Offering money to addicts…ethical?

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AbstractIs C.R.A.C.K ethical? An organization that pays drug-addicted women and men to get sterilized is increasingly getting referrals from publicly funded agencies. Its supporters say it's saving babies from being born into hellish lives. But others believe that C.R.A.C.K is taking advantage of addicts by offering them money in exchange for sterilizing them, instead of helping them with their real problem. Decide, ethical or not?Offering money to addicts….ethical?A flier hanging on a pole in ones local neighborhood, at first glance, might look as though it is offering a room for rent or a job. There are phone numbers, dollar signs and tabs for people to tear off and take with them. But this special flier is an offer intended for a specific group: drug-addicted men and women.

The flier reads, "Get birth control, get cash, if you are addicted to drugs and/or alcohol then this offer is for you." While distribution of condoms in particular offers of birth control to drug addicts are common, it also is to stem the spread of AIDS.

But condoms are not what the flier was referring to. Instead, it offers men and women $200 to be sterilized or put on long-term birth control. The group making the offer, is Children Requiring a Caring Kommunity, also referred to as C.R.A.C.K, contends that the program is a humane effort to keep children from being born to women ill-equipped to raise them. Critics counter that it is little more than a bribe to women to make an irreversible decision, and argue that counseling is the best method for both ending drug use and promoting responsible parenthood.

So far, the presence of the group in New York is minimal; it is based in California, and its only chapter in New York consists of a 27-year-old office worker from Brooklyn, who with the help of her husband and another volunteer has posted fliers across the city and held meetings with hospitals and community groups. But if C.R.A.C.K's reception in other cities is any indication, there is likely to be heated debate about the efficacy and the ethics of its offer. "The program is fundamentally incompatible with a health care policy that respects a woman's right to choose," said Donna Lieberman, executive director of the New York Civil Liberties Union. It certainly raises ethical policy concerns for government entities to be providing referrals to this program or endorsing it in any way.

The organization was started in Orange County, Calif., in 1997 by Barbara Harris, a housewife and former waitress, after she adopted four children from the same drug-addicted mother. Children born to drug addicts regularly suffer emotional scars and medical disabilities and end up in foster care at taxpayers' expense, she said.

Why should a drug or alcohol addict get pregnant or get someone pregnant? Barbara Harris watched how her children suffered when she brought them home from the hospital, and she believes no child should go through that. Critics, however, say that C.R.A.C.K's stance is aimed not at helping children but at selective breeding. They point to comments like those Mrs. Harris made in 1998, when she was quoted in the British edition of Marie Claire magazine saying: "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 organization has softened its message, and now refers to itself as Project Prevention as often as it calls itself C.R.A.C.K.

But opponents say C.R.A.C.K's $200 offer misses the real issue, which is helping people get treatment for their addiction. What Lynn Paltrow, executive director of National Advocates for Pregnant Women, is suggesting there are certain neighborhoods where it is dangerous for some people to be reproducing. Bystanders say that what Lynn is suggesting is unethical and that she is accusing them of not being worthy of reproducing. It is very much like the eugenics history in America. The Nazis said if you just sterilized the sick people and Jews you would improve the economy.

When it first started, C.R.A.C.K offered payments on a sliding scale, giving more money to women who chose tubal ligations and men who chose vasectomies than to those who chose long-term birth control like intrauterine devices, Norplant or Depo-Provera. But the criticism was so harsh that the group changed its policy and began offering a flat payment of $200. Women submit such documents as an arrest report or doctor's letter to prove they use drugs. They have the procedure done, usually paid for with government assistance, and then they send Crack written proof.

Brookdale University Hospital and Medical Center in Brooklyn has plans to refer patients recovering in the psychiatric emergency room to C.R.A.C.K, officials there said. The director of chemical dependency services at Lutheran Medical Center in Brooklyn said he was reviewing the program. Dr. Attilio Rizzo Jr., a social worker in Brookdale's psychiatric emergency room, said that the program was "a godsend" and that he had already referred one woman, who did not respond to his offer. A lot of them are homeless and have H.I.V. and are on drugs and they don't want to have any more babies. Dr. Rizzo believes it's up to the individual to make that decision.

The program was introduced to the hospital by Asia Tepper, 27, a Brooklyn resident who heard about C.R.A.C.K on a radio program two years ago and volunteered to run its fledgling local chapter. She spends many evenings and weekends carrying a black bag filled with rolls of tape for the fliers and handouts on the organization and scouting out what she calls "prostitution-infected areas." Tepper believes it's about the children. It's about preventing a child from being born in what is not the best environment. She said she had received favorable comments at police precinct stations and hospitals and from social workers.

But not everyone is lining up to support the program. Dr. Van Dunn, the chief medical officer of the New York City Health and Hospitals Corporation, which oversees hospitals in all five boroughs, said no hospital in his organization would have anything to do with C.R.A.C.K. It raises a lot of ethical questions about trying to pay women and men for sterilization. Reproductive choice should always be an option, and people shouldn't be paid. They should be providing family planning counseling and let them make their decision. Across the country, reaction also has been mixed.

In the San Francisco area, opponents tore down C.R.A.C.K's signs; in Kansas City, billboard companies took down the group's messages after a public outcry. But since May, C.R.A.C.K volunteers in Albuquerque have met weekly with female inmates in the county jail, said Matthew Elwell, programs director for the Bernalillo County Metropolitan Detention Center. And last spring about 30 C.R.A.C.K billboards stood in Detroit, where Mrs. Harris was invited to speak to a predominately black church congregation of 5,000 people. Rev. Charles H. Ellis III of the Greater Grace Temple in Detroit doesn't see the controversy. This is where Mrs. Harris told the congregation that people in the Betty Ford Clinic have some kind of support. In urban Detroit, a lot of time there is no support system for addicts.

C.R.A.C.K has stated that of the 833 women and 21 men nationwide, who have been paid by C.R.A.C.K since its inception, 369 have been sterilized and the others have had long-term birth control. Theresa Prautzsch, 24, an alcoholic who lives in a drug rehabilitation home in Niagara Falls, N.Y., accepted C.R.A.C.K's offer to get Depo-Provera birth control injections last year. It is believed that most drug addicts don't think about having a kid when they are drunk or high. The C.R.A.C.K representatives believes if everyone that has an ethical issue or any issue at all could see a child born from a mother who was under the influence of any drug or heavy alcohol, would rather have the mothers have their tubes tied than have those babies. If anything, it's the smartest thing they can do.

We can all agree that we ought to do what we can to protect the interests of children, but we can go too far. Does preventing the birth of a child protect his or her interests? Should we focus on discouraging drug-addicted women from having babies, or on the drug abuse that is the root cause of questionable decision-making? Programs that combine drug abuse rehabilitation with free contraception might give women the means they need to make better choices for themselves and their children.

Long ago we once determined that no one should be forced to give up their right to procreation, and while offers of payment are not the same as threats of force, both succeed by undermining free decisions. Programs such as C.R.A.C.K. force us to ask just how free we want these decisions to be.

One might ask how this relates to ethical issues in the health care organization. Simple, the doctors/clinics/hospitals ethics are being questioned for performing the sterilization procedures for C.R.A.C.K., knowing that the patients were paid to do it. This issue has brought a couple of hospitals to court, because the addicts have eventually received therapy and cleaned up; but because they were high when they made a decision to be sterilized they now can not have children. Being that these are addicts they might not be thinking straight, they might be just thinking about the $200 they will be receiving, and how the money can get there next fix.

Since, doctors take an oath to what is best for their patients and clinics/hospitals are obligated not only to provide health related goods, but to promote good internally and externally and support it; bystanders seem to think the doctors/clinics/hospitals should help the addict realize they have a problem not encourage them to take money to support their habits. Where if the doctors/clinics/hospitals and C.R.A.C.K would help them get therapy the addicts need, may be the real problem would be fixed. This is where the two types of ethical reasoning come into play: what benefits the doctors/clinics/hospitals the most (Ethical Egoism) or what benefits all involved (Utilitarianism). This is for them to decide given that ethics is the discipline that systematically analyzes and rationally justifies our moral choices (Pellegrino, 1978).

ReferencesBoyle, P.J., Dubose, E.R., Ellingson, S.J., Guinn, D.E., & McCurdy, D.B. (2001). Organizational ethics in health care: Principles, Cases, and practical solutions. San Francisco: Jossey-Bass.

Carnell, B. (2001, December 3). Paying crack addicts not to have children. Abstract Retrieved July 17, 2005, from EquityFeminism.Com database.

Nelson, O. (2001, November 15). Advocate of sterilizing addicts to Toronto. National Post.

Pellegrino, E. Ethics and the Moment of Clinical Truth, JAMA, Vol. 239, No. 10 (March 6, 1978), p. 906-96Vega, C. (2003, January 6). Sterilization offer to addicts reopens ethics issue. The New York Times.