Give them sterile razors: controversial self-harm
12 February, 2017
Reproduced under Creative Commons licence
Some people who self-harm should be provided with sterile
razors, says a mental health expert in the
Journal of Medical Ethics. Patrick Sullivan, of the
University of Manchester, argues that this approach may be
more respectful of patients' autonomy.
He suggests that a harm-minimisation strategy for
self-harming individuals could include provision of sterile
cutting implements, education on how to self-injure more
safely to avoid blood poisoning and infection, as well as
therapy and alternative coping strategies.
Sullivan argues that high rates of self-injury among
people admitted to mental health units suggest that the
standard method of dealing with this behaviour--forcibly
stopping them--doesn't work.
People who self-injure do so because the negative
feelings they experience threaten to overwhelm them: injury
reduces tension and increases control, providing a coping
mechanism. Infringements of this are likely to be seen as
confrontational and distressing rather than therapeutic, he
contends. These patients usually understand the nature and
consequences of their actions, so denying them this freedom
thwarts their autonomy.
"Where the risks of serious injury are low, limitations
on basic freedoms are more difficult to justify," he
suggests. Restrictions could even make the problem worse;
many of those who injure themselves have a history of abuse
or trauma, and stopping them from doing it could intensify
their feelings of powerlessness.
"This increases the risk that individuals will
self-injure covertly, in more dangerous ways, or attempt
suicide," he contends, citing anecdotal evidence indicating
the increasing use of other forms of self-injury, such as
hanging, among those in mental health units who prefer to
cut their skin.
He emphasises that he is not advocating a blanket ban on
restrictive measures. Nor is he advocating blanket
permission for self-injury. Rather, it is about permitting a
lesser harm to prevent a more serious one, he says.
In response to this controversial proposal, Hanna Pickard
and Steve Pearce say that supporting autonomy and
independence among vulnerable people is "fundamental to good
But they point out that Sullivan ignores the practical
problems with such a policy. "Put bluntly, witnessing or
even just hearing about self-injury increases the chance
that people try it themselves. The impact on other patients
of facilitated self-injury on wards needs to be factored
into any assessment of costs and benefits."
Furthermore, "sanctioning" such behaviour could reinforce
the low self-esteem already associated with self-injury. It
could also be extremely distressing for staff, particularly
if continued cutting unintentionally or deliberately
resulted in life-changing injury or death.
"Facilitated self-harm" is not a new topic and cutting in
mental-health clinics is not its only manifestation. As a
Julian Sheather, wrote a few years ago:
If self-harm is the condition requiring treatment,
can it be right to provide a cleaner knife? There are
some possible parallels, some near analogies. I have
worked with medical charities being asked to provide
sterile equipment for female genital mutilation. There
is also body dysmorphic disorder, where someone so takes
against a healthy limb that they will chop it off
themselves unless a surgeon is willing to assist. In all
these cases an argument runs that because they will do
it anyway, medicine should intervene to minimise the
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