Should healthcare professionals sometimes allow harm? The case of self-injury

Abstract

This paper considers the ethical justification for the use of harm minimisation approaches with individuals who self-injure. While the general issues concerning harm minimisation have been widely debated, there has been only limited consideration of the ethical issues raised by allowing people to continue injuring themselves as part of an agreed therapeutic programme. I will argue that harm minimisation should be supported on the basis that it results in an overall reduction in harm when compared with more traditional ways of dealing with self-injurious behaviour. It will be argued that this is an example of a situation where healthcare professionals sometimes have a moral obligation to allow harm to come to their patients.

‘There is no progression in prevention’ – The experiences of mental health nurses working with repeated self‐harm

“…); however, participants in this study reported a hypervigilance around self‐harm which often resulted in risk‐averse and controlling practices including seclusion and one‐to‐one observation. Current clinical management of self‐harm focuses largely on stopping the person engaging in acts of self‐harm (Sullivan ). The finding that mental health nurses’ approach to people who self‐harm is predominantly focused on prevention and control methods is therefore unsurprising and is in keeping with other studies (Dickinson et al .…”

“…; Pickard & Pearce ; Sullivan ). However, crucially within this approach is the need for the person to engage in psychological therapy to explore the function and meaning of their self‐harm to sustain longer term change and the development of alternative coping strategies (Edwards & Hewitt ; Sullivan ). Furthermore, a harm reduction approach also presents the opportunity to offer information and education to those who self‐harm which participants in this study reported doing.…”

“…; Edwards & Hewitt ; James et al . ; Sullivan ). In addition, it has also been reported that mental health nurses may not feel skilled, comfortable, or empowered to discuss harm reduction techniques with patients (Pengelly et al .…”

Harm‐reduction approaches for self‐cutting in inpatient mental health settings: Development and preliminary validation of the Attitudes to Self‐cutting Management (ASc‐Me) Scale

“…Nevertheless, there has been a growing interest in harm‐minimization approaches for self‐injury, and such techniques have been advocated by some who suggest that a more baldly preventative approach can be distressing, stigmatizing and detrimental to the therapeutic relationship with professionals, and can contribute to behavioural escalation (Duperouzel & Fish, ; Holley, Horton, Cartmail, & Bradley, ; Lindgren, Öster, Åström, & Graneheim, ; Pembroke, ; Shaw, ). Much debate around the use of harm‐minimization approaches has been rooted in non‐empirical discussions of ethics and legalities, much of whose tone suggests a stark binary choice between adopting or proscribing such techniques (e.g., Edwards & Hewitt, ; Gutridge, ; Sullivan, ). In the UK, official guidance is to recommend “tentative approaches to harm reduction for some people who self‐harm in the community ” (National Institute for Health and Clinical Excellence, , p. 259.…”

Sometimes, not always, not never: a response to Pickard and Pearce

“…I would like to thank Hannah Pickard and Stephen Pearce for their informed and clinically focused response to my paper on harm minimisation 1. They argue that harm minimisation is not a viable or responsible approach within an inpatient environment 2…”