Annals of Long Term Care

To the Editor:
Justice, autonomy, and beneficence are succinctly discussed in the article “The Ethical Principal of Justice: The Purveyor of Equality.”¹ It is commendable that the long-term care facility took steps to implement a smoking cessation program. However, the facility failed to recognize or neglected a factor likely to contribute to success of smoking cessation: no one smoking around those trying to quit smoking will benefit the cessation program.^2-4 Just on this basis for success of the program the facility should have enforced no one smoking in the facility in the first place. This would have avoided the complex issues of justice and autonomy.

Sincerely,
A. Praisoody, MD, FACP
NF/SG Veterans Health System
Gainesville, FL

References
1. Feinsod FM, Wagner C. The ethical principal of justice: The purveyor of equality. Annals of Long-Term Care: Clinical Care and Aging 2008;16(1):23-24.
2. Gilpin EA, White MM, Farkas AJ, Pierce JP. Home smoking restrictions: Which smokers have them and how they are associated with smoking behavior. Nicotine Tob Res 1999;1(2):153-162.
3. Lee CW, Kahende J. Factors associated with successful smoking cessation in the United States, 2000. Am J Public Health 2007;97(8):1503-1509. Published Online: June 28, 2007.
4. Borland R, Yong HH, Cummings KM, et al. Determinants and consequences of smoke-free homes: Findings from the International Tobacco Control (ITC) Four- Country Survey. Tob Control 2006;15(Suppl 3):42-50.
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Response from Fred M. Feinsod, MD, MPH, DSc, CMD, and Cathy Wagner, RN, MSN, MBA, CHPN, CLNC:

Excellent point. Accepted standards of practice certainly dictate that staff avoids smoking in the presence of those encouraged to quit. As this is a well known principle and standard, it heralds the ethical principles of “health care provider (physician)-patient relationship (establishing a therapeutic alliance)” and “non-maleficence (doing no harm)”. The Ethics Committee examining this issue mentioned this point. However this particular facility was remote in location and as such had great difficulty recruiting and retaining staff. Preventing staff from smoking on facility grounds (in designated smoking areas) was felt by the facility to jeopardize staff retention and encourage staff to leave and seek employment at nearby prisons and/or healthcare clinics. The ethical principle of “limited resources” was discussed and felt by the facility to trump the other principles.