Intended for healthcare professionals


Patients’ charters and health responsibilities

BMJ 2007; 335 doi: (Published 06 December 2007) Cite this as: BMJ 2007;335:1187
  1. Harald Schmidt, assistant director
  1. 1Nuffield Council on Bioethics, London WC1B 3JS
  1. hschmidt{at}
  • Accepted 16 October 2007

We all have responsibility for our health, the health of others, and to the organisations that provide health care. But, as Harald Schmidt describes, specifying and formalising these duties can create ethical problems

The BMA recently called for a charter setting out the responsibilities patients have within the National Health Service and what patients can expect from the NHS.1 The proposal raises questions about the scope, specificity, and status of such a charter. Should it be legally binding or simply set out aspirations? How many and what kind of responsibilities should be included? I examine how initiatives in Scotland, Germany, and the United States have dealt with these questions and look at the ethical tensions raised.

In sickness and health

The BMA’s discussion paper refers to patient responsibilities and a patient charter. But at its annual representative meeting 2007 delegates also resolved with an overwhelming majority the need for a charter that “focuses on the individual’s responsibility both in health and illness” (motion 25). The focus on patient responsibilities is too narrow, and in the following I will therefore use the term health responsibilitiesto cover the obligation of healthy and sick people to maintain, improve, or restore their health; to respect the health of others; and to contribute to the efficient operation of healthcare services.

I have chosen examples from three countries to illustrate the different ways that these responsibilities can be set out: the 2005 Scottish NHS’ patients’ charter The NHS and You,2 which the BMA highlighted as a good model; book V of the 1988 German Sozialgesetzbuch (social security code), revised in 2007; and the Medicaid member agreement, implemented in West Virginia, United States, in 2007.3 These documents all apply to publicly funded health programmes but set out responsibilities with varying degrees of specificity, legal status, and enforceability …

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