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Julian Sheather: Should we help people self-harm?

5 Nov, 09 | by BMJ Group

Once in every while an ethical dilemma will swim across the horizon, a dilemma whose wake will induce in me a bout of moral seasickness. My compass spins, my bearings wheel and lurch. One such is the reappearance of “facilitated self-harm”. I am not over-fond of the word “facilitate”. It drips with the oil of evasion. It sits too easily on the smoothest tongues. What is meant here is helping people to hurt themselves. It refers to the practice of providing people who self-harm the sterile means to accomplish it.

There are those who work in ethics, robust souls on the whole, who don’t give much house room to moral feeling. They will tend to snicker at the “yuk factor”, at squeamishness, at moral disgust, arguing instead that only reasons count, that there is no place for sentiments in ethical debate. Being weaker minded, I am not of their party. Moral seasickness is my Davy lamp. It tells me when a dangerous dilemma is drifting my way. It tells me when it is time to start thinking. Yuk! can be the beginning of argument, though it cannot be its end.

So what to make of helping people to harm themselves? A good consequentialist, someone who holds that the consequences of an action are what matter morally, could well say that if the provision of sterile blades leads to less overall harm then it could be justified. The argument is a strong one. Looking behind the stories, it seems to be the case that self-harm is a strategy used by some to cope with terrible emotional conflict, that it helps them to manage otherwise unmanageable misery. If self- harming cannot be stopped, then it is surely right to limit the damage it causes. As an aside, it is interesting that many of the calls for the provision of safer methods of self-harm come from nurses, from those who work more intimately and daily with people in emotional extremity.

Try as I might though I cannot entirely rest with this consequentialist conclusion. 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 harm.

Thinking about my unease, I suspect it has something to do with the consequentialist conclusions running up against a deep-lying principle about the purposes of medicine, a principle so deeply digested as to form part of our ordinary moral sentiments: the principle that medicine should do no unnecessary harm. The weighing of such a principle against the measurable consequences of assisting or not assisting can never be easy. I suspect these cases will always present a dilemma and any decision will always feel approximate and imperfect. But if we decide to go with “facilitation”, if we accept the consequentialist arguments, then I think we accept an attendant duty: to undertake rigorous audit and assessment. If we are going to argue from consequences then we have to have a pretty good idea what those consequences might be.

Julian Sheather is ethics manager, BMA. The views he expresses in his blog posts are entirely his own.

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  • http://paracademia.blogspot.com Scar

    ‘…the principle that medicine should do no unnecessary harm.’

    Is it ‘unnecessary’ harm though, if the whole point is that the harm will happen anyway? Perhaps the harm is necessary – or at least as necessary as any other form of intervention/therapy/release – and therefore medicine, whilst facilitating harm, is not doing so unnecessarily.

  • Julian Sheather

    One useful analogy would be providing drug addicts with clean needles. It mitigates the harms. Or the provision of methadone which is safer than street drugs. These are more or less accepted. But what about removing a healthy limb? Or facilitating the cutting of healthy female genitalia? I am not necessarily opposing ‘facilitated harm’, more trying to get a purchase on my own unease.

  • John Coggon

    Hi, Julian.

    This is a very interesting post.

    I wonder about the point you make about consequentialist reasoning, given your reference to the purposes of medicine. A system that has the sorts of purposes you’re referring to also recommends consequentialist appraisals! Rather than look at the act itself, I think you’re also concerned with the end to which the act is aimed. So there’s nothing intrinsically wrong with giving someone a clean needle, or amputating a limb. Rather, you question their propriety in some circumstances.

    In other words, your issue (it seems to me) is not with appeals to consequences, but the weight that might be given to certain consequences in certain circumstances.

    And there’s nothing wrong with that, of course. Even if we assume that it’s okay to give clean needles to drug addicts, it does not of necessity follow that doctors ought to be doing it.

    (And I think the matter’s made more complex if we do consider it in a healthcare context, because in fact there are manifest disagreements about the very meanings of “harm”, “benefit”, and indeed “health”, which means assessing the ends sought is not a matter subject to straightforward consensus.)

    Interesting stuff…

  • Fabian Alexander

    Thank you. Those were very interesting examples.

    It raises the question of consent. If a patient is willing to remove his limb, do we have the right to deny him that ? Equally, if a patient refuses to have a limb amputated, even though without the amputation he will die – do we have a right to go against his wishes ?

    In the same vein – if someone wishes to die, what right do we have to deny him that ? And if we have no problem switching off machines that keep someone alive, why do we have a problem letting someone jump off a roof ?

  • Kirsten

    Hi all,

    I think the scenarios presented vary greatly. Someone self-harming by cutting is vastly different from the ethics surrounding female genitalia removal. As 70% of people who self-harm by cutting have been abused as children more often than not they are doing so as a survival mechanism. Many need to have access to some form of cutting device so they have the control to chose to do it whether they actually will or not, therefore often allowing a self harmer who cuts to have a safe way of doing it is enough and will reduce their desire to do so more effectively than removing all vaugly sharp objects from their surrounding area. I imagine this ties in with the safe needle argument.

    Other forms of self harm are ingrained as part of our society – alcohol consumption, drug abuse etc etc so a doctor’s ethics really will be tested if they decide to start adjusting treatment around whether a person’s behaviour is not quite the model of health protection. More extreme examples such as the patient who doesnt believe their leg is their own and wants it amputated, are a lot more circumstantial. In this situation I would imagine (forgive my unqualified status) psychological therapies would be exhausted before considering the amputation, however if the disorder persisits through psychological therapies the patient is more than likely to continue attempting to damage the limb so a safe way of achieving the same outcome is probably a necessity.

    As for the female genitalia mutilation, whilst it is a tricky one, i can only imagine that the same arguments apply, it IS better that safe instruments are used if the procedure must go ahead, however if a charity/organisational body is providing these instruments and don’t fully approve of the procedure surely an education/culture changing intervention should be utilised at the same time- as with condoms being given to young people in order to help achieve safe underage sex. Naturally we would prefer all under 16 year olds to suddenly adhere to the law but realistically its damage limitation at the moment isn’t it?

  • Julian Sheather

    Many thanks for your comments.

    John I suspect you are right, and that I am just expressing a kind of nervousness about accepting some consequences, or a doubt about the weight that should be ascribed to certain consequences. Medicine concerns itself with outcomes and reducing harm is as legitimate as preventing it. I still find it hard to subdue my unease though, and suspect that, once again, I have too rapidly come up against the limits of my ability to think. In reponse to Fabian’s point, what troubles me here particularly is less the prevention of people harming themselves, than medical involvement in the ‘facilitation’ of that harm. I suspect again though that if, as Scar points out, overall outcomes are improved then the harm could be said in some way to be ‘necessary’. My doubts do not, however, quite fall away, and I shall continue to brood on it, though probably unprofitably.

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