The concept of patients' charters is inadequate and should be replaced with charters of health responsibilities, argues an expert in this week's BMJ.
But even these raise ethical tensions, says Harald Schmidt, a research associate at LSE Health.
The British Medical Association (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.
Although it lacked detail, it raised questions about the scope, specificity, and status of such a charter, says Schmidt. So he assessed how health responsibility initiatives in three countries have dealt with these questions and looks at the ethical tensions raised.
He examined the 2005 Scottish NHS' patients' charter: The NHS and You; 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.
These documents all apply to publicly funded health programmes but set out responsibilities with varying degrees of specificity, legal status, and enforceability.
The documents all contain explicit health maintenance obligations, such as "Look after your own health and have a healthy lifestyle" (Scottish charter) and "I will do my best to stay healthy" (Medicaid agreement).
But Schmidt warns that, while it is easy to make appeals not to risk health, it is far more complicated to decide whether and to what extent people should be held responsible when things go wrong, especially when expensive treatment is required.
He urges clarity about such decisions, especially for documents with a binding status.
The documents also emphasise obligations to contribute to fair and efficient use of healthcare resources, but these may give rise to several problems, he adds.
For example, appeals to "only use emergency services in a real emergency" may lead people to not request treatment when they need it, or with delay, which may result in poorer overall health and higher costs for the healthcare system.
Similarly, emphasising the need to keep (or cancel) appointments may be unfair for patients who may have good reasons for missing appointments.
With rising healthcare costs, higher burdens of chronic diseases, and increasing evidence about the contribution of genetic and behavioural factors to disease, the issue of personal responsibility for health is here to stay, says Schmidt. There have already been concerns about the decision of some primary care trusts to require, for example, patients to lose weight or stop smoking before routine surgery.
The BMA's proposal for a health responsibility charter, and similar initiatives towards spelling out "rights and responsibilities" as part of Lord Darzi's current review of the NHS, offer unique opportunities to clarify which types of responsibilities are compatible with the ethos of the NHS, and which ones are not, he concludes.