Harm Reduction

I have always been suspicious of zero-tolerance; it implies intolerance as much as anything else. A thousand people crossing a bridge, are a thousand people crossing a thousand bridges… We are simply not all the same, nor are our worlds, our needs, our perspectives. And even if some issue could be proven beyond a reasonable doubt, there would always be those for whom it was still not acceptable -or even relevant. Our views are just not theirs.

Many of us see things through cultural and socioeconomic lenses, parental filters, and with confirmational biases in full bloom, assume that we have good and verifiable evidence: what we accept is universally applicable, validated and therefore reasonable.

This leads to various problems, both ethical and legal however. Take smoking as an example. If we accept -as most of us do- that smoking is a major health hazard, what should we do about it? What can we do about it? Well, at least two options suggest themselves. We could ban cigarettes outright, make them illegal -zero-tolerance- much as we do for other undesirable drugs.  Or, in Canada (or any other country with universal health benefits), we could sell the cigarettes (and profit from the sales) but deny tax generated health benefits to smokers with conditions caused by the cigarettes… Even if the smokers are themselves contributing to those taxes.

Perhaps a better and more useful, more benevolent approach might be to change societal attitudes towards the problem: make it unfashionable, undesirable, say, to smoke. This is widely seen as the answer nowadays -albeit a plodding and often unpredictable approach. The results are slow in coming, and often different from what we had originally intended. And there is the ever-present danger of intolerance and prejudice -a new, self-righteous view of the way things should be…

I see this in obstetrics. Alcohol, which in other circumstances is acceptable -even the norm- is very much stigmatized in pregnancy. There are certainly many good and evidence-based reasons for concern -the Foetal Alcohol Spectrum Disorder (FASD) among the most serious of them. And the fact that there is no unequivocal evidence of a threshold for alcohol intake below which it is safe in pregnancy adds to the worry of both doctor and public alike -to say nothing of the mother. Clearly, it would be safest for mother and foetus not to consume alcohol at any level.

But how realistic is this? I advise my pregnant patients not to drink, and yet I try to do it in a non-judgemental fashion; the last thing I want to do is make it difficult for them to talk to me about it. Many are reluctant -even ashamed- to admit their alcohol consumption for fear of criticism or censure. And in hospital, they are even afraid of their baby being apprehended if their behaviour were detected and judged by someone in authority.

One way to approach the problem is routine screening of all patients for alcohol consumption -letting them know that this is standard practice, not a judgment. This is helpful in many ways: promoting awareness of the problems sometimes seen in pregnancy with alcohol, and dealing with what might be termed ‘problem drinking’ early so that a reasonable plan can be formulated.

The standard brief intervention -and endorsed by the SOGC (Society of Obstetricians and Gynaecologists of Canada)-is simple, brief, and helpful: Assess, Advise, and Assist -quite self-explanatory, really. But it does not equate to zero-tolerance of alcohol in pregnancy -that would alienate, not assist. Those that had an alcohol problem would simply not admit it for fear of censure or the other ramifications that attend suspected, or potential foetal abuse…

No, we must aim for harm reduction, and set realistic and achievable goals if we truly want to help. Yes, it’s a compromise, but one that will likely keep the woman in antenatal care. The important thing is trust; if she feels she can talk to me about things and that I won’t judge her unfairly if she admits to issues that usually engender societal censure, she is more likely to be amenable to suggestions, maybe even motivated to change or modify her behaviour.

At least this is what sustains me in those hours between dusk and dawn when, sleep denied, I try to convince myself that anything is possible… That someone is actually listening.

Ignorance is the curse of God; knowledge is the wing wherewith we fly to heaven.

I can only hope.

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