Ethics

As a local GP you are approached by a headmaster concerned about the large number of pregnancies among his sixth formers. He asks if you would be willing to give a talk on use and availability of contraceptives, especially condoms. You are aware of a number of girls coming to your practice requesting abortions, or treatment for their STIs.

You face a request from an opiate addict on your practice list. He asks if you would be willing to ease off on the methadone reduction programme, which he is finding impossible to comply with, and agree to prescribe a maintenance dose of methadone for the foreseeable future.

Your local council has decided to hold an enquiry into developing a red-light zone in one of the nearby suburbs. You are asked to give evidence as a local consultant and resident.

It is the ethical background to these kind of issues that I want to address today.

The Example of Josephine Butler

Let me begin by telling you something about the life of Josephine Butler.[1]

Born in 1828, she was brought up in a well-to-do Northumberland family and made a commitment to follow Christ in her late teens. She married a Durham classics don called George at the age of twenty-four.

After bringing up a family, the couple moved from Oxford to Liverpool where her husband had been appointed headmaster of a local senior school. There, in Liverpool, Josephine started to visit a nearby workhouse at the suggestion of a local Baptist minister. She found she had a natural way of speaking with the women there. Some of them had been prostitutes. One thing led to another and very soon prostitutes dying of disease were invited into her home to stay. After a few months, Josephine decided to expand the work by setting up her own refuge.

One day in 1866 Josephine was reading a report in The Times about the House of Commons' decision to extend the Contagious Disease Act. The Act horrified her. A system of licensed prostitution was to be introduced in eleven designated parts and garrison towns. Any women suspected of being a prostitute was required to undergo a medical examination or face imprisonment. Diseased prostitutes were also imprisoned, and their imprisonment did not require a magistrate hearing but only the signature of a doctor.

The Government's motivation for extending the Act was its concern that so many soldiers had venereal disease. A sick soldier couldn't do his job. A Lancet report at the time estimated that one fifth of the army were in hospital suffering from VD. The average hospital stay was three weeks. The Government's solution was an attempt to control VD, by ensuring a clean supply of infection-free prostitutes.

There was considerable disquiet about this Act. After a campaign meeting in Bristol in 1869, and in view of her well-known concern for the plight of prostitutes, Josephine was asked, and after some heart-searching, agreed to take up leadership of the campaign against the Act. It was not to be an easy fight, not least because it was very rare for women to speak in public in mid-Victorian England. Nevertheless, Josephine set up the society, and put all of her intelligence, charm and practical wisdom at the service of Christ.

Her society drew up eight arguments against the Act, and the first of these was their objection to the State regulation of vice. Josephine called it legalised harlotry. The protest stated 'the path of evil is made more easy to our sons…..as moral restraint is withdrawn the moment the State recognises, and provides convenience for the practice of vice which it thereby declares necessary'. At the time many in society thought that prostitution was essential for the needs of the normal man. In effect, the State was declaring, 'Prostitution is going to happen; we can never banish it from out streets through legislation, so let us limit the damage of VD by keeping our prostitutes as clean as possible'.

I've learnt much from the tenacious life of Josephine Butler.

I've learnt that the rebuttal of evil legislation did not come easily, even in an era which we now look back upon as a high point of Christian influence on the State.

I've learnt that great battles, the victory of which we still now benefit from in our society, were often won not by mass movements of a godly populace, but by the tenacious and prayerful work of vulnerable individuals, often feeling themselves ill-prepared and no match for the fight. Josephine often spoke of the pain involved in taking up the cause. She described 'the restless days and nights, for my heart had been well nigh broken before I felt able to take up the work'. Her campaign ended sixteen years later when the Act was suspended. During this time over 900 public meetings were organised, 520 books and pamphlets published and 17,000 petitions raised.

I also learnt that a policy of 'harm reduction' is not only a recent approach but a recurring theme in Government thinking. If Josephine were alive today, she would be distressed to see that our Government is keen to expand the programme of 'safe areas' for prostitutes in our inner cities.

Doctors as Harm Reducers

Harm reduction is the essence of a doctor's role. We attempt to reduce the suffering and pain caused by our patients' sickness. This suffering is, in turn, a direct or indirect consequence of sin. There are at least three contexts in which a doctor may attempt to soften sin's consequences of sickness and suffering through prevention or cure:

1. The general consequences of the fallen world. Here neither the patient nor anybody else is directly responsible for his sickness. Our patient is suffering because of the curse on all Mankind that follows on from Man's choice to rebel. This consequence was first expressed in the curse of the pain of childbirth in Genesis 3:16. A child with meningitis would be one example of this kind of suffering. A preventative approach might involve immunization against infection.
2. The consequences of another person's sin on our patient i.e. innocent suffering at the hands of evil men. I see this in my paediatric practice in children abused by their parents. Here prevention might be achieved through active surveillance of potential injuries.
3. The consequences of sin committed by the patient himself e.g. treating sexually transmitted HIV disease. Prevention of this category might involve one of two approaches:-
   • to stop the anticipated sin
   • to attempt to limit the consequences of future sin

It is the latter approach that constitutes what is known as 'harm reduction'. This phrase is much used in the press and medical literature these days but a definition is hard to come by. This is in part because the world finds it so hard to recognise and name sin. But this is essential to its definition: 'An activity or policy aiming to limit the consequences of future sin for the individual or society which involves facilitating a person in their future sinful act'

Today our Government is enthusiastically pursuing such 'harm reduction' programmes in at least two areas of health care:

1. The promotion and provision of 'safe sex'.
2. Drug control programmes, which support those unwilling or seemingly unable to leave their addition.[2] They aim to reduce criminal activity, protect abusers from infectious diseases and limit the unwanted effects of the drugs themselves. They include the prescription of maintenance methadone or heroine and stand-by naloxone, as well as the provision of needle exchanges and safe injecting rooms.

I am now going to examine the ethical issues that such 'harm reduction' programmes raise.

Katie's dilemma

To keep the arguments firmly rooted in the real world, let us consider a familiar clinical situation. The ethical principles apply equally to other types of 'harm reduction'. You are a school doctor on your way out of school after a busy drop-in clinic and you are approached by a girl called Katie looking rather desperate. She tells you that she and her boyfriend Tom have had a long talk, sense a growing commitment and wish to go further. They have decided to sleep together tonight (rarely is first sexual intercourse in young people so premeditated or rational). In their haste she forgot to discuss contraception, knows Tom would be useless at remembering and asks whether you can help her out of a difficult situation by supplying a condom.

I want to convince you that it would never be right to supply her with a condom. This is because of what the Bible says about sin - its consequences and the role of a Christian in deterring sinful actions.

Professor Arthur Rendle Short wrote 'If the Christian has definitely come to the decision that the Bible is the Word of God for him, what follows but that it becomes his unfailing guide, which must at all costs be obeyed?'[3] Often, when we take the Word of God seriously it makes for uncomfortable reading. It disturbs our settled living and practice. It challenges us to costly obedience. At first sight some of my conclusions may seem impossibly demanding to our every day practice. At other times they may seem to border on the legalistic and hard-hearted. However, when you absorb the full implications of the practice and consequences of harm reduction, I hope you will see the desperate need for a radical and, I believe, biblical alternative.

Does Katie need our protection?

Whatever her age, if Katie is being coerced by her boyfriend into having sex, then Katie needs help and you should seek her legal protection against rape through the police.

If Katie is under 16 and willingly giving her consent to sex, the law assumes that she does not fully understand what he/she is consenting to (another consequence of Josephine Butler's campaigning). Katie's boyfriend would be breaking the law in having sex with her, unless he believes Katie is over sixteen. Therefore Katie rightly needs your protection as well as your persuasive words. This is rarely sought by health professionals at the moment. The law on the age of consent is often overridden in favour of the so-called Fraser guidelines. These allow provision of contraception without parental consent to those under 16 providing the health professional considers that the child understands the implications of their use and that provision is in their health interests. But you could always assume, as the law does, that no child under 16 is able to consent to sex. In which case you could try to help Katie, preferably with her permission, by seeking her protection through her parents or the police. Sadly, I have usually found police very reluctant to get involved in such a situation. Finally of course, if you knew his name and whereabouts, you could approach her boyfriend to remind him that he plans to break the law. Even an approach without Katie's consent could be justified because of your concern that the law is about to be broken.

Is Katie morally responsible for her actions?

If Katie is over 16, can you be sure she is morally responsible for her plan? Is Katie's plan sinful?

Katie cannot be responsible for what she has never known - at the age of five she knew little, if anything, about sex and was therefore sexually innocent. But as knowledge was given to Katie, her moral understanding has been provided through her conscience, and therefore she became or will become morally responsible and accountable.

Romans 2:15 reminds us that even to the non-Christian 'the requirements of the law are written on their hearts, their consciences also bearing witness, and their thoughts now accusing'. Even the non-Christian has or has had a moral sense of the right context for sex within the lifelong commitment of marriage. It is for this reason that we see taboos about the keeping of sex for marriage across many cultures, Christian and non-Christian, and down the centuries.

Nevertheless, consciences become seared. Katie may no longer be aware that extra marital sex is wrong because of the standards of her peers and family or a daily diet of Eastenders and teenage magazines, which all advocate the acceptability of recreational, ex-marital sex. However, this does not diminish Katie's moral accountability anymore than a drug addict or alcoholic loses responsibility for his regular shots or binges though he may have stopped realising they are wrong. This should remind you of your role in resuscitating Katie's damaged conscience by encouraging her to regain her sense of the right boundaries for sexual intercourse.

Two possible aims

If you accept that Katie has moral responsibility for her plan to have sex (for the sake of the discussion, you establish that she is sixteen), what choices now face you?

There seem to be two chief aims you might have in trying to help this girl:

Aim A

To deter her from her sinful plans. Or to express it another way, to convince her of the goodness and rightness of God's command not to have sex outside marriage.

Aim B

To protect her from the unwanted consequences of having sex - of what we recognise as a sinful act.

I want to ask you what you would do in this situation? Would you try to dissuade her from having sex? Would you give her a condom if this dissuasion failed? I should say that until now I've not had to face exactly such a request - although you may not be surprised to hear that I see more than a few mothers of babies nine or so months after such a decision! I defend my role in setting out these arguments by observing that it is often more difficult to discern the ethical principles of an issue when you are in the midst of an ethical battleground than when you are on its edge.

Whilst issuing a condom may be quick and easy, the route of dissuasion will often be costly, requiring time and energy to go over the issues with Katie. You will need to explain why it is not in her best interests to have sex with Tom including the possible medical, social and spiritual implications. You may need to discuss with her how her desires for intimacy, acceptance and pleasure can be fulfilled in other ways and how she can explain these things to Tom. It may be necessary to find someone of the same sex or nearer Katie's age who can talk convincingly to her about the issues.

If, despite this, she ignores you, there may be further costs involved. You or someone else may have to pick up the pastoral pieces or face her anger especially if she becomes pregnant or catches an STI. You may also incur the anger of your colleagues who see you as an unloving, religious legalist unwilling to help the vulnerable when they ask you for help.

Should we pursue aim A or B or both?

Before looking at biblical perspectives on each of the two possible aims above, here are three general observations about them together:

If you successfully dissuade her, you have also effectively protected her. On this basis Aim B must be subordinate to Aim A.

You cannot wholeheartedly pursue both simultaneously. If you pursue Aim B and give her a condom, you will encourage rather than deter her from having sex, whatever you say to her in dissuasion, because you open to her the apparent opportunity for sex without undesired consequences.

You can never be sure, right up to the point of intercourse, that your dissuasion has failed - never sure enough to be able to say 'sexual intercourse is inevitable, I must give her a condom'. If at any stage you do give her a condom, you may be influencing her decision in favour of having sex.

Biblical perspective on Aim A - Should we deter people from sinning?

God lays down commands for us to obey. 'Whoever has my commands and obeys them, he is the one who loves me' John 14:21. We mustn't leave God's commands behind as we enter the secular and often hostile work environment. Jesus is Lord of our workplace as well as our homes - and in both our obedience to His commands is a sign of our faithful discipleship.

His commands reflect His character 'Be holy, because I, the Lord your God, am holy' Leviticus 19:2. When we obey God's commands before colleagues and patients, we unavoidably reflect His holiness to those around.

God's commands are for both Christian and non-Christian. As we have seen, God's commands reflect His nature. God is God of all earth, and having made a covenant with all people through Noah, God wants all people to obey His commands. Indeed the Law remains 'in these last days', not to make the righteous more aware of their righteousness (which it will constantly fail to do), but to convict and instruct the evil doer of his folly and to protect others by restraining him (see 1 Timothy 1: 8-10). We have a responsibility to non-Christians to encourage them to obey God's commands.

We are accountable to God for influencing the sin of others. 'Woe to the world because of the things that cause people to sin! Such things must come, but woe to the man through whom they come' Matthew 18:7

We are accountable to God both for what we do and what we don't do - for sins of omission and commission. 'Anyone, then, who knows the good he ought to do and doesn't do it, sins' James 4:17

So putting points 4 and 5 together, we have a responsibility, as within our influence, to dissuade people from sinning, and we will be accountable when we don't. The Old Testament Law puts it clearly enough. 'Rebuke your neighbour frankly so that you will not share in his guilt' Leviticus 19:17

Biblical perspectives on Aim B - Should we soften the consequences of future sin?

Whether in banishment of Adam and Eve from the Garden after eating the forbidden fruit, or in the suffering and death experienced by David and his family following adultery with Bathseba, or in the fruit of a godly life, there is a constant biblical theme that actions have consequences. We are accountable to God for our actions and we have to face the consequences.

Bad consequences of sin are contrasted with the good consequences of obedience. These are clearly set out in the blessings and curses of Deuteronomy 30: 15-18

God warns us of the bad consequences of disobedience in order to encourage us to obey. This is one purpose of the above passage from Deuteronomy. Jesus warned the invalid healed at the pool of Bethesda, 'stop sinning or something worse may happen to you' John 5:14

Denial of the sin's consequences is a ploy of the devil to encourage us to sin. The serpent said to Eve 'You will not surely die' (Genesis 3:4) as he enticed her to eat the forbidden fruit

God uses the consequences of committed sins to draw people back to Himself, and the merciful softening of their consequences as a sign of His compassion. The Prodigal Son was drawn back to his senses and back to his father when he saw the pigs eating better than he. His father's enthusiastic rescue showed him how much he was loved despite past rebellion.

But nowhere in the Bible does God reassure us that in anticipation of sinning, we can expect the consequences to be softened. Indeed, God's response is the exact opposite. He warns us of the peril of sin.

In summary, we have a prophetic responsibility to warn patients that their plans are sinful and will have bad consequences. We are often called to demonstrate God's compassion in softening the consequences of sins already committed. However, in anticipation of a sinful act, we have no biblical mandate to soften the blow of an individual's sin on himself. This undermines the necessary deterrent effect of sin's consequences. We cannot say with integrity, 'Warning - you shouldn't do what you are doing - it will appropriately hurt you' and then say 'but if you do it this way, it won't hurt quite as much'. Accordingly, we have no mandate to provide Katie with a condom. Instead we must warn her that her plan to have sex is wrong and will have bad consequences. More positively, we need to encourage her to see the goodness of God's ways by keeping sex until the committed relationship of marriage.

Collateral damage in the Provision and Promotion of Safe Sex

A decision to provide a condom would have other consequences:

1. You have offered Katie the illusion that the condom will protect her from the damaging consequences of sex with her boyfriend. Condoms are forgotten or break, don't effectively protect her from several STDs including warts and herpes,[4] and don't protect the heart from emotional damage.
2. If under sixteen, you are undermining parental authority through applying the Fraser guidelines discussed above.
3. However unintentioned, you have made it known to Katie and her classmates that you are a potential future source of last minute condoms, so long as they hold out for a few minutes against your barrage of dissuasion. You have started on the road from a single pastoral demand to a public service.
4. You, both as a doctor and a Christian, may be (wrongly) perceived by Katie's classmates and school staff to have blessed the sex act.

Of course, there may be collateral damage if you don't give her the condom. If she fails to improvise with a condom from the school toilets or a local chemist, she may get pregnant or catch an STD. But at the risk of appearing concerned about our righteousness at Katie's expense, both Katie and ourselves will be accountable for our own actions when we come before God's judgement throne.

I have alluded to the fact that by giving out one condom in a pastoral setting, we have started a public service. And to be consistent there can be no provision of condoms without publicity about availability and instruction in their use. This line of thinking has lead government organisations like the Teenage Pregnancy Unit to promote safe sex and provide condoms in our schools, youth clubs and wherever else young people (as young as eight) can be given access.[5] Such teaching gives rise to other collateral damage:-

1. It directs resources away from a message of sexual abstinence.
2. It encourages sexual experimentation through exposure to sexually explicit ideas (also encouraged by holding out the false hope of sex without consequences)
3. It associates sex with bad consequences. This is clearly expressed in a quote from Victoria Gillick,[6] 'a girl's fertility and potential for motherhood is represented to her, not as a precious gift of God to be cherished and enjoyed in adult married life, but a curse of nature which only continual contraception, backed up by abortion, can keep under control.'
4. It dissociates sex from a relationship. To quote a non-Christian writer, Melanie Phillips,[7] 'Spiritual and emotional meaning distinguishes human sexual activity from animal behaviour. Genital gratification separated from a permanent loving commitment is a form of degradation.'

But do 'harm reduction' programmes actually work?

Is there any evidence that these policies bring about good results in the areas of safe sex and drug abuse, even if we don't agree with the means of achievement?

1. Teenage Sexual Health

Children in the UK have been the subject (and victim) of a huge experiment. Never have the subjects of sex and contraception been so actively taught from such a young age, and contraception made so widely available. If you believe the promise of its advocates, the safe sex approach should have produced a generation in control of their choices. They may be more sexually active but if so, informed and enjoying it, and able to protect themselves from its 'unwanted' effects.

But are our young people making informed choices? A UK study of 2000 13-15 year olds in 1999 looked at the reasons for first sexual intercourse:-

• 19% were drunk
• 9% were under pressure from peers or partner
• 4% said that they had no choice
• 32% were either coerced or not in full control
• 19% were in love with their partner[8]

First intercourse at this age is typically an unplanned and loveless event, often under pressure, always outside the union of marriage. Not surprisingly many look back on the event with regret.[9] How sad it is to find one of God's richest and most delightful gifts so squandered.

Are they protected? There has been an exponential rise in under sixteen use of contraceptive services.[10] Approximately 14% of all fifteen year olds attend family planning clinics in England. Only 12% say that contraception is difficult to obtain.8 Yet a third of all thirteen year olds, and a quarter of all under sixteen year olds use no form of contraception at first intercourse.8

How effectively have unwanted conceptions been contained? The mean age of first sexual intercourse has fallen by four years for women and three years for men over the last forty years.[11] Yet teenage conception rates have been fairly steady in this country.[12] You may see this as a sign of success. However, there has been a steadily rising abortion rate in the 15-19 age group. Over twice as many such pregnancies are aborted now as in 1970. More often now conception occurs in an environment where the baby is unwanted.

How effectively have STIs been contained? Rates of almost all STIs are rising in all age groups. For the commonest of STIs, Chlamydia, there has been a 20% rise in infection rates each year and about one in ten of all sexually active women under twenty-five are probably infected at any one time.[13] STI services throughout the country are struggling to cope with demand.

2. Drug Abuse

Since the setting up of the Rolleston Committee up by the British Government in the 1920s, 'The British Approach'[14] has been well known throughout the world for its view of the drug abuser as victim of his condition rather than a law breaker. For this reason the state has been willing to maintain drug abusers on heroine or in recent decades methadone, without necessarily threatening to withdraw it in order to wean the abuser off his drug. The extent of such maintenance provision has greatly increased in the last two decades.

Has this approach been effective? Clearly there are other important influences, but as might be expected with such a policy, the number of opiate abusers has risen exponentially from 126 in 1962 to a conservative estimate of 160,000 today.[15]

A major aim of the harm reduction programme has been to reduce criminal activity needed to fund an addiction. However, a recent government report estimated that the yearly cost of each abuser to victims of crime is £30,000 (off treatment) and £9,000 (on treatment) - a total of £3.4 billion each year. The estimated total yearly judicial, social and health cost of drug abuse to the UK is £12 billion or a fifth of the total NHS budget.

So, in summary, has the harm reduction approach been effective at softening the consequences of sin? Not at all - rather it has increased sin and its destructive effects. It is as though we have a leaky dam - we stop one hole, and three more holes appear. Can we and dare we ever undermine God's warning about His wrath against 'all the godlessness and wickedness of men' (Romans 1:18), that having been given over to 'shameful lusts' (26) and 'depraved minds' (28) ' they received in themselves the due penalty for their perversion' (27) ?

An Alternative Approach

What opportunities are there for dissuading people from their sin? Is there evidence that these are more effective? Two recent Triple Helix articles have reviewed projects that challenge people to abstain from sexual activity and drug misuse.

Trevor Stammers[16] highlighted the efficacy of government-funded sexual abstinence programmes in the US and Uganda. There are encouraging reports of the success of individual projects and favourable epidemiological trends in both countries, much of which can be attributed to abstinence education.[17,18] In the US teenage pregnancy rates are falling and the percentage of students leaving high schools as virgins is rising.[19] I have been involved in setting up an organisation called 'Lovewise', which teaches biblical perspectives of marriage and sex within schools and youth groups of the North of England.

In the area of drug addiction, a lady called Maxie Richards provides us with a fine example. In 1990 she was approached by a drug abuser seeking a place to stay for her and her two children whilst she broke her addiction. Maxie invited them into her home and has been doing this ever since - always with the aim of freeing people from addiction, either by a clear timetable of drug reduction, or supporting them through the painful process of immediate abstinence. She has recently set up a residential facility in the Scottish countryside as a stepping stone to learning a trade and finding their feet again in the community away from temptations of urban street life. All six now in this hostel are attending local churches and involved in local prayer groups.

The international Betal homes project[20] challenges drug addicts to withdraw and undergo 'cold turkey' surrounded by the love, encouragement and prayer of other house members. Of those that made it through the first two weeks, 31% remained drug free for more than six months.

And finally there is the result of Josephine Butler's campaign. When the Contagious Disease Acts were introduced 26.1% of soldiers had VD in any one year. Sixteen years later when the Act was suspended the figure remained at 26%. A Royal Commission of 1913 noted that the rate in the army and navy had fallen to 6% after the repeal of the Contagious Diseases Acts. During the first World War only 4% of soldiers had VD.

Conclusion

Jesus had some salutary words about our responsibilities for those whom we care for and have influence over. He addressed it to those who hold up his ways to a desperate and sinful world and do nothing to relieve them from the burden of sin. 'And you experts of the law, woe to you, because you load people down with burdens they can hardly carry, and you yourselves will not lift one finger to help them'. Luke 11:46

I believe we should do all we can to distance ourselves from and argue against 'harm reduction' programmes . But when we do, we may be culpable of as great a sin if we fail to throw ourselves wholeheartedly behind the true harm reduction approach of those programmes outlined above. It will honour God that we do these things regardless of the response that we receive.

But we know, as Christians, that even this is ultimately not enough. Rational warnings about the consequences of sin may not in themselves be convincing. The fallen will usually dominates over the fallen intellect. Something more than persuasive words may be needed to prevent people 'conforming to the pattern of this world' Romans 12:2. Indeed our patient may eventually be worse off if our dissuasion is effective, but one sinful activity is replaced by others with even worse consequences. Remember Jesus' cautionary story of the demon who leaves the house but returns to find it swept clean and habitable, and is then joined by seven other demons. Ultimately it will not be our words but power of the Holy Spirit that will be convict our patients to permanently change course and 'be transformed by the renewing of (their) mind(s)' Romans 12:2.

Our attempts to dissuade may seem feeble and ineffective and will often be met with rejection. But a girl like Katie may remember our loving concern for her predicament, and our determination to go the extra mile in persuasion. She may see a glimpse of the goodness of God's character and love in what we say. Sooner or later the Holy Spirit may convict her of her foolish ways, and her need for the Lordship of Jesus in her life.

Many of you will be familiar with this verse of Charles Wesley's famous hymn 'And can it be….'

Long my imprisoned spirit lay,
Fast bound in sin and nature's night,
Thine eye diffused a quickening ray,
I woke, the dungeon flamed with light,
My chains fell off, my heart was free,
I rose, went forth and followed thee.

Can our persuasive words to Katie and others in the bondage of sin be that quickening ray, that marks the dawning of God's grace on their lives? And what about those chains? Have we been guilty of softening the shackles of sin, thereby making prison life more comfortable? Or have we, in contrast, had the deep satisfaction of helping the shackle of one particular sin fall off the prisoner? Or greater still, experience one of the deepest joy of the Christian life by watching all these chains fall off, and a free heart walk out of the prison door to a life of faithful service to Christ?