Defending the rights of the mentally ill to do something that harms them is not a popular cause, but this much needs to be said: preventing psychiatric patients from smoking on hospital grounds is inhumane.
I am responding to the situation in a particular ward in a hospital in NHS Grampian region. At the time of writing my forty year old brother Mark is there, as he has been before. He is surrounded by other adult patients, many of whom are thought disordered, dysfunctional, and up to their eye balls in medication. Mark has given me permission to write publicly about his situation, but he is not well enough to grasp the full context. I am taking the liberty of making the following case on his behalf.
Many psychiatric patients are habitual smokers, but at the moment they are strictly not allowed to smoke anywhere on hospital grounds. Smoking has been banned in hospital buildings for about a decade, but in the hospital in question secure gardens adjacent to the locked wards and smoking shelters within the general grounds of hospitals were available to smoke. This arrangement seemed to work until the authorities decreed that the shelters should be knocked down and the secure gardens should be smoke free. Some psychiatric patients, staff and visitors now face the mild stigma and hassle of having to escape the hospital to smoke, but if you are sectioned under the mental health act it’s not so simple. The hospital ward is your de-facto home, and also your de-facto prison, so where do you go?
The ruling is unenforceable. In fact most staff feel they have no choice but to turn a blind eye. Patients are now smoking in their rooms or in the bathrooms; anywhere where the staff can have plausible deniability of not seeing them. Alas, the collateral damage of this necessary open secret is that none of the patients can now go to the outdoor area assigned to the ward. The small secured gardens are the most humanising place on the ward and a vital source of fresh air, but they lie unused due to the risk, not that patients will smoke, but that they will be seen to be smoking, and get staff into trouble as a result.
It’s madness. Really. But it’s an elective madness that impacts on those who have no such choice. There are important clinical details in some cases about the impact of smoking in conjunction with some psychiatric medications, but in many cases preventing those afflicted from smoking looks distinctly counter-productive and anti-therapeutic, reducing autonomy and increasing anxiety. NHS Grampian region has decided not to make an exception for such cases, presumably on the grounds that it sends a bad signal to suggest that the physical health of psychiatric patients is somehow less important that the health of other patients or staff.
They have a point. I have never smoked, and in response to the claim that smoking leads to hideous forms of cancer and avoidable deaths, a white flag of surrender is my weapon of choice. It’s all true. There is no defence to the claim that smoking is bad for your health and the health of others.
But while health is a preeminent good in life, it is not the only good, and it needn’t trump other goods when they have a stronger claim at any given time. When your mind is ravaged by psychosis and you find yourself in the phantom purgatory of a psychiatric ward, a cigarette is often your only friend. Smoking ends lives prematurely no doubt, but it also has life-giving properties; tempo, ritual, stimulation and a reason to talk and share. All of which provides consolation where there might otherwise be despair.
My brother is two years older than me and was diagnosed with schizophrenia when he was nineteen. After several rocky years, he had been stable on a particular psychiatric drug for a prolonged period, living more or less autonomously in supported accommodation, taking further education music courses, going to church, writing songs, playing his guitar, and looking tentatively to the future. Then about six months ago he noticed that his medication contained lactose. As a strict and gently obsessive vegan, he immediately came off the medication, rapidly became psychotic and dysfunctional, and has not yet recovered. My mother, 67, now lives in Troon, but she still travels across Scotland regularly to do something, anything, to bring Mark back from what feels like an outer circle of hell.
This issue is real for me because Mark is quite a heavy smoker, and it pains and angers me to think that after everything that he has endured over the last two decades, he is not allowed his small reprieves. If he has to be hospitalised, he should at least be able to escape the day time television, the trolley regimens and the relentless corridor pacing of fellow patients. In such a place it means the world to be able to walk out, sit amid some smatterings of green, and ignite your own moment of solace and freedom.
I don’t doubt the good intentions of those who insist on this current policy, but I do doubt the depth and fullness of their understanding. There is measurable health and immeasurable humanity, and in this case I feel the function of smoking for psychiatric patients has been lost. In failing to honour the reality of madness, there has been a dereliction of sanity.