Does an alcoholic have a right to a liver transplant, even if he has no intention of giving up drinking? Should the NHS treat a smoker with blocked arteries, even if he refuses to give up his 15-a-day habit [Ref: BBC News]? What about someone who is clinically obese? Does she have a right to IVF treatment or a hip replacement, even if her weight means that the treatment will be less effective [Ref: Guardian]? These are just some of the cases in which a decision has to be made about whether lifestyle should play a role in entitlement to healthcare. Do we have a duty to use the NHS responsibly and not to burden fellow citizens? Should we have to change our lifestyle in order to make treatment more effective? The emphasis on personal responsibility for health is part of a broader shift in government thinking about welfare policy towards the idea of conditionality [Ref: IPPR]. This is the idea that citizens cannot expect to get ‘something for nothing’. With rights come responsibilities and certain conditions must be met in order to qualify for benefits. But does this conflict with the right of everyone to receive treatment, whether they’ve taken care of themselves or not? Is there any contradiction in the government saying both that ‘it’s not the government’s job to tell people what to do’ and that ‘everybody should try to look after themselves better, by not smoking, taking more exercise, eating and drinking sensibly’ [Ref: Official Documents]?

Should people be expected to take more responsibility for their health?
The rights and responsibilities agenda plays a central but controversial role in government thinking. It emphasises the obligations that citizens have to other members of their community, in health and other fields. Unhealthy behaviour is increasingly seen as socially unacceptable, and whether it’s binge drinking, smoking, obesity, or eating five portions of fruit and veg a day, everyone seems to be more preoccupied by their health. A recent survey [Ref: BBC News] found that four out of 10 people supported penalties for those with self-inflicted health problems, and 8 per cent went further, arguing people who led an unhealthy lifestyle should be denied treatment. Only 44 per cent thought the government should be responsible for looking after people’s health.

How have concerns about public health changed?
The nineteenth century focus on acute, infectious diseases caused by social factors like poor sanitation and housing has been replaced by concern for lifestyle illnesses affecting individuals, including obesity, alcohol related diabetes and sexually transmitted infections (STIs). Some research suggests that lifestyle can make a contribution to preventing cancer and mental illness, although this is contested.The government is concerned by the warning in the 2002 Wanless Report thatunless the nation becomes healthier, NHS costs will rise by an extra £30 billion by 2020. In addition to public information campaigns attempting to persuade people to better look after their health, tougher approaches are being considered. The government denies accusations that it is creating a nanny state [Ref: Wikipedia], claiming that it is concerned with enabling people to make informed and healthier choices. Particular concern is expressed about the relatively poor health choices available to people in deprived areas where, for example, fast food outlets (dead link) are more prevalent. But critics protest against singling out particular groups. They argue that unless we have the right to make the ‘wrong’ choices then we don’t have choice at all and are being treated like children. The move away from a universal social right to healthcare has, they say, led to increasingly obtrusive interventions into individual behaviour. And encouraging people to continually worry about their health is itself unhealthy, creating unnecessary anxiety.

What new policies have been proposed?
One idea that was floated and then dropped was that of doctor-patient contracts [Ref: BBC News], which would formalise the rights and responsibilities of both parties. More recently, the National Institute for Health and Clinical Excellence (NICE) [Ref: NICE] gave the clearest indication yet that lifestyle should play a role in healthcare. It said that doctors could refuse treatment to patients if their lifestyle made it unlikely that the treatment would be successful or cost-effective. This fell short of suggesting that judgments should be made on the basis of whether conditions were self-inflicted, as this was felt to be too difficult to assess. However, the door has been opened to the denial of treatment on the grounds of lifestyle. Critics argue that people have paid taxes to support the NHS and are entitled to healthcare. They ask where rationing will stop. What about people who are promiscuous and run the risk of getting STIs, or those liable to injury by playing dangerous sports?

How does this change the relationship between doctors and patients?
The government believes that people are more likely to listen to health messages when they come from doctors and their own communities. Doctors are being encouraged not just to treat a patient’s illness but to play a wider role in promoting healthy lifestyles. Does this undermine the relationship of trust between doctors and patients, turning doctors into bureaucratic agents of government control? Or do doctors have a positive role to play in supporting patients and helping them avoid unhealthy influences?