It is a fact that sexual practices among young people has increased over the past decade or so. Teenage pregnancies and single motherhood have become almost a norm and most GPs would admit that whereas a decade and a half ago one would perhaps have seen a handful of ‘unwanted’ pregnancies, nowadays one sees at least one or two cases a month and we cannot really refer to them as unwanted, thanks to policies which helped single parents, and which now verge on being abused, as sometimes mentioned in this column. By abuse of course one would include not declaring a known father in order to benefit from assistance intended to help only mothers who truly find themselves in dire situations. In a recent Public-Health-Ethics meeting the difference between ‘public health’ and the ‘health of the public’ was raised, which can help identify what should and what should not be public health measures.

If it were only about pregnancies outside marriage one would not be in a strong position morally to speak about it being a public health issue. Rather it would be a problem affecting individuals of the public and therefore more of a health of the public issue. The importance of this distinction is the moral responsibility we put on correcting anything which harms the population health-wise. It is important therefore to appreciate that if I am in a theatre and I smoke a cigarette I am causing harm to others and it is therefore a public health issue.

If on the other hand I eat a hamburger, I am not causing harm to the public around me (other than indirectly by increasing the expenditure burden perhaps due to the ailments obesity can cause the country – but this is not public health). Nevertheless public health usually falls within the realm of departments of health and therefore these two examples are usually lumped under a general term public health and many a public health specialist may indeed disagree that the hamburger does not within the realm. What we can agree on is that it can cause an indirect effect by diverting costs of health care from otherwise more important areas. It is not the eating of the hamburger per se which causes imminent danger to the public, as is the case of a cigarette, but the general concern of obesity in a population which in turn causes more morbidity. There is this subtle difference of what is a direct effect on the health of others and what is a behaviour which can cause damage to self.

When it comes to sex education there is however an imminent danger to the public, namely sexual transmitted disease. We may all agree that abstinence is what should be preached and practised, and that perhaps condoning the use of a method (condoms) which is known to decrease sexual transmission of infection may be interpreted by some as actually condoning the act itself. I would not agree to that but be that as it may, the moral issue is two-fold: On the one-hand it is true that providing easy solutions can have an impact on young minds who may get the message that sexual practice is acceptable as long as you are careful, but on the other hand there is also the grave moral responsibility to prevent harm, especially to innocent partners (the recent surveys show that many STDs come from extramarital relationships as well.

It is the genito-urinary infections which make this a public health issue and therefore of moral concern. Pregnancies to single mothers can be a health issue to individuals – most probably a mental health issue – if they undergo stress in the process. This would be what I referred to as a health-of-the-public issue. Therefore we can all be relatively healthy but still have public health issues (such as cigarette fumes or a bad water supply), which will cause harm to many. Public health does not depend on the sum of individuals who are healthy or ill – it depends on practices and environmental issues. The health of the public can on the other hand be affected, without having an issue for public health. If single mothers are stressed due to non-planned pregnancies, it is not really a public health issue as otherwise there would be no point in the classification, as every ailment would be a public health issue.

Sexual practices in and of themselves are not necessarily a public health issue (although one needs to ask whether it is a mental health issue, as it has been proposed that lack of home security may lead young people to other forms of intimacy) and therefore one understands the resistance to condone the use of condoms, etc. What is a public health issue is the disease which may be transmitted through this practice. Statistics show facts and if other methods (such as advocating abstinence) fail, then we have a problem of sexually transmitted disease on our hands.

Principles of ethics include the principle of doing good (beneficence) and of doing no harm (nonmaleficence). Doing no harm does not consist only in a reference to a future action but refers first and foremost to not causing harm (by omitting, for example to take the right action), by preventing harm, by removing from harms way, and finally by promoting the good. Health Promotion is about the principle of nonmaleficence and anyone preventing this would automatically be acting maleficently (I here distinguish maleficent from malevolence, as one may be unintentional and the other quite so).

Why mention this? A sister column pointed out that the Curia may be pulling strings to keep back a sexual health policy. I would doubt that this is so as clergy are involved in the teaching of bioethics. In teaching bioethics to doctors and public health officials we are training people to be responsible for individual and public health. As doctors we cannot shy away from issues such as sexual health. Of course doctors with a relativist morality, or who are morally neutral can be wrong not to respect societies’ normative values and its elected government which has the responsibility to implement those values. On the other hand consultants cannot be silenced when it is part of their duty to inform and educate the public as part of preventive medicine. To do so is to take us back to the era which itself triggered off the field of bioethics, when medicine went wrong because doctors followed government orders rather than ethical codes.

The bare fact is that condoms do prevent the transmission of infections from one person to another and if we do not consider it a moral duty to promote the use of such measures, doctors are indeed liable to malpractice – they are breaching their professional duty of informing patients and should a harm be caused because of this omission you have a connection between the breach of duty and the harm caused, which, in tort law, is negligence.

Now the dilemma which is being raised is this: Should a health policy promote the use of condoms? Doctors, even given their moral right to refuse to participate in things which they consider immoral, have duties. A doctor who sees teenagers, for example, who admit to sexual practices, is duty-bound to inform them of methods that exist to prevent infection. Failing to do so is to be legally and morally negligent. One is failing patients who can get ill and in turn failing one’s duty towards society as this same person may infect others.

Now we cannot simply leave this to individual family doctors. Medicine does not work that way. If individual doctors promote health this way, the collective body, through health promotion measures is obliged to do likewise. Whilst individual doctors play an important role in education, so does the department of health. Just as we take measures to prevent the transmission of airborne viruses, we should take measures to prevent the transmission of sexual infection. Those of us who have children understand that sexual education carries with it the fear that we are telling them that sex is OK as long as they use protective measures; but we also understand that prevention from disease should be condoned and that moral values cannot be left solely to the classroom. We have to consider peer pressure and admit that our society has failed in imparting the same values we were brought up with. It is not right that our children suffer for it because we did not inform them of dangers in the hope that they would avoid certain practices.

Of course I will not bother to answer those who retort that it serves these people right and that they should not have had sex in the first place and that they should carry the responsibility of their actions. Medicine does not work that way. If it did we would prefer to give a kidney to a 40-year-old father of two, instead of a 65-year-old widow, or we would decide not to treat people from our tax money who have spent their lives smoking one or two packets of cigarettes a day. Equality and fairness must reign for health, which cannot be subject to meritocracy.

The condom does not condone; it prevents condemnation to contagion! We may shrink from use of the term publicly, but whoever deleted that term from the draft document of the Sexually Transmitted Infections Prevention Committee should not be working in social policy and health. Admission of preventive measures is not an admission of guilt and neither an admission of practices. It may be an admission of failure – at least where other methods could have in theory prevented the rise in sexual practices amongst the young in particular. If we speak of a moral wrong, we cannot accept the moral responsibility of treating disease that come out of that ‘wrong’ without also trying to prevent it. It is not the contraceptive which we are speaking about, it is the deadly infection. Those who see contraception as an evil must surely recognise that one is accepting that evil not for its own sake, but to prevent two greater evils – transmission of disease, and, lack of professional responsibility to prevent that same disease.



Pierre Mallia is Associate Professor in Family Medicine, Patients' Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of Family Doctors.