In a bit of utilitarian logic that seems overdue (though I admit I hadn’t seen it coming), a group of mental health nurses in the UK is debating the introduction of a “harm reduction” strategy to deal with self-mutilating behavior among mental health patients. Specifically, they are talking about providing clean “sharps”, and potentially advice on how to perform “cutting” safely, to patients who cut their skin in response to internal tensions. Some nurses have even been sitting with patients to comfort and monitor them during this procedure.

NURSES want patients who are intent on harming themselves to be provided with clean blades so that they can cut themselves more safely.
They say people determined to harm themselves should be helped to minimise the risk of infection from dirty blades, in the same way as drug addicts are issued with clean needles.

This could include giving the “self-harm” patients sterile blades and clean packets of bandages or ensuring that they keep their own blades clean. Nurses would also give patients advice about which parts of the body it is safer to cut.

The proposal for “safe” self-harm — which is to be debated at the Royal College of Nursing (RCN) Congress in April — is likely to provoke controversy.

At present nurses are expected to stop anyone doing physical harm to themselves and to confiscate any sharp objects ranging from razor blades to broken glass and tin cans.

However, Ian Hulatt, mental health adviser for the RCN, said: “There is a clear comparison with giving clean needles to reduce HIV. We will be debating introducing a similar harm-reduction approach. This may well include the provision of clean dressing packs and it may mean providing clean ‘sharps’.

To some – especially those who oppose harm reduction for drug users, or condom distribution to prevent AIDS or unwanted pregnancy – this may seem a reductio ad absurdum of utilitarian health policy. What could be more antithetical to healthcare ethics than helping patients hurt themselves? At the very least, this is another example of complicity in behavior that should not be condoned in the first place – of focusing on the immediate consequences of the behavior rather than eliminating the harmful behavior itself. (And from that point of view, this may be an even starker example of a misguided policy than needle exchanges or condom distribution. There is a value to safe sexual behavior in itself, beyond merely the good of remaining disease-free, that is promoted by condom usage, and there are those who argue for an abolition of drug laws on the same grounds – that taking drugs is a personal decision that should be supported, not opposed, where it is voluntary. Self-harm, though, is . . . harmful.) Even from a more rational view of healthcare ethics, there can be something startling in this policy: the idea that behavior that is by definition self-destructive should be encouraged as long as it is merely less harmful, especially when the alternative, under current policy, is active intervention to prevent the behavior. It sounds like a policy of advising suicide jumpers to try a lower window. Add in the question of dubious decisionmaking capacity (these patients are, again by definition, mentally troubled to the point of making self-destructive decisions), and the idea of enabling and supporting the behavior in question can seem shocking. (I am a very strong autonomy advocate, but not only did I not see this proposal coming, when I first encountered the story on a conservative blog I assumed it was a parody.)

However, understanding this policy requires understanding the behavior it addresses. “Self-mutilation” is a complex behavior that often has nothing to do with suicidal ideation, or with a true intention to harm oneself as the patient sees it. “Cutting” and other pain-infliction methods (hair-pulling, scratching the skin, piercing, etc.) are often a way of reducing internal tensions or the feeling of losing control of oneself due to psychological pains. This has a sound physiological basis; pain sensations do reduce the felt intensity of competing pain sensations, a fact which is taken advantage of clinically and informally. Dentists use “pressure anaesthesia” (pinching or pushing on the gums) to reduce the pain of needles, and “piercers” – people who pierce their skin either as a demonstration or for S&M purposes – do the same thing. “Cutters” report that their tensions ease and they feel calmer – and feel less need to do other, more extreme things to themselves – when they inflict pain. The wounds cutters inflict are often very superficial – barely breaking the skin, as opposed to truly suicidal cuttings which often go very deep. Viewing cutting only in respect of the physical damage it does to tissue, and not in terms of its psychological importance to the patient, or its calming effects, gives a very distorted perspective. (It’s important not to be too glib about this, though. Many patients making “suicide gestures” inflict superficial wounds, either because they do not truly intend to die or because they don’t know how to go about it or can’t force themselves to do so. Similarly, many “cutters” do inflict more serious wounds, and many are left with lifelong scars. It would be a mistake to say that “cutting” cannot be truly life-threatening, or that superficial injuries do not betray very serious self-destructive impulses. It would be a serious mistake to say that “cutting” and suicide are mutually exclusive impulses. And, most importantly for this blog, I am not a clinician or a mental health expert, and this material should be read with an accordingly skeptical mind.)

Seen this way, it is a mistake to insist that cutting is by definition self-destructive, or “harmful”. For one thing, the actual injuries it involves may be no more severe than those undergone – willingly – by persons receiving tattoos or participating in BDSM play. More importantly, the intent behind the act is very different from an actual intent to harm oneself – to make oneself worse off, or less healthy. The intention of many cutters is to make themselves more healthy by aleviating a pain that is not responsive to ordinary analgesics. To the extent that it succeeds in this way – and is not, in fact, an expression of truly self-destructive desires or a half-hearted attempt at suicide – cutting is a coping strategy – a way of pushing away the tensions and needs that otherwise haunt the patient – and in that sense not so very different from what getting a fix is for an addict. Seen in this light, a harm-reduction strategy towards cutting may be as reasonable as a needle exchange for drug users.

This is not the last word on this policy. The matter of distinguishing cutting which reduces a patient’s psychological symptomatology from that of self-destructive behavior which could exacerbate into truly dangerous acts is of paramount concern. The question of mental capacity is also an important one (though, again, for “cutters” the act in question is not self-destructive or counterproductive, but is in fact a supremely rational – and staggeringly desperate – reaction to conditions). But, assuming these questions of clinical fact can be addressed and managed, the idea of harm reduction for cutting makes sense, however sad and despairing an act cutting itself may seem.

What this issue brings up – as do so many matters of healthcare ethics and policy – is the question of the role of the healthcare professions in general. Predictably, in response to the suggested policy above, a traditionalist view of healthcare provision was held up against it:

However, Ian Hulatt, mental health adviser for the RCN, . . . admitted there would be significant opposition: “Some nurses will not support this because our code of practice says we should not do patients any harm. But this may be less harmful than patients using dirty implements. There are mental health units that already allow the use of sterile implements.”

But this view of healthcare defines provider roles independently of what is actually good for their patients. One can only suggest that “harm reduction” violates a proscription on doing “harm” (as adherents of the dwindling Hippocratic school often do) if one defines “harm” in some absolutist, prescriptivist sense, and not in terms that reflect the patient’s own values. If patients themselves decide where their own interests lie, then effective harm reduction must be the proper policy (assuming no “harm elimination” policy is achievable), even from the point of view of non nocere. The claim that providing safe sharps to people who are going to cut themselves anyway is a “harm” is only defensible if the fact of the behavior is taken as the harm in question, and not the relative magnitude of its consequences. And that kind of absolutist categorical thinking underlies an entire school of healthcare ethics in which the patient, and the patient’s own values, make only fleeting appearances. That, I suggest, is a real harm to be reduced.