Harm reduction is the essence of a doctor's role. We attempt to reduce suffering and pain caused by sickness. Today our Government is enthusiastically pursuing 'harm reduction' by the promotion and provision of 'safe sex' and drug control programmes, which support those unwilling or seemingly unable to leave their addiction. Such 'harm reduction' programmes raise important ethical questions.
Let us consider a familiar clinical situation. You are a school doctor on your way out of school after a busy drop-in clinic. A sixteen-year-old girl called Katie looking rather desperate approaches you. She tells you that she and her boyfriend Tom 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 by supplying a condom.
I will now set out the arguments to support my conviction that it would never be right to supply her with a condom, based on 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?' Often, when we take the Word of God seriously it makes for uncomfortable reading. It disturbs our settled living and practice. 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.
Is Katie morally responsible?
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. The Apostle Paul argued that all humans have 'the requirements of the law written on their hearts, their consciences also bearing witness, and their thoughts now accusing'. (Romans 2:15) I suggest, then, that even someone like Katie, as a non- Christian, has or has had a moral sense of the right context for sex.
Nevertheless, consciences become seared. Katie may no longer realise 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. My role as a Christian will include resuscitating Katie's damaged conscience by encouraging her to regain her sense of the right boundaries for sexual intercourse.
Two possible aims
If I accept that Katie has moral responsibility for her plan to have sex, what are the options available to me? There seem to be two main aims I might pursue:
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.
Now what would you do in this situation? Would you try to dissuade her from having sex? Would you give her a condom if this dissuasion failed? I suggest that 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 also 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 the biblical perspectives on each of the two possible aims above, here are three general observations about them together. Firstly, if you successfully dissuade her, you have also effectively protected her. On this basis Aim B must be subordinate to Aim A. Secondly, 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. Thirdly, 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.
Now let's briefly identify some biblical perspectives that might inform these aims:
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)
- His commands reflect his character. 'Be holy, because I, the Lord your God, am holy.' (Leviticus 19:2)
- God's commands are for both Christian and non- Christian. (see 1 Timothy 1: 8-10)
- We are accountable to God for influencing the sin of others. 'Woe to the world because of the things that cause people to sin!' (Matthew 18:7)
- We are accountable to God both for what we do and what we don't do. 'Anyone, then, who knows the good he ought to do and doesn't do it, sins.' (James 4:17)
So 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)
Aim B: Should we soften the consequences of future sin?
- Actions have consequences (see Genesis 3) such as the events following David's adultery with Bathsheba (2 Samuel 11ff), or the harvest of a godly life.
- Bad consequences of sin are contrasted with the good consequences of obedience (see Deuteronomy 30: 15-18)
- God warns us of the bad consequences of disobedience in order to encourage us to obey (as per the above passage). Jesus warned the healed invalid, 'stop sinning or something worse may happen to you'. (John 5:14)
- Denial of sin's consequences is a ploy of the Evil One to encourage us to sin. (see Genesis 3:4)
- God uses the consequences of sin to draw people back to himself and the merciful softening of their consequences as a sign of his compassion, (see the Prodigal story, Luke 15: 11-32).
- Nowhere in the Bible does God reassure us that in anticipation of sinning, we can expect the consequences to be softened.
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 deterrent effect of the consequences of sin. 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:
- 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 STIs including warts and herpes, and don't protect the heart from emotional damage.
- 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.
- Katie's classmates and school staff may (wrongly) perceive that you, a doctor and a Christian, have blessed the sex act.
There may of course be collateral damage if you don't give her the condom. She may get pregnant or catch an STI. 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 and must give account to God.
By giving out one condom in a pastoral setting, I suggest 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.
Such teaching gives rise to other collateral damage:
- It directs resources away from a message of sexual abstinence.
- It encourages sexual experimentation through exposure to sexually explicit ideas (also encouraged by holding out the false hope of sex without consequences).
- It associates sex with bad consequences.
- It dissociates sex from a relationship.
Do 'harm reduction' programmes work?
Or to put it another way - is there any evidence that these policies bring about good results even if we don't agree with the means of achievement?
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. But are our young people making informed choices?
A UK study of 2,000 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
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.
Are they protected? There has been an exponential rise in under sixteen use of contraceptive services and only 12% say that contraception is difficult to obtain. 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.
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. Yet teenage conception rates have been fairly steady in this country. 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. STI services throughout the country are struggling to cope with demand.
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.
This article is abridged. The full text is available on the CMF website at: www.cmf.org.uk