AMA Journal of Ethics^®

Case

Mr. Benjamin was a middle-aged construction worker with a history of hypertension and congestive heart failure who sustained a vertebral fracture in a job-related accident. He was admitted to Rockport Hospital's orthopedic surgery ward in unstable condition for treatment of his injuries.

To complicate matters, Mr. Benjamin was angry at having had his cigarettes taken away upon admission, as required under Rockport's smoke-free policy. The policy, part of a wide antismoking initiative, banned smoking on hospital grounds and within 50 feet of hospital property, eliminating even the possibility of walking outside for a cigarette break.

Mr. Benjamin was not doing well. He had smoked for more than 20 years and had no intention of stopping, despite counseling from his primary care physician. Though the hospital provided him with nicotine patches, he made it clear to the entire medical team including Dr. Thorman, the hospitalist in charge of his care, that he just wanted his cigarettes back. Over the course of 5 days, Mr. Benjamin grew extremely irritable and became short-tempered and uncooperative with the treating team. He threatened to leave the hospital against medical advice, refused to hold still for IVs or blood draws, and constantly tried to leave his hospital room despite being told to limit unnecessary movement.

Dr. Thorman realized that Mr. Benjamin's recovery would be greatly expedited if he were more compliant and wondered if Mr. Benjamin's outcome would improve if he were allowed to smoke during his stay. Dr. Thorman offered everything he could think of to help his patient relax—the nicotine patch, smoking-cessation therapy—all of which Mr. Benjamin refused.

Dr. Thorman knew that smoking was bad for his patient, particularly since he had heart disease, and that it was in direct violation of hospital rules. He recognized, however, the importance of speeding his patient's fracture recovery and allowing him to return to his family and work. Faced with this dilemma, he sought the assistance of the ethics consultant.

Commentary 2

 Like most clinical ethics problems, this one is a dense, multilayered composite of many questions. In seeking a resolution, it is useful to begin by defining each of the component questions and examining its relative importance. Some may prove irrelevant or trivial and can be eliminated from consideration along the way. Others may require the assistance of additional resources (the patient's orthopedist, internist, nurse, consulting psychiatrist, and the patient himself). With luck, the answers to key questions can be melded into a practicable solution. Following this algorithm allows us to (1) identify the fundamental issue; (2) examine it in the full context of the case, and (3) formulate a resolution that most comprehensively addresses the issue and its ramifications. Let's see how this process plays out in the case of Mr. Benjamin.

Medical Questions

1. How serious are the patient's injuries? How much of a risk is it to the patient if he is allowed to leave without further treatment?

The treating team states that his spine is not stable enough for him to terminate treatment. We can infer from the team's concern that this is a serious safety issue.

2. What is the patient's overall state of health? What is the basis for his congestive heart failure? Would either his new or underlying medical problems be exacerbated by allowing him to smoke?

We do not have all of this information and may need to talk with his primary caregiver. As a general rule of thumb, however, smoking does not acutely exacerbate heart disease or impair bone health. Chronically, it does both, and future efforts should continue to stop Mr. Benjamin's tobacco use. For now, it seems unlikely that a strong medical argument can be marshaled against letting him smoke in the hospital. We could argue that we are justified in permitting him to smoke under the ethical principle of "double effect," which holds that the physician is justified in pursuing a management course that may lead to an unintended consequence if the likelihood of achieving the intended benefit is high.

Psychosocial Questions

1. Why are cigarettes such a highly charged issue for Mr. Benjamin? Is he addicted to nicotine or does the right to smoke really represent a control issue for a relatively young, active man who suddenly finds himself in a position of helplessness?

2. Is he making a rational, authentic decision, or are his thought processes clouded by delirium, depression, or anxiety?

These two psychosocial questions demand due diligence. Interview the patient, but be prepared for an irritable response to any questions as to why he's so angry or upset about being denied cigarettes. Ascertain that he understands the consequences of refusing treatment. Make certain he is not suffering from some medication-related or metabolic derangement that is adversely affecting his sensorium. Ask his nurse and anyone familiar with him if his behavior has changed markedly and whether he is manifesting confusion or signs of depression. Request a psychiatric consultant, if necessary. For the sake of discussion, let's assume that you have eliminated delirium or a primary psychological cause for Mr. Benjamin's anger. He is simply an irritable, nicotine-addicted adult taking a rational—if unproductive—position.

3. If he were to leave the hospital, could he receive necessary care in an alternate environment wherein he would be allowed to smoke?

Many hospitals are adopting strict tobacco-free policies, which may make it difficult to find adequate, acute care for his vertebral fracture in a setting that tolerates smoking. If the patient is a veteran, a Veterans Administration hospital may offer such a solution, although even the traditionally smoke-laden Veteran's Administration hospitals have joined the smoke-free movement. Depending on his resources, he may be able to receive comprehensive care at home; you will need to ask his social-service case worker and orthopedist if this is feasible from the financial and medical perspectives, respectively.

Policy and Legal Questions

1. Is the hospital's antismoking policy ever waived in extraordinary circumstances?

Antismoking policies are generally inflexible. If exceptions were tolerated, enforcement of the policy would become almost impossible. A valid argument can be made that smoking anywhere on the premises compromises the health and safety of others. This is a critical point. To be sure, we allow narcotic-addicted patients to receive methadone while hospitalized to satisfy their cravings, but one patient's use of methadone has no adverse effect on anyone else on the premises. We can assume that a settlement allowing Mr. Benjamin both to smoke and remain in this hospital is not an option here.

2. What is the hospital's liability if he is discharged prematurely, even at his own instigation?

If this patient were to suffer injury or death as a result of his refusal of treatment or leaving against medical advice, the hospital and physicians should not be held liable. In fact, however, there is no way to prevent him from suing. It is critical to document exactly what the patient has been told about his condition, his need for ongoing inpatient care, and the potential consequences of his refusal. The hospital's risk-management and legal officers must be alerted preemptively.

3. Are there grounds for holding and treating him against his will, without cigarettes, in the hospital on the presumption that his position, "either I smoke or I refuse treatment," is self-destructive?

Definitely not. Mr. Benjamin has the capacity to make his own decisions and is entitled, under the principle of respect for autonomy, to have them honored.

Working toward Resolution

We can now winnow out those questions, namely the last two, that are not immediately relevant to any advice we will offer as ethics consultants. Adequate attempts to educate and negotiate with the patient have been made and documented in the medical record. And the central issue has been identified: this rational, autonomous patient is adamant about continuing to smoke through his hospitalization—one that is necessary for his health and safety—yet the hospital will not permit him to smoke under any circumstances.

When a conflict seems irresolvable—as this one does—negotiation comes into play. The ethics consultant can serve as a mediator between the treating team and patient and may even develop conditions to be "put on the table." Most hospitals also have patient advocates or representatives who can assist in negotiating terms of care with patients. Here are some possible concessions to offer Mr. Benjamin: (1) shorten his inpatient treatment as much as possible under the circumstances if he'll bear with you a little longer, (2) suggest appropriate medications to take the edge off his cigarette cravings (benzodiazepines, buproprion, nicotine supplements, etc.), and (3) ask if there is anything you can do to help him through this difficult period.

Presenting Mr. Benjamin a time frame for discharge and treating him with respect may lead to common ground. It would be glib to argue that any of the above strategies is likely to work. Still, they must be tried. Everyone loses if Mr. Benjamin doesn't get the treatment he needs. The prospect of transfer to an institution that permits smoking or to his home with home health care are last resorts.

The trend toward making hospitals smoke-free is two decades old and spreading rapidly. In spite of this, almost nothing has been written about the implications of patients refusing to comply with smoke-free rules. We can anticipate broader questions ahead. How will we handle such cases if all hospitals become smoke-free? Will we need smokers' and nonsmokers' hospitals or hospital wards? What other self-destructive behaviors will physicians have to use as bargaining chips in negotiating care plans with patients?