Abstract
Questions about smoking policies in hospitals, and how exactly to implement them, have been difficult to answer for many years. Policy-makers must consider a tangled web of personal versus public goods. Administrators often have to creatively decide how policies can best be adopted at their particular site. Clinicians and hospital staff must then implement those policies, often compelling them to consider whether a slight violation might be in a particular patient’s interest, and then whether to assist in the violation or not, and whether to share their decisions with colleagues. Getting such questions right can have important consequences for the wellbeing of patients, administrators, and clinicians alike, so a careful balancing of the issues is warranted.
Introduction
It is an
A variety of tools for ethical deliberation
The pursuit of “balance” after the consideration of complex ethical questions is what John Rawls calls reflective equilibrium, and it can be a useful ethical tool. Ethical tools are the ideas and concepts that have arisen in the field of health ethics in recent decades that organize thinking around complex issues. The profoundly difficult questions that come with advanced technology and modern healthcare systems have generated the need for such tools. A key goal of health ethics is to identify those ideas, from the collective wisdom of the world, which might be useful to decision-makers in health systems, and apply them in real situations.
Reflective equilibrium is useful in the way it designates an end point for ethical deliberation. It offers a way of resolving the inevitable conflicts that arise when analyzing complex issues from a variety of perspectives, using some of the other tools of ethics. These include considering key principles such as respecting patients’ autonomy, helping them clinically, minimizing harm, and being fair. 2 Practically minded people might use more outcomes-based tools, like identifying the good and pursuing it. Some will look to professional codes of ethics, mission and vision statements, or codes of conduct to determine their duties in a particular situation. An “ethic of care” advises that one first consider compassion for the patient, in relationship with the caregiver, in the attempt to determine a course of action. Complex issues always demand consideration from multiple perspectives, which creates the mental to and fro of rational deliberation. Achieving reflective equilibrium after due consideration of all relevant angles improves decisions and lightens the burden for decision-makers.
Examples of ethically challenging scenarios
Ethical challenges related to smoking can take many forms around a hospital. A senior administrator is invited to sit on a regional committee to review whether property-wide bans are good and successful; a security guard charged with enforcement must decide whether to hand a $200 fine to a patient who has not left the property to smoke; nurses on a transition unit must decide whether to provide cigarettes to a penniless patient whom they know would spend part of her day seeking cigarette butts on the ground; an aide in a nursing home is asked by a wheelchair-bound patient with a movement disorder whether she would light a cigarette and hold it to his mouth while the patient smokes. Such examples are undoubtedly familiar to many, as they take place frequently in hospitals across the country.
Applying ethical tools
Case
A simple case review illustrates how the journey toward equilibrium might work. A site administrator is asked by the nurse manager of a surgical unit how to deal with Mr. Dudley, a 46-year-old electrician who has had a fall and suffered some arm lacerations and a complicated ankle fracture. He is scheduled for surgery tomorrow and is expected to need a few days in hospital after that. A pack-a-day smoker for 25 years, he has expressed deep anxieties about whether his injuries might jeopardize his future career. Mr. Dudley politely refused a standard offer of nicotine replacement and indicated that he “needed” to smoke five to eight cigarettes daily during his stay. After being advised that he had have to leave the property to smoke, he has requested whether he might be exempted from this, as he struggles to move his wheelchair.
Justice
The site administrator has a range of ethical considerations. First, and most immediate, is the local policy that prohibits all smoking on hospital property. In a strictly rules-based system, the administrator’s ethical deliberation might end there. But the administrator is simultaneously aware that a handful of other patients with mobility challenges often smoke near a particular side door, unofficially. Should Mr. Dudley be informed of this, in the name of fairness?
Respect for autonomy
Next the administrator considers other key principles. His stated wish to smoke seems clear and informed, and thus an expression of his autonomy. But in another sense, his autonomy is compromised by his nicotine addiction, and she suspects he may not appreciate just how effective nicotine replacement is, so perhaps his rejection is not fully informed.
Maximizing benefit, minimizing harm
The demands of the principle of beneficence are similarly unclear. Like most smokers, Mr. Dudley would be well served, over time, to slow down or stop smoking. But currently, his acute medical crisis has him anxious, and it might be better for the team to minimize any additional anxieties, such as the prospect of not being able to smoke. Many patients who find themselves in acute care hospitals have a current medical problem that is far more immediate than their chronic smoking habit, and enforcing the policy strictly can add to their anxieties and thus be harmful.
The administrator’s deliberations are complicated further when she imagines the competing outcomes she would like to see. A hospital property where no one has to smell the unpleasant odour of cigarette smoke is desirable. And perhaps Mr. Dudley will experience benefit from going a week without smoking, in the end. She might also suspect that a greater good is served when health institutions demand that the ongoing fight against smoking be led on their premises; no smoking, no exceptions. A steady stream of reasons might momentarily persuade her that there should be no exception for this patient—a sort of “rules are rules” moment. But that is the moment to reflect further and balance those reasons against other possible outcomes. Is it any better if the smokers are just off the property, which is where they go when property bans are enforced? Will denying his request lead him to feel he must sneak away, and lie to his caregivers, and increase his anxiety substantially? Might this undermine the quality of his care and of his relationship with bedside caregivers?
Comprehensive consideration of difficult ethical questions generally depends on such back and forth thinking that eventually comes to rest somewhere between two positions. Rawls recognized this ongoing tension among applying rules, evaluating goods, and heeding one’s intuitions, and his description of reflective equilibrium can thus be a useful tool for anyone wishing to make good decisions, in healthcare or beyond.
Pursuing equilibrium in ethical deliberation is similar to Aristotle’s ethic of seeking the middle path, or the mean, between two extremes. In modern healthcare, this is often the best approach for both policy-making and bedside caregiving—that the best answer to the tough question involves finding the mean. Although our administrator is tempted to enforce the property ban, in the end she decides that this would fail to respect his reasonable wishes, and not be patient-centred. But she also does not wish to be overly permissive and simply allow any such request to be granted in the name of unfettered autonomy. She advises the unit manager to let Mr. Dudley know about the unofficial smoking location, but also to ask staff to work with him to see if he might initiate a tobacco reduction plan while in hospital. Not only was he able to leave hospital needing fewer daily cigarettes than before, but several staff on the unit went home after his discharge with some personal satisfaction that they had compassionately helped him manage his tobacco addiction while receiving acute care.
Conclusions
For the policy-maker, administrator, security guard, physician, or nurse, there is simply no easy way to address complex questions without considering all of the angles. Sound policies should leave enough wiggle room for staff to exercise judgment when caring for patients who smoke. If their sense of compassion, and their practical assessment of a patient’s needs, lead physicians and nurses to determine that a patient is likely to benefit from being allowed to smoke, they should not then have to violate policies to enable this. Harm reduction policies recognize this reality.
For smoking in and around hospitals, we have come a long way. Just 25 years ago, these discussions were about whether indoor smoking was reasonable or not, and consensus emerged that it was not. The activism of many has led to a drastic reduction in our smoking rates over a few generations. There is no reason to believe that these rates will not continue to drop, possibly to under 10% of the population, which is to be celebrated. But even if it is just two or three of a hundred of our future patients who smoke, we will still be challenged to help such people face acute illness in hospitals and hopefully be compassionate and trustworthy in assisting them. It is excessively aspirational to think that we could eliminate smoking completely, from our cities or our hospital properties.
Ethically challenging policies should be discussed among clinical teams. Reflective equilibrium is enhanced when shared with colleagues, who, together with administrators, must decide how best to care for hospitalized smokers. Employing ethical tools, like the deliberate pursuit of reflective equilibrium, can assist with such decisions, which are likely to only get more complex in Canada. It will be interesting to see how cannabis legalization affects hospital smoking in the upcoming years. It is a topic worth revisiting in the near future.