Moral judgments about treating smokers or obese patients have no place in the health service They say it is purely a medical decision, based on the fact that evidence shows that people who are very overweight are at greater risk of developing serious complications and recover more slowly from surgery. So in order to make sure that patients are in the "best possible health" before they have an operation, they require the fatties and the smokers to lose weight or quit smoking. And if they fail, they don't get the treatment. And yet - when an obese person or a smoker is refused an operation that is offered to someone who is slim or who has never been near a cigarette, it is hard to avoid the feeling that a moral judgment about who deserves the treatment more has been made. And, indeed, has been made rightly and properly. It is very tempting to think that those who bring health problems on themselves by their own stupid or reckless behaviour do not deserve to have scarce NHS resources expended on them. An alcoholic who has destroyed his liver through years of unrestrained drinking surely does not deserve a liver transplant as much an individual whose system has collapsed through no fault of his own - and if a choice has to be made about which of them is to get a liver transplant, no one is going to think that it would be right to prefer the alcoholic. Tempting though that line of thought is, it is also wrong. It can't form the basis on which to decide how to distribute medical resources: the line between health problems that are an individual's own fault and those that are not simply cannot be fixed in the way required. You get skin cancer. You have spent many years sunbathing, despite knowing the risks. Is it your fault? Well, perhaps not in the same way as losing your liver is because you drink too much alcohol. But it is increasingly clear that there is a genetic predisposition to alcoholism, as there is for obesity - and there is not for a tendency to enjoy lying in the sun. Do people become alcoholics or very fat through there own free choice? Most psychiatrists would say no. The point isn't that trying to fix the dividing line between health problems that are "chosen" and those that are the result of bad luck produces anomalies. It is that the line cannot be drawn with any clarity and certainty at all. As a taxpayer, I may wish that those who have brought their health problems on themselves were excluded from expensive NHS operations. As a patient, I'm going to be glad that judgment is not applied to me. Allocating scarce medical resources only on the basis of how cost-effective they are, rather than based on any moral calculation, may have cruel and heartless consequences. But it is a hell of a lot better than the alternative. We must all hope that a cold calculation of cost-effectiveness remains the only basis for rationing decisions in the NHS.