A smoky issue.

Imagine falling off your bike and being rushed to the hospital with blood streaming from your head. When you get there, the doctors say, "Sorry, we won't treat you. You weren't wearing a helmet."

Something similar to this happened in England last year, when doctors refused to perform heart surgery on patient Harry Elphick. Elphick, 47, had suffered a heart attack. Doctors told him he would need coronary artery bypass surgery to improve blood circulation to his heart. But they also said they would not perform the operation. The reason: Elphick was a smoker.

Smoking is a major cause of coronary artery disease, which often leads to heart attacks. According to the doctors who treated Elphick, it is their hospital's policy to deny bypass surgery to smokers (except in cases of emergency). Smokers. they say, have low recovery rates and little chance of benefit from the surgery--unless they kick the habit first.

TO TREAT OR NOT TO TREAT

Elphick did manage to quit his pack-a-day habit, and had an appointment to return to the hospital. But he died of a second heart attack just days before his pre-surgery tests.

Outraged? Many people feel doctors have a duty to treat patients no matter what their circumstances. "Smoking is terrible and patients should stop, but they should not be penalized," says Lawrence Cohn, chief of cardiac surgery at Brigham and Women's Hospital in Boston. "[Smokers] should have the care like everybody else...You can do the operation and then get them to quit."

Daniel Ullyot, a California heart surgeon, agrees. "When somebody is sick and vulnerable, you cannot require them to modify their behavior in the face of a life-threatening illness. You have an obligation to treat that patient."

WHO PAYS?

"But it's not just a question of what is good [for a patient's health]," says Duke University cardiac surgeon Robert H. Jones. Someone has to pay the bills. And the people who pay have the right to decide what kind of treatment they'll pay for, he says.

Currently in the U.S., you can get almost any treatment if you're willing and able to pay for it--or for an insurance policy that will cover the treatment. That's true in England too, adds Jones. Even Mrs. Pat Elphick agrees. "If you have the money to pay for treatment, you can have it even if you smoke 500 cigrettes a day," he said.

The Elphicks, apparently, didn't have the money. Instead, they relied on England's government-paid health care system. And like most Britons, they probably thought it would give them all the treatment they'd ever need.

But there are often shortages of funding and bed space in hospitals run by the government. Nearly 400 people were on a waiting list for bypass surgery at the hospital where Elphick was treated.

Given those limitations, says Dr. James le Fanu of London, there's nothing wrong with "discriminating against those [patients] with the least chances of survival in favor of those with the best." And in the case of bypass surgery, says John Bailey, a cardiac surgeon in Leicester, England, smokers "have more infections, longer hospital stays, and are more likely to require a second operation, which is not only risky but costly."

THE FUTURE FRONT

Such debates over who is entitled to medical treatment--and what kind--will likely become more common in this country. President Clinton is trying to institute a national health insurance policy to help pay the medical costs of some 37 million Americans who are currently uninsured.

Some states, such as Oregon, have already begun "rationing" treatments in an effort to extend medical coverage to more people. There, patients who rely on Medicaid, a form of government-paid health insurance for the poor, can be denied certain medical procedures--such as liver transplants for alcoholics who continue to drink.

The bottom line, say the creators of such plans, is that we do not have enough money to pay for everything medicine can do for every patient. So we have to decide whom we're willing to treat.

How would you decide?