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Embrace the controversy: let’s offer Project Prevention on the NHS

A controversial US-based charity that pays drug addicts to undergo sterilisation or long-term contraception has recently opened for business in the UK. Project Prevention pays drug users $300 if they provide a medical certificate of drug dependency and another certifying that they have had tubal ligation, vasectomy or a contraceptive implant. The founder of the charity points to the significant physical and psychological problems in children born to drug-using parents. Noone would deny that it would be good to avoid these problems. Drug counselling often includes advice about contraception, and encouragement of those who are interested to take up options including long term contraception or sterilisation – we don’t think that that is a particular problem. So what is wrong with Project Prevention?

The first potential problem with the project is that its stated aims seem misdirected. Barbara Harris, who heads the charity, refers to the rights of children born to drug addicted parents. “What makes a woman's right to procreate more important than the right of a child to have a normal life?”, and “I'll do anything I have to do to prevent babies from suffering.” But this way of justifying the project runs into the non-identity problem. There are no existing children whose suffering is prevented. Nor are there any individuals whose right to have a normal life are upheld by encouraging the sterilisation of drug-addicted parents. And the children who are born to drug-addicted parents, even if they have substantial problems, usually have lives that are worth living. Although they might have preferred that their parents’ did not use drugs at the time of their conception, they would usually be happy to exist. The justification for Project Prevention cannot be the interests of current or future children to drug-addicted parents. But at the same time, there are no existing or future children who are worse off if drug users undertake contraception.

One worry that we may have about Project Prevention is that drug users’ decision to undertake sterilisation may be compromised by their drug addiction and by their intermittent desperate need for money, either to pay bills or to pay for illegal substances. A decision to undertake sterilisation appears particularly problematic since it is irreversible (or at least difficult and costly to reverse), and it is quite conceivable that drug users will later change their minds, particularly if they later recover from their addiction. From this point of view providing incentives for long-term contraception would be less worrying. On the other hand, within the public health system in the UK, decisions to undertake sterilisation can’t be taken quickly. Patients require a referral from their GP, wait (often many weeks) before getting an appointment, and may have a further wait before the procedure. Project Prevention only provides money after users have had the sterilisation procedure. It does not seem likely that the financial incentive (which is not huge) would cloud an individual’s judgement sufficiently to invalidate a decision that is sustained over a period of weeks or months.

Finally, a potential concern about Project Prevention is that it represents a form of eugenics, an attempt to manipulate people’s decisions about reproduction in order to prevent certain types of people from having children. We might think it particularly troubling that a private organization is embarking on a form of social engineering. But it also 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. Perhaps it would be better if programmes designed to foster these goals were based in the public health system itself, but the programmes themselves don’t seem troubling.

A suggestion then: we should measure whether incentive schemes for contraception in drug users actually work to reduce the number of children conceived with drug-dependency related health problems. If such financial incentives work we should embrace them within a public health system rather than rely on private organizations. We should encourage reversible forms of contraception over irreversible forms. Incentives should be offered as part of a broader programme of support including help for users to overcome addiction. Incentives such as vouchers that can't be used to purchase drugs may be preferable to cash grants (especially if they are equally effective).

Delaying conception if that would avoid health and other problems in children is worth promoting. But (given long waiting lists in the public health system) providing financial incentives for sterilisation for those who have a sustained desire to stop reproducing may also be ethical.*

Storm over women drug addicts paid to be sterilised The Sun 8/3/10

Should drug addicts be paid to be sterilised BBC 8/2/10

*We might offer long acting contraceptives as the primary option for drug users. However, those users with no desire to have further children, and whose preferred method of contraception was tubal ligation or vasectomy could be offered (and rewarded for) this option. The financial incentive should be equivalent with either option.

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8 Comment on this post

  1. This contribution offers nothing to this serious debate – it is full of gaps, and ethical issues are raised then sidestepped. What’s more, before a conclusion is reached about whether financial incentives are ethical, the author wants to measure whether they work. This is irrelevant to the ethical question.

  2. Dominic Wilkinson

    Damon, thank you for your thoughts.

    Empirical research might help clarify the ethical issues in several ways. If financial incentives do not have any impact on the incidence of unwanted pregnancies to drug-addicted parents, then there would be a strong argument against providing them – even if they were ethically unproblematic.
    Alternatively, if such a programme had a major impact in reducing the number of children born with complications from drug addiction and drug use during pregnancy, then it would provide a strong argument in favour of the programmes. Then we would have to decide whether the arguments against them outweighed the reasons in favour.
    (Separate empirical research might also clarify the views of drug users about their fertility, and incentives of this sort, which might be relevant to the debate)
    If you hold (as I suspect you do) that these sorts of incentive are unethical regardless of how effective they are, and regardless of the views of users, then you may not be interested in this empirical research. However, I have suggested (though I freely admit not demonstrated conclusively) that the standard objections to Project Prevention may be overcome, particularly if it were set up to primarily focus on delaying conception rather than preventing reproduction.

  3. Thanks for the reply Dominic – and good to have a name to the contribution.

    First I should re-state my first line above – it is not that this contribution adds nothing. I was wrong on that, or more accurately, a bit simplistic. It raises far more questions than it answers and the suggestion of a potential pilot programme and related research raises further questions without solving the questions first raised. Your reply does not assuage any fears about this and similarly your focus on long term contraception versus sterilisation does not answer all concerns (e.g. no. 3 below for example).

    Here are some thoughts – in haste, admittedly

    1.Non-identity vs stigmatisation of existing children. Project prevention suffers from the non-identity issue as you mention quite rightly. But the knock on question is ‘what are we saying about those children who are born to drug users?’ Are we saying they are doomed to a life of misery, that their life is of less worth? I am guessing not – but this is hard to explain when the aim of project prevention is to reduce the birth of substance exposed children to zero. See my comments below re root causes and needing to address the real problems we’re facing.

    2.Eugenics. As I said above some questions are sidestepped. One is eugenics. Now, for me this is a bit over the top for what’s being proposed here, but still the question is raised and has to be dealt with properly. It is not enough to sidestep this by saying it’s not for a private organisation to do – it’s not for the NHS/state either. Nor is it enough to say let’s drop sterilisation for long term contraception as this raises further questions – such as…

    3.Public health messaging – in short, what about condoms? Money in the project prevention scheme is not an incentive as much as a reward for accepting a certain type of predetermined/preferred contraception – one that does nothing for STIs such as HIV. As we are dealing with drug users including injecting drug users at considerable risk of HIV and other blood borne viruses the public health strategy also has to be taken into account. Here we are muddying the waters because this one woman has decided that preventing births is the primary goal (see again non-identity above – this time veruss very real public health problems). Take the example of a man accepting the money for a vasectomy. What, really, is a man’s main concern when using a condom? HIV? Not in most cases. It’s pregnancy. So what does this intervention add or take away from public health responses to epidemics? There are more comprehensive and less intrusive, less ethically problematic, ways to delay conception if this is desired.

    4.This of course leads to the disproportionate focus on women here and the lack of focus on absent fathers .

    5.Who determines what is an ‘unwanted’ pregnancy? Project prevention seems to have decided that it is any pregnancy to a drug using mother (or father). You say my view is ‘regardless’ of users’ views. This is absolutely not the case. In fact I just spent a week with over a hundred drug user activists at the international harm reduction conference in Liverpool. Trust me, this project was not viewed favourably – particularly among those who are parents and among people who work with mothers who are drug users

    6.Who next? Alcoholics? The obese? People with mental health problems? See the eugenics question above. Here’s a thought experiment. Replace “substance-exposed children” as per project prevention’s message with “low income-exposed”. Now imagine research has shown that children born to low income families experience more abuse than high income families. This question directs us to dealing with root causes – should we provide a financial incentive to not have kids, or assistance with the circumstances that render child bearing an undesirable option at a given time? The same goes for drug dependence, of course.

    7.Related but so basic as requiring a separate bullet – What about abuse and neglect of children to non-drug users?

    8.As your initial piece stated, for long term contraception or sterilisation a lot of things have to be in place such as a GP referral etc before it can happen and before money can be received. In this case, then, what does the money do? What role does it have? You have used it above almost as a defence of the incentive as not being too much of a pressure, but to me it raises serious questions of motivation and where motivations should come from for life decisions such as these – and especially for people who are vulnerable to economic pressure. The decision should be solely about the user’s wishes as well as their and their family’s wellbeing. In fact, $300 seems, in that case, irrelevant if the decision is made in advance – (see again above about reward for a type of contraception as distinct from an incentive)

    Finally (for my post anyway) the trial you propose:

    9.As someone who works in harm reduction I am always interested in empirical and other research related to drug use, and related interventions. But what is more I am of course interested in research ethically constructed and carried out. So, some questions about your idea which relate to the subjects of the trial:
    1.Who would be the participants? e.g. among a notoriously hidden, hard to reach and diverse group: a. How would they be representative enough in order to draw any meaningful conclusions? b. What criteria would identify them?
    2.How would the study be randomised, and what would be the control group?
    3.How would it be blinded? (What would participants be told?)
    4.What if the financial incentives were effective in reducing drug related complications? How would this answer the questions 1-8 above? It’s true, I am not convinced by efficacy in ethical arguments – compare torture or the death penalty. Even if they worked I do not think they could be supported. Extreme examples but this question is key.
    5.But what if it were ineffective – how would this be explained to the participants?

    And so on…

  4. Dominic Wilkinson


    you raise many excellent questions, and I am afraid I don’t have time to do justice to all of them. The aim of the original post was not to defend Project Prevention, nor to suggest that we should definitely adopt a version of it – rather to suggest that the standard objections to it are not necessarily decisive, and that there may be ways to overcome some of them.
    I share with you a concern that Project Prevention as it stands, and perhaps my hypothetical replacement version could stigmatise both drug users and current children of drug-using parents. But it need not do so. Programmes of prenatal testing, or in this case programmes that aim to reduce the number of infants born with substance addiction or complications of drug use during pregnancy do not assume that such lives would not be worth living. And they do not necessarily imply that certain people, or a certain class of people should not reproduce. Rather they rely on a set of fairly uncontroversial assumptions.
    1. If it is possible to avoid birth-related complications or health problems in a child by delaying conception it would be good to do so
    2. At least some of those with drug dependency problems would prefer not to conceive children who will be affected by drug use during the pregnancy
    3. Financial incentives (of a certain level) do not coerce individuals to take decisions that they would rather not take; rather they change individuals’ motivational structure to make it possible for them to do things that they would like to do, but have trouble achieving.

    If we take as a starting point these assumptions, then we may be led to consider seriously whether Project Prevention or a variant of it is worth pursuing.

  5. Apologies for returning to this late, but I just read this latest reply. A problem for me is that number 3 is problematic as an assumption. e.g. my point no. 8 above.

    It is not about coercion into a decision they would rather not take but encouragement into one they might not otherwise have taken – this is compatible with assumption 1, but not necessarily no. 2. And it contradicts the second part of the assumption (makes it possible for them to do things they would like to do…)

    Also – if contraception is free, then the lack of money is no barrier to doing it, even for someone who has none. And if there is a psychological or emotional block about going for long term contraception, then it seems to me that money is not the right way to go about resolving that.

  6. This so-called ‘project prevention’ MAy have been started by someone with good intentions–I dont know. But the way to HELL is paved with good intentions, as the saying goes. And this project is most definately Eugenics, and I urge everyone to do research about this and it will lead you into Nazi Germany.

    This project is heinous. it does not take into account the injustice of our society against people forced into various degrees of poverty, and the crap ‘education’ system which maintains this social division, and the pressures to take drugs, and the so called ‘war on drugs’ that is designed covertly to keep this show on the road. ALl this is not looked into at all.

    Did you know that entheogenic medicines are banned by this culture even though they offer the most drmatic help for all forms of drug habits? YET with this ignore-ance people are being asked to sacrifice their very fertility for a few notes. It is a disgrace, It IS Eugenics!!

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