Leading Article: The fag-end of medical care?

SMOKERS find it difficult enough that they are becoming social outcasts, confined to certain areas or banned from smoking indoors. Suspicion that they may also receive second-rate medical care is in danger of adding injury to insult. Reports that a man suffering heart disease was refused coronary surgery because he continued to smoke will raise understandable fears among Britain's 12 million smokers.

They may ask: has health fascism and survival only of the fittest come to the National Health Service? If so, does this incident mark the beginnings of a policy that could write off others with self-inflicted illness? What hope for drinkers, the promiscuous, motor-bike riders, fat people and even those who, through their careful lifestyles, survive into old age and chronic, expensive illness? What hope for any of us?

The case at the centre of the controversy concerns Harry Elphick, 47, whose doctor ruled out bypass surgery because he continued to smoke. When Mr Elphick finally kicked the habit, he was booked for tests in preparation for an operation, but he died while waiting. His doctor regrets the death, which is all too common for heart patients - smokers and non-smokers alike - who are awaiting treatment. The explanation of the hospital's policy was, however, unapologetic and simple: people who continue to smoke after heart surgery do not live any longer than if no operation took place. So surgery is a waste of time.

Is the controversy therefore a lot of fuss about nothing? Not according to expert opinion. First, the general medical view is that continued smoking reduces but by no means eliminates the benefits gained from bypass surgery. Second, even if all the benefit was eliminated, an operation might be justified since an apparently incorrigible smoker might suddenly decide to give up after surgery. Who would dare predict when a long-addicted smoker finds the will-power to stop? So there is a medical case for operating on smokers.

It may be that doctors, aware that resources are strained in the NHS, may grow reluctant to operate on smokers because so much more can be achieved by focusing on non-smokers. If that were to become policy, it would have to be made explicit and professionals could not hide behind medical arguments. If doctors are discriminating against smokers or plan to do so, the public is entitled to know.

Smokers might, for example, point out that they contribute more than pounds 6.6bn a year in taxation, which helps to fund the NHS. They might argue that at the very least the NHS should be a life-saver for all, even if this is at the expense of treatment for some ailments which do not threaten life. There are a host of other arguments - most notably the principle of equity - which would need to be properly and democratically debated if the NHS were to alter its priorities against the interests of a particular group.

At the moment, there is little evidence that doctors in general discriminate against certain people. They tend to assess suitability for treatment on a host of factors, including age, medical history, lifestyle and likely outcome. Professionals are trusted to consider the best interests of patients. Concern about the death of Mr Elphick reflects public fears that doctors may be tempted to moralise about their patients' behaviour. Such a development would be damaging to the NHS. A doctor's job is to heal, not to judge.