We write in response to the paper by Jayne Lucke & Wayne Hall  regarding their discussion about offering incentives to drug-using women to use long-acting forms of contraception. Their premise, that cash and non-cash incentives could be used in this group of women, only partly addresses many of the key ethical and clinical issues in this debate. Indeed, it is difficult to explore these ethical issues fully without addressing the many barriers experienced by this population in accessing appropriate contraception.
Women with substance abuse issues report difficulties using conventional systems of care for a number of reasons, including a mistrust of health-care services, fear of forced treatment or fear of losing custody of children, guilt, denial or embarrassment regarding their substance use, stigma and the costs and difficulty of accessing services [2,3]. Other barriers these women face in accessing contraception include a belief that contraception is not needed due to impaired fertility while in drug treatment (e.g. methadone) and misinformation about different methods . As it stands currently, women in specialist drug treatment needing sexual and reproductive health care are usually referred to external services, either to their general practitioners, sexual health clinics or family planning centres.
A recent survey of women in our specialist drug treatment services indicated that only 55% of women not wanting to conceive were using contraception , and only 13% were using high-efficacy long-acting reversible contraceptive methods. We maintain that the initial clinical approach should be one of providing information about different contraception methods (and the advantage of non-user-dependent methods), and reducing barriers to access to these services. For example, integrated care models are more effective in enhancing health-care utilization (e.g. hepatitis B virus vaccination and hepatitis C virus treatment) in drug treatment populations, and we hope to trial an integrated contraceptive service, as suggested by previous work with drug treatment populations in the United States .
Any discussion of the ethical issues of providing financial or other incentives for women to utilize effective contraception must take into consideration the extent to which this patient population has access to accurate information and consumer-friendly, affordable services. Financial or other incentives should be considered ethically only where there is poor uptake of health-care options despite accessible services. In most drug treatment settings, these conditions do not currently exist. It is certainly appropriate for services to reduce or remove financial barriers to accessing contraception—however, this is a very different clinical and ethical proposition to financial or other incentives.
The danger of Project Prevention and similar propositions is that they undermine the need to address systemically the barriers to reproductive health in this population, somehow presupposing that this group of women are incapable of informed decision-making. This bypassing of the need for consumer information and accessible health care creates the paternalistic conditions for clients to be directed towards one method, which has been mainly sterilization.