Patients who refuse to change their unhealthy lifestyles could be refused medical treatment, under proposals from the Government's NHS watchdog.

Patients who refuse to change their unhealthy lifestyles could be refused medical treatment, under proposals from the Government's NHS watchdog.

The controversial suggestion from the National Institute of Healthcare and Clinical Excellence would mean that a smoker in need of heart surgery might be denied the operation unless he or she promised to give up the habit.

The proposal is contained in a document which sets out for the first time the social values that should underpin decisions by the institute on which treatments to provide on the NHS.

It says all patients should be treated equally regardless of their age or social responsibilities and rules out discrimination on the grounds of gender, race or socio-economic status.

The only exception should be where a patient's age might affect the chances of success of the treatment. "Health should not be valued more highly in some age groups rather than others," it says. On self inflicted illness - that caused by "unhealthy lifestyles", such as casual sex, smoking, drinking or dangerous sports - it rejects the idea of "deservedness" in deciding who should receive treatment and says it would be impossible in many cases to determine which illnesses were self-inflicted.

It adds: "If the self-inflicted causes of the condition influence the likely outcome ... of an intervention, it may be appropriate to take this into account." A spokesman admitted there was a "grey area" between denying treatment on clinical grounds, because a patient might not benefit from it, and "blackmailing" them to change their behaviour in line with medically accepted health norms.

"It was felt that it wasn't fair to punish someone because they were, say, a smoker, but if the success of the treatment might be affected because they refused to give up smoking then it might be appropriate to take that into account. It is not about how they ended up in that situation but given they are there what do we do now."

The recommendation carries echoes of the case of Harry Elphick, 47, who was told by consultants at Wythenshawe Hospital, Manchester, in 1993 that they would not conduct a test to determine whether he needed heart surgery unless he quit his 25-a-day habit. He eventually agreed but died before he could have the test. The case provoked a dispute about rationing in the NHS which has erupted often since, mostly in relation to patients denied liver transplants because their lifestyle has been judged "unstable" when other patients - including the footballer George Best - have had a transplant and subsequently returned to drinking.

A spokeswoman for the BMA said: "We do appreciate the health service is not a bottomless pit. We would not be in favour of blackmailing a smoker to give up before he got his operation but if there is a strong likelihood that, because of his lifestyle, he will be back on the operating table in three months then you have got to take that into account."

The document is out for consultation until the end of June. The spokesman added: "This is our first attempt at this. Of course it is bound to be controversial. We would be enormously surprised if everyone came back and said yes to it."