Castration and conscience

A recent editorial in the British Medical Journal (Grubin D,
Beech A, BMJ 2010; 340:c74) discusses the efficacy and ethics of chemical
castration for sex offenders.  

Its efficacy is not in doubt. Recidivism rates of less than
5% over long periods are consistently reported. The expected rate, absent ‘treatment’,
is 50% or more.

But is it treatment? And if it is not, should doctors
participate in it?

Grubin and Beech note that ‘[a]lthough castration is
ostensibly for public protection, it also carries with it a sense of symbolic
retribution…Some people argue that not only does medical input in these cases straddle
the border between treatment and punishment, but that it also shifts the doctor’s
focus from the best interests of the patient to one of public safety.’

Probably most doctors’ knee-jerk reaction to chemical
castration would go something like this:

(a)        It is a
fundamental principle that doctors should act always and only in the best
interests of their patients.

(b)       There may be
cases where a sex offender genuinely wants to be rid of his impulses, and will
freely ask for chemical castration. In such cases there is no difficulty. This
is treatment for an affliction. It can and should be given.

(c)        If the State
orders chemical castration as an expressly punitive measure, to administer it
cannot be reconciled with any decent understanding of a doctor’s duty. The
doctor should refuse to co-operate.

(e)        (i)        If
the State orders chemical castration on public safety grounds, the ethical
position is more difficult. Even if the State does not actually compel
castration, the position might be tantamount to compulsion. If the deal is: ‘Submit
to chemical castration or spend X more years in jail’, it is hard to
characterise any request for castration as free. It may, however, be in the overall
best interests of the patient to have the ‘treatment’ and therefore be

(ii)        There are situations where the State compels treatment or
otherwise truncates basic freedoms on public safety grounds. Examples include the
incarceration of violent offenders for public protection, treatment or
detention under the mental health legislation for behaviour that will be
dangerous to others, the compulsory reporting of certain diseases, and the addition
of fluoride to public water supplies. The acceptability of these measures will
be determined (obviously) by balancing the magnitude of the insult to basic
freedoms against the magnitude of the risk and the damage that will be done if
the risk eventuates. In the case of some sex offenders it seems difficult, when
talking about chemical castration, to say that the ratio of the truncation of
freedom to the public dangers obviated  is
of a different order to that seen in (eg) sectioning a homicidal patient. But,
that said, the thoughtful doctor will still feel more queasy about signing a
prescription for antiandrogenic drugs in a way that he would about signing a
Mental Health Act section declaration.  And
why is that? Is his queasiness justified?

Four points:

(a)        The motives
behind legislation are rarely pure. If compulsory chemical castration arrives
in the UK, it is likely to have been swept onto the statute book by a wave of red-faced
 outrage from the red-tops. The campaign
that produced it will have been articulated in both punitive and public safety
language. A doctor instituting ‘treatment’ will always wonder how much of his action
is ethically illegitimate (dictated by the front page of the Sun) and how much
is legitimate (because it is justified by analogies with the sectioning of
homicidal patients).

(b)       Changing what
happens inside someone’s body may be different in ethical nature to doing
something that simply determines the position and circumstances of someone’s
body (eg by detention).

(c)        Most of the
things done compulsorily to patients can, by some route or other, be said with
a more or less philosophically straight face to be in the patient’s best
interests. The compulsory sterilisation of incapacitate patients is said to be
in their best interests. It can similarly be said that forcibly to prevent a
homicidal patient killing or a sex offender raping is in their best interests. But
sometimes, in the case of a sex offender, that argument will be more difficult
to sustain. Libido might be everything.

(d)        The queasiness
might arise from a reluctance to modify the old model of the doctor-patient
relationship. That model has uses: it also has limitations. Doctors in public
health positions are used to seeing the community as their patients. But we
should be wary of diluting the old model. It has many advantages. One of them
is that it is relatively immune to the fickle winds of social change. If you
assert that ‘The world is my patient', what you might find yourself saying, if
you’re not careful, is: ‘I’m a tool of the social policies of the moment.’

There is enough in these four points for the doctor to be
able to say intelligently: ‘My queasiness is analytically explicable’. And that
might be a comfort.

This is all very well, but what should the doctor do?  Doctors sometimes have a duty to overcome
their queasiness and opt for the lesser of two evils. But they never have a
duty to do anything that will keep them awake at night. Insomnia should be the
lodestone. This isn’t a counsel of philosophical despair – an acknowledgment
that argument and reason have failed. It is just an acknowledgement that
doctors are human beings, which is actually rather a good thing – if only
because human beings are best treated by other human beings.

[See too Tom Douglas' related blog post on chemical castration ]

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One Response to Castration and conscience

  • Dennis Tuchler says:

    Make it voluntary, and as an inducement, take the offender’s name of the list of people who, as sex offenders, have an extremely limited choice of places to live and to engage in normal life activities.

    No one knows what to do with sex offenders except isolate them from society. That can mean life imprisonment or hospitalization; it could mean registration and very tough life-activity limitation; or it can mean chemical castration.

    By the way, that leaves the 5% who commit sex offenses after castration. What do we do with them?


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