BMJ  2006;333 (5 August), doi:10.1136/bmj.333.7562.0-f

Editor's choice

Rite of passage

Patients have rights but do they also have responsibilities? John Major's 1991 Citizen's Charter set out for the first time in the UK the right of "consumers" of health care to a certain level of service. It was an important initiative but it got the balance wrong. It made no mention of patients' responsibilities.

Why are responsibilities important? Because the patient is central to health care. Luisa Dillner, who set up the BMJ's Best Treatments website for patients, has always (I think rightly) disputed Liam Donaldson's airline analogy for patient safety. Patients should not be seen simply as passengers, entirely dependent for their safety on others. They can actively influence the outcome of care, both for good and bad. Tony Blair's call last week for the nation to take more responsibility for its own health indicates a shift in government thinking, driven partly by the growing cost of unhealthy lifestyles.

So what are patients' responsibilities, and do they vary in different healthcare settings? At a meeting last month at the Nuffield Trust, ethicists and others gathered to discuss health care and the public interest. The conveners, Iona Heath, Stephen Pattison, and Martyn Evans, asked us to consider how individual liberty and individual responsibilities could be combined to create justice in a publicly funded health service. We considered examples where public and individual interests clash: immunisation, screening, sharing of data, and even participation in research.

Martyn Evans has previously argued that if you are going to benefit from treatments tested on previous patients you have a responsibility to take part in future clinical research (Journal of Medical Ethics 2004;30: 198[Abstract/Free Full Text]) In this week's BMJ Jenny Hewison and Andy Haines take a less extreme view (p 300). They criticise the current preference among research ethics committees for patients having to opt in before being invited to participate in research. "Recruitment procedures are part of the science, not an administrative add-on, so if patients and the public want certain kinds of research to be conducted, recruitment procedures need to aim to reduce bias and improve recruitment as far as possible." But should patients be compelled to take part? And what about prevention programmes? Strong voices at the meeting argued that these should always remain voluntary.

The meeting aimed to move from academic debate (and at times despair at the lack of public engagement in health policy) to action. One concrete idea was that people could be asked to actively join the health service as patients, with a rite of passage at age 16 and a contract. Schools do this after all, asking parents to sign up to the school rules and to read with their younger children every night. What might such a contract include? Perhaps at the least a commitment to look after your health and to understand the communitarian values of a publicly provided health service. Some general practices and hospital departments may already have something like this in place. If so we'd like to hear from you.