Intended for healthcare professionals


When should patients be held responsible for their lifestyle choices?

BMJ 2006; 332 doi: (Published 02 February 2006) Cite this as: BMJ 2006;332:279
  1. John Gillies, general practitioner (john.gillies{at},
  2. Mark Sheehan, lecturer2
  1. 1 Selkirk Health Centre, Selkirk TD7 4LQ
  2. 2 Centre for Professional Ethics, Keele University, Staffordshire ST5 5BG
  1. Correspondence to: J Gillies

    Many would argue, in a case like this,1 that individuals should be held accountable for the lifestyle choices that they make. People should be allowed to live their lives as they see fit, but when this goes against the generally received (medical) wisdom society is required to do only a limited amount to redress the consequences of those choices. So, when someone freely chooses to live life in a particular way, he, not society must shoulder the responsibility for those choices.2

    This response is powerful, but two points can be made against its use in this case. The first raises questions about the freedom of Mr Bond's choices, the second calls into question the underlying resources monopolised by those who make such lifestyle choices.

    Firstly, this response is legitimate only if the lifestyle choices in question are freely made. We do not typically hold people responsible for choices that they could not help but make. This case is interestingly complex in this regard, especially given Mr Bond's admission to enjoying drinking in the way that he does. However, he has a maternal history of alcoholism, known to contribute to a high incidence of alcohol related problems in offspring, mediated through genetic or environmental factors, or both. Of course, the genetic factors are beyond his control, as are many of the behavioural lessons learnt in the course of his upbringing. None of this suggests that Mr Bond has no control or responsibility for his situation—this is evident from his own testimony. What it does suggest is that the lines are not so easy to draw.

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    Secondly, the tendency is to think that heavy drinkers cost the NHS more than moderate drinkers—they take more than their fair share.3 The evidence (for smokers at least) suggests this is not the case.4 5 Because low risk individuals are likely to live longer, they are also likely to cost more than high risk individuals. It may turn out that heavy drinking is good, costwise, for the NHS, taken over the lifetime of the patient. However, we all think that he would be better off with his drinking under control and, at times, it would seem that he agrees.

    What makes this case particularly difficult is that the patient presents when acutely ill, so something must be done with little time for reflection. Also, the available choices may be limited by availability of beds in the intensive therapy unit or facilities for treatment. This aspect of the case brings the issue of beneficence to the fore. This founding tenet of the NHS may trump thoughts of whether one individual has had his fair share. Sometimes, doing what is best, even if it is best according to us, is more important than doing what is just.


    • Competing interests None declared.


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