Taking a stand in Timmins: quit smoking, or forgo surgery
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* Brad Mackay

Dr. Alberto de la Rocha is a stubborn man. For 12 years the Ontario surgeon has continued his one-physician attack on smoking by refusing to operate on patients who refuse to quit. And de la Rocha, a cardiovascular and thoracic surgeon in Timmins, has taken his stand in the area with the province's highest smoking rate.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/168/12/1582.1/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/168/12/1582.1/F1)

Figure. **The doctor will not see you now** Photo by: Barbara Sibbald

“When you see the carnage day in and day out, the putrid lungs and the gangrenous legs, you realize that you're working against an ebb tide that you cannot contain,” the 59-year-old doctor told *CMAJ*. “The only way to contain it is by making people responsible for their actions.”

As the sole lung cancer surgeon in Timmins, de la Rocha performs between 400 and 500 operations a year. More than a decade ago, he began demanding that smokers facing surgery for a host of illnesses, including lung and mouth cancer, agree to stop smoking before he operates. If the patient refuses, he suggests they look elsewhere for treatment. He estimates he's turned away 20% of potential patients over the issue. “I've gotten the occasional finger from patients, and [had the odd] door slammed,” he adds.

De la Rocha, who started practising in the northern Ontario city 16 years ago, was shocked by the high volume of smokers he saw. Recent data indicate that Timmins, with a population of 50 000, has the country's highest proportion of smokers, and de la Rocha estimates that 75% to 80% of his patients are heavy smokers. 

“I said that this was enough,” he noted. “This was the only way I was going to be able to make a difference.”

Although de la Rocha made his antismoking stand nearly 12 years ago, it only gained widespread attention in April when he mentioned the policy to a visiting reporter. He supports his stand with medical evidence. “We know that people who smoke have a hard time recovering. This way, they get better sooner.”

Margaret Somerville, director of the Montreal-based McGill Centre for Medicine, Ethics and Law, says he is walking a fine ethical line. “I think the big problem is that he's said, ‘This is my policy,’ ” she explained. “You're looking at a spectrum. You can't just have a rule that's your policy, and then apply it to everyone no matter what.”

She said physicians are legally and ethically required to operate under a “primary obligation of personal care” to each patient, which means each new case has to be assessed using a precise, multistep ethical analysis. Such an equation is further complicated by the fact de la Rocha is the city's sole lung surgeon.

De la Rocha accepts the criticism, but he won't change his contentious approach. “When push comes to shove, let the ethicists come to my world and look after my patients who are in respiratory failure because they refused to stop smoking,” he said. “Come and spend a week with me looking after these patients.

“More people come to me and thank me because of butting out [than complain] to me,” he said. “I see them in the street or in the hospital or I see a relative and they all say, ‘Thank you very much. You made me see the light.’ ” — *Brad Mackay*, Toronto