Mill, advocacy and the tobacco endgame

Though its stricture has not been universally followed in modern liberal states, Mill’s harm principle remains important in public health ethics. Banning an individual from doing something because it’s bad for him requires stronger reasons than banning it because it harms others. In England, justification for smoking bans in enclosed spaces was firmly presented in terms of preventing harms to others, even if its subsequent evaluation also included health gains to smokers. The legal ban did not cover smoking outside where harms to others are less.
Care homes and hospices were granted exemption but in mental health units this was temporary, so that when they expired, the ban became de facto a complete ban where patients cannot go outside. During legal challenges in England, justification for the ban was sought in health gains for patients, including regarding the habit as self-harm. Recent NICE guidelines recommend total smoking bans inside and outside hospital for the benefit of smokers. For smokers, Mill’s principle has been overturned.
The supremacy of personal autonomy is central to nursing ethics, though less so in public health ethics. Smoking bans and their effect on individual patients is one area where these disciplines collide. Nursing claims (or requires) a role for patient advocacy but this can be variously interpreted and nursing can no longer prevaricate. It must choose to advocate for patients’ health (in favour of a ban) or for patients’ choice (against a ban), and the direction it takes clearly identifies where the profession’s values lie.