When an Enclosed Public Space Becomes Home: The Smoking Ban and Mental Health Units

by Dr. Nileema Conlon Vaswani in

The widely publicised smoking ban that came into force on 1 July 2007 was met with much controversy. As the ban disallowed smoking in enclosed public places, the Government was criticised for curbing people's liberties. Now, however, the smoking ban is in the news again for a controversy of a different sort. It has emerged that the ban does not extend to prisons and mental health units at present, although by 1 July 2008, mental health units will also come under the remit of the ban. Is this inconsistency in the implementation of the ban morally justifiable? More importantly, what are the moral implications of extending the ban to mental health units?

Before we discuss the ethical implications of imposing the smoking ban in mental health units, it is important to try to make sense of why prisons are being exempt from the ban. One reason could be that because prisoners are being denied their liberties by being locked up, they ought to be granted small pleasures such as smoking. Another reason could be that the Government is less worried about the health of prisoners than it is about the health of other people. Exemption from the ban might also be due to the simple right to smoke in one's home and prison serves as home to its prisoners. Either way, the expression of the alleged right to smoke in prison does also violate the right to live in a smoke-free environment. It is not clear which rights the Government is trying to protect in a prison setting and which ones it is not. Neither is it clear why the same line of reasoning does not apply to other public spaces, such as mental health units, that also serve as homes to those who live there and who, by virtue of not being criminals, ought to have more rights.

Quite apart from the inconsistency with regard to the application of the ban, there are ethical concerns surrounding the smoking ban in mental health units that deserve consideration. If people are in mental health units for an extended period of time it is because they have been deemed necessary to be there. The purpose of their being there is to receive help. If they wish to smoke and are not allowed to do so, their illness may worsen. It is, therefore, contrary to their interests to prevent them from smoking. Imposing the ban will hurt rather than help them.

One may argue that smoking is bad for one's physical health and therefore should be disallowed even in mental health units. While this may be true in general terms, medical advice ought to be context dependent. Any sort of medical advice, regardless of whether it pertains to how many portions of fruit and vegetables to eat, or how much exercise we should do, or whether or not to smoke, has to be considered in the context of the individual patient. For example, a ninety-year-old patient who has only a few days to live might prefer a diet of "favourite foods" rather than one that fulfils the recommended daily allowance of fruit and vegetables. Likewise, advice not to smoke is only good advice if it is likely to help the patient.

One of the reasons for imposing the ban in mental health units is to prevent harm to others. This is also the reason, and a morally justifiable one, for banning smoking in enclosed public places like pubs and restaurants. The idea is that if an individual wants to smoke, at the very least, it must be ensured that others do not suffer because of it. In the case of a mental health unit as well, those who wish to live in a smoke-free environment ought to be able to do so.

Although at one level the reasoning behind the ban in general can be applied to mental health units, on a closer examination, it cannot. Those smokers who visit pubs and restaurants, places where they are not allowed to smoke, still have the opportunity to smoke at home or in public places that are not enclosed. These alternatives are not available to patients in a mental health unit. Apart from being denied the right to smoke, if not smoking is in fact detrimental to their mental health, we ought to think very carefully before extending the ban to cover mental health units. Equally, those non-smokers in mental health units also have the right, as any of us do, to a smoke-free environment. Regardless of whether or not the ban is extended to cover mental health units, either the smokers or the non-smokers of these units will be denied their rights. A solution to this problem needs to ensure that both sets of rights are honoured.

People are, of course, allowed to smoke in their homes. And herein lies the problem. This debate is largely a war of definitions. If a mental health unit is a public place, then the smoking ban applies whereas if it is home to those who live there, then it is a private space and does not fall within the jurisdiction of the ban. The reality is that it is both a public and a private place. Trying to define it as one or the other will not solve the problem of whether the smoking ban ought to be applied there because it is an "enclosed public space" that also serves as a home. It is best, therefore, to consider the needs of all the patients when determining a solution.

It is interesting to think about whether a patient who has an extended stay in hospital for a physical illness could be perceived under the same circumstances. For that person, the hospital is an enclosed public space and hence well within the remit of the smoking ban but it could also serve as a home for the patient because of the lengthy nature of his stay. If this patient were at home, he would be allowed to smoke as his home is not an enclosed public space but in hospital that may seem like home to him after a number of weeks, he would not be allowed to smoke. Ought he to be allowed to smoke or, if not, ought the smokers in the mental health unit also forfeit their right to smoke as would this patient who is in hospital for a physical illness?

The major difference with regard to smoking between patients with physical illness and those with mental illness is that the former do not suffer for lack of cigarettes whereas the latter who depend on their cigarettes do suffer if denied them. Patients who are physically ill do not have their illness worsened as a result of not smoking but patients with mental illness who are smokers do run the risk of having their illness worsen if they are made to stop smoking.

The solution to the problem of smoking (or not smoking) is mental health units is a simple one. There ought to be designated smoking areas so that the rights of both smokers and non-smokers can be honoured. Several people have, of course, proposed this solution already but in order to understand why this might be a suitable moral solution, it was important to consider the ethical issues in some detail in order to be sure that this would be the right moral solution. Easier solutions might entail either banning smoking completely in mental health units or allowing it, both of which would be unfair to some patients. Persons with mental health problems are often vulnerable and to impose the same rules on them as we do on those who are free of these problems would be less than sensitive. Awareness of their needs is of paramount importance even if these needs lie contrary to those that lie outside of a mental health setting.