A US group that pays drug addicts to undergo sterilisation visits the UK this week, having recently paid its first British client for undergoing a vasectomy. “Project Prevention” claims that its goal is to make addicts and alcoholics use long-term birth control until they can care for the children they conceive. Founder Barbara Harris has said: “We don’t allow dogs to breed. We spay them. We neuter them. We try to keep them from having unwanted puppies, and yet these women are literally having litters of children.”
The visit has provoked strong responses. Some have compared the group to eugenicists, while supporters point to the cost to the children and society of conception by addicted parents. Dominic Wilkinson has controversially suggested on this blog that a version of the programme could be offered on the National Health Service.
This ethical debate is on the level that Mackie (1977) identifies as first order. However, the issue also highlights second order moral issues about the nature of morality. What are we doing when we express a moral view and how do we know that our views are reliable? One approach to answering these sorts of questions is to understand human morality as an adaptation that contributed to our ancestors’ evolutionary fitness. Without addressing the strengths and weaknesses of such an approach here, if correct, it has the potential to illuminate second, and by implication first, order questions.
Pinker (1997:42) suggests that if “the Pleistocene savannah contained trees bearing birth-control pills, we might have evolved to find them as terrifying as a venomous spider.” Those of our ancestors who used birth control would have fewer descendants and those with the opposite tendency would have had more. Descendents of the latter may also have inherited a disposition to avoid birth control, which could be manifested negatively as fear or positively as desire. However, as nothing akin to modern forms of contraception existed in our evolutionary past, humans have not evolved such responses.
Just as humans lack an adaptive response to contraception, they seem to lack such a response to people paying for them to be sterilised. From an evolutionary perspective, the sum Project Prevention is paying for permanent sterilisation seems small. The media reports that the first British citizen to undergo a vasectomy, a 38-year-old heroin addict identified as “John,” was paid £200. The free telephone number for the UK advertised on the group’s website confirmed a similar amount ($300) being offered to women.
The worry might therefore be that the response of addicts to such offers is unreliable because it is maladaptive. Individuals would be accepting £200 to surrender something that may be as valuable – in an evolutionary sense – as life itself.
The problem is compounded for both addicts and the rest of society by something else that probably did not exist in our evolutionary history: the addictive drugs. Addiction to substances such as crack cocaine and heroin causes substantial behavioural changes. Addicts tend to prefer short-term gratification and are more likely to engage in behaviour that is harmful to other members of society, including any children they may have.
The effect of these evolutionary novelties is likely to be complex. It may be that addiction to drugs causes individuals to have more descendants or fewer descendants. Of course sterilisation, particularly when a person has by then had no children, will substantially reduce the prospects of having descendants.
The impact on the first order moral debate of these second order issues is not straightforward. It is not obvious how one could move from a descriptive account of our morality to a normative account of how we ought to act. One possibility may be to incorporate the knowledge that our normative responses to evolutionary novelties may be unreliable into the normative debate. For example, if a Rawlsian approach were to be adopted, this could be the type of knowledge available in the original position. Another possibility might be to seek to provide incentives to drug addicts that weighed against the effect of the addictive substances. Adopting this approach, incentives that assisted individuals to resist short-term gratification might be acceptable, but incentives that resulted in permanent sterility might not.
Interestingly, it seems that Project Prevention is not just focussed on permanent sterilisation. According to their telephone helpline at least, they pay similar sums for medium-term contraceptive to more permanent options. For Essure and tubal ligation, both of which are difficult to reverse, they pay $300. However, they also pay $100 for having a contraceptive implant or inter uterine device fitted, together with $100 after confirmation after 6-months that the method is still being used, and another $100 after 12 months.
This medium-term option might suggest a way forward. There are clearly some uses of contraception that are adaptive. For example, where it assists individuals to have children at a time when it is most advantageous, or to dedicate greater resources to fewer children. Such considerations apply equally to drug addicts.
Rather than condoning or supporting a group as polarising as Project Prevention (also known as C.R.A.C.K. or “Children Requiring a Caring Kommunity (sic)”), it may be that incentives provided by the National Health Service as suggested by Dominic Wilkinson may be the most acceptable first order moral response for both drug addicts and society, provided of course that the incentives were for medium term contraception rather than sterilisation.
Paul, I would be interested in your views as to whether a utilitarian approach, based on maximising some measure of overall well-being (where this is interpreted as including psychological, not only material well-being) can help us to move convincingly from a descriptive to a normative account, both generally and in this specific case.
From such a utilitarian perspective, the concern that addicts’ response to this type of offer might be maladaptive in the context of evolutionary fitness seems rather marginal, given that the whole modern world in which we live is rife with messages to which our response is likely to be maladaptive. That battle is simply lost already. But the following considerations may help to shed light on this issue.
1. The concern that “Project Prevention” is trying to address, namely that addicts are giving birth to children for whom they are unable to care adequately, leading to various forms of misery and other social ills, appears to be a genuine one.
2. This problem is by no means limited to drug (including alcolhol) addicts.
3. Addicts, and those who empathise with them, are understandably going to see this type of initiative as a slap on the face.
4 It is true that the project seems to be inspired by a basically eugenecist motivation, and this has very negative historical connotations, especially for Europeans.
To really sort this out (from a utilitarian perspective) one would presumably need to consider a wide range of different options that could potentially be pursued, perhaps in combination, to tackle the problem. For example, Dominic’s suggestion regarding the NHS could be applied to everyone, not only to addicts. This would avoid the eugenics/discrimination association, but would of course have cost implications. A better alternative might be to subsidise *non-discrimatory* private initiatives offering medium- and/or long-term contracepton.
A final word on evolutionary fitness: who’s evolutionary fitness are we worried about here, and why? From a utilitarian perspective we are presumably talking about the human race, in which case the most promising approach might be to forget about drug addiction and focus on tackling systemic risks to civilisation. (Unless we actually think drug addiction *is* a significant threat to civilisation, which seems somewhat unlikely.)
As to point 4 in Peter’s note; I don’t understand how this relates to eugenics unless it is determined that addiction is an inheritable trait. Is it an inheritable trait? Or is it the case that children of addicts become addicts because of social influence (for we all have some tendency to prefer occasional attachment to a pleasure machine).
I agree with points 1 and 2 in Peter’s note, and add only that pursuing an attack on unfit parenthood limited to a population in which the likelihood of such parenthood is high is not in itself unjust, if the general goal (preventing incompetent parenthood) is just and there is too little information to expand the offer of money for sterilization beyond this group, or because there is too little money to make the offer to others outside this group. Perfection should not defeat good.
What of the argument that sterilization is irreversible and is therefore unjust because drug addicts can overcome their addiction? What is the likelihood of that? In any case, sterilization of men can be made reversible. I am not sure of tubal ligations.
It is most likely that many addicts will accept their unfitness as parents, and will need no money, just the offer of free medical care associated with sterilization. Offering them money may have no or perhaps a hurtful effect.
It is also likely that many very poor persons will take money for sterilization in order to pay for another dose or fix, without regard to their future parenthood. The preference for the drug fix over fertility is a kind of choice it is ethical to honor, either from an individualist or a utilitarian point of view. Is the addict’s consent to take the money an be sterilized coerced (by the offer of money) or not made competently? If the addict is incompetent to make important agreements, then drug addicts are incompetent, a danger to themselves (and perhaps others) and may, in justice, be committed to an institution. Then, the choice of sterilization by the people in charge of her welfare, given the possibility of sexual activity, is a proper one. I rather prefer the less restrictive approach utilizing the bribe.
This discriminates “against” the poor. They are most likely to take the money and the knife. But is this discrimination the purpose of those who offer the money in exchange for sterilization, or is it simply the result of the likelihood of resistance by better-off people to the procedure? The better off are likely to become poor and eventually take the money. If they don’t become poor, it is likely they have the means to have someone else raise the child.
There is, of course, another approach. Should drug addiction, as such, be ground for taking the child from the mother or parents? Is this better than paying the potential parent to become sterilized?
“Those of our ancestors who used birth control would have fewer descendants and those with the opposite tendency would have had more.”
No. Its much more complicated. You could have fewer and healthier births and ultimately more that live to sexual maturity. Or you could have fewer but healthier offspring that achieve sexual maturity but they would achieve sexual maturity earlier and have increased fertility. In addition, our ancestors used birth control methods all the time. One method is lactation. Another is infanticide. This type of inaccurate discussion is really not relevant to the issue at hand, so why bring it in?
Dennis: I take your point regarding eugenics, on reflection my point 4 is probably incorrect. I would take issue however on the following statement: “The preference for the drug fix over fertility is a kind of choice it is ethical to honor, either from an individualist or a utilitarian point of view.” From an individualist / liberatarian point of view, perhaps, but utilitarian? I think this would be quite a narrow interpretation of utilitarian. If by “ethical from a utilitarian point of view” we mean something along the lines as “such as to maximise the overall well-being of sentient beings” then surely a case can be made that addicts should be saved from their own bad decisions. There’s still something that makes me uncomfortable about encouraging people to sterilise themselves – and I think it’s related to my point 3 above – and that discomfort is only increased by your (very pertinent) point that they might accept such offers for “bad” reasons. While the distinction between competence and incompetence is an important and necessary *legal* one, from an ethical and even policy perspective I think we need to consider that there are shades of grey.
Ralbin: I agree it’s more complicated, and not obviously relevant to the ethical issue, but I’m not sure that you’re observations entirely invalidate the statement you quote, particularly in its context (the thought experiment regarding the birth control tree). Pinker’s point, I believe, is that any form of free and unlimited access to easy birth control would lead to the evolution of some kind of (psychological) defense mechanism, since those that lacked it would tend not to reproduce as much. I think that basic conclusions stands.
Dear Peter
Thank you for your insightful analysis and interesting question as to whether a utilitarian approach of maximising some measure of well-being could assist us to move convincingly from a descriptive to a normative account. The suggestion that I explored in my original post was rather limited, namely that if we are aware that our normative responses might be biased / unreliable / maladaptive because of evolutionary novelties, perhaps we should take steps to counterbalance those biases. Your question raises a more fundamental point, which I take to be whether it is possible to construct a utilitarian account of morality “from the ground up.”
One of the main problems, that I think you identify at the end of your post, is that if morality is just an adaptation that contributed to the evolutionary fitness of our ancestors, this gives no obvious way of choosing between different actions that will affect individuals’ evolutionary fitness differently. My view is that an evolutionary account would imply that there would be no objective or neutral account of well-being that we could use, even if psychological well-being tracked individual fitness (about which I have serious doubts).
However, there are still fundamental issues which could be addressed without answering that question and which seem to me more of a priority. You raise the issue of systemic risks, ie, those that threaten us all. I do not suggest that drug addiction falls within this category, but other issues such as global warming or weapons technology probably do. If these are all maladaptive responses, there may be common approaches that could be used to address them. Hence I disagree with your view that “the battle is lost already.” It may be that maladaptive responses are endemic in our modern world and we presently have no effective response to them, but it seems to me that they are crucial issues that are in principle capable of redress.
Of course, it is extremely difficult to know with certainty whether behaviour such as drug addiction is really maladaptive. Concerning the example of alcohol, I suspect it has some adaptive benefit. Those familiar with the English character might doubt whether they would ever reproduce if alcohol were not available to overcome their fear of approaching the opposite sex in the first place.
There seem to me to be at least two important general considerations. The first is that in circumstances where the environment is drastically different to our evolutionary past, it is more likely that the behavioural consequences will be maladaptive than adaptive, so a precautionary principle might be preferable. Secondly, in an environment that is rapidly changing, diversity is of crucial importance in adapting to this environment such that preserving diversity should be a priority.
Finally, I think I disagree with your suggestion that incentives for all to adopt medium term contraception on the NHS would overcome either the discrimination or the eugenics allegation. Discrimination can also exist where people in different situations are treated the same. My concern here was also that those such as Project Prevention who took the view that addicted individuals were having too many children and should be sterilised were taking disproportionate advantage of the latter’s maladaptive preference for short-term goals.
Many thanks for this Paul – there are many thought-provoking considerations here, and I laughed out loud at the point about the English character!
Two quick points.
1. I think a utilitarian basis for morality can work, at least in principle (in practice of course problems of scope and definition abound). Evolutionary fitness would be one of the factors determining in particular the *sustainability* of our well-being.
2. Point taken about the battle not being lost. I think what I meant was that we’re not going back to a “natural” environment where our “natural” responses can be assumed to be adaptive – so I agree with your point about precaution. In any case the important point, for me, regards the systemic risks that you correctly cite (among others of course): they are indeed crucial issues that are in principle, and I very much hope also in practice (even if I have my doubts), capable of redress.
Would need to think further about your comments regarding medium-term contraception and discrimination, might come back to this.
OK I’ve thought further…I take your point Paul about discrimination existing where people in different situations are treated the same. Regarding your concern about taking “disproportionate advantage of (addicted inidivduals’) maladaptive preference for short-term goals”, I think it depends a bit on what kind of benchmark one is applying. If we are wondering whether the project should be “supported or condoned” by public policy then I would tend to agree. But if we are thinking of actively *disapproving” of such practices, then we would need to basically overhaul the whole basis of the consumer society, which is almost 100% oriented towards taking advantage (sometimes “disproportionate” advantage) of people’s maladaptive preference for short-term goals. It’s not clear to me why this is qualitatively different from displaying chocolates at the check-out counter.
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