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Editorials

Chemical castration for sex offenders

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c74 (Published 12 January 2010) Cite this as: BMJ 2010;340:c74

Primum, non nocere (First, do not harm)!

Despite the lines of argument followed in the editorial by Don Grubin
and Anthony Beech (1), it is most perplexing to find the English Health
System expressing support for a legislative initiative meant to authorise
the prescription of a pharmacological therapy based on antiandrogenic
drugs to volunteer patients recruited from among individuals found guilty
of sex crimes.

Apart from any side effects that a similar protracted (chronic)
pharmacological therapy would inevitably have on the patients who
volunteer to undergo it, (1), what proves chilling is the thought that, by
backing a similar initiative, an institutional body whose very title
contains the qualifier “health” has approved a stark reversal of what
should be the natural outlook in the practice of medicine.

For, as has been clear since the time of Hippocrates, the physician
is never to act against the interests and the wellbeing of the patient.
The physician is the trustee of the patient who seeks to be healed,
meaning that the healer’s sole professional responsibility is to cure the
patient, for the wellbeing of the latter, drawing every available skill
and knowledge while following the highest standards of professional
conduct. Nature provides the physician with the definition of the best
interests of the patient: the undiminished wellbeing of all his or her
organic functions. This optimal condition is the rule, with individual
parts to be sacrificed only when necessary to keep the organism as a whole
alive (2). But such a need should always be personal rather than social in
nature. Otherwise, given the enormous problem posed by demographic growth
in certain geographic regions, it would only follow that approval should
be extended to measures such as nationwide programs of chemical castration
or to the preventive abortion of female foetuses: both aberrations that
clash not only with the Hippocratic principle of “nil nocere”, but also
with the liberal principles universally accepted by democratic states.

It could be objected that, in the case in point, the patients have
consented to the treatment. But, while this is technically true, there can
be no denying that consent to a pharmacological therapy based on
antiandrogenic drugs by an individual suffering from a tumour of the
prostate, and not subject to incarceration, is quite a different matter
from consent to the same therapy by an inmate who has been presented with
the alternative of continued limitation of his personal freedom. It is the
barter between “diminished health/freedom” implicit in this and similar
proposals that proves offensive to the dignity of the individual offered
the alternative: offensive because it constitutes an abuse of the
condition of objective inferiority in which the inmate, though convicted
of a despicable crime, finds himself.

At the Nuremburg trials, the attorneys for the defendants are said
(3) to have embarrassed the United States experts for the prosecution by
reminding them of experiments carried out on healthy inmates by a number
of American physicians. It goes without saying that experiments of the
kind carried out by the American doctors were incontestably different, in
terms of both their objectives and procedures, from those performed by the
Nazi physicians. Nevertheless, underlying both positions is the same
unsettling mentality that runs counter to the best interests of the
individual, at the same time lacking a solid grounding in any ethical-
legal principle other than the utilitarian criterion of the greatest good
for the greatest number of people.

Such a mentality would appear to be at the root of the increasingly
frequent calls for more extensive freedom for administering
pharmaceuticals, apart from any therapeutic benefits corroborated by
medical evidence, to certain categories of individuals, such as inmates.
The same panel of studies cited by the authors (1) demonstrates that there
is no consensus opinion in the literature on the effectiveness of the
various therapeutic protocols proposed; indeed, certain reviews argue that
there is no scientific evidence to support of the chemical castration of
inmates convicted of sex crimes (4).
And so the contention that the treatment works to the advantage of the
inmate, the idea that the convicted criminal redeems himself in the eyes
of society through a voluntary gesture of reparation – though, in reality,
this amounts to nothing less than an (in no way unconstrained) acceptance
of mutilation sine die, albeit a merely pharmacological mutilation, as
well as the essentially replacement of a punishment handed down by the
legal system with a pharmacological punishment consisting of (forced,
because there is no alternative) acceptance of the risk of damage to one’s
health inherent in treatments with antiandrogenic drugs, all represent
pseudo-humanitarian alibis that utilise, under a logic of greater or
lesser returns, a form of punishment already questionable in its own
right, employing it in the name of a indeterminate collective good.

Medical science is indeed called on to provide society with support
in identifying the best possible approach to take in treating criminals
who present a high risk of repeating their crimes, but this support cannot
result in a castration of the physician’s therapeutic principles, which
rest, first and foremost, on the rule of not diminishing the individual’s
wellbeing, but rather respecting the dignity of whomever is to be treated.
Such respect means not only obtaining the patient’s consent, but, even
more to the point, ensuring that such consent has been given free of
constraint and without consideration of factors of a merely utilitarian
nature

References

1. Grubin D and Beech A. Chemical castration for sex offenders. BMJ
2010; 340: c74;

2. Hans J. Technick, Medizin un Ethik. Zur Praxis des Prinzips
verantwortung. Suhrkamp (German), January 1, 1987;

3. Cahiers d'Action Religieuse et Sociale, Paris, 15.02.1953, 103;

4. Heim N, Hursch CJ. Castration for sex offenders. Treatment or
punishment? A review and critique of recent European literature. Arch Sex
Behav 1979; 8:281-304.

Competing interests:
None declared

Competing interests: No competing interests

04 March 2010
Giuseppe Vetrugno
Medical Directorate
and Fabio De Giorgio
Policlinico Universitario "A. Gemelli", 00168 Roma