Harm-Reduction Initiatives Violate Hippocratic Oath

California propositions deal with cigarette taxes and condoms in pornos.


Most of us have heard the dictum, "First, do no harm." It's often thought of as part of the Hippocratic Oath—the traditional oath that new physicians take, in which they pledge to uphold the finest traditions of medical practice.

Those precise words don't actually appear in the oath, but they were penned by the Greek physician Hippocrates in another work. The advice is pretty clear—physicians should never do more harm than good.

Such lofty ideals don't usually work their way into debates about California state ballot initiatives, but this year, two of the more prominent measures are based on the simple idea of "harm reduction." Proposition 56 increases the state's relatively low tobacco tax by $2 a pack of cigarettes (and equivalent amounts for other nicotine products). Proposition 60 requires actors in pornographic films to use condoms during sexual intercourse.

The key promise behind Proposition 56 is that higher taxes will discourage people from smoking cigarettes, which unquestionably are dangerous products. The foundation of Proposition 60 is that adult-movie actors are at-risk of becoming infected by various sexually transmitted diseases such as HIV and hepatitis B. Condoms are known to limit such harm. So on the surface, at least, these measures seem to advance legitimate harm-reduction goals.

As with all initiatives and legislation, one needs to look closely at the actual language to see if it lives up to the lofty promises. In both cases, the initiatives clearly do more harm than good. For instance, Proposition 56 dramatically increases the rate of taxation on e-cigarettes and other vaping products. Public Health England, as well as studies in the United States, find that vaping is not totally safe, but is 95 percent safer than cigarette smoking.

If Proposition 56 supporters' premise holds true, higher taxes discourage the use of such products. That means the initiative would discourage the use of cigarettes—but would also reduce the use of much-safer e-cigarettes. Those e-cigarettes have been shown to be an effective tobacco-cessation device used by smokers trying to break their habit.

Proposition 56 has other problems, too. It is mainly a money grab by those seeking additional reimbursements through the Medi-Cal system, which provides health care for poor Californians. But from a "do no harm" standpoint, the e-cigarette tax hike is the measure's biggest flaw.

As the nonpartisan Legislative Analyst explains, under Proposition 60 "any California resident could request Cal/OSHA to address some alleged adult film workplace health and safety violations. If Cal/OSHA does not take certain actions within specific time frames, that person could file a civil action against the adult film producer."

As the Los Angeles Times opined, "The proposition would, in effect, make every Californian a potential condom cop by both mandating condom use and creating a private right of action so that any resident who spots a violation in a pornographic film shot in the state could sue and collect cash from the producers and purveyors if they prevail in court. … There's also the possibility that some people might use the new law to harass adult-film performers." In rare unity, the Democratic and Republican parties have come out against it.

Those provisions are harmful in a different way than, say, a venereal disease. But Proposition 60 could prove to be a terrible measure from a health perspective, also. The heart of the adult-film industry is in the San Fernando Valley, most of which is part of the City of Los Angeles. That city already passed a less-onerous condom requirement in 2014. The net result: The initiative could send what remains of the adult-film industry to Nevada, which has fewer health requirements for these actors. Others fear it would send the industry underground, where there are no requirements at all.

This November, California's ballot has 17 statewide initiatives, many of them complex and significant. Voters will typically read the short titles and summaries and make their decision. Based on a cursory look, both Propositions 56 and 60 promise to reduce harm—and might therefore look appealing to voters. But a more detailed look shows that instead of improving public health, they do much harm.