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Harm Reduction, Not Enough

Tolstoy’s Kreutzer Sonata begins with a conversation among passengers on a train about the growing permissiveness on divorce in Russian society. But it quickly turns into an extended philosophical monologue about sex and marriage. Pozdnyshev, the protagonist, anxiously reflects back upon his relationships with women – including his wife whom he eventually kills. Pozdnyshev initiated his liaisons not out of an overpowering love for a single woman, but in compliance with convention. It all begins as half-hearted indulgence. No one discourages him from this course of action; on the contrary, respectable members of society encourage him to do so. What about disease? Not to worry – the doctors are taking care of that. Passion soon rules him.

He becomes utterly tormented by the “abyss of error in which we live regarding women and our relations with them.” His anguish far exceeds the mysterious phenomenon Aristotle observed long ago: post coitum omne animale triste (after intercourse, every man is sad). One of the most memorable characters of Larry McMurtry’s novels about the American West, Texas Ranger Augustus McCrae, recognizes a truth in that adage, and wishes that Aristotle – “that old man who talked about it to begin with” – had explained why this was so. But this is mere passing sadness.

Pozdnyshev, on the other hand, needs to assuage deep internal suffering brought about by an acute awareness of his dissolute life. The answer to this problem, for Tolstoy, is to be found not in the Redeemer and reconciliation, but in the renunciation of what he views as the source of the problem: the sexual act itself. Pozdnyshev can only now feel outright disdain for it, even going so far as to call it “unnatural.” Here Tolstoy goes off the rails, and with misguided zeal proselytizes for the Manicheanism that St. Augustine himself held prior to his conversion to Catholicism.

But interspersed throughout the short story, published in 1889, Tolstoy does make some arresting observations about the efforts of authorities to contain lifestyle-related diseases. These are of great contemporary relevance, and cannot be so easily dismissed.

He is critical of what today would be called “Harm Reduction” measures – the default approach of the public health establishment – which studiously avoid the moral and spiritual implications of behavior, and generally refuse to encourage risk-free behavior.

“You are not living rightly, live better,” Tolstoy observes, is something you cannot say to others, or even admit to yourself.

Our own non-judgmentalism – inescapably a judgment itself – is not so new after all.

Harm Reduction measures do not necessarily convey neutral messages. Tolstoy implicates “paternal government” that seeks to make profligacy safe, as well as doctors, the “priests of science” who benefit financially from offering pills or devices that “safeguard vice.” The net effect: “they organize proper, well-regulated debauchery.”

He could easily be describing the World Health Organization (WHO). Or George Soros’ Open Society Institute (OSI).

They would be more accurately described as cultural institutions rather than medical or health institutions when it comes to dealing with lifestyle diseases. Like most other national and local bodies or NGOs, they have essentially become vehicles through which the creeds of scientific materialism, radical individualism, and non-judgementalism are promulgated. That is why Tolstoy’s word “debauchery” startles us today – its use is more unacceptable than the acts it describes.

Technological fixes are manifestly not the solution to Russia’s staggering population implosion and multiple health crises. Demographer Nicholas Eberstadt points out that Russia’s astonishingly high rates of cardiovascular disease, accidents, and poisonings are each deeply influenced by massive alcohol consumption. Russia’s HIV epidemic, one of the fastest growing in the world, is fueled in large part by injecting drugs, such as heroin.

Soros’ OSI, and many others, agitate for Russia to reverse its ban on methadone – classified as an “essential” drug by the WHO – and other opiate based “replacement” drugs such as Buprenorphine, as a means of minimizing exposure to contaminated needles. But that is the last thing Russia needs. Recent experience from the former Soviet republic of Georgia explains why.

The Buprenorphine that was prescribed to heroin addicts in Europe wound up on the black market and was smuggled into Georgia, where it quickly became the drug of choice – 39 percent of clients at drug clinics became addicted to it. A 2006 Lancet article reported that its arrival has led to an 80 percent increase in the number of drug addicts nationwide. Local authorities complain they are fighting a “big-business” juggernaut: each tablet of Buprenorphine is sold on the streets in Georgia at a rate forty-two times higher than it goes for in France. The experienced British physician and prolific author Theodore Dalrymple also argues that it is hardly “essential” treatment – given that it has been readily relinquished and resold for cash by those who allegedly need it – even if most choose to overlook this point of logic.

Russia’s crises point to a deeper malaise which can not merely be “treated” superficially. Tolstoy recognized that, and wrestled with it. He wound up in profound error by denying the goodness of the body, but he was onto something with respect to the cultural and philosophical lethargy that exalts the Harm Reduction approach to lifestyle disease control.

Happily, we need not go to Tolstoy’s extremes to conclude that culture and spirituality need to be taken seriously. Much contemporary scientific evidence also indicates that, for human beings, Harm Reduction is just not good enough.

Matthew Hanley

Matthew Hanley’s new book, Determining Death by Neurological Criteria: Current Practice and Ethics, is a joint publication of the National Catholic Bioethics Center and Catholic University of America Press.