Clean Razors For Women Who Cut Themselves? What Happened to First Do No Harm?

Physicians long ago abandoned the Hippocratic Oath, for at least the reason that its call for physicians not to cause harm went against the modern acceptance, and even boasting, of killing. Which is to say, abortion and suicide, assisted other otherwise, were not countenanced in the old oath, but they are well loved today.

But harm doesn’t include only death. What about those physicians, or rather medical professionals, who maim women for religious reasons? And what about those knife wielders who, for example, chop off various useful or otherwise healthy body parts of patients by patient request?

And what about those associated with medicine who give clean needles to heroin users? The argument for this largess is that heroin users, were they to use dirty needles, are apt to contract hepatitis or some other disease; therefore, the clean needles (when they are used) will stop infections.

The argument is valid: if dirty needles carry disease and clean ones don’t, supplying clean ones will cause a reduction in disease rate (naturally, heroin users won’t always, in the hunger of the moment, use the new needles). And this has been seen.

But it is also so that the clean needles will encourage folks to take heroin, or other drugs, and that heroin causes harm, and that when under the influence of heroin (and other drugs) harm is often caused to the user and others. So the physician, while creating a barricade for one harm, clears the path for others. How can we calculate the total harms, with and without clean needle programs?

Enter the peer-reviewed paper “Should healthcare professionals sometimes allow harm? The case of self-injury” by Patrick J Sullivan in the Journal of Medical Ethics.

This is being talked of as the “clean razor” paper, because Sullivan would supply clean razors to the (mainly) women who habitually cut themselves. The paradigm case:

Alison is 35 years old and has a long history of mental health problems. As a teenager, Alison started to cut herself and this has continued. In conversation Alison describes how she started to self-injure almost by accident and found that it made her feel better. Her self-injury follows a particular pattern and she becomes anxious and distressed if prevented from acting in this way. She describes wanting to stop and understands that there are better ways of coping but at the moment cutting is her preferred means of dealing with feelings of distress…

The proposed solution:

Rather than trying to stop Alison cutting herself the clinical team has agreed that she be able to access clean razors for her own use and that staff should work with her to help her understand how to injure herself more safely.

Nick the wrong blood vessel, and you bleed out. Use a dirty razor and open yourself (a bad pun?) to all kinds of diseases. Give Alison clean needles and a copy of Gray’s Anatomy and her opportunities for contracting diseases are lessened (but not eliminated), as are her chances of cutting the wrong thing at the wrong time.

Since she is being supplied by what she wants, in equipment and guidance, she might be encouraged to continue slicing herself open. Perhaps at a higher frequency than when she was doing it the old fashioned way. And if she cuts herself more often, she increases the opportunities for disease and death.

Objections? Sullivan considers, “It could be objected here, that self-injury is not an autonomous choice and therefore the decision to engage in such behaviour should not be respected, even less valued.” But this cannot be so, since it is by free will that self-injury occurs. How about plain counseling? Doesn’t work, he says.

…Furthermore, even if the choice to self injure were not autonomous, their [sic] still remain moral and clinical questions about the means used to prevent such behavior. Enforced interventions are often ineffective and are certainly perceived negatively.

Significant infringements on basic freedoms are likely to produce a confrontational rather than therapeutic environment that increases levels of distress and reduces the chance of a positive outcome in the longer term. In such circumstances attempts to take away someone’s ability to self-injure reduce their coping options and are likely to increase their distress or increase the risk of harm. For example, it must be noted that many individuals who self-injure have a history of abuse or trauma and preventative measures may increase their feelings of powerlessness and in extreme cases result in additional trauma and therapeutic alienation.

All of this is highly disputable, especially given the statistical nature of the claims. However, we’ll forgo those criticism here to concentrate of the “pro self-harm” arguments.

Sullivan says, “Self-injury is being allowed, in order to maintain its role as a coping mechanism, based on the understanding that this occurs safety [sic].” It isn’t occurring safely, a major flaw in his argument. Self-injury by definition is the opposite of safe. Clean needle programs are invoked, though Sullivan does admit others “note that it encourages drug use, it sends a mixed message and it fails to get people off drugs. Whether it is cost-effective and its validity as an appropriate treatment have also been questioned.”

“Where the risks of serious injury are low limitations on basic freedoms are more difficult to justify.” This is easy to write, but tell it to a mother whose teenage daughter sneaks off to slice herself open. It’s doubtful the mother will love the “freedom to cut” argument.

The argument Sullivan relies on most is that stopping a person from self-injury removes this person’s way of “coping.” But then this person also has to cope with the cutting, and from the stress of hiding this (as is usual) from others, and from other worries associated with the cutting. And then it does not follow that self-injury is the lone way a person can cope with life.

7 Comments

  1. If I’ve parsed your grammar as you intended, something of which I am less than fully confident, you seem to make the claim that being in possession of clean needles “encourages” the possessor to inject himself with heroin or another injectable drug of abuse. This seems counter-intuitive, but I will accept it if there is sufficient evidence for it. Can you take the trouble to supply some links to a couple of studies that support this? There is certainly an abundance of anecdotal evidence against the proposition. I have been in possession of fresh, clean syringes, but was not overcome by an urge to go on an opioid bender. Every day millions of doctors and nurses handle clean needles (the ones not working in Mother Theresa’s torture chambers, at least) and most of them do not become heroin addicts (although some do). In light of common knowledge, some data supporting your claim would be interesting.

  2. Lee: The claim is clean needles will encourage heroin users to use more and longer—NOT that it encourages everyone to become a user.

    This is much like an argument I read once about so-called multiple chemical sensitivities (and we can throw in Morgellan’s, gluten intolerance, chronic lyme disease and numerous other “diseases” that people often self-diagnose to explain something they did not want to be their fault)—At the time, it was argued you wouldn’t let someone believe there were huge silver spiders living everywhere in their house. It wouldn’t be humane. Now, humane is leaving people in tortured mental distress but giving them clean needles and razors. (Or in the case of the spiders, leaving them with antibiotic and spider bite kits in case the imaginary spider bites them.) Like giving the homeless their very own shopping cart. What’s next? Medicine has been taken over by sadists and torturers who love defective people and are pleased to keep them that way.

    (Note: I have sensitivities to specific chemicals and will react to others just because one’s brain gets carried away. I never discount the psychological nature of many of the reactions and try to ferret out which is real and which is not. Never would I utter the excuse of “multiple chemical sensitivities—I have a list that is verified by experiment mostly. I also know that not all medicine and doctors are bad, but the number of sadists and torturers seems to be increasing. Telling people they are broken and here’s a clean razor blade is just outright evil and wrong. This is NOT medicine, it’s torture of the population. It’s leaving someone in dire straits—like watching someone with a broken leg drag the leg around but giving them aspirin and saying orthopedic surgery is unnecessary because the person is doing fine limping. Then convincing the person limping is what he wants to do. Or the idea that deafness is a “gift” and should not be corrected. What next? Cancer is gift? Insanity is “gift”? Science has lost all credibility.)

  3. This boils down to the common Argument “They will do it anyways, lets make it safe.” This is a Liars argument. It means the Arguer is in favor of the Action but cant admit it, either to Himself or Others, Sloth or Malice. Whether it is Sloth or Malice depends on whether or not They are actively aiding or passively enabling the Action.
    These so called Doctors are no better then Witches handing out poisons as well as cures whenever it pleases them.

  4. Consider this ‘Either/Or’ ethical dilemma regarding treatments of a mentally ill patient:

    1) Implement a course of treatment that will improve the patient’s long-term outcome without making things worse; or,

    2) Implement a course of treatment proven, in many cases, to be more damaging in the long run (if chosen, whether this course of treatment will be more harmful in a given case is only known after it is too late).

    Which is better*?

    Put that way, option #1 seems like a slam dunk no-brainer.

    * Chris Sterling, publishing in Linkedin, noted the above dilemma in his first paragraph (see his article, “Should we enact our duty of care to prevent people from self-harming?” Feb 20, 2017).

    Is that the core ethical dilemma Briggs is debating, or, is Briggs taking a mere element of that dilemma out of context, or too far out of context, to make all the relevant factors clear?

    He does present the negative effects, but without clarifying just how bad they can be, presenting only some of the academic gobbledygook jargon from the paper somewhat devoid of its clear implications — facilitating a different interpretation within the overall context presented (kind of like a magician using distraction & sleight of hand to hide). Is that presentation style ethical?

    THEN, there’s the familiar logical flaw of sweeping generalizations:

    “Physicians long ago abandoned the Hippocratic Oath, for at least the reason that its call for physicians not to cause harm went against the modern acceptance, and even boasting, of killing. Which is to say, abortion and suicide, assisted other otherwise, were not countenanced in the old oath, but they are well loved today.”

    SEE ANY QUALIFIERS THERE…there are none (and none in the larger story). Its ALL physicians guilty of the sins cited … only that’s patently false. Most physicians do not practice abortion, fewer assisted suicide (the latter being negligibly small). There’s probably data out there identifying how many physicians who don’t do those things are personally/morally opposed to them. According to Freakonomics, some 97 percent of ob-gyns have been approached to perform an abortion, but only about 14 would (1,144 surveyed; http://freakonomics.com/2011/08/24/abortion-is-legal-but-what-percentage-of-ob-gyns-will-provide-one/). Presumably that’s factually reported, the sample size seems credible enough … but per Briggs, the class called “physicians” is presented as absolute. Are such uses of the sweeping generalization fallacy by Briggs ethical presentations?

    The Hippocratic Oath states, at its essence, ‘first do no harm’ — is a physician who allows a mentally ill patient with a cutting compulsion to continue doing what they’ve been doing, but under safer conditions AND medical supervision, doing, or not doing, “harm” — especially when we KNOW that denying the continuance of the compulsion outright IS the key factor that creates, in many enough cases, added harm? That is practically a rhetorical question, not a moral dilemma.

    (Compulsions are NOT “free will”; those afflicted with obsessive compulsive disorder – e.g. excessive hand-washing, etc. – for example, know their behavior is unreasonable and even harmful, but cannot control themselves. Neuroscience has proven, neuroplasticity, physically “rewires” the brain and thereby facilitates such compulsions, including food cravings when one goes on a diet; this is something physically tangible that can be measured/seen)

    He also asks, rhetorically, sort of, “What about those physicians, or rather medical professionals, who maim women for religious reasons?”

    “If your right eye causes you to stumble, gouge it out and throw it away. It is better for you to lose one part of your body than for your whole body to be thrown into hell. And if your right hand causes you to stumble, cut it off and throw it away. It is better for you to lose one part of your body than for your whole body to go into hell.” – Matthew 5:27-30, quoting Jesus

    In those days, that type of punishment wasn’t unusual (they still amputate hands of criminals in some places today) so a literal interpretation seems reasonable…though today its argued by some that was said in hyperbole. Though that seems a bit hard to swallow given the subsequent remarks about being saved to heaven incomplete vs going to hell whole. Not to mention Mark 11:12–14, where Jesus killed a fig tree for not having figs for him to snack, ‘because it was not the season for figs.’ If a fig tree wasn’t bearing figs exactly when it wasn’t supposed to — as Jesus’ Father designed fig trees — and Jesus killed it anyway, why wouldn’t we believe his literal remarks about entering heaven bodily mutilated by our own hand?

    Seems like the wrong question was posed, “What about those physicians, or rather medical professionals, who maim women for religious reasons?” should be, “Why aren’t more physicians maiming, or, treating patients who’ve maimed themselves, for religious reasons?”

    Consider how many “Christians” maintain a belief in the literal words of the Bible (6000 yr old Earth, etc.), surely some proportion of them ought to be hacking away at themselves (or getting a physician to) … but that’s extraordinarily rare. Why is that?

  5. The underlying truth is that we simply have almost no understanding of mental/emotional illness — and literally none-at-all of how to cure it.

  6. We have some understanding, Kip. But ya’ can’t do double-blind studies on individual human beings! In other words, the science is complicated by lack of controls.

    The idea that this is some dire portent is ridiculous. It’s similar to the way conservative bash college and university campuses, using the occasional anecdote to impugn the entire system.

    JMJ

  7. JMJ. I wonder how many observations of “loonism” in Liberal Arts departments of major universities it requires to move those observations from anecdotal to empirical. Perhaps there could be some worth to a regression analysis of the subject, (LOL).

Leave a Comment

Your email address will not be published. Required fields are marked *