg, Sweden. joar.bjork@gmail.com.
Joar
J
Björk
Karolinska Institutet, LIME, Stockholm Centre for Healthcare Ethics, Stockholm, Sweden. niels.lynoe@ki.se.
Niels
N
Lynøe
Karolinska Institutet, LIME, Stockholm Centre for Healthcare Ethics, Stockholm, Sweden. niklas.juth@ki.se.
Niklas
N
Juth
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D001294:Attitude to Health; D004992:Ethics, Medical; D005260:Female; D015438:Health Behavior; D017048:Health Care Costs; D015276:Health Care Rationing; D006801:Humans; D008297:Male; D008875:Middle Aged; D000072103:Oncologists; D005791:Patient Care / Q000191:economics / Q000941:ethics*; D028701:Patient Rights; D010820:Physicians; D000072106:Pulmonologists; D012309:Risk-Taking; D012907:Smoking; D012935:Social Justice; D013548:Sweden; D055815:Young Adult