Should those who abuse their bodies pay the price?

"Disease generally begins that equality which death completes," said Dr Samuel Johnson. But in the world of modern health care it seems some patients are now more equal than others.

The allegations made last week that a 15-year-old girl had been denied a liver transplant after taking ecstasy raised once again the moral question: if a patient is a smoker, a drinker or a drug abuser does that somehow make them less worthy of treatment than virtuous people who have eaten their greens every day?

The details of Michelle Paul's case are not yet known, as the fatal accident inquiry has been adjourned until April when Ms Paul's surgeon, Hilary Sanfrey, will have the chance to testify. But if it does emerge that Ms Paul was denied the chance of a liver transplant solely on "moral grounds", because of her drug use, this will make us question anew the values we apply when deciding who gets treatment.

Drug users are not the first people to fall foul of implicit rationing in the NHS. In the past there have been claims that smokers and drinkers have been left at the back of the queue. In 1993 Harry Elphick, 47, was refused treatment for a heart condition because he was a heavy smoker. Consultants at Wythenshawe hospital in Manchester told him that tests to show if a by-pass was needed were not carried out on smokers. Mr Elphick quit his 25-a-day habit but died a week before he was due to see doctors again.

Then in 1995 it was reported that transplant units were under pressure to stop offering pounds 60,000 liver transplants to alcoholics, after evidence from the US that most patients return to heavy drinking after the operation. By some criteria it seems a logical policy. The UK Transplant Support Services Authority reports that there was a 6,000-strong waiting list for all organ transplants at the beginning of 1996. By the end of the year, despite 2,750 taking place, the waiting list had grown by 5 per cent.

So why should the rest of us pay for a new heart for someone who has brought their condition upon themselves by puffing away on 40-a-day? Why should someone who regularly consumes three bottles of vodka a day - as Jim Baxter, the former Scottish football international who received two new livers was said to do - receive a new organ after bringing cirrhosis upon themselves? This is, after all, the real world where there are never enough organs to go round and the dangers of excessive drinking or smoking have been clear for years.

But to start rationing because of deviant lifestyles is a dangerous step. The General Medical Council felt the need to make its view explicit in 1995 when it issued revised guidelines making it clear that doctors "must not allow their views about a patient's lifestyle, culture, beliefs, race, colour, sex, sexuality, age, social status, or perceived economic worth to prejudice the treatment they give or arrange". The council added that doctors "must not refuse or delay treatment because [they] believe that patients' actions have contributed to their condition". The British Medical Association said decisions must be made on clinical need and "patients should not be discriminated against on the basis of moral judgements".

Where, after all, do moral judgements leave us? There have also been allegations of discrimination and prejudice against drunk drivers, gay men with HIV, women seeking abortions, people from ethnic minorities and the elderly. In the end, should dentists refuse to treat children who have persistently and defiantly eaten sweets all their lives?

If a smoker, a drinker or a drug user is unlikely to survive a complicated transplant operation then, in the real world, it is better to give the organ to someone who can benefit more. But to condemn them purely for their habit and refuse to treat them on that basis is repulsive.

Surely it is more important to encourage more people to pledge their organs for use after their death so the waiting list can be contained, rather than stigmatising people for their habits. "Life unworthy of life" was, after all, the phrase used by the Nazis to justify the murder of 100,000 psychiatric patients in the run-up to the Final Solution.