Aug 19, 2019, By: Michelle Danda
- Substance use is not inherently problematic, but the moral judgements that we place on substance users results in stigma, shame and poorer health outcomes for those who need and seek help.
- People have the right to live at risk, and we have an ethical responsibility to promote autonomy of those we care for, despite our own values and beliefs about substance use.
- Letting go of our agenda and listening to the needs and goals of our clients who use substances can result in building trusting relationships that embrace a holistic perspective where those we care for can be honest about their substance use.
There is nothing inherently problematic about using psychoactive substances. People in many cultures around the globe use them—for example, alcohol, cigarettes, and caffeine—on a regular basis, sometimes as a part of religious ritual (Pickard, 2018). Public perception of substances often shifts when the conversation includes illicit drugs. Moral judgments may drive perceptions of the risks and benefits of substance use (Coulon & Gorji, 2016).
Most people who use psychoactive substances, whether legal or illegal, do not develop addiction (Toronto Public Health, 2018). Substance use occurs on a spectrum ranging from experimentation and social use, to problematic use, with addiction considered most problematic.
The legality of a psychoactive substance does not determine how healthy or problematic an individual’s relationship with it may be (Toronto Public Health, 2018). Individuals have the autonomy to choose whether to engage in substance use. The recent legalization in Canada of cannabis may bring about a shift in the conversation and attitudes toward substance use, among the public and among health care professionals, away from moral judgments and toward an approach based in public health. As nurses, we have the opportunity to engage in an ethical conversation about individuals’ right to live at risk.
I work in mental health. Sometimes the patients that I see use substances that exacerbate the symptoms of mental illness. Sometimes their substance use leads to risky situations. Most often, their decision-making and subsequent actions take place outside of the hospital. In my career I have had to work hard to let go of the idea that I can control and mitigate the risks in patients’ lives. The reality is that despite the best nursing assessment and collaborative team approaches and interventions, a patient may knowingly choose to act against clinical recommendations, despite risk.
There is value in reminding ourselves that patients are competent to make their own decisions; their life choices are their human right, even if that means living “at risk.” Nurses have a duty of care to provide the relevant information about substance use and potential risks to inform clients and patients in making their choices. In an acute hospital setting, or in the case of involuntary mental health patients in a locked unit, it is much easier for staff to control risks. However, beyond the hospital setting, the risks to clients are theirs to take.
The right decision for the client, given their experience, personal values, and beliefs, may differ from ours, and that is okay. When we, as nurses, try to take control of situations over which we have no power, there is the potential for harm, including moral distress. We can conduct an assessment, provide interventions, and offer information about risks and benefits—but the decision ultimately belongs to the patient. When patients are deemed to be a risk to themselves or others, and are certified under mental health legislation, the decision may seem less clear. Do we have the right to control patients’ decisions, and can we mitigate risk outside of the hospital unit? It can be difficult for health care professionals to relinquish control, especially if we are invested in the outcome.
Perhaps one way we can reframe the situation is by engaging in a regular “self check-in” regarding our assumptions and beliefs, and how these may be based in moral judgments rather than the principle of patient autonomy. This kind of reflection may feel scary, but if we choose an ethical lens to frame our nursing care, the result may better uphold patient autonomy.
Coulon, P., & Gorji, A. (2016). Tightrope or slackline? The neuroscience of psychoactive substances. Trends in Pharmacological Sciences, 37(7), 511–521.
Pickard, H. (2018). The puzzle of addiction. In The Routledge Handbook of Philosophy and Science of Addiction (pp. 29–42). Abington-on-Thames, UK: Routledge.
Toronto Public Health. (2018). Discussion paper: A public health approach to drugs.
Michelle Danda, MN MPN RN CPMHN(C) is an RN who practices in the Lower Mainland, BC. She graduated from the University of Calgary in 2008, and has worked in many of the mental health and substance use programs in the Lower Mainland, BC and Calgary, AB. Her passion is decreasing stigma of substance use and making compassion a central principle of nursing. She is currently a Senior Learning Specialist for Mental Health with the Clinician & Systems Transformation project.