Living with Chronic Illness - Julian Seifter's Wise Guidance

I've never met Dr. Julian Seifter, but over the years I heard about him from patients with kidney disease who he treated. (He's a nephrologist.) My patients were impressed with his skill and touched by his humanity.

Today's New York Times has an interview with Dr. Seifter about living with chronic illness. I learned from the interview that he has had diabetes since his early 30s (he's 61 now) so he knows first hand about chronic illness, which he sees every day in his practice. Here are some of the pearls from the interview, with my comments in bold italics:

• "I counsel my patients to replace what they’ve lost with something new. I had one patient who was a scuba diver and who loved discovery. I had to tell him that with his condition scuba diving isn’t safe for him. So I’ve encouraged him to prospect for Native American relics in the Southwest desert, which he’s also interested in. It’s a way he can still be an explorer, but not risk his kidney." [What a creative idea! Even if it hadn't clicked for the patient, it showed that Dr. Seifter understood the patient's soul! Once in my practice I realized that a patient with depression was describing the symptoms in wonderfully evocative, gallows humor language. I asked - "have you ever thought of doing stand-up comedy? You've helped me understand that some humor consists of depression turned on its head." My patient ended up studying comedy for a while. Anti-depressant medications caused miserable side effects and did very little. Cultivating humor had no noxious side effects and helped a lot.]
  
  
• "[Chronic illness] can shake you out of old habits and routines. It takes away the 'taken for granted.' You’re invited, almost forced, to find new directions and pursue unexplored potentials. I had a patient, Cassandra, an opera singer, who first came to me because it was thought she had a kidney problem. It turned out she had a severe inflammatory condition in the head and neck — in the larynx, her instrument. She could no longer sing professionally. With no science background, she began reading the papers on her treatment and cultivated an interest in the illness. Eventually, she went back to college, took science courses and got accepted to medical school. She’s about to become a nephrologist." [Here Dr. Seifter doesn't comment on what was probably the most "active ingredient" in Cassandra's treatment - her identification with him and his ways of adapting! As Albert Schweitzer said, with only slight exaggeration - "example is not the main thing in influencing others; it is the only thing."]
  
  
• "If someone rejects dialysis, I want to make sure they’re not doing that because of depression. If a patient is wavering, I’ll say: 'At least try it. You can always come off.' I had a patient who, at first, rejected dialysis, but who agreed to a trial and then found that the treatments made him feel so much better that he then wanted to stay on. It was a three-times-a-week commitment, but he came to see how he could fit it into his life — which he’d still have." [The challenging part of what Dr. Seifter is describing is conveying to patients that as much as he hopes they will find a way to savour life, he's prepared to support them in refusing dialysis and letting life come to an end.]
  
  
• "I try to meet my patients wherever they are so that they will [try dialysis.] I had one who wanted to go to Florida a last time before starting dialysis. I worried about him. His condition was such that he might have heart failure. But I also knew he’d never go onto dialysis without doing this. I said, 'O.K., call me when you land in Miami.'
  
  He said, 'Doctor, you don’t understand, I’m driving down.'
  
  Now, this was really dangerous. So I said, 'Call me from each state and I’ll have the address of someone you can check in with in case there’s an emergency.' [Here Dr. Seifter is applying the "dignity of risk" principle in an elegant manner. From a strictly medical perspective, or a CYA approach to liability concerns (if you don't know what the acronym means, see here), the patient's idea was cockeyed. But Dr. Seifter understood how important a last visit to Florida was for his patient and put himself out to help the patient pursue his dream in the safest possible way. (For a short video discussing "dignity of risk" from a medical-legal perspective, see here.]
  
  The phone calls came in regularly until the last day of his trip. I was worried and I called his home in South Florida, and there was such an incredible noise in the background that I could hardly hear his wife. 'What’s going on?' I asked. 'That’s the rescue helicopter on the front lawn,' she said. He’d made it there, but then needed to be airlifted to the hospital!
  
  [I don't regret enabling his journey.] From my own experiences, I understood why patients sometimes resist doing what’s best. The idea of sticking yourself with a needle every day for life: that wasn’t easy for me to accept. I hated the thought that every morning I was going to wake up knowing, 'I have diabetes.' So I’m not a puritan with my patients. You have to do what is possible...Everyone needs the opportunity to forget their disease for a while and think of other things. Otherwise, they can become their disease. So: I’m not a diabetic. I’m a doctor who has diabetes." [Dr. Seifter's distinction between the ailment and the person is especially important in psychiatry, where the condition affects perceptions, thoughts and emotions. Sometimes "bad behavior" was best understood as a product of the illness. But at other times patients (and their families) - appreciated comments like - "just because you have schizophrenia doesn't mean that you won't sometimes act like a complete jerk the way everyone else does." And given the wonderful differences between people, some patients reject Dr. Seifter's distinction for good reasons, as when a patient of whom I'd "you have alcoholism" replied, with some heat, "Doc, you don't get it - I don't 'have alcoholism,' I'm an ALCOHOLIC. If I forget that I'll get to thinking I no longer 'have alcoholism' and can start drinking again.!"]

(I haven't yet read the book "After the Diagnosis: Transcending Chronic Illness," written by Julian Seifter and his wife Betsy, but I've looked at it on line and it looks terrific!)

Psychiatrists, God, and Lying

A psychiatrist in Texas submitted an important question to Randy Cohen's "The Ethicist" column today. I've taken the liberty of copying the question and Randy's response below, with my own comments in bold italics:

I am a psychiatrist who happens to be an atheist. Occasionally a patient asks me what religion I follow and, displeased by my answer, seeks another psychiatrist. I am a physician, not a priest. Religious beliefs seem as relevant to my profession as they are to an accountant’s. Nevertheless, candor sometimes costs me a patient. May I claim a belief in God to avoid damage to my credibility and business?

VAIDYANATH IYER, THE WOODLANDS, TEX.

To rephrase your question slightly: May you lie to a patient to initiate a relationship of trust? O.K., I’ve rephrased it totally and unflatteringly, but the answer — no — is provided by the American Psychiatric Association’s “Principles of Medical Ethics,” which requires you to be “honest in all professional interactions.” And rightly so.This is vintage Randy Cohen writing. His question brings out the "right answer" without being weighed down by tedious theorizing. And the quote from the APA shows that the profession agrees. But we should ask (a) what's going on when patients ask Dr. Iyer about his religion, (b) why honesty is so important in the patient-doctor relationship, and (c) what the wisest response is.

What you may do is decline to answer such questions. Glen O. Gabbard, a professor of psychiatry at Baylor College of Medicine, told me in an e-mail that “it is not dishonest to use restraint in responding to questions of a personal nature.” He added, “One can also inquire about the reasons for the question.” The patient’s reply might offer insights useful in treatment. Glen Gabbard is perhaps the most eminent clinical teacher in contemporary psychiatry. His advice, as usual, is spot on. Especially in psychiatry it's crucial for Dr. Iyer to know what patients are communicating about themselves when they ask him about his religion.

Many years ago I had a first meeting with a gay man in recovery from severe substance abuse problems. At the end of the appointment I said - "I've asked you a lot of questions. Do you have any questions for me?" He replied - "Just one. Are you gay and in recovery?" I responded - "If it's OK with you I won't answer directly. I'm not sure what form of treatment I'm going to recommend, and in some treatments it's best to explore questions like this, not to answer them directly." He said - "That's OK. I know the answer - it's 'yes.'" He felt comfortable with me and felt understood, which to him meant I must be gay and recovering with a history of substance abuse. (Neither was true, but the treatment went well.)

The patient’s question need not reflect mere prejudice but could express a desire for a psychiatrist whose personal experience will yield a deeper understanding of the patient. On such benign grounds, some women seek a female psychiatrist, some homosexuals a homosexual. But it is also true that you need not be a Presbyterian to effectively treat a Presbyterian. Even a gay female Presbyterian.

It's crucial to consider the context here. "Iyer" is typically a South Indian Hindu name, which leads me to guess that Dr. Iyer is of South Indian background.The Woodlands is an almost all white, upper middle class community near Houston. It's just a year since the Fort Hood killings, for which Dr. Nidal Hasan, a Muslim of Palestinian background, is the presumed killer. Some of Dr. Iyer's patients may be wondering if he is Muslim, which, sadly, is the focus of widespread prejudice. At an unconscious level they may fear that psychiatrists are not trustworthy and treatment will do them harm. Patients who feel good rapport with Dr. Iyer may tell themselves "he looks foreign, but I know he's really a good Christian, like me," much as my patient assumed I was gay and recovering from substance abuse.

And so you should respond courteously to such queries, answering those about your training and technique but not those you deem irrelevant to the work. Are you Jewish? A Republican? An opera buff? This demurral could cost you a patient or two, but so be it. A patient’s determination to make an unwise decision does not justify a doctor’s deceit.

I wish Randy had picked up on Dr. Iyer's comment "I am a physician, not a priest. Religious beliefs seem as relevant to my profession as they are to an accountant’s."

When I visited the Indian National Institute of Mental Health and Neuroscience in 1989, I was told that many rural Indians, but also educated urban dwellers, only consult a psychiatrist if religious practice - puja - hasn't relieved their symptoms. And in my clinical office I often felt that an anthropologist would see underlying structural similarities between medical practice and religious practice. The line between "priest" and physician" isn't as absolute as Dr. Iyer's question implies!

I think Dr. Iyer's comment about accountants is correct, but not in the way he intended it. Unless we're looking for an accountant to help us cheat, as Enron and its ilk did, the accountant's character matters a lot, just as it does for a physician. Accounting isn't just a matter of adding up numbers - it rests on decisions about how to deal with expectations about how we conduct our economic lives and meet expectations of the state (ultimately, our fellow citizens). If we only trust an accountant (or physician) who belongs to our own denomination (including the atheistic denomination) we'll miss out on some good ones and trust some bad ones. Dr. Iyer's patients are wrong to focus on his theological beliefs, but correct to be concerned about what kind of a human being he is!

(For an excellent film in which the name "Iyer" is central, see "Mr. and Mrs. Iyer."For previous posts about Randy Cohen, see here and here

The FBI and Martin Luther King

I recently came upon a letter I had written to the Washington Post, published on June 14, 1969. (I was living in Washington at the time, during a two year post-residency fellowship at the National Institute of Mental Health.) It had recently been revealed that the FBI had tapped Dr. King's telephone for many years. Here's what I wrote:

Sensible citizens should no longer be shocked by disgraceful misconduct on the part of our national leaders, but your description of the FBI's most recent foray into electronic surveillance deserves comment. The FBI cannot be allowed to excuse itself with a bland acknowledgement that it "did not follow regular policy on this particular (Martin Luther King) surveillance." Mr. Hoover is deserving of public rebuke at the very least, though removal from office is a more reasonable response to this illegal and immoral intrusion on the right to private communication.

The actions of a Federal agency cannot be regulated if its leaders are not held strictly accountable for the agency's conduct. Mr. Nixon attacked student radicals for their "moral arrogance" in his recent speech on the basis of their lack of "respect for the rights of others." The FBI deserves to be judged by the same standards we apply to the SDS.

Subsequent investigation revealed that J. Edgar Hoover's actions were actually much worse than I'd imagined in 1969. Here's a paragraph from a 1976 report to the Senate Committee on Governmental Operations:

The FBI campaign to discredit and destroy Dr. King was marked by extreme personal vindictiveness. As early as 1962, Director Hoover penned on an FBI memorandum, "King is no good." At the August 1963 March on Washington, Dr. King told the country of his dream that "all of God's children, black men and white men, Jews and Gentiles, Protestants and Catholics, will be able to join hands and sing in the words of the old Negro spiritual, 'Free at last, free at last. Thank God almighty, I'm free at last."' The FBI's Domestic Intelligence Division described this "demagogic speech" as yet more evidence that Dr. King was "the most dangerous and effective Negro leader in the country." Shortly afterward, Time magazine chose Dr. King as the "Man of the Year," an honor which elicited Director Hoover's comment that "they had to dig deep in the garbage to come up with this one." Hoover wrote "astounding" across the memorandum informing him that Dr. King had been granted an audience with the Pope despite the FBI's efforts to prevent such a meeting. The depth of Director Hoover's bitterness toward Dr. King, a bitterness which he had effectively communicated to his subordinates in the FBI, was apparent from the FBI's attempts to sully Dr. King's reputation long after his death. Plans were made to "brief" congressional leaders in 1969 to prevent the passage of a "Martin Luther King Day." In 1970, Director Hoover told reporters that Dr. King was the "last one in the world who should ever have received" the Nobel Peace Prize.

A week after my letter was published in the Washington Post I got a letter of Hoover, berating me. I remember the combination of chill and anger that I felt on reading it.

I confess to feeling proud and happy about the 41 year old letter. I believe that advocacy, which comes in many flavors, is important for personal health as well as the health of society. When my sons were at the age when children whine, my wife and I countered "don't whine - argue!" (Not surprisingly, they became excellent arguers.) Sometimes health conditions can be definitively remedied, but often, like mortality itself, they are fixed parts of our experience. I once asked a French patient who had suffered greatly from the impact of bipolar illness what a psychiatrist in France would say at the end of an appointment. "Courage" was the answer. "Courage" comes from the French word for heart - "coeur." The stance of advocacy both reflects strength of heart and helps to create it.

(See here, here, and here for posts that touch on the issue of advocacy and health.)

After Visit Summary - Little Things Mean a Lot

When I was in high school, the singer Kitty Kallen had a #1 hit - "Little Things Mean a Lot." The ballad is decidedly uncool by current standards, but as a teen-ager I liked its romantic dreaminess.

The song popped into my mind as I was musing about the after visit summary I was given at the end of an appointment with my primary care physician yesterday. The visit involved discussing a treatment decision, tweaking a medication dose, and scheduling a test. Nothing complicated. Even with my porous memory, I would have remembered the key points of the visit.

Even so, I was happy when at the end of the appointment my PCP gave me a simple printed summary and went over it with me. Doing that reinforced what we'd discussed and what the next steps would be. But the tangible "gift" was important as well. An anthropologist would see elements of a ritual behind the medical act - a form of "godspeed" token.

One of my patients as a first year psychiatry resident came into my care when he was hospitalized for a first episode of depression. After discharge he moved to another state. I gave him a handwritten letter summarizing what we'd concluded about his condition and what I'd recommended, and encouraged him to show it to his clinician at the clinic we'd referred him to.

As often happens when depression lifts he just went about his business and did not go to the clinic. But some years later a psychiatrist in the other state called to tell me that my former patient had experienced a recurrence of depression and had come to the clinic clutching the letter as if it was a religious relic. The psychiatrist, a seasoned hand, wanted to let a youngster in Massachusetts (me) know how important the simple act of writing and giving the summary had been.

I don't know how much time it took my PCP to prepare the after visit summary. If the electronic medical record software is well configured it could print out from his own note. This would represent a valuable way for "high tech" to support "high touch." (See here for a description of John Naisbitt's book on "high tech/high touch.")

Kitty Kallen was right. Little things mean a lot!

Making Accountable Care Organizations Acceptable to the Public

The most recent issue of the New England Journal of Medicine has a valuable article about the "Patient's Role in Accountable Care Organizations," by Anna Sinaiko and Meredith Rosenthal, researchers at Harvard Medical School.

The authors report that among Medicare beneficiaries, 73% of visits took place within a primary hospital and the extended multispecialty staff associated with it, and 64% of the hospital admissions were to the primary hospital. These findings suggest a tendency for us, when we are patients, to receive our care from a "clinical community." But this pattern isn't consistent enough for ACOs to work. An ACO can't take responsibility for quality and cost if a quarter of the visits and a third of hospital admissions are outside of the group.

In my own work on the issues that emerge in health plan appeals and in independent external review of health plan decisions, I've seen how often patients bridle at being asked or required to stay within the group for care. Patrick Henry was on to something basic about American culture in his "Give me liberty or give me death" speech. Or, less elegantly, the song group "The Animals" in the chorus "it's my life and I'll do what I want."

Years ago, when my employer offered a "point of service" plan as one of the health insurance options, I chose it. The plan allowed enrollees to go outside of the ACO (called "HMO" at the time), but required a substantial degree of coinsurance to do so. I was (and am) very happy with the care I receive from the ACO medical group (I used to practice in it and have used it for my care for decades), but I liked the option of going elsewhere if I needed "mechanical" care, like joint replacement or specialized neurosurgery. These services were available within the group, but I took comfort in the idea that for interventions of this kind I could look for what the business gurus call "focused factories" that specialize in providing the services.

Here's the key sentence from the Sinaiko/Rosenthal article: "There has been little discussion about binding patients to ACOs, largely because the freedom to choose one's providers is highly valued in U.S. health policy." If the "binding" force is the need to get PCP approval for going outside of the ACO, the system will ultimately generate too much conflict to succeed. If it's obvious that a service isn't available within the ACO, the PCP will not hesitate to make the referral. But what happens when a good level of care is available, but the patient believes it is not good enough and prefers to go elsewhere? If "elsewhere" is clearly of lower quality the PCP will not feel uncomfortable saying "no" and explaining the rationale. But when "elsewhere" is high quality the rationale for saying "no" is, to a substantial degree, cost containment for the ACO.

As I've argued ad infinitum, cost containment done for the right reasons in the right way is an ethical requirement, not the abomination our political discourse portrays it as being when we excoriate the crime of "rationing." But this perspective won't fly for an ACO. We're simply not mature enough as a body politic to for wide acceptance of the need to share responsibility for the health care commons.

Sinaiko and Rosenthal suggest - wisely - the principle of "allow[ing] patients to share in their ACOs cost savings." This can be done by allowing access outside of the ACO but requiring patients to make a substantial contribution for that access - through a combination of higher premium for the plan with access and higher cost sharing for the outside services. This would prod me to investigate whether my wish to go outside of the ACO was "worth it" to me. Years ago, my employer steadily raised the cost of the "point of service" plan. At a certain "price point" I concluded that although I could afford the plan, it was no longer worth the cost.

Critics will argue that this approach will create wealth-based inequality. They would be right. But if ACOs provide good care, members without the additional choices will still be well cared for. Critics of the approach Sinaiko and Rosenthal describe would do better by focusing their moral ire on the degree of income inequality in U.S. society.

Advocating for the Future of Medicare

I've admired Randy Cohen's "The Ethicist" column in the New York Times Magazine ever since he started it more than ten years ago. I don't always agree with him, but I love the verve of his writing. He has an unusual gift for turning thoughtful ethical analysis into engaging prose! (See here for a previous post about Randy.)

But what caught my attention in a recent column was the question posed by a reader:

At 65 years old, I am facing a final diagnosis for lung cancer and the prospect of a 15 percent survival rate. If this is confirmed, would it be ethical to put myself through painful long-term treatment and to have the people who love me endure this? At my age, is it ethical to consume the health care dollars involved? What is the tipping point to elect aggressive care? Thirty percent? Sixty percent? G.M., JACKSON HEIGHTS

In my 45 years of practice I was struck by how often my patients - especially those in GM's phase of life - made similar comments. "Doc - you should be spending your time with young patients - I'm not the future - they are!" These comments were not symptoms of depression or low self esteem - they reflected an ethical perspective that I, now in that age group myself, share.

In my view, giving priority to the younger segments of the population is correct moral reasoning, but it's neither politically correct nor tactically wise. When the health reform process proposed support for conversations between older patients and their physicians about the values they wanted to guide their treatment by, right wing zealots fulminated against "death panels," and much of the public believed their misinformation. And in the election campaign we've just been through, Republicans made hay with scare tactics about the "assault on Medicare." (See here for a post on the campaign.)

I see great potential value for an advocacy process that brings together progressively-minded folks who are Medicare recipients or who are, like me, Medicare eligible but still receiving health insurance through employers, to advocate for clinically informed, ethically justifiable, and potentially socially acceptable Medicare reforms. The Affordable Care Act contains the potential for a better future for Medicare in programs like the Independent Payment Advisory Board, the Center for Medicare and Medicaid Innovation, and other initiatives.

The Republican strategy for the new Congress is to "starve" these promising programs by withholding funds. The Republicans will present their effort as "protecting the elderly." But it's not. The status quo for Medicare ensures unsupportable cost increases for Medicare itself and undermining of other social efforts that seniors largely support. In our personal financial lives the elderly population hopes to preserve a legacy for the next generation(s). The progressive aim is to do the same at the societal level. We can't do this without substantial Medicare reforms, many of which are promoted by the Affordable Care Act.

I'm planning to explore the world of Medicare advocacy and will write more about it as I learn and get involved.

(Randy Cohen's column has a happy ending: "Exploratory surgery determined that G.M. does not have lung cancer. He recently returned to work. His doctors continue to monitor him.")

On Not Hiring Smokers

Five days ago I wrote a post defending the new Massachusetts Hospital Association policy decision not to hire tobacco users.

I usually agree with the editorial page of the reliably liberal Boston Globe. But today's editorial about the MHA policy gets things backwards. Here's the editorial, with my own editorial comments interlaced in bold italics:

Don't puff, don't tell?

IF THE country’s most brilliant expert on computerizing medical records came for a job interview at the Massachusetts Hospital Association with Marlboros in her pocket, she wouldn’t get the job. Neither would President Obama. Or House Speaker-to-be John Boehner. As of January 1, the organization that represents the state’s hospitals will no longer hire smokers for its 45-person workforce.

As easy as it is to sympathize with the motivation behind this policy, it is deeply — and unconscionably — intrusive into workers’ private lives. An employer like the hospital association should not set requirements that have nothing to do with an applicant’s ability to meet the demands of the position.

The word "unconscionable" is way too strong here. The Globe could see the policy as wrong without seeing it as "unconscionable," which is variably defined as "not guided or controlled by conscience," "unusually harsh and shocking to the conscience," or "unscrupulous or unprincipled." I don't understand what drove this editorial hissy fit.

On that score, the state was right in the 1990s to start prohibiting smokers from joining police and fire departments on the grounds that their habits would eventually make them physically unable to do their job. If the Globe really means what it says here, it should apply the same policy to its own employees - at least to those who do physically demanding work. No one wants to have to rely on a wheezer in an emergency. But there is no such reason for the hospital group, a lobbying and training operation, to reject a candidate who, at home, likes to light up.

As much as I want to see smoking eradicated, if the state's policy decision was based on a prediction that smoking "would eventually make [police officers and firefighters] physically unable to do their job, it was unnecessary. Employees who can't do their jobs don't get to keep the jobs. Perhaps the state anticipated having to pay disability pensions to smokers and wanted to avoid that future expense. This would be a reasonable business concern, but if it was the rationale for the policy it should have been acknowledged so that it could have been debated openly.

“We want a role model,’’ said association president Lynn Nicholas. This is a justifiable rationale. If I was the best qualified applicant for director of the Big Sister Association or the National Association for the Advancement of Colored People, we wouldn't, and shouldn't, fault those organizations for not hiring a Caucasian male! She notes that smoking costs the Massachusetts economy $6 billion a year in health costs and lost productivity. The diseases that tobacco causes or worsens are far and away the most preventable and take the greatest toll in lives. Nicholas believes that if more employers adopted her policy it could be the factor that keeps young people from taking their first cigarette.

Nicholas is not moved by the fact that two of the country’s most powerful elected officials — Obama and Boehner — are smokers. “[Obama] wouldn’t be a good fit for my organization,’’ she says, “when someone else who is equally qualified would.’’ With all the challenges facing the state’s hospitals as they deal with public demands for reduced health costs, the association should not be turning away highly skilled staffers who happen to be nicotine-addicted.

Nicholas is correct that "if more employers adopted her policy it could be the factor that keeps young people from taking their first cigarette." But the MHA policy shouldn't be generalized. Using access to employment as a primary approach to preventing tobacco use would be a bad policy, though not as "unconscionable" as allowing the large numbers of deaths, substantial disability, and huge drain on public resources, that tobacco causes. Continued increase in tobacco taxes, continued regulations to prevent second hand smoke exposure, and selective "role model" driven policies like the one the MHA is instituting, is the way to do.

Nanny Employer or Public Health Leader?

The Massachusetts Hospital Association announced yesterday that as of January 1, tobacco users will not be eligible for employment. The blogosphere responded quickly. "Big Brother," "totalitarianism," and "fascism" were among the terms applied to the MHA policy.

Apart from fiery rhetoric, the most persuasive critique of what the MHA is doing is the "slippery slope" argument. Even those who favor high tobacco taxes and other preventive messages worry about the potential for employers to develop hiring policies that reflect prejudice, not public health. (In the 1980s, Electronic Data Systems banned facial hair and fired an employee who claimed that he wore a beard for religious reasons!)

In my view, it is entirely justifiable for a health organization to do what the MHA is doing. I formed this opinion as a fourth year medicine student on a medicine rotation at the Boston City Hospital. A man in his 50s died of lung cancer. I joined the resident in meeting with the family. As would be unthinkable now but was not so shocking in the 1960s, the resident was holding a cigarette. The widow was outraged - "How can you talk to me about my husband's death and smoke cigarettes yourself?" Of course she was right. It would be hypocritical at best for the MHA to preach public health without taking a strong stand against tobacco use.

But what about organizations not in the health sector? Banning smoking on the premises is justified by the risks second hand smoke poses to fellow employees. But not hiring smokers is problematic. The policy would contribute to anti-tobacco pressure, but it would have greater impact on low income workers, since tobacco use is more prevalent in low income groups. And it would fly in the face of the strong value Americans place on individual liberty.

In principle, further increases in tobacco taxes would be a preferable approach. Price increases lead established smokers to cessation efforts, reduce the rate of smoking, and discourage adolescents from initiating tobacco use. Critics, including tobacco company lobbyists, are correct in arguing that "sin taxes" are regressive - the poor pay proportionally more than the wealthy. But since there are more low income smokers, the relatively larger number who quit will, over time, make the tax less regressive. And, as a practical matter, determined low income smokers generally have access to lower cost black market products.

But we are likely to see non-health organizations following organizations like the MHA (or the Cleveland Clinic, which instituted a non-hiring policy in 2007), driven by concern about health care costs. Employers will justify the policy by (1) public health values but also (2) the potential that reducing (and ultimately eliminating) smoking among employees has to lower insurance costs for the company. Insofar as health care costs come out of wages, my liberty to smoke comes out of my fellow employee's paycheck. As I argued in a previous post, my liberty right to smoke if it's legal doesn't give me the right to lower your pay.