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Letter   |    
Kenneth Marcus
Psychiatric Services 2008; doi: 10.1176/appi.ps.59.3.330
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To the Editor: Recent nationwide initiatives to ban smoking in state psychiatric hospitals, although laudatory in many respects, pose a dilemma when applied coercively to a class of patients whose lengths of stay are indeterminate—that is, to patients for whom the institution has become home. Neither state legislatures nor the U.S. Congress have yet passed statutes regulating smoking in individuals' homes; such measures have thus far been limited to public settings. Is there a valid rationale that can be used to justify this selective imposition? Put another way, why is it that I can smoke in my home, you can smoke in your home, but long-term residents of psychiatric institutions cannot smoke in their homes? If self-determination, equity, and respect are core principles of recovery, what justifies this selective suspension?

One is reminded of C. S. Lewis' quote: "Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep … but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience."

Three caveats are in order. First, any policy that permits even limited smoking must respect the right of nonsmokers not to be exposed to second-hand smoke. Second, restrictive policies should be applied equitably (that is, either to all or on a case-by-case basis according to established principles); or if a specific group is subject to differential treatment, the basis upon which this discrimination is made must be explicated. Third, this argument applies only to patients for whom the institution has become home and for whom no viable and clinically appropriate residential alternative currently exists; patients who require short- or intermediate-term hospitalization for clearly defined purposes are not included.

To be clear, this is not a "right to smoke" issue. The issue is: Is there just cause to grant a specific class of individuals the right to smoke in their homes while depriving another class of individuals that same right solely on the basis of the fact that this "second class" has the distinction of being mentally disabled and residing in long-term institutional settings?

The conflict is between two sets of values: tobacco cessation and wellness on the one hand and "enlightened" paternalism (versus client choice) on the other. In other words, "we 'normal' people can tell you mentally disabled people what is good for you and insist upon your compliance, even if some of you do not agree and even if we don't apply these same rules to ourselves." As Orwell observed in Animal Farm, "All animals are equal, but some animals are more equal than others."

Martin Luther King, Jr., in his "Letter From Birmingham Jail," distinguished between just and unjust laws: "An unjust law is a code that a numerical or power majority group compels a minority group to obey but does not make binding on itself…. [A] just law is a code that a majority compels a minority to follow and that it is willing to follow itself."

Despite intentions that are understandable—intentions that might even be called beneficent—the unilateral imposition of smoking bans on long-term residents of psychiatric institutions is not consistent with our core values.

Dr. Marcus is medical director of the Connecticut Department of Mental Health Services and Addiction Services, Hartford, and lecturer in psychiatry, Yale University School of Medicine, New Haven, Connecticut. The opinions expressed are those of the author and do not reflect the policy of the Connecticut Department of Mental Health and Addiction Services.

The author reports no competing interests.

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