The inhumanity of modern social policy

In a story on 13 March 2013 in a story headlined as Tobacco ban leaves mental health groups fuming, Sydney Morning Herald health reporter Louise Hall began:

A BAN on smoking in all psychiatric facilities will go ahead despite vehement opposition from some members of the mental health community, who argue that strict anti-smoking rules will destabilise acutely ill patients and put staff at risk of violence.

NSW Health has ordered all facilities, including emergency psychiatric centres, to close designated outdoor smoking areas, confiscate tobacco products and supply free nicotine replacement therapy to staff and patients.

Anti-smoking groups say the department's decision to enforce its longstanding smoke-free policy in wards that had been granted an exemption will help to break down the "deep-rooted smoking culture" among mental health staff and patients.......

About one-third of people with a mental illness smoke, rising to two-thirds for people with schizophrenia, compared to about 17 per cent of the general population.

The ban was welcomed by anti-smoking groups. I quote:

The chief executive of the Cancer Council NSW, Andrew Penman, said arguments that people with psychiatric disorders smoke to self-medicate or relieve symptoms, stress and anxiety "are too easily used as excuses to justify inaction about smoking".

This type of ban had some medical support. In December 2011, the WA branch of The Royal Australian and New Zealand College of Psychiatrists had stated:

Allowing smoking would be a backward step for mental health patients who have higher smoking rates than in the general community....

"We need to help people with mental illness stop smoking, not encourage it," the branch's chair, Dr Alexandra Welborn, said.

She said people with mental illness had high rates of physical illness and higher death rates, with many suffering from smoking- related conditions such as heart disease.

"As doctors, we have a key role to play in the physical health care of patients.

"We do not allow smoking in our general hospitals and should not go against national and international trends to reintroduce smoking in secure mental health facilities," Dr Welborn said.

She said the state's mental health units offered smoking withdrawal, nicotine replacement and education programs to temporarily stop smoking and they increased the likelihood patients would stop smoking altogether.

In December 2012 in regard to a proposed ACT ban ( Anxiety rises over effect of smoking ban on the mentally ill) the President of the Canberra Action on Smoking and Health, Dr Alan Shroot, stated "addictions should not be tolerated at any health site."

In March in NSW, Ashley Coleman took his life after being granted an unsupervised cigarette break off-site from NSW's Liverpool Hospital's mental health unit - where smoking has been banned.Apparently, as a sufferer of schizophrenia, Coleman had been in and out of Liverpool Hospital's mental health unit for six years. Previously, he and other patients were able to smoke, under supervision, in a small, open-air courtyard next to the ward.

His father said: ''When people like my son are admitted, they are already suffering from conditions such as severe depression, anxiety issues and suicidal tendencies - without the added burden of suddenly being told they must quit. It seems cruel and unjust.'' This view was shared by leading anti-smoking campaigner. I quote:

Professor Chapman, who has won international awards for leadership in tobacco control, said he is in favour of ''dedicated smoking zones where people can go''.

''There are some important and under-discussed ethical issues in depriving people of their rights,'' he said. ''But somehow, when you are a patient, your rights to do as you please are suddenly suspended - even if you are not hurting other people.''

This view was not shared by the anti-smoking lobby:

Anne Jones, chief executive of Action on Smoking and Health Australia, said mental health units were given a much longer period of time to go smoke-free and it would be a ''retrograde step'' if they returned to the ''bad old days''.

She said: ''There is overwhelming evidence that the health and treatment of people with psychiatric illnesses is significantly worsened if they smoke - and significantly improved if they quit.''

Liverpool Hospital said:

A Liverpool Hospital spokeswoman said its smoke-free policy mirrored NSW Health guidelines across the state.

''Inpatients are routinely assessed for nicotine dependency and offered appropriate advice and nicotine replacement therapy to manage withdrawal.''

She said it was wrong to imply inpatients were granted ''smoke breaks'' off-site.

''After careful assessment and, where clinically appropriate, mental health patients are granted escorted leave as part of their rehabilitation plan,'' she said. ''If patients respond well, they can be granted short periods of unescorted leave.''

Smoking is legal. It is totally inhumane to tell a sick person that, by fiat, they are not allowed to do something, that they must have "therapy" imposed on them when that has little to do with their immediate condition, when they are not harming others. It can be hard enough to get a person to seek necessary help. It can become impossible unless they are forcibly detained when they are provided with a powerful reason for refusing help.

There is no health gain from this. It is a cruel infringement of human liberties that really benefits no one, it is (and I accept that this is a bias) another blind application of universal rules based approaches that has become so prevalent in what is called social policy. In pursuit of goals and targets, in the desire to control, we have become inhumane, censorious, lacking in fundamental human empathy.  

Postscript

This post drew a long and very thoughtful comment from a mental health nurse presenting an inside picture that that I thought demanded full inclusion in the man post. I was writing because I was actually shocked by the story, but it was an external view. This is an internal view.

The Comment

"As a Mental Health Nurse that survived the implementation of a no smoking policy, I would rate it as one of the most risky 12 months of my life. The stress and tension that was created during this period was incredible. Nurses used to using cigarettes for managing behaviour were at a loss as to intervene during a patients escalating behaviour. We saw an increase in the use of as required medications and there was an increase in the reported assaults against staff. We also had to negotiate harder to get at risk patients to comply with treatment and even to accept admission into hospital. Some medical staff even admitted to being forced to make "poor clinical decisions" with regard to complying with the non smoking policy.

As for enforcing the policy, this duty once again, fell to the nursing staff. Other departments, such as security refused to participate and exemplified it by this quote: "If we did that, we wouldn't get time to actually do any work and besides; if we give them an infringement, do you think they would pay it?". Eventually we ended up with a blind eye policy that was even less effective than previously and created for the staff another avenue of vulnerability and manipulation.

Another factor that this change produced, was the sudden emergence of staff and patients smoking on the footpaths outside the hospital grounds. This visual reminder was only reinforced with the removal of the smoking bins in the grounds. So, where once a smoker would dispose of their butts correctly, there was a massive rise in the littering of cigarette butts all over the hospital grounds.

There ended up being a positive out of all this though, as prisoners were allowed to smoke in prison and refused permission in a psychiatric facility, the numbers of prisoners that we accepted for admission plummeted dramatically!

I have done some further research into the brain and brain function with the understanding that the more that we stress these populations, the worse the health outcomes and the reactive behaviours become. THIS evidence IS demonstrated through all the jurisdictions throughout the world that have implemented a smoking ban in psychiatric facilities.

A decision that is considered only by a bureaucrat in a high office who's last clinical contact (if any) was at least 15 years ago?

That's gotta end well.

Kind of remind me of a beach somewhere in Turkey where the most successful part of the operation was the retreat.

Oh and @Evan, C.S. Lewis wrote it best...
"Of all tyrannies a tyranny sincerely exercised for the good
of its victim may be the most oppressive. It may be better to live
under robber barons than under omnipotent moral busybodies.
The robber baron’s cruelty may sometimes sleep, his cupidity may
at some point be satiated, but those who torment us for our own good
will torment us without end for they do so with the approval
of their own conscience.""

ENDS

This and the other comments do confirm my view, and I really loved that quote from C S Lewis. But aren't my commenters wonderful in extending and critiquing discussion?  In this case there is agreement, but that's not always the case.