Patients Need Care, Not Policing

Being hospitalized, for most, means being stripped of agency and autonomy. Decisions are often made for patients without their input or insight. The hospital structure itself disallows free will: medications are administered and vital signs (such as blood pressure and heart rate) are checked up to every hour and often through the night, limiting agency in leaving hospital rooms and certainly the hospital itself. Hospitals are well known to be dehumanizing, bereft of practices ensuring patient agency and individuation. These systems date back decades. In The Birth of the Clinic (1973),philosopher Michel Foucault describes how the extensive disciplinary control core to hospital systems functions to “promote health” by reducing a person to the medical problem they are experiencing and, in so doing, fails to recognize their individuality.

These injustices are most pronounced for people who use drugs, who often have to suffer through agency-limiting medical care while experiencing withdrawal and cravings, both of which modern medicine is limited in effectively treating. Further, many hospitals have policies forbidding patients who use drugs from leaving hospital floors, not because of the need for continuous monitoring, as above, but because of a paternalistic desire to prevent ongoing unsupervised drug use which may interfere with medical care. This ultimately represents a form of pseudo-incarceration for patients who are already more likely to have experienced medical trauma, over-policing, and harm on the basis of having a substance use disorder.

People with substance-use disorders are as such more likely to leave the hospital prior to their medical conditions being fully treated, and thus more likely to have bad outcomes. Counter to the do-no-harm ethos of medicine, some patients are even administratively discharged, meaning they are told to leave the hospital before they have received complete medical care, on the grounds that they have failed to comply with the hospital’s agency-limiting policies. This leads to a cycle of poor health outcomes from under-treated medical conditions, which balloon to be life-threatening over time.

This is a problem we can fix. Short of revamping the structure of control and deindividuation baked into modern health care, there is a case to be made for supervised drug use for hospitalized patients with substance-use disorders. We know that adequately treating patients’ withdrawal from drugs increases the likelihood that they will feel capable of staying hospitalized to treat their medical conditions. But withdrawal is often painful and unpleasant even when treated adequately. It stands to reason then that preventing withdrawal may further improve outcomes. Furthermore, preventing drug use like we are currently doing may directly cause harm by increasing rates of overdose: tolerance to drugs decreases in periods of involuntary abstinence and people who use drugs again after hospitalization are more likely to die from overdose than their peers.

There is an (often unfounded) fear that allowing people who use drugs to leave the hospital for brief periods will lead to unsupervised drug use. Yet in truth, patients routinely leave the hospital during their stay, without incident. They do so to smoke cigarettes, meet up with loved ones, and a host of other reasons. Patients who do not have substance-use disorders and are also hospitalized are typically permitted to get away with these brief furloughs without issue. Leaving the hospital to use drugs—and thus prevent intolerable withdrawal syndromes—should be treated no differently. Physicians and health-care staff remain duty-bound to continue caring for them. Humanely allowing people this opportunity will improve their overall health care.

There is ample evidence that supervised drug use leads to fewer overdose deaths and fewer complications from drug use. Affording patients that opportunity while hospitalized would also increase their likelihood of staying hospitalized until they have completed treatment for their medical illnesses. This should be common sense: there is no better place than a hospital ward to be cared for while using drugs, with continuous monitoring systems and medications to treat overdose readily available.

Supervised-use sites and post-use sites have been implemented with positive effects in non-hospital settings with fewer resources and staff. The leap to implementing them in hospitals, then, where patients are already being cared for in monitored wards, is logistically less challenging and resource intensive. Transitioning our current model of hospital-based care to one of openness and harm reduction—where patients are invited to openly share their needs regarding substance use and are then cared for in accordance with these needs—could represent a transformation in our ability to reduce poor health outcomes for people who use drugs. We can begin allowing patients who desire to continue using drugs to do so safely, with sterile supplies and continuous monitoring after use. We can offer addiction care services early and often to those who desire to stop using. We can allow patients to leave their rooms and the hospital freely, so long as there exists a sense of mutual openness and commitment to care. We can restore agency in a way that not just supports our moral duty to care for people as people, but also contributes to an overall improvement in health outcomes for a group at substantially increased risk of morbidity and mortality both in and out of the hospital.

In short, hospitals and health-care providers are duty-bound to care for all people who come through their doors, and care for them well. Our current policies policing free movement and drug use are not working. We have an opportunity to fundamentally change the way we care for people who use drugs. We can allow people to leave the hospital as desired, treat withdrawal early and effectively when it does happen, and monitor and support people who continue to use. Restoring agency and autonomy to those from whom it is taken most often and most violently is a step toward shifting our health-care system to one of care and dignity. This is what it means to do no harm: to care for people fully and deeply, independent of the moral value society has assigned to their behaviors.

_{Image: camilo jimenez / Unsplash}

Contributors

Divya Manoharan Divya Manoharan is a resident physician at Brigham and Women's Hospital in Boston. She has an MD from Johns Hopkins School of Medicine. Her work centers around decarceration, particularly as it relates to Immigration and Customs Enforcement (ICE) detention, and expanding access to harm reduction services for people who use drugs.

Topics

• Institutions & Practices

Tags

• carceral continuum
• drug addiction
• health care
• medicine and hospitals