Welcoming the editor's request to write something about nutrition, mental health, substance use and ethics, I started with a literature search of a few major clinical and ethics databases. Three topics seemed to stand out for health care workers and policy makers. Most common was the ethics of providing artificial nutrition and hydration to a person with a terminal illness, which includes seniors with advanced dementia and infants with severe neurological conditions. The second most common topic was ethical considerations of involuntarily feeding people with advanced anorexia nervosa through a nasal or gastric tube. The third topic relates to women who consume alcohol or use illegal drugs during pregnancy.
Two articles from my literature search demonstrate why nutrition shouldn't remain at the margins of contemporary health care. In a 2008 article in Nursing Standard, authors Bottomley and McKeown identify the many issues that contribute to nutritional problems among people with mental health issues: psychotic symptoms, social withdrawal or exclusion, hyperactivity, memory impairment, lack of energy or motivation, low income, hospitalization, physical changes, psychiatric medications and depression. In other words, achieving good, sustainable nutrition is a complex, often daunting, endeavor for people with mental health and substance use issues. But it has profound effects: A 2009 article about nutrition and cognitive neuroscience published in the Proceedings of the Nutrition Society discusses how nutrition impacts the brain and neural pathways.
Without knowing it, we can be overly biased in favour of new interventions, technologies and trends. We can believe that bottled water is better than tap water (it depends on the brand and local water) or that organic is better than non-organic (again, it depends, and the differences may not be meaningful). We can stubbornly rely on outdated folklore about particular foods; for example, believing that chicken has fewer calories than beef (depends on fat content) or that carrots help improve eyesight (only if you are deficient in vitamin A). Add to this the ubiquity of food and beverages in our communities--a veritable saturation of restaurants, cafes, retail stores, vending machines, workplace cafeterias, advertisements and sales promotions.
In The Paradox of Choice: Why More Is Less (ECCO, 2004), Schwartz describes the unintended consequences of innumerable choices. He notes that we devote too much thought, activity and time to an excess of options, unimportant matters and illusionary distinctions. In terms of what we eat and drink, I think we often experience something akin to food fatigue and, at other times, food boredom. Schwartz also provides various examples illustrating that we are less rational decision makers than we realize or admit. For instance, we do not recognize distortions, biases and fallacies associated with our everyday preferences and choices. As Bottomley and McKeown note, if health care workers have not received focused training, they will have their own biases and folkloric beliefs about food that can unintentionally influence their assessments and discussions about nutrition with clients.
Nutrition is important to mental and physical well-being; but eating and drinking are not just biological needs. As with mental health, nutrition involves biopsychosocial features. For instance, eating and drinking are part of meaningful relational activities, as evidenced by the familiar lament about the demise of family meals. Social considerations are not limited to the home. Food security -- reliable access to affordable, healthy food -- affects what we eat and is a particular concern for people with mental health and addiction issues, many of whom have limited incomes.
Nutrition is more complex than many of us think, which helps to explain why many people do not yet have their own nutritional success stories to tell. Sustainable and accessible nutrition requires commitment and effort, not just by individuals, but by entire communities.
Barbara Russell, bioethicist at the Centre for Addiction and Mental Health in Toronto, answers ethics questions that arise in the mental health and addiction fields. She is connected with the University of Toronto's Joint Centre for Bioethics and heads the neuroethics interest group of the Canadian Bioethics Society. She is also a contributing editor to the Journal of Ethics in Mental Health.