Deborah Orr: A new NHS contract is all very well, but linking rights and responsibilities is inherently dishonest

The compulsive behaviour that results in obesity or addiction is most usefully viewed as a disorder in itself

There would be no need to be particularly concerned about Gordon Brown's comments regarding the "rights and responsibilities" of NHS patients, if those comments were not quite so tired and meaningless. I have no problem with telling people that there is no point in operating on their ankles until they have lost some weight; that they can't be on the liver-transplant list until they've stopped drinking; or that the triple bypass is dependent on their ability to give up smoking. But I'm aware also that those are threats as well as straightforward and helpful behavioural prescriptions, and that democracies should think twice before issuing threats to its law-abiding participants.

That's surely what bothers the patient organisations that argue that Brown's as-yet fairly inchoate threats about threats undermine the "right to access to care". Or at least I hope it is, because otherwise they are more concerned about making an intellectual defence of the highly contestable "right" to care than they are about securing the best health outcomes for the users of the health service that they represent.

Habitually ignoring the advice of one's doctor, and indeed of all health advice in the known universe, after all, is a very good way of undermining one's own "right to access to care". What is the point of this right of access if the care, once accessed, is completely ignored, again and again? What is the point of defending a right that is treated as without value by the person on whom the right is conferred? The point is simply to defend its status as a right, whether that is useful or not.

In the new NHS contract that Labour promises, services will depend on compliance. All the airy talk of rights and responsibilities is meaningless. If a "right" has to be paid for in the currency of responsibility, and can be taken away from those who don't have the wherewithal with which to pay, then it isn't a right. In that sense the "right to access to care" is indeed undermined. But maybe it should be, if the result of defending that right is poorer health outcomes instead of the better ones that were envisaged when the NHS was launched, and the probably untenable expense that is the most worrying of a number of threats to the continued existence of the institution.

There is clearly a decadent imbalance in a system that allows no one to deny the right of access to care, yet gives all of its consumers the right to carry on squandering the care by behaving as if it had never been accessed. That's precisely why Labour has sought for so long to introduce "responsibility" into the equation. Yet linking rights and responsibilities is inherently dishonest, even though it sounds sensible and grand. Good citizens accept their responsibilities because that's what being a good citizen is. They don't do it in return for "rights", even though they are annoyed when the irresponsible get the same rights.

The problem with attempting to link rights and responsibilities in a carrot-and-stick system can be seen most starkly when it is applied to health issues. The conditions that are usually cited when this debate surfaces and it does, very regularly, year after year are of a particular kind. They are addiction and compulsion issues. People are obese because they have lost control of their appetites. They smoke because they are addicted to nicotine. They cannot stop drinking because they are alcohol dependent. Their other health problems generally are linked to this primary health problem.

The compulsive behaviours that result in people being obese, alcoholic or hopelessly addicted to fags are most usefully viewed as disorders in themselves. Pretty much everything that is viewed as being a preventable drain on the NHS involves an inability to control the intake of addictive substances. Or, put more simply, victims for a number of reasons have lost touch with their sense of responsibility to others and to themselves. They end up in hospital precisely because they do not possess to currency with which they may soon be expected to pay for their treatment. They will only have to right to be treated for their addiction, and the further symptoms it creates, if they are responsible enough to be able to manage their addiction in the first place. It's a cruel sort of catch-22, which I think is why its prospect worries people so.

Just as access to Lanvin dresses is rationed because the pool of people with the cash to pay for them is small, access to NHS treatment, it is proposed, ought to be rationed according to whether you have enough of the currency of responsibility to deserve it. That's what's really being suggested, and the government would sound a lot less hollow if it were honestly to suggest that access to healthcare cannot be a right but must instead be part of a contract.

Anyway, it could much more honestly be argued that the denial of supplementary treatment to addicts, as early on as possible, is a valid treatment in itself not a threat, but a wake-up call. It is well known that "intervention" can trigger the psychological process that is utterly necessary in order for an addict or a compulsive to recover. Intervention, in the language of 12-step programmes, is emotional confrontation, an attempt to get the addict to see what damage he is doing to himself and to other people. Refusing medical treatment to a person who is unable to face their addiction and accept that only they, ultimately, can free themselves of the damage it is doing to them, is a valid form of psychological intervention, and therefore not a threat but a treatment in itself.

Yet the NHS is not in the least geared up to towards orchestrating such interventions, especially in the early stages of addictive illness. Smokers are given antibiotics for their winter bronchitis. The alcoholic are given pills to reduce their blood pressure. The obese are given statins to drive down their cholesterol.

There is help available to addicts who want to change. But the sad fact is that part of addiction is the ability to kid yourself that change is not necessary. The passivity of the people most ill with addiction is accepted and is medicated until the health difficulties their primary conditions cause are huge. Instead of being challenged, and referred for psychological help at an earlier stage, sufferers are mollified and are given medical props with which they can shore up the denial that is their real problem.

For some people, the eventual refusal of a major operation will be their "rock-bottom", the low-point at which denial finally stops. They are the ones who will lose the weight, kick the booze, or stop smoking at last. For others, even this will not be enough. They, tragically, cannot be saved, because they cannot save themselves. Their inability to discharge their responsibilities to the state is far less relevant than their inability to take responsibility for themselves. As for the "right" they once had to be given advice they ignored, it was most probably even a part of their problem.

d.orr@independent.co.uk