Friend of 'sinners'?

Thank you for publishing Dewi Hughes's thoughtful article on harm reduction strategies. His theological view is refreshingly practical and much needed, addressing useful examples from my field of work: sexual health. It sometimes feels there is no area of medicine more likely to call forth criticism from Christians than sexual health (and its earlier incarnations: GU medicine, family planning, etc). Adolescent sexual activity is increasing worldwide in most societies. Limiting the damage caused by unwanted pregnancy or sexually transmitted infections is worthwhile, and NHS campaigns do invite young people to consider whether they are ready to be having sex, and if they could say 'no' (see eg www.ruthinking.co.uk).

Jesus spent much of his time associating with the weak and vulnerable, and rather than judging them, met these people at their point of need with wisdom and compassion. My prayer is for God to enable me to treat people with respect and care, to be aware of spiritual needs, and to know when and how to challenge unhealthy choices and behaviour and refer on where necessary, including when there are concerns about child protection.

Rachael Pickering is a police surgeon in North Yorkshire:

Congratulations to Triple Helix and to Dewi Hughes. The other side of the harm reduction debate has been given prominence at the CMF National Conference and subsequently in print,1 so it was encouraging to read a pro-harm reduction piece. Dewi got to the heart of the matter: 'Is it possible to call ourselves the friend of a drug addict...while refusing to countenance any harm reduction strategy?' I agree that the answer is 'No!'

I haven't yet swopped my silver Fishy Badge for a rubber WWJD Bracelet2 but actually it would be better because I often forget to ask, 'What would Jesus, the Friend of "Sinners",3 want us to do with this patient?' He would surely tell us to be true friends, albeit professional ones: to listen, and offer support and advice; to stick by our patients in spite of the fact we don't agree with their lifestyle choices; and, while not doing anything designed to hurt them, to help our patients get out of their tricky situations.

Regardless of what national statistics may (or may not) say, I have seen that, deployed in the right way, harm reduction techniques can be truly life-saving. Patients and their families can and do gradually get out of their 'dark corners' and walk into brighter, safer places in the world.

What the harm reduction machine needs is an influx - rather than an exodus - of Christian practitioners. It is both interesting and sad that most of its critics work outside the specialties where it is most needed and deployed. We fear most what we do not know or understand. To remedy this, perhaps those with doubts could spend a week's study leave shadowing CMF members working in these hard places?

Newcastle consultant paediatrician Chris Richards began this debate. He maintains that 'harm reduction' is really harm promotion:

Dewi Hughes offered a biblical defence of harm reduction strategies, which I had rejected in the 2003 Rendle Short Lecture. I take issue with his definition and the biblical basis of his conclusions. First, he did not critique these strategies as I defined them - 'policies or activities which attempt to soften the consequences of future sinful behaviour'. Such strategies must be distinguished from a) preventative medicine, attempting to reduce future harm through legitimate interventions; and b) medical care for patients suffering because of their own past sins.

He, nevertheless, proposes that doctors can sometimes legitimately be a 'friend to sinners' through harm reduction programmes. We can only follow in Jesus' footsteps if we walk as he did in humble obedience to his Father's will.[4] Jesus never promoted sin when he befriended prostitutes and outcasts but on the contrary told them to 'sin no more'. [5] [6] God's law enables us to distinguish approaches that heal from those that harm. We cannot do good by encouraging wrong.

Dewi implies that if we refuse harm reduction, we are responsible for the moral decision of our patients if they go ahead and suffer the consequences. However, it is not us making the decision, but them. The real situation is quite the opposite - we would be wrong to aid and abet their sinful action. He seems to view preservation of life as the ultimate ethic; our supreme responsibility is to honour God through obedience to his commands.

Medical studies affirm the biblical sanction. There is much evidence that condom provision to the unmarried, needle exchanges [7] and methadone replacement [8] to drug abusers have each failed to produce the expected benefits, but rather made matters worse. Why do harm reduction strategies actually promote harm? First, they attempt to reduce the effects of sin, thus making sinning more attractive, so encouraging further sin and suffering as a consequence. Since the 'safe sex' message, sexual activity has risen in teenagers, partly because they think they can sin safely. This has in turn led to a rapid rise in sexually transmitted infections and abortions.

Secondly, health professionals resign themselves to sinful action and so stop trying to change sinful behaviour. Education programmes promoting 'safe sex' rarely include any substantial challenge to consider abstaining from sexual activity outside marriage. Thirdly, trusted state-employed professionals affirm sinful behaviour and give official legitimacy to sinful actions.

Dewi states most doctors cannot warn patients not to sin. Most doctors would warn patients about alcohol excess; it is society's moral sensibilities that deter us regarding sexual immorality. Such warning is more likely to cause offence - for this reason we need wisdom in doing it. We may have to be content with the powerful witness which ensues from our refusal to take part in such programmes, but surely we must 'fear God rather than man' as we refrain from promoting sin.