The ethics of an opt-out default in tobacco treatment.

Abstract

In their paper 1, Richter & Ellenberg advance an argument that a key way to improve public health is to reduce the number of smokers by increasing the uptake of tobacco cessation (and, one might add, harm reduction) programmes by current smokers. They note that in many health systems the default position is that patients seeking clinical care are only offered tobacco treatment if, in the opinion of the clinician, they are either expressing a wish to quit smoking or otherwise give signs of ‘readiness to quit’. They argue further that this creates a barrier to treatment, which can be removed by mandating clinicians to offer tobacco treatment to all patients who smoke without assessing ‘readiness to quit’, leaving the decision to the patients as to whether or not they take up this offer of treatment. The theory here is that some patients who might otherwise not have been considered ‘ready to quit’ by their clinicians will accept the offer of treatment, and that some of those will complete treatment successfully. Moreover, it is assumed that no (or minimally few) patients who would accept treatment under the current default will reject it under the new default. While the authors mention the possibility that the simple offer of treatment, by communicating implicitly that the treatment will be beneficial to the patient, will actively influence some patients to agree, they do not rely on this influence as the mechanism of action underlying the intervention. They simply suggest that offering treatment to more people will probably lead to more people accepting the offer, with net beneficial consequences.