You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our Group site.

Project Prevention? Well, since you asked…

21 Oct, 10 | by Iain Brassington

So the Guardian got in touch to see if I’d be able to contribute a Comment is Free column on Project Prevention, which has just started operating in the UK.  For one reason or another, I didn’t get the email until the deadline had passed; but since I was planning on saying something about PP here anyway, this is roughly (word-limits notwithstanding) what I would have said.  Warning: it’s long - I may have gone off on one…

For those not in the know, Project Prevention is an American organisation – well, more of a family outfit – that (according to its website) aims to raise

public awareness to the problem of addicts/alcoholics exposing their unborn child to drugs during pregnancy.  Project Prevention seeks to reduce the burden of this social problem on taxpayers, trim down social worker caseloads, and alleviate from our clients the burden of having children that will potentially be taken away.

The organisation is controversial, though, because it does more than raise public awareness: it offers money to addicts of one sort or another in return for being sterilised:

Project Prevention offers cash incentives to women and men addicted to drugs and/or alcohol to use long term or permanent birth control.

Another page on the site glosses this:

Project Prevention does not have the resources to combat the national problems of poverty, housing, nutrition, education and rehabilitation services. Those resources we do have are spent to PREVENT a problem for $300 rather than paying millions after it happens in cost to care for a potentially damaged child.

According to the BBC, PP has had at least one client in the UK already: a heroin addict from near Leicester who had a vasectomy in return for £200.

I don’t really want to cast doubt PP’s good intentions – but good intentions are not sufficient to avoid getting into all kinds of mess; and PP is morally a mess as far as I can see.

The first problem is that it’s unclear from the reportage I’ve seen what’s actually driving the project.  From some perspectives, PP seems to present itself as working on behalf of people who recognise that their lives are too chaotic to allow them to raise a child well.  OK – but, if that’s the case, why concentrate on addicts alone?  There’s any number of people who might feel that they’re incapable of raising a kid; but if that’s the worry, then whether or not they’re addicts is beside the point.  I’ll come back to this point later, because there’s more to be said.

Now, it may well be the case that addicts are sub-optimal parents: it may even be the case that some addicts are all-round dreadful parents.  But you don’t have to be an addict for that.  Very few parents are the best possible parents – they could all be a bit wealthier, a bit less stressed, and so on; and on the reasonable assumption that it’s better to have wealthier and more relaxed parents, it would seem to follow that all parents could be better.  But that’s not important.  Noone expects parents to be the best possible parents, or even good parents.  What counts is that they’re good enough.

Is there any reason to suppose a priori that addicts would not be good enough parents?  None that I can see.  (I was at primary school with at least one kid whose parents were heroin users; of course it would have been better for him had they not been, but I don’t think that they were bad parents.  If they were bad parents, then it’s not obvious that they’d be worse than certain others; the addiction seems to be a mere detail.)  So the strongest point that could be made is that addicts are likely to be less good parents than non-addicts – but this doesn’t generate a reason to prevent their reproducing, because we’re only talking about likelihoods, and a less good parent is not the same as an insufficiently good parent.

Seen from other perspectives, PP seems to be working from a platform of something like procreative beneficence.  It’s not really disputed by anyone that children born to addicts are more likely to suffer from medical problems: foetal alcohol syndrome is a real problem even when alcohol intake is fairly modest; and there’s no shortage of stories of babies who have developed a powerful crack or heroin addiction even before they’ve had their umbilical cord cut.  Children born to addicts face an elevated risk of all kinds of cognitive, physiological and developmental retardations.  So, prima facie, we might think that there’s a good reason to be sterilised to prevent conception.

There’s a couple of problems with this line, though.  The first is that much would seem to depend on accepting the proposition that a child born to an addict – even a child with all the health complications that that might entail – would have been better off never having come to exist.  While I accept the formal possibility that there are people whose life is so blighted that they would have been better off not having existed at all, in practice this condition affects very few, if any.  There’re people born with all kinds of health problem who will cheerily admit that, of course, things could be better for them (who wouldn’t say that?) but that their lives are plentifully worth living all the same.  So the PP claim that they’re acting on behalf of the child depends on us buying the idea that the child can be saved from a fate worse than never existing.  That strikes me as being quite a stretch.

But let’s put all this aside, and allow ourselves to suppose that it is, after all, better for addicts not to reproduce.  The thing that I think sets many alarm bells ringing is the part about payment.  The problem with this is that we might well worry that it increases the likelihood that the addicts being offered the money would choose a course of action only because of the money.  I don’t believe that merely being an addict makes you de facto vulnerable to monetary pressure – but it’s obviously the case that, if there’s one thing of which addicts are frequently short, it’s ready cash.  So there’s a genuine worry here that getting a sterilisation is not wholly an authentic choice.  Indeed, it might be the case that addicts are amenable to bribery just because of their addiction.  I mentioned above the idea that there’re non-addicts who might not feel that they could raise a child – but maybe that’d be a good reason for PP not to offer the scheme to them: they’d never allow themselves to be bought off like that.  Maybe, to that extent, addicts are different.  I hesitate to say it, but maybe at least some addicts are a bit more biddable because of their addiction.

The coercion point is particularly pertinent in the UK, of course.  In the US, it might be hard for an addict to get affordable medical care at all; and $300 to be sterilised might mean that an echt decision to have the procedure has some of the financial sting drawn.  Maybe in the US there is an enablement argument available.  (It’s probably not enough to overcome all the other problems, but it’s a start.)  But in the UK we’ve got the NHS.  It’s creaky and the current government hates it, but it’s there, and it means that sterilisations can be had for free by anyone who wants one.  That’s brilliant.  One wonders why a cash incentive is necessary, then…  Oh, yes.  It’s to convince people that they really do want to be sterilised after all.

There’s a couple more worries.  For one thing, PP arguably does not aim at the right target.  If addicts having children is a problem, it’s arguably because of the addiction, not because of the children.  By eliminating the pregnancy, PP leaves the thing that would have made it ostensibly regrettable untouched.  Moreover, payment won’t help solve this underlying problem – indeed, it’s just as likely to exacerbate it.  An addict with £200 in his or her pocket may well use the money for rent and shopping – though they won’t get much – but there may well be other things on their shopping-list, too.

And what about this: an addict who decides that he or she is too dysfunctional to be a parent and so goes to PP seems to me thereby to give at least some evidence that they are pretty functional after all – quite possibly functional enough to ensure they get the proper medical attention throughout the pregnancy, and quite possibly functional enough to raise a child, in fact.  Meanwhile, the really chaotic ones will fall below everyone’s radar.  So even if we allow that PP could help some, those who would benefit most from the help would be those least likely to get it.

The people at PP probably aren’t bad people.  I think their hearts may well be in the right place.  But I think that they’re pretty naïve, and pretty misguided.  Their programme seems to me to be pretty much indefensible.

By submitting your comment you agree to adhere to these terms and conditions
You can follow any responses to this entry through the RSS 2.0 feed.

Latest from JME

Latest from JME

Blogs linking here

Blogs linking here