Primaquine is an anti-malarial drug. When taken as a single dose by someone infected with the falciparum malaria parasite, it reduces the risk of transmission to mosquitoes and so to other people. However it confers no direct benefit on the individual who takes the drug. Indeed it poses a net risk, since it has side-effects, including the potential for a severe haemolytic reaction (breakdown of red blood cells) in a certain class of individuals (those with genetic G6PD deficiency). Nevertheless, primaquine is taken as a single dose by millions of people annually.
Cyproterone acetate (CPA) is a testosterone-blocking drug that has been used to ‘chemically castrate’ certain sexual offenders, including paedophiles. It can’t redirect misplaced sexual desires. But it can attenuate them, thereby reducing recidivism. Again, though, it can have serious side effects for the user, including liver damage and possibly depressive mood changes. Still, more than twenty countries allow the use of CPA in sex-offenders, and several US states have authorised the use of a related agent (MPA).
Primaquine and CPA might appear to have little in common. But ethically, there are some interesting parallels.
For example, the use of both agents has raised concerns about consent. Are the individuals who take these drugs really choosing voluntarily and on the basis of full information? Or are they being softly coerced or mislead by authorities anxious to protect the public from, respectively, malaria and sexual abuse.
Perhaps more interestingly, some worry that these use of these agents might be ethically problematic even when fully informed and voluntary consent is obtained. The concern stems from the fact that these are drugs which, in some cases at least, are used to achieve social objectives rather than to protect or promote the health of the user. For example, on the use of cyproterone to prevent sexual recidivism, Don Grubin and Anthony Beech ask
Given the risk to the individual’s health, is there a clear medical rather than social reason for prescribing powerful drugs. . ?
The implication is that ‘powerful drugs’ should be used only where a ‘clear medical reason’ can be given. Meanwhile, regarding single-dose primaquine use, Kevin Baird and Claudia Surjadjaja suggest that, while it may be ethically acceptable for individuals to take on some risks in order to benefit others, there are limits on how significant these risks can be:
Measured risks for the benefit of others can be taken, but the range of ethically acceptable risk excludes significant risk of serious harm.
The concern expressed in these passages is not that these drugs have benefits for third parties, nor even that the prospect of these benefits might be one of the reasons for which doctors prescribe them, and individuals choose to take them. Many medical interventions are pursued in part for their benefits to third parties. Consider the case of an AIDS patient who uses anti-retroviral therapy in part to reduce the risk of infecting others. This seems unproblematic. Rather the worry is that, in some cases at least, the use of primaquine and CPA may have no benefit for the user and indeed pose a risk of serious harm. It may thus violate the requirement that seriously risky medical interventions–even voluntarily undertaken ones–should be provided only when they’re in the best interests of the individual who undergoes the intervention. (Call this the ‘best interests requirement’.) Seriously risky interventions should not be provided solely to bring about benefits to the third parties.
The best interests requirement is widely accepted, at least as a rough rule of thumb, both by medical ethicists and medical practitioners (though some might allow an exception for cases in which the third parties are friends or family, as, for example, in cases of sibling-sibling organ donation). I find this puzzling. It’s generally regarded as ethically acceptable for a person to undergo a risky procedure to benefit herself. And surely it’s more admirable to take a risky drug to benefit others. So why adopt a principle that rules out that latter while allowing the former?
One suggestion might be that individuals do not have the right to inflict serious physical risks on themselves in order to benefit others (perhaps doing so involves wrongfully instrumentalising oneself). But this suggestion seems unpromising. Many individuals who voluntarily joined the allied armed forces during WWII thereby imposed serious physical risks on themselves in order to achieve diffuse social benefits. Yet we ordinarily think their actions were ethically permissible.
A more plausible suggestion would be that the best interests requirement is necessary to prevent the misuse of medical technologies. We should accept the requirement since, if we do not, we are likely to engage in seriously immoral uses of medical technology (such as the coercive use of highly intrusive and risky medical techniques intended to benefit society). Though the voluntary use of risky but socially beneficial medical interventions might be ethically acceptable taken in isolation, we have no way of pursuing such interventions without also creating a risk of more extreme, ethically objectionable practices. So we should adopt a moral requirement that rules out all seriously risky interventions that are not in the interests of the user.
It’s not difficult to see why this rationale might seem persuasive. Humanity does have a rather bad track record of coercively and misguidedly adopting intrusive and risky medical interventions perceived to have social benefits: think of the past use of frontal lobotomy to control putatively anti-social behaviour and of coercive sterilisation to achieve the social benefit of better genes for future generations.
However, it’s at least open to question whether concerns about about misuse are sufficiently powerful to justify forgoing the social benefits of interventions like single-dose primaquine and chemical castration via CPA. The social benefits of primaquine and CPA may well be substantial enough that some risk of misuse ought to be tolerated. Moreover, in some countries–those that have witnessed a ‘medical ethics revolution’ in recent decades–the risk of serious misuse may be low. Arguably, these countries have learned from the worst abuses of medicine in the past and are now a lot less prone to adopt unjustified, coercive medical practices.
Perhaps in the wake of diabolical attempts to achieve (objectionable) social goals through medicine last century it seemed necessary to introduce a strict best interests requirement. But we have since made a good deal of progress in medical ethics. And we’ve acquired greater technological capacity to achieve genuine social benefits (e.g. reduced rates of malaria, reduced rates of sexual abuse) through medicine. Perhaps it is now time to rethink the requirement.