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The suggestion that some patients may be more deserving than others has divided medical and lay opinion for decades. Should smokers be treated equally with non-smokers? Do the obese deserve sympathy or blame? And what of those who ride motorcycles, knowing they are the most dangerous form of transport?

The suggestion that some patients may be more deserving than others has divided medical and lay opinion for decades. Should smokers be treated equally with non-smokers? Do the obese deserve sympathy or blame? And what of those who ride motorcycles, knowing they are the most dangerous form of transport?

In a first attempt to set out the social values that should underlie the delivery of NHS care, the National Institute for Health and Clinical Excellence wisely rules out discrimination against patients who may be judged to have brought their illness upon themselves. Care must be non-judgmental if it is to be humane.

There may be an exception: it suggests, however, that when a patient imperils the success of the treatment by continuing with the behaviour that made them ill in the first place. So the smoker who refuses to give up might, on this ground, be denied heart surgery.

In a health service where cash is finite, there is an ethical requirement to use resources efficiently - and that means not wasting them on a patient unlikely to benefit. When George Best, the footballer, was spotted drinking after his liver transplant he was rightly criticised. But requiring a smoker to give up in order to preserve the fresh blood vessels being stitched to his heart is one thing. Telling a motorcyclist to sell his machine after being put back together by the surgeons is another. Clinical decision-making must not shade into social engineering or doctors will become even more god-like than they already are.

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