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Ethics in Action The Right to Smoke vs the Needs of the Many A Complicated Ethical Case
The Right to Smoke vs the Needs of the Many: A Complicated Ethical Case
By Gerald Maloney, DO, MS The Case
A 73-year-old male patient comes in by emergency medical services for facial burns. He has advanced chronic obstructive pulmonary disease (COPD) and an 80-pack-a-year history of smoking. He is on three liters of oxygen around the clock. Despite being advised strongly against smoking while wearing oxygen, he has continued to smoke. This is his second visit in three months for flash burns to face and nares from a fire that was triggered by his smoking. You quickly assess him and determine that his burns are superficial, and he has no significant airway burns or inhalation injury. The patient declines an offer for admission and wishes to go home. He lives in an elderly high-rise building that houses approximately 100 other residents. He relates that he lives alone, is severely limited in any physical activity from his severe COPD, and his only enjoyment is smoking. He has severe hypoxemic respiratory failure and even on his three liters of oxygen is saturating only 92% at rest. A discussion ensues among the medical staff present as to whether he should be allowed to continue using oxygen if he is going to continue smoking.
The Discussion
This case illustrates several ethical principles. Patients are generally allowed to make decisions, even unwise ones,
if they have capacity. However, does this right to autonomy extend to activity that clearly has the potential for harm beyond the generally accepted risks of smoking (such as worsening COPD, cancer, etc.)? Does his now recurrent episode of facial burns acquired from smoking while wearing oxygen constitute a point at which his choice, obviously an imprudent one, to accept the risk of burns conflict with our duty to avoid harm? He lives in a building with others who may not be able to escape if he causes a fire with his smoking around oxygen; therefore, even if we accept that he can choose the risk to himself, does he have the right to both smoke and wear oxygen if his doing so potentially puts others at risk?
From an autonomy standpoint, the patient is within his rights, however ill-advised, to continue smoking. He is already severely functionally impaired from his respiratory illness and taking away his oxygen would likely hasten his demise and cause undue suffering in the process. While the patient can also choose to quit smoking, he is a lifelong smoker who derives what limited pleasure he has in life from smoking. His decision to risk injury from smoking while wearing oxygen, when viewed from his perspective, may seem to be an acceptable risk for him.
What about our duty to nonmaleficence? Can we provide a treatment that we know may cause him avoidable harm? While it seems that there is not a good alternative to supplemental oxygen for this patient, because we know he has twice suffered an injury from his oxygen that could have been avoided, do we draw a hard line in the sand to quit smoking or lose his oxygen? Given that he may sustain severe burns that can lead to worse suffering, death, or disfigurement, and that those burns can be avoided by either stopping the oxygen or forcing him to quit smoking, can we justify allowing this practice on his part to continue?
Do we have an obligation to his fellow high-rise residents? What if he causes a major fire in his building, and residents who cannot get out quickly perish as a result? Does he have the right — and are we obligated by our control over the provision of his supplemental oxygen — to turn a blind eye to his smoking? Does his right to choose the risk of burns for himself allow him to potentially put many others, who would not make the same choice, at risk of potential harm?
Weighing the needs of the many versus the rights of the individual is complicated ethical ground. It has long been established that we have a duty to warn a person at identifiable risk of harm from another’s actions (Tarasoff vs Regents of California). However, in this situation we have potentially identifiable victims in a more theoretical risk, i.e., unlike the person who specifically indicates an intent to harm an individual, here we have someone who is not intent on harming any individual person but who may inadvertently cause harm to one or more members of a group. If the building has a no-smoking policy, then perhaps letting the building management know of his smoking is more justifiable; if the building allows smoking, since any smoking in the building causes a slightly greater risk of fire than in a building with no smoking allowed, one could argue that by living in a building that allows smoking the other residents have already accepted a certain degree of risk and that the activities of our patient do not there constitute any appreciably greater risk than the other residents have already assumed. Another option is to engage with case management to work on finding him housing where he will not be potentially risking so many others in the building. A significant risk (e.g., a serious fire having already happened because of his smoking) would be required to justify overriding his privacy rights for the protection of the other residents.
While the paternalistic view would be to simply make him choose between oxygen and smoking — and some would argue this is the ethically correct thing to do, otherwise, if we help him maintain the status quo, we are party to any further harm he does to himself. However, this again conflicts with his right to make his own choices regarding what risks he feels comfortable taking with his health. We do not have to support or endorse his decision, though threatening to remove a life-sustaining treatment that he desires to force him to comply with our wishes is not respecting his autonomy.
This is a case with many interesting points, chief among them where the rights of the patient intersect with the obligations of his physicians and the risks to other people he lives with. There is not an answer that is perfectly ethically correct as the decision that most respects autonomy of the patient requires acceptance that he will likely suffer harm from that decision and possibly may cause other parties harm as well.
The Conclusion
The conclusion to this case? The patient was ultimately discharged, with oxygen, back to his home. A hospital ethics committee meeting was convened to discuss the ethics of forcing him to quit smoking or lose his oxygen therapy. Before a final decision was reached, he was admitted for worsening of his severe emphysema and wound up in a skilled nursing facility where no smoking was allowed. The ethics committee did not reach a final opinion, though the most likely recommendation being discussed was to continue to provide oxygen for the present but provide him with a time frame in which he had to quit smoking or would have to find a different prescriber for his oxygen.
ABOUT THE AUTHOR
Dr. Maloney is an associate professor of medicine, Case Western Reserve University, Cleveland, Ohio and medical director, emergency department, Louis Stokes Cleveland VA Medical Center.
