Jun 4, 2012

Ethics of Sterilization for Drug Addicts

An issue which ought by its very nature to provoke controversy of all sorts -- reproduction and childbirth by drug addicts -- has come to the fore again, centered around an organization, Project Prevention (PrPr, just so as not to confuse them with Planned Parenthood, often abbreviated as PP) whose main activity involves paying drug and alcohol addicts to get sterilized or to use long-term birth-control.  There's much more to be said about the purposes of the organization, as well as the moral issues involved, the deeper problems raised, and the ethical status not only of Project Prevention but also of their supporters and critics -- all of which I'll explore in some detail below. 

First, though, it's worth mentioning a few useful and specific sources -- given that this controversy has not often risen to the level of headline news or talking-heard-worthy burning issue of the hour.  New York Daily News, BBC News, and Time Health, among others have recent, well-balanced pieces about the organization, its mission, and its critics.  The Guardian ran a longer, somewhat more in-depth article nearly a year back, and Practical Ethics published a short blog post raising a few additional issues and proposing Britain's NHS do what PrPr does.  Africa Is a Country has an interesting though clearly anti-PrPr discussion of the expansion of the organization to Kenya, and its mission to include HIV. A Care2 piece also discusses Haiti and South Africa.  In 2006, the Committee on Women, Population, and the Environment levied a number of charges of being unethical against Children Requiring a Caring Kommunity (CRACK), the earlier version of PrPr.   Open Society Foundations held a panel discussion a little over a year ago, specifically on the ethics of Project Prevention, its aims, and its activities.  So, all that said, what should we think about this?

 

Some Preliminary Remarks

Before looking over some of the arguments out there, all over the map, from all sorts of quarters, many of them resting on all kinds of assumptions, it might be useful to peel away some sources of possible misunderstandings by making a few needed distinctions.  It would also be prudent to note where there are relevant connections or comparisons to be made.

So, first off, what precisely is being done?  What kind of policy or action is in fact being carried out?  What sorts of transactions are being proposed or engaged in?  What type of  policy or action is being advocated, and what alternatives are being considered?  What goods or values are at stake, and for which persons?  What justifications are being provided or being criticized?

If we just stick with its American incarnation -- setting aside the issue of Aids raised in Africa for the time being -- Project Prevention's mission, looking at their stated objectives, is really twofold.  One part is raising public awareness about the problem  of drug addicts or alcoholics using while pregnant, and the effects on their children.  The other part is providing chronic drug users with payments as inducement for going on long-term or permanent birth control.  Supporting the second part, they also provide referrals to drug treatment clinics, and carry out some follow-up and emotional support with their clients.

So, a few distinctions having to do with what issues one can legitimately make moral evaluation of this organization, its aims, and the broader society turn on.
  • Is using contraception a good, bad, or morally neutral course of action? It is morally required, permissible, prohibited -- or in some other category?  Does its moral value depend on any other factors, like consequence, intention, etc.
  • What about providing contraception to another person?
  • Or, what about subsidizing contraception for another person?
  • How about making a deal, providing an incentive, etc. to induce another person to use contraception?
  • What about imposing contraception or sterilization on another person?
  • Where does advocating use of contraception to another person fall?
Clearly from certain moral perspectives -- any which regard using contraception as intrinsically wrong -- all of these issues should be quickly resolved and in the same way.  Project Prevention would hold roughly the same moral status as an organization like Planned Parenthood, or the zealous health teacher handing out condoms and urging kids to practice safe sex so as to not "ruin their lives."  The fact that PrPr espouses a different agenda and offers a different justification would not make it fundamentally different from PP on a moral level.

If, on the other hand, contraception is viewed as generally wrong or bad, but can be weighed off or balanced against other wrong or bad things, it might be viewed -- and chosen -- as a lesser of two evils.  Typically, this line of reasoning would develop by looking at consequences -- for instance by carrying out a Utilitarian calculation of goods and harms for all those involved or interested -- but it need not necessarily do so, a point we'll come back to.

If contraception is viewed as essentially morally neutral, then it can come to be regarded as a good thing or as a bad thing depending not on whether contraception takes place, but according to something else.  For those who regard contraception as a good which ought to be provided or subsidized, and not outlawed or interfered with, precisely because it allows women to avoid economic and psychological consequences of an unplanned and inopportune pregnancy, contraception is an instrumental good -- it leads to some other good, or it keeps one from losing some other good.  Likewise, even if one regards it as an instrumental good along these lines, if, say imposing it on someone were to thereby destroy another good, like their autonomy or human dignity -- even for some perhaps causing them a great amount of displeasure -- one would then regard contraception as also something bad or wrong, in that case, under those conditions.

Why is Project Prevention so Controversial?

What is Project Prevention engaged in that raises so much controversy?  They're not imposing contraception on drug addicts or alcoholics?  The only way one can claim that is to essentially deprive addicts of agency and to argue -- and it's incumbent on the one claiming this to make a solid case -- that some real coercion is taking place.  They are advocating contraception pretty strongly, but pretty qualifiedly, focusing specifically on drug addicts or alcoholics who are likely to become parents of children who are likely to be harmed during gestation by drugs or alcohol.  They are certainly proposing and making deals about contraception with addicts.

They're also making several other connected (and for many uncomfortable) moral issues public and problematic.  There is a cost to society involved in the number of children born to addicts, many of whom are born addicted to various drugs, some of whom require extensive and expensive medical treatment, a number of whom are disadvantaged by handicaps stemming from the effects of their parent's drug or alcohol abuse.  There are questions that ought to be asked -- and not with answers already presupposed.  Who ought to bear those costs?  Is it right or wrong to impose those costs upon society?  It is right or wrong even to impose such disadvantages and harms upon children?  What ought to be done about these things?  Who ought to take action?  Or should these matters just be set aside, allowed to work themselves out?  What kind of society do we have that allows such harms to be imposed and inflicted?

One might argue that the existence of this organization really ought to be seen as a sign of scandal, rather than the source of scandal it has become.  It strikes me, in reading through many of the reviews and criticisms, that a portion of the controversy centers around Barbara Harris herself, her own  actions, stances, articulations of the organization's goals.  It also seems to me that this is one of those matters on which for many, the divisiveness is less a matter of deep, reasoned philosophical disagreements and much more reflective of dividing lines in the culture wars, in contemporary ideological alignments and oppositions.  Still, there are real ethical issues to be raised, some genuine moral gold to be culled out of typical party-line dross.  Let's look at some of the accusations made against the organization

 

Charges Against Project Prevention

Setting aside any undue focus on Katherine Harris' personality, narrative, and statements, what are some of the relevant charges and lines of argument about Project Prevention?  Let's look at them all together, and then a few of them in turn.

One common charge is that the organization, its aims, and its activity are racist:
In a logic reminiscent of eugenics, CRACK claimed that the children of these women would be a burden on society  . . .CRACK spread into a number of U.S. cities where staff targeted poor communities of color, sometimes accompanying police on their neighborhood rounds . . . .In truth, the organization's main mission is ideological—eugenics with a 21st-century face.   -- Betsy Hartman

People supporting Project Prevention will be giving money to a program that serves a political ideology over the needs of women, children, and families. Project Prevention suggests that there is a particular portion of the population that should not be, or that is not worthy of, reproducing the human race. The risk is that this will be easily interpreted to mean that this group is unworthy of being regarded as fully human and deprived of the rights, health, and support to which all human beings are entitled  -- Lynn Paltrow
Another is that their approach is  inherently coercive, taking away the rights of women to choose competently about contraception for themselves and for their potential children.
Giving cash or in-kind incentives for women to undergo sterilization or long-term contraception is a form of coercion and violates reproductive choice and rights. They push women into making decisions about birth control based on money, rather than which contraceptive is the healthiest and best choice for them. -- Betsy Hartman

The groups selected share similar characteristics: they are on the margins of society, ostracized, and suffer double marginalization. . . .  There is a false assumption that they are weak and lack capacity to decide what is good and bad for themselves -- Anne Gathumbi

CRACK's Chicago director has argued that it "supports a woman's right to choice and self-determination" because women choose to participate and can do so either by getting a tubal ligation or by using one of several long-acting methods of contraception. This argument does not acknowledge the coercion inherent in a program based on economic incentives that limits women's options to methods which, in addition to being either permanent or long-acting, may put their health at risk.-- Committee on Women, Population and the Environment
At the same time, some of the critics worry that the women concerned are not able to competently choose for themselves in their circumstances:
Anything that involves permanent sterilization for money is a bad idea . .. The women are too young, too impressionable to make that kind of irreversible choice. . .  I think it should be taken off the table completely. The solution to having babies when you're not ready is not to make more bad decisions. --Arthur L. Caplan

What about the question of informed consent? The addicts may not be in a fit state of mind to give it, so Harris leaves it to doctors to judge whether their patient is able to make a rational decision about something as life-changing as sterilisation. But the doctors aren't told by Project Prevention that their patient will be getting money in exchange for the procedure, so they aren't fully informed of the addict's motivations when they make their assessment. -- Jenny Kleeman
One main accusation is that supporting Project Prevention means taking resources away from other, morally better approaches.
Such an approach undermines public will to fund and support effective public health and development models that Project Prevention suggests, falsely, would be unnecessary if only certain women would stop procreating. -- Lynn Paltrow

A constructive approach to the problem of addiction among pregnant and parenting women would support programs to help addicts take control of their lives, not programs that take away their control. The programs which truly hold the potential to have a positive impact on the lives of children born to addicted parents are those which expand access to health care services for children and parents, extend supportive services such as high quality child care, and make effective addiction treatment programs available to parents. -- Committee on Women, Population and the Environment
Another very interesting accusation is that it diminishes or deflects attention from male responsibility:
The considerable public relations they do to promote Project Prevention all make it appear that the biggest threat to children's health is their own mothers. This model ensures that blame for medical and social ills will be placed on mothers, distracting attention from male responsibility and the public health, political, and economic conditions that profoundly effect the lives and health of children regardless of what their mothers do. --Lynn Paltrow
Yet another is that the focus on addicts is inherently unfair:
You're out there focusing on one segment of the population. . . Why only focus on addicts? Not people with high blood pressure, diabetes? --Arthur L. Caplan,

 

Assessing Criticisms of Project Prevention

Unless one stretches racism's meaning rather far, that line of accusation seems weak.  While PrPr certainly does target poverty-stricken and addict-heavy neighborhoods, it's hard to make a case that this represents some sort of racist crypto-eugenicist strategy.  If the organization were racist, they would be doing a remarkably poor job at it, given that a majority of the women who've received their stipends are actually white.  One can always write off Harris' husband being black, and her adoption of four black children with the same old tropes that are typically trotted out for such occasions and exceptions.  And one might wonder why racism is such a quick go-to for the critics.

I think it would be much more interesting, though, to think about two other matters.  Do the critics of PrPr's programs exhibit any similar concerns about the statistically higher representation of abortion clinics in minority neighborhoods?  Or is that seen as not involving racism targeting the putatively undeserving, but perhaps its opposite, deliberately targeting the underserved for needed assistance?  Setting aside the thorny abortion issue, would the critics have any qualms about federally and state subsidized Planned Parenthood's involvements in bringing contraception to largely minority areas, or is that viewed as a liberating, a progressive, a laudable commitment to overcoming "health disparities"?  And, as a last thing to mull over -- and just to make it clear, I'm not advocating or excusing racism in this -- even if PrPr were openly racist, would that automatically render their entire project morally bad?  If one offers to subsidize another person's contraception, and if that contraception is regarded as a good thing, does a bad motive render it no longer good, nullifying any good that one would otherwise consider done?

The second and third criticisms almost seem to be at antipodes from each other.  One ought not offer any financial inducement, because by doing so one is essentially removing or diminishing the autonomy, the freedom of choice, the women participating would otherwise possess.  Or, one ought not offer any financial inducement, because these women don't really have autonomy, freedom of choice, a capacity to choose for themselves.  So, which is it, you'd almost like to ask?  Are you coercing people who if it weren't for the fact that you're offering them money would know and choose better, i.e. presumably not to use long-term contraception?  Or are you taking advantage of the fact that these addicts generally make bad, poorly-thought-out, uninformed choices, have diminished capacities, are less than autonomous agents to swindle them out of reproducing -- and you, perhaps, out of the $300 inducement?  Or are you behaving in a paternalistic manner, incentivizing your own version of the right decision for people you don't trust to make that decision for themselves.

Again, a lot of considerations to reflect upon.  Why would the plethora of generally progressive-leaning agencies, causes, organizations, and individuals already out there promoting, providing, subsidizing, lauding various types and methods of birth control be any less paternalistic?  Are young women taking advantage of Planned Parenthood's services any less impressionable than those who might consider the deal offered by Project Prevention?  Dominick Wilson, in my view, notes some relevant points:
[It] doesn’t seem problematic to encourage people to delay conception until a time when they are best able to care for the children that they conceive, nor to delay conception if doing so would reduce the chance of health problems in the child. It isn’t a problem for us to encourage teenagers to use reliable forms of contraception, or to encourage those who are taking medications that would cause birth defects to delay attempts to conceive until after they have finished taking those medications.
If drug addicts and alcoholics are counseled by a contraception provider to use it, does that thereby remove the autonomy they otherwise possess?  Is that paternalism, and as such automatically to be deplored?  Or are they then both applauded for displaying responsibility, for promoting autonomy, for rightly exercising reproductive rights?  All of this conversation, of course, assumes that it's always a bad thing to be morally paternalistic, which is a strange thing to assume when dealing with addicts, who are unproblematically treated paternalistically in so many other manners -- precisely because they're addicts. 

What about the argument that by supporting Project Prevention, one is in effect depriving better qualified, more well-established, right-thinking organizations and agencies of the resources that ought to be given to them to address the problems arising from addicts who continue to abuse drugs or alcohol during their pregnancy?  I suppose that in some sense, those who donate to PrPr might be depriving other organizations or government agencies tasked with addressing these problems.  It does seem a bit strange to suggest an organization which explicitly arose out of a perceived need to do something more about a problem which was not being well-addressed ought to be passed over so as to provide just those additional resources to the organizations and agencies that had such a mixed record.  It's difficult not to see a sort of invidiousness to this line of criticism, as well as some worn-out hand-waving assuming that if the right people and projects were just properly funded, everything would come out so much better. 

I'm not myself endorsing Harris and PrPr, but I can certainly understand the urgency and energy of the appeal they make -- one which in some of its content seems in many respect so similar to those of other agencies and agents supplying women with contraception or abortions -- if you want to prevent this sort of misery, here's what needs to be done, and here's how we'll get it done.  And, once you've adopted that line of march, the question has to be Who is going to do it?  Should it be the government?  Should it just be a matter of private individuals?  Should it be local community organizations?  Church groups?  Other voluntary organizations?  Non-profit, volunteer-using, national or international organizations-- often deeply entangled with government in myriad ways, politically aligned, both pushed and pushing an ideology that effortlessly glides into an associated culture? 

For the time being, I'm going to skip the other two criticisms.  I'd like to revisit the issues raised here in what strikes me as a fairly surface look at Project Prevention and some of its critics -- there are some deeper moral questions which are raised by, though not particularly well explored and examined, this controversy, issues which much more explicit use of moral theories would illuminate.