Journal of medical ethics, 1995; 21: 281-287

Smokers' rights to health care

Rajendra Persaud Bethlem and Maudsley Hospitals Trust, London

AbstractThe question whether rights to health care should bealtered by smoking behaviour involves widerangingimplications for all who indulge in hazardousbehaviours, and involves complex economic utilitarianarguments. This paper examines current debate in theUK and suggests the major significance of thecontroversy has been ignored. That this discussion existsat all implies increasing division over the scope andpurpose ofa nationalised health service, bestowinghealth rights on all. When individuals bear the cost oftheir own health care, they appear to take responsibilityfor health implications ofpersonal behaviour, but whenthe state bears the cost, moral obligations of thecommunity and its doctors to care for those who do notvalue health are called into question. The debate hasfar-reaching implications as ethical problems of smokers'rights to health care are common to situations wherehealth as a value comes into conflict with other values,such as pleasure or wealth.

IntroductionUnderwood and Bailey, two cardiothoracicsurgeons, launched the recent controversy with aBritish Medical Journal paper (1) which begins: '...when resources are restricted and some form ofrationing of health care is effectively taking place, isit ethical to restrict access of patients to particulartreatments if there are alterable factors in theirlifestyle which make the treatment less likely towork?'. A fierce debate then began within the profes-sion (2,3), crystallised around the slogan: 'Shouldsmokers be offered coronary bypass surgery?' (thetitle of Underwood and Bailey's paper).

Subsequently, surgeons at two separate UKmedical centres were reported to have withdrawnnon-urgent coronary bypass operations from thoserefusing to give up smoking (4), and later that monthThe Times newspaper found four other hospitalswhere this practice was widespread (4). When asked

Key wordsSmokers; rights to health care; ethics; medical treatment.

to comment, British government ministers tacitlysupported this new method of health-rationing,declaring these decisions should be left to doctors,even if 'they were now playing God' (4).

The wider issueThe issue has implications well beyond the smoker;if individuals wilfully endanger their health, it maybe unreasonable for the state to pay for theconsequences. Hence the question: Shouldhealth service budgets be 'squandered' on thosewhose drinking, diet and poor compliance withmedication damages their health' in contrast tothose whose illnesses arise despite efforts to remainhealthy?By extension those who take part in dangerous

sports could also find themselves without statehealth care in the event of injury. One estimate of thecost to the British NHS of road traffic accidents isabout 90 million pounds per annum (5). Wouldthose who are willing to withdraw treatment fromsmokers also consider doing so from those who donot wear seat-belts?

Alternatively, the fact that people still smokecould be viewed as a failure of public health cam-paigns. Preventative health makes good economicsense, but when public education campaigns fail, thestate frequently forces us to look after our health, forexample road safety laws compel us to wear motorvehicle seat-belts. These measures followed thefailure of such road safety education campaigns asthe 'clunk-click' campaign, which had not signifi-cantly influenced public attitudes towards seatbelts (5).

Before the 1983 legislation only 40 per cent ofdrivers wore them. Since then, however, it has beenestimated that 95 per cent of motorists obey the newlaw and that as a result, calculations are that 700deaths and 6,000 serious injuries have been avoidedin a single year (5). At no point did anyone suggestsurgery should not be offered to those not wearingbelts. Furthermore, well before that stage could everhave been reached, legislation has been used tocoerce 'healthful' behaviour. It would follow that if

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smoking is a serious enough behaviour to affecthealth rights, then a rational first step to take beforethis situation arises might be to legislate against thebehaviour itself, ie, to ban smoking.

Doctors concerned with health care implicationsof smoking may want to consider campaigns to influ-ence state legislation of this behaviour as an alterna-tive or a precursor to withdrawing care fromsmokers.

Why do smokers continue to smoke?It could be argued that wearing seat-belts is signifi-cantly different from smoking; doctors rarely advisepatients on driving safety, but they persistently andforcefully forewarn on the dangers of smoking. Ifpatients knowingly ignore their doctor's advice, doesthat alter their future claims on their physicians, andhence their health rights?The argument partly rests on the notion that

smokers choose to smoke of their own free will, infull cognizance of the facts, and could give up if theyplaced the same value on health as they expect theirsurgeons to. There would appear to be an ethicalworld of difference between the harms that othersinflict upon you, those you inadvertently administerto yourself, and harms that you knowingly and freelywreak upon your own body.

Yet there are many risks which smokers are not

explicitly warned of in health education campaigns.While much stress is laid on lung cancer, the risk ofcirculatory diseases such as Buerger's disease, isseldom emphasised (6). Ironically, this area, ofcirculatory diseases, is precisely the area withinwhich cardiothoracic surgeons operate, and fromwhich they seek to exclude smokers. In one poll,while most smokers were aware of the links withlung cancer, 63 per cent did not know that smokingcauses most cases of bronchitis, and 85 per

cent were unaware that it causes most cases ofemphysema (6).

Another ethically relevant issue is how freesmokers are to give up. If they were suffering from an

addiction, this could excuse them from failure togive up. Receptors for the active ingredients oftobacco have been discovered in the brain, whilenicotine dependence has been classified as an addic-tion by the American Psychiatric Association (7) andthe World Health Organisation (8). Surveys suggestthat 90 per cent of regular smokers have tried to quiton at least one occasion; one study found that only36 per cent had succeeded in maintaining abstinencefor a whole year, while relapse rates after a givenperiod of time are almost the same for nicotine as forheroin (9).

This is not to say giving up is impossible, just that itmay be difficult. But no matter how difficult: dosmokers have an ethical obligation to their cardio-thoracic surgeons to try giving up, or even to succeedin giving up?

Are there ethical obligations to give upsmoking?If there is a moral obligation for doctors to promotetheir patients' health - do patients have a cor-responding ethical duty to seek their own health? Inother words, are doctors and patients engaged in acommon moral enterprise which legitimately claimsthe allegiance of both parties?

Parsons (10) delineated the existence of a 'sickrole' (ill persons are viewed as having social obliga-tions), to positively value health and co-operate withdoctors in order to regain it. In coming under thecare of doctors, it appears patients enter a relation-ship defined and oriented by the importance ofhealth values (1 1). Not to value health while seekinghelp and advice from doctors might represent anattempt to enter such a relationship under falsepretences.

Hence, implicit in the very act of any medical con-sultation could be the agreement that both parties,doctor and patient, value health (11). But smokingwould seem to suggest, at the very least, that othervalues, such as pleasure, have a higher priority thanhealth. Do not doctors have the right, when thisimplicit contract within which they attempt to workmeaningfully with patients has been violated, towithdraw care (1 1)?The problem with this argument is that patients

rarely value health as much as doctors do (exceptpossibly in the case of hypochondriacs). Doctors, bytheir personal orientation and professional training,probably value health more than anyone else insociety. For most people, other values, such as thoseto do with money or pleasure, frequently takepriority over health. In fact it could be argued thatpatients often do not see doctors because they valuehealth - they avoid doctors so as to avoid suffering.Hence their tendency to make appointments afterexperiencing pain or discomfort, rather than attend-ing for health check-ups or preventative healthadvice.

If this is the case, the notion of shared valuesbetween doctor and patient becomes questionable,and equally so would any ethical obligations basedon such values. While doctors may value health, theycould not meaningfully make their medical practicecontingent on these values being found in theirpatients. Among other problems this would auto-matically exclude many, such as the suicidal and thementally handicapped, from rights to medical care.On the other hand, the suicidal and the mentally

handicapped are presumed not to value health forreasons other than fully conscious rational choice. Ifpatients in full possession of their faculties and thefacts choose a hierarchy of values which represents arelative depreciation of health, should doctors' con-trasting set of priorities be relied on to come to therescue?

It seems morally inconsistent to expect to behelped precisely because those who provide the help

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hold a set ofvalues you have rejected. The individualcan maintain moral consistency only by relinquish-ing expectations of help in the context of behaviourwhich does not value health, or by accepting the setof values which provides the context in which help isprovided, and hence changing his/her behaviour.

Are smokers' health rights a medicalissue?The gap in health values between doctors andpatients means that if doctors had their way, patientsmight be subject to much more restrictive legislationthan at present, for example, the freedom to box, ordrink in public houses or bars at any time of the daycould be limited (12). Given the tension in valuesbetween profession and public, primarily ethicaldecisions such as those to do with smokers' rights,should perhaps be left to the state and not todoctors. While doctors have ethical obligations toprovide good treatment for patients - who shouldactually receive health care is possibly not a medicaldecision - but instead one society and its electedrepresentatives should resolve (13).

For example, in many countries, if they cannotafford it, people do not receive medical care. This isnot a decision taken by doctors, but by those whoconstructed that health care system. The public, viatheir governments, have decided that medical careshould largely be rationed through the free market.Even in the British National Health Service (NHS)there are many treatments which are no longeroffered - much dental care, for example. Again theseare not rationing decisions taken by health profes-sionals, but by those who administer the healthservice, and therefore it could be argued that it isthey who ought to wrestle with the ethics of whetherdoctors should treat smokers, and not doctors (13).

While this is the line taken by some of the cor-respondents involved in the debate over smokers'health care rights in the British Medical Journal (13),it seems an inadequate response for, among others,British fundholding general practitioners. Thesehave a budget allocated by the state, with the preciseundertaking that they will be responsible forrationing decisions within the constraints of thatbudget (14).

Part of the power of fundholding was alwaysintended to be the product of bringing togethermedical expertise with wider management andadministration skills under the same roof (14).While this has undoubted efficiency advantages, itdoes also push fundholders into the front line ofethical rationing dilemmas precisely of the kind:'Should smokers be referred for expensive treat-ments?'

Even doctors who are not fundholders are morallyimplicated in these questions - frequent attempts aremade to disguise the ethical dilemma as a clinicalone. In Underwood and Bailey's original British

Medical JIournal paper, the emphasis was on thepoorer prognosis of smokers receiving coronarybypass surgery (1). The problem with this perspec-tive is that while a terminal prognosis is often thebasis of a decision to withhold treatment on thegrounds of mercy, a poor prognosis is not necessarilya good clinical reason for withholding treatment - infact often the contrary applies, very ill people oftenattract more care from doctors not less.

Smokers' rights to healthAnother way of looking at the dilemma is: Do somepeople lose their right to equal access to health careas a result of their behaviour? After all we readilyaccept that while everyone has a right to liberty, thatright is lost in committing a serious crime.

Just as we all have obligations to obey the law, illpeople can also be viewed as having certain socialobligations, for example, to positively value health,and to co-operate with doctors in order to regain it.Those who do not fulfil these obligations shouldsurely lose their claims on others. For example,patients who are violent to general practitioners havelong been considered as relinquishing the obligationof being kept on the practice list.

However, these examples also illustrate theprinciple that while we are used to giving peoplemany social and economic rights, and also takingthem away in certain circumstances, there is a dis-tinction between these and even more fundamentalrights - human rights - rights to life, for example,often considered as worth preserving under almostany circumstances (15). For example, howeverheinous the crime, criminals have a right to trial, andto certain basic conditions in prison. Might nothealth be considered such a basic human right?

Another ethical principle which comes to bear onthe dilemma over smokers and their rights to healthcare, is the general acknowledgement that our indi-vidual actions should not endanger others, and thatwhere necessary this principle should be enforced bylaw. The smoker who uses up the health servicebudget on expensive operations could be seen asendangering the life of others, since their healthresources get squeezed as a result (16).

This leads to a utilitarian question: does thedoctor have less of an ethical responsibility for theindividual patient sitting in front of his desk, and amore primary obligation to the group of patients onhis list? Should he not make decisions whichmaximise the well-being of the group, even if that isat the expense of the smoking minority?A characteristic feature of an individual 'right' is

its regulation of how individuals may be treated,however desirable the collective goal. For example,individual rights to freedom take precedence overthe well-being of the population at large. Utilitari-anism conflicts with rights theory precisely at thispoint. Utilitarianism allows significant individual

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interests to be sacrificed in order to attain collectivebenefits.Any nationalised health system is likely to exhibit

a compromise between principles of individualresponsibility and community solidarity, as it assumesthat the financial risks of ill-health should be borneby society at large. The risk in doing this is thatindividuals are no longer penalised for overeating,drinking and smoking. Yet any lifestyle involves animplicit valuation of one's own health. Average healthunder such a system becomes rather like a publicgood, such as clean air or uncongested roads, fromwhich everyone benefits, but towards which nonehave an incentive to contribute.The problem is that this very discouragement of

personal responsibility for health may eventuallybecome detrimental to the individual herself in thelong term. Hence, another aspect of the dilemma oversmokers' right to health: if smokers are denied rightsto health care this may in itself act as a forceful incen-tive to give up smoking. This becomes an empiricalquestion for which there is currently inadequate data.However, if one long-term consequence of denyingsmokers' rights is to reduce the number of smokers,enabling those who have given up to have access tohealth care, a utilitarian argument may then super-vene, namely, do more smokers benefit in the long runfrom depriving a minority of rights to health care?This argument resonates with several key elements ofthe legislation-over-seat-belt-wearing debate.

A nationalised health service andsmokers' health rightsPerhaps one thing this debate about smokers' healthrights has made clear is that the ethical principles onwhich the British National Health Service werefounded, have been forgotten. The possible referralstrategies for smokers which are being contem-plated, contravene these principles.The welfare state is based on the assumption of

'each according to his ability, to each according tohis need'. This is sympathetic both to the right to beunhealthy and to a duty to care for the unhealth ofothers, paid for through heavy taxation (17). Inother words those who cannot look after themselvesshould be looked after by those who are more able. Itis important to remember this in the currentsmoking debate, as wealthy smokers will always beable to afford bypass surgery: the issue is really oneof the rights ofpoor smokers to health care.The nationalised health service was founded to

ensure wealth should not make a difference (whetherit succeeds or not the intention still stands) andrefusing to refer the smoker for health care returns tothe days when affluence did matter. The rich smokerwill always be able to obtain his operation, while thepoor smoker will not.

Yet if the wealthy smoker is forced to pay for hisown treatment because he smokes, this will save the

health service money, which can be used to treatmany others - a solid utilitarian argument. Thepotential savings to the health service seemunlimited if the same principle is applied to othermedical problems - drinkers in need of liver trans-plantation, HIV patients who acquired the infectionthrough drug addiction or promiscuous sex, heartpatients who are overweight, accident victims whohad been driving carelessly or under the influence ofdrink, and those with sports injuries.

In fact the very best economics might be to encour-age people to smoke. This is because no matter howmuch a patient does exactly what his doctor advises,everyone dies of something sooner or later. Doctorstend to forget that the medical costs of smoking-related diseases can only be calculated after the coststhat would have been incurred had the people killed bysmoking died of something else later, are subtracted(18). In fact, in terms of overall medical expenditureover the course of their lives as a whole, there is someevidence that there may be no significant differencebetween smokers and non-smokers in medical coststo society (19). Smokers even save the state moneyby dying early.

Smoking tends to cause few problems during aperson's productive years, and then kills them beforesocial security and pensions payments are made(1 8). In fact, it is the non-smoking pensioner whobenefits financially from the contributions hissmoker counterpart never lives to claim. And then,let us not forget the billions in tax revenue cigarettescontribute to the exchequer: eight per cent of totalBritish government revenue (20).

Denying the smoker treatment on the utilitar-ian/economic grounds of costs to society ignoreshazardous behaviours smokers might replacesmoking with if it did not exist, and the healthproblems they would live to develop if they did notdie of smoking. Utilitarianism taken to this extremealways extinguishes individual rights. If a healthservice were founded on principles of maximumeconomic utility, then it might even make sense toencourage smoking!

When can rights to health care bechanged?Part of the force behind many of the arguments oversmokers' rights to health care is the unfairness of'changing the rules after the game has begun'. Fordoctors to practise medicine within a health servicewhich embodies certain implicit values, only then toattempt to change their personal practice in a waywhich becomes inconsistent with that health service,demonstrates an inconsistency which requires thesedoctors either to leave that form of employment, orreform their personal practice.

There is another sense in which 'changing therules after the game has begun', applies to smokers'rights to health care. If smokers were informed

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before their decision to start smoking that suchbehaviour would jeopardise their rights to healthcare, then there is a sense in which such decisions tosmoke, taken on that understanding, appear toreduce these smokers' entitlement to demand healthcare as a right.

An important distinctionIf this argument is accepted it should also beapparent that starting smoking with no awarenessthat such behaviour would reduce rights to healthcare, does not permit the smoker the chance tochange his behaviour in the light of this information.Therefore subsequently to enforce such a restrictionon rights to health care appears unfair. This con-tention suggests that rights to health embodied in asociety or a health care system, whatever they mightbe, cannot be made up or changed 'on the hoof', andthat patients have the right to know how their behav-iour will affect entitlements to health care before theymake decisions about such behaviour. Hence,attempts to reduce smokers' rights to health careshould only be made with generations who have yetto take up smoking. This should logically apply to allhazardous-to-health behaviours.

Here then we have an important distinction: whileit may be possible to hold a smoker at least partlyculpable for subsequent ill-health (as it is commonknowledge that smoking is injurious to health) itappears less fair to withhold treatment unless thesmoker was also aware that such treatment would bewithheld before she began smoking, or aware in suf-ficient time after she had begun smoking to give herthe chance to change her behaviour in the light ofsuch information.

This point also has a bearing on doctors' andpatients' responsibilities for health. If a doctor with-holds a treatment and consequently a patient diesfrom an illness that the patient could not havereasonably prevented, then that doctor would beseen as responsible for the patient's death. If,however, the illness was partly produced by thepatient's behaviour, which the patient knew wouldbe self-injurious, then although the doctor still hassome responsibility for the patient's death if treat-ment is withheld, it now appears that as the patientcould also have prevented death by a prior change inpersonal behaviour, the patient now also sharessome responsibility for her own demise.The patient appears to have even more responsi-

bility for her death if she further knew also that herbehaviour would lead to the doctor deciding towithhold treatment. If by withholding treatmentfrom one patient the doctor instead saves another,then the doctor is ho longer responsible for a death,but merely for who dies. Supposing that someonehad to be treated and therefore someone else had togo without treatment, the fact that in this situation asmoker dies could be seen as being even more that

smoker's responsibility, if she had prior knowledgesuch a choice would be made, and she could haveprevented that death by not smoking.

Looked at from the perspective of varying patientand doctor responsibilities for death, and thereforeconversely health, although there is always somemedical responsibility for the outcome of withhold-ing treatment, as patient responsibility waxes andwanes depending on the patient's ability to avoiddeath by choice of behaviour, it is possible that theresponsibility for the death of the smoker by thewithholding of treatment, should be placed less atthe door of a surgeon, than if similar treatment iswithheld from the non-smoker. What I am suggest-ing is that there is some diminution of the responsi-bility of the surgeon for the smoker's death iftreatment is withheld.On the other hand, just because a particular set of

circumstances makes a doctor less responsible forthe death of a patient, does that mean these circum-stances produce any less of a moral obligation on thedoctor to attempt to save the patient's life?

In fact it is acknowledged that while doctors dohave moral obligations to save their patients' lives thisdoes not appear to be significantly different from theobligation we all have to save life if we find ourselvesable to do so (21). Doctors may possess special skillswhich enable them to rescue others more frequentlythan the rest of us, but the reasons why they should doso are the same as the reasons why we should all doso. If doctors' moral obligation to save life is no dif-ferent from anyone else's, it follows that doctorsshould not be expected to value life any more than thecommunity within which they function values life.

However, if doctors find themselves working in acommunity which does not appear to value health orlife as highly as the profession may feel it ought to,then doctors may wish to attempt to alter the com-munity's views by health campaigns or individualpatient counselling. However, if doctors should notimpose their own values of health on a community,similarly a community must abide by the decisions ofits doctors, if these merely reflect the values of thatsociety.

DifficultiesWhile doctors may be expected to value life morethan particular individuals they care for may chooseto do, such as the suicidal or drug abusers, theycannot be expected by the community in which theywork, to value life more or less than the culture inwhich they function. Hence, it also follows theycannot be expected by their patients to value life in away not required by the values of the system ofmedicine constructed by the society (and hence theirpatients) within which they function.

Difficulties for doctors occur when they appear tobe expected by patients to value life or health more orless than the health service constructed by the society

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in which the doctors live and work. For example, in ademocratically approved, strict fee-for-service systemfor non-emergency health care, it would appear oddfor the general public to expect doctors still to have amoral obligation to provide non-emergency medicalcare for those who could not afford it.The system that society evolves for distributing

health care embodies within it values which apportionmoral obligations to doctors. However, individualswithin that society, even large groups, may disagreewith the majority view of the moral obligations ofdoctors to provide non-emergency health care, andmay campaign to change that system. Yet this doesnot mean they can expect doctors to practise medicinein ways which radically depart from the views sharedby the rest of society. Their disagreement is not, then,with doctors, but with the rest of society.

It is important to remember that there are othercircumstances which convey society's estimations ofthe moral obligation to save lives. For instance, oncesomeone engages in a hazardous behaviour, animplicit value is placed on the life put in danger bythe amount society is willing to invest in a rescueattempt. It appears inconsistent to expect doctors toplace a higher or lower value on a life than thatconveyed by society's general attempts at rescue.

However, there are several different ways of inter-preting the value society puts on life and these maynot be entirely consistent. For example, the amountspent on making roads safer may not place the samevalue on human life as that invested in rescue services.

Hence, if as a society we choose not to invest agreat deal in warning smokers of the dangers to theirhealth of that behaviour, it appears we have made acollective and implicit decision as to the value ofsmokers' lives. On the other hand, if much more isspent in providing health care for the same smokersonce they become ill, this might lead to a differentcalculation as to the value of smokers' lives. Hence itappears possible to ascertain the value society placeson life by certain policy decisions, and by the way itorganises and funds its health service.Not just societies, but also individuals, may

appear inconsistent in the degree to which they valuehealth. Patients who make, but then fail to attend,appointments represent a significant cost in doctors'time and resources (22), and doctors may wonderhow obligated they are to push health care ontothose who fail to attend by vigorously pursuingthem. Given that some patients may not want to bepestered by doctors, it appears patients may alsohave a right not to value health care as much as theirdoctors. This right is enshrined in the Mental HealthAct of 1983 which allows medical treatment againsta conscious patient's wishes in only very narrowlydefined circumstances; usually only when there is asignificant risk to the safety of self or society as aresult of a severe mental illness (23).

Therefore, even if doctors do value health morethan their patients this does not mean they can

usually force these values on their patients. Patientsappear to have the right to place their own value onhealth in circumstances when this conflicts withdoctors'. Given the various circumstances in whichdoctors' and patients' values on healtlh may conflict,we are left to ask what should guide behaviour inthese situations. If patients are not to be dictated toby doctors or vice versa, it appears the only remain-ing resort is to an inspection of the generally heldvalues of health in the society within which doctorsand patients live and work.

Complex interplayIt therefore follows that the outcome of a procedureto save a life is the product not merely of an inter-action between an individual doctor and an indi-vidual patient, but the result of a complex interplaybetween the values placed on life by an individual, asociety, a health care system and a doctor. It thusfollows that it is in fact discrepancies which arisebetween these different values which account for themoral difficulties created by the rights to health careof those who indulge in hazardous behaviour.

Such difficulties could not arise if hazardousbehaviour did not lead to controversy over what con-stitutes an unreasonable risk to personal health,implying contrasting health values in differentsections of society. At an individual level a confusionover values also frequently exists. For example, thevery fact smokers demand health care means thattwo behaviours, smoking and seeking health care,which place a very different value on health, canoriginate within the same person.

Highlighting the contradictory nature, in terms ofhealth values, of such requests for health care mightlead society at large to begin resolving these contra-dictions, one way or the other. As doctors tend to bemore knowledgeable about the health implicationsof various behaviours it might fall to them to drawattention to conflicts between healthful behavioursand other values; conflicts which would not other-wise occur to those choosing how to behave.

While it seems fairly uncontentious that doctorsshould play a role in fostering this discussion, it isless obvious that they should determine theoutcome. Withholding treatment seems to be takinga firm position before the dispute has had a chanceto get off the ground. On the other hand, in taking acontroversial stand, those doctors who attempted towithhold treatment from smokers put the debate onthe front pages of national newspapers, whichprobably catalysed the controversy and engaged thepublic far more than the back pages of academicjournals ever could.

ConclusionThis paper has attempted to marshal the mainarguments involved in the debate over whether

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hazardous behaviours, especially smoking, shouldaffect rights to health care. The particular context ofthe health care system in which this debate occurs iscrucial, as this determines implicit 'rights-to-health'assumptions which underpin doctors' behaviour.In an extreme free-market health care systemwhether smokers receive treatment will dependsolely on whether they can afford it; smoking itselfwill be an irrelevancy.

If an alternative health care system is constructedwhich attempts to assign certain basic human rightsto health care, and hence to ensure that personalfinancial considerations are irrelevant to treatment,decision-making within that system should attemptto be consistent with the principles underpinningsuch a service.

Hence, it would follow that denying smokers healthcare because they smoke would be inconsistent with theprinciples on which that health service was founded.An interesting implication of this argument is that

one test of whether a nationalised health caresystem, based on universal and equal rights tohealth, has become terminally underfunded, is whendebates of this kind begin to occur.

Rajendra Persaud, MPhil, MRCPsych, MSc, is aConsultant Psychiatrist at the Bethlem and MaudsleyHospitals Trust, London.

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