Project Prevention? Well, since you asked…

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.

  • Ruth Stirton

    Thanks Iain. I think you've summed up the ethical concerns nicely.

    I think there are also some concerns about the lawfulness of PP's activities. We can imagine a situation where an addict receives £200 for sterilisation and takes it straight to their dealer, buys much more of their chosen poison than they would normally buy, and ends up overdosing, and suffering death or serious injury. It might be possible to argue that PP has a duty of care towards the addicts it engages with, and that payment to them amounts to breach of that duty of care. (I won't go into the specifics of the legal case here, but for those lawyers amongst the readers, you'd have to go to first principles in Caparo v Dickman to establish a duty). PP would be liable in the tort of negligence for the death or serious injury that was attributable to the payment.

    Further than that, in a situation where a drug addict has died, we might think that giving a drug addict enough money to overdose amounts to gross negligence manslaughter. For the non-lawyers, the test is that the negligence is so gross as to be criminal. And it's up to a court to decide.

    So, PP (or the individuals who make up PP) could be liable in tort for damages, or if found guilty of GNM, given a prison sentence.

    Of course, all this is dependent on the state of affairs occurring, but it strikes me, that PP is walking a difficult line.

  • Obviously I'll defer to your legal knowledge on this – but would the duty of care stuff carry much weight here?

    For example: I used to be paid in cash for my bar job. Imagine that I'd made it known – or at least given strong reason to believe (and not just suspect) – that I would use that cash to go out and get off my chops. And suppose that I got horribly injured as a result. You seem to be saying that I'd have a claim against my employer – have I understood you? But that seems odd; I'm an adult, and adults can generally do damn-fool things. So I don't see how it'd work in this case – unless the addiction bit makes a difference.

    What've I missed? I never did understand the law…

  • Lindsay Stirton

    Hi Iain,

    You know that old line (I think it is from the Three Stooges), “I'm trying to think but nothing happens”? Well, I have been trying to think about Project Prevention all week and, well, I haven't actually come up with what you would dignify with the term “thoughts” on the subject. So in lieu of that, I'll simply snipe at yours a bit. Overall, I find everything you say, vaguely persuasive–but not more than that. I don't for a moment pretend that this comment amounts to a coherent argument, more an attempt to engage you in a conversation that might end up with me forming one.

    First of all, like the good philosopher that you are, you steer clear of the ad hominem argument, stating that you don't doubt their intentions. Well, maybe, but don't you have to cast aside your philosopher's good manners when an organisation gives out flyers which say “[D]on't let a pregnancy ruin your drug habit”? Maybe they have good intentions insofar as they intend a good outcome (something you yourself actually challenge), but someone's intentions must surely also be judged by how they pursue those ends, and how they treat others in the pursuit of those ends which in this case could not be much more callous. So while I appreciate the grace that attributes good motives to people, and that this is often necessary to keep the discussion civil, I don't think it is always appropriate.

    On the other hand, I am not entirely convinced by the coercion point. One procedural point: like any other medical procedure, sterilisation standardly requires informed consent. No doctor would I think undertake such a procedure without obtaining informed consent (and to do so would be unlawful). We must therefore presume that informed consent has been given, and therefore there is no coercion.* And if there is coercion, surely the person who should be primarily accountable for this should be the medical practitioner who carries out the procedure. If there is a problem with the payment, it is not coercion in the standard meaning of that term. So what is it?

    We discussed this in class today, and my students were pretty much agreed that this was exploitation rather than coercion. Maybe such careful choice of words does not get you much further but one of my students argued (and I am elaborating on the idea as I recount it here) that people in general (and drug addicts in particular) tend to prefer immediate gratification over gratification in the longer term, but that in general it is a good thing to persuade people to see beyond the here and now. So whereas an individual who (off his/her own back) went and sought long-term contraception would be doing the (relatively) praise-worthy thing, by introducing a payment you actually are destroying the addict's already diminished ability to look to his/her longer-term consequences. Is there a sense in which the problem not PP that is coercing individuals; what is “not wholly authentic” about the choice is that is made without what little capacity for long-term thinking the addict might otherwise have? I don't know.

    But even if there were coercion, would that be a problem? Surely it is bad to interfere with autonomy, but the whole of public health law is concerned (in one way or another) with the question of whether individuals' freedom to make individual decisions should give way to a public interest in promoting health outcomes (and if so, which policy instrument(s) are effective and acceptable). If you grant that there is a space for such decisions in the collective interest, then the question isn't whether the decision is wholly authentic (quite plainly it is not), but whether this is one of those areas where the collective interest is trumped by a concern for autonomy or not. I really don't know the answer to that, but of course I recognise that in relation to procreation, “the state and its partners” (to quote Gostin's definition of public health law) should tread very carefully. Article 8 ECHR recognises this, and makes that question one of law (i.e. it is for the courts, not the executive to decide). And if it came to a question of proportionality, wouldn't treasure (paying people) be a less invasive option than authority (commanding people)? The former seems decidedly light-touch by comparison, provided we are agreed that there is a legitimate public health interest in reducing cases foetal alcohol syndrome, or children born to addiction, and that the measure would be effective to a high degree. I am not sure that the latter condition is actually satisfied, but that is a different question.

    Finally, I am not entirely convinced by your argument that PP aims at the wrong target. On one level it is obviously true that it is the addiction that is the problem and not the parenthood, but I don't think it is obviously foolish for a policy intervention not to aim at the root cause of a problem. Maybe the root cause is too difficult, too expensive, too whatever to address effectively, and therefore requires a degree of palliation.

    PS. Your argument about the essential goodness of all life (even that blighted by addiction, foetal alcohol syndrome, neglect and worse) would be right at home in a Papal encyclical. Strange bedfellows on this one.

    PPS. I am not saying that your conclusions are wrong in any of this. My intuition is that this is monstrous, but intuition does not equal reasoned argument, even if it can inspire one. Somehow your argument didn't provide the rigorous support for my unexamined prejudices that I was hoping for.

    * I am skating over the possible problem of concealment of the payment from the doctor, who then makes a faulty judgement about whether informed consent is given. That is a real problem, I dare say, but not one I care to take up.

  • Thanks for this, Lindsay. It's not just politeness that leads me not to doubt PP's good intentions: I genuinely do think that they believe they're doing the right thing, and I'll stick to that genuine thought for as long as the libel laws are as they are.

    Your point about coercion is interesting, and I'll have to mull over it a bit. I'm not wholly sold on the exploitation claim, though. But what's really interesting is the possibility that a person can give wholly valid consent on the basis of a desire that was coerced – a situation in which my acting on disposition x is no different from my acting autonomously on any other disposition, but in which that disposition was inculcated in me by cash promises/ hypnosis by an evil genius, rather than the normal process of acculturation, biochemistry, and so on…