First it was the sensible point that if you're an alcoholic about to receive someone else's liver, or a smoker someone else's lung, then you should drop the booze and fags and stick to it. Then it was the reasonable argument that if smoking (or drinking, or obesity) made an operation significantly less likely to succeed, then you should be asked to address that. Now, a primary health trust is considering a policy of denying smokers routine surgery that has nothing to do with smoking.
The proposal of the recently formed Leicester city primary care trust is that, as smokers are slower to recover from surgery and their wounds are slower to heal, they might be denied routine but lengthy operations like hip-replacements, knee surgery and hysterectomies unless they give up.
So what's wrong with this? The trust is keen to emphasise it is not suggesting a blanket ban. Although smoking is declining, heavy drinking and obesity are increasing, and making it harder to get routine surgery is one way to encourage abstinence. And why should beds be blocked by people whose condition is exacerbated by their own indulgence? If you can't be bothered to look after yourself, why should the NHS look after you?
What's wrong with it goes to the heart of what the National Health Service was set up to be, and ought to remain. The most obvious argument against denying people care on the grounds of unhealthy lifestyle is: where do you stop? If you deny care to smokers, drinkers or fat people, why not people who indulge in other self-harming activities that may require medical attention? Aside from climbing and skiing accidents, most serious sportspeople seem to have permanently damaged something that gives them trouble in later life. People don't have to indulge in the activity that spreads chlamydia. What advertisers call today's hectic lifestyle leads to what doctors call stress-related illnesses. GPs and consultants have the right to advise and encourage people not to play contact sports, go potholing, sleep with strangers, work 60-hour weeks or fail to wrap up warmly, but no one would argue they shouldn't treat people who fail to follow that advice, particularly when they present with unrelated illnesses.
But there are also issues of principle. Underlying Leicester's proposal is the presumption that the NHS is a charity, which has the right to distinguish between the deserving and undeserving in the benefits it graciously distributes. In fact, patients have a right to be treated because they've paid for the service. As an individual, I paid my national insurance and my taxes on the understanding that I would be treated by the NHS in the future if I got ill. If Leicester or any other care trust wants to renege on that commitment, I think I have a good case to get my money back. More important, I have made those contributions (and cast my vote in many elections) on the basis that other people would be treated free at the point of delivery - not on the basis of virtue or value, but of need.
Of course, smoking should be discouraged and made harder and more expensive to do. But if you're stopping smokers from having surgery not because the operation might not work but because they might take a day or two longer to recover, you've crossed the line from a medical judgment to a moral one. (After all, old people take longer to recover from operations.) You are distinguishing between one patient and another on the basis of a judgment as to their behaviour.
I have to confess an interest here. My wife Eve Brook and I, both heavy smokers, gave up on the same morning in March 1984. I haven't smoked since; she lasted a couple of days, and died of lung cancer nine years ago. I know that I was lucky to have hit a moment in my life when my ambitions, my fears and my willpower were in alignment. Maybe Eve would have managed the same trick another time. Perhaps she could have tried harder (though, God knows, she tried). All I do know is that while she was failing to give up smoking she was chairing Birmingham city council's social services committee, and thus looking after thousands of old people in distress and young people in care. If you want to look at it this way (which I don't), I think her contribution to the public good outweighed what she cost it.
Most people suffering from lung cancer are elderly working-class people who've conceded that they don't deserve top-level care because their disease is their fault. Eve got committed and consistent (if sometimes inefficient) care because she insisted on it. Women in particular have fought to end the top-down, doctor-knows-best ethos of the early NHS years. Rationing treatment on grounds of lifestyle is a way of reintroducing patrician, patronising, producer-led healthcare by the back door.
Finally, stopping smokers getting surgery is a way of passing the buck. One of the arguments for the policy is the claim that smokers are more vulnerable to MRSA; but the answer to sick hospitals is not to keep vulnerable people out of them, but to make them better. In its last assessment (2005-06), the Healthcare Commission judged the quality of service provided by Leicester's then two primary care trusts to be fair rather than good. Among the core standards the trust failed to meet were those relating to protecting patients' safety, management of patient records, adequate provision of hospital food, and programmes for disease prevention and health promotion, including those to tackle smoking and obesity. The trust should put its own house in order before taking it out on people it's failed to help in the past.
· David Edgar is a playwright and chair of the Eve Brook Scholarship Fund
