No easy answers

By Robert Landauer – editorial columnist for The Oregonian, August 1, 1998. Not available elsewhere online.

The sequence is as predictable as an instant replay in sports: Mentally ill persons stop taking medicine. Grow suspicious of caseworkers. Become confused, angry, isolated. Reject treatment. Behave bizarrely. Cant be forced to take medicine that controls symptoms or be kept in hospitals unless clearly dangerous to selves or others.

The rights compass is stuck in the wrong direction, families and mental -health workers complain; people who are ill cant make knowing decisions.

Oddly now, some of the very people who feel strongly that the mentally ill often cant make informed choices hesitate to limit their choices. The issue arises at Oregon State Hospital. A committee is studying whether smoking should be banned for severely mentally ill residents.

This looks easy at first glance. Reasons the Department of Corrections banned smoking for Oregon prison inmates 21/2 years ago might apply to state mental hospitals, too. The ban is expected to improve health and lower medical costs. It ends exposure to secondhand-smoke lawsuits. Inmates (and staff) dont have to be shifted because of smoking/nonsmoking preferences. Buildings are cleaner. Fire safety improves.

Then there is the effect that only prison guards might foresee. Banning smoking raises the demand for tobacco but seems to reduce the flow of illegal narcotics. Limited amounts of contraband get in, and we would rather deal with tobacco than with narcotics, explains Perrin Damon, the departments communications manager.

So the idea of banning smoking in prisons and other public buildings rides high in the water. Reasons of health, legal liability, economy, safety and public-policy consistency make it buoyant and stable.

Applied rigidly to state hospitals, though, this vessel might quickly capsize, because its ballast shifts wave by wave:

Making smoking taboo would simply apply state policy restricting smoking in public buildings and extend it to the hospital grounds, advocates say.

Patients would have no place to light up, opponents counter. Unlike prisoners, most patients have not committed crimes; they are in the hospital against their will on civil commitments; freedom of choice should be restricted as little as possible.

Smoking harms patients physically.

Yes, but the nicotine in tobacco seems to relieve symptoms that some mental patients find most disturbing about their diseases.

Smoking interferes with beneficial effects of patients medicines.

Yes, but smoking offsets some side effects that patients find most annoying.

Smokers try illegal drugs more than nonsmokers. Those drugs make treating mental illness harder. So mental hospitals ought to fight tobacco as a gateway drug.

Yes, but experience shows that patients become difficult to deal with if you try to wean them from tobacco while trying to initiate treatment of their mental illnesses. When tobacco becomes contraband, confrontations and conflict with staff mount in settings where building trust is paramount.

Tobaccos destructive use as currency to exchange for food, sex and other favors and services interferes with treatment and frustrates doctors and caseworkers.

No doubt, yet other mental institutions say they allow smoking but can control widespread use of tobacco as currency for destructive purposes.

Tobacco takes over patients lives; if they arent smoking, they are figuring out how to get a smoke.

Uh-huh, but rituals such as borrowing and lighting cigarettes may be the sole group activity that patients control. Smoking is often the only carrot to get patients to gather to talk, and community and its social supports are huge parts of the healing process.

The arguments ricochet like shots in a tennis match — every slam returned with a well-placed lob.

I root for the underdog. It is more cruel than curative to ban smoking when patients are struggling with their symptoms and using cigarettes to calm themselves.