The Ethics of Harm Reduction

Abstract

The article attempts to set harm minimization within drug settings into a larger framework of harm minimization practices. It seeks to provide a plausible account of harm reduction and then explores four ethical challenges for harm reduction strategies.

Keywords:

• bottom line
• code of ethics
• delivery conditions
• harm reduction
• permissible strategies
• reduction of harm
• socially contested
• social cost
• value-neutrality
• voluntary vs. mandatory

Notes

Notes

1. George W. Bush, Response of Governor George W. Bush to the AIDS Foundation of Chicago (2000): http://www.aidschicago.org/pdf/GWB_response.pdf. It is, of course, arguable that even Bush was in favor of harm reduction or harm minimization, even if he talks about harm elimination as though it is a higher road. But the term has come to have a narrower use and it is that to which my comments are here directed.

2. On April 25, 2007, the Texas legislature voted 135-2 to bar the vaccinations until 2011. Perry's political mistake was to attempt—for motives that appeared suspect—an end run round the legislature and to make it compulsory.

3. In Australia voluntary programs already exist. See Leung, C. C. (2007, April 17). Vaccine steps up the cancer fight. The Age (Melbourne). Programs are also underway in some European Union countries and are likely to be initiated elsewhere http://www.theage.com.au/news/national/vaccine-steps-up-the-cancer-fight/2007/04/16/1176696758073.html

4. It shows, I think, the extent to which the phrase has been politicized http://www.nytimes.com/2005/06/02/national/02embryo.html?_r=1&adxnnl=l&oref=slogin&adxnnlx=1196525381-iTzbuMvpzDT774PLfBRNYw

5. See Belluck, P. (2005, June 2). From stem cell opponents, an embryo crusade. New York Times. For the program's Web site, see http://www.nightlight.org/snowflakeadoption.htm.

6. For an attempt to address such arguments, see Buchanan, D., Shaw, S., Ford, A., and Singer, M. (2003). Empirical science meets moral panic: An analysis of the politics of needle exchange.Journal of Public Health Policy 24(3–4), 427–444.

7. Wodak, A., Saunders, B. (1995). Harm reduction means what I choose it to mean. Drug and Alcohol Review, 14, 269 (special issue on harm reduction).

8. See, for example, Single, E. (1995). Defining harm reduction. Drug and Alcohol Review, 14, 289–290.

9. Erickson, P. G., Riley, D. M., Cheung, Y. W., O'Hare, P. A. (Eds.). (1997). Introduction: The search for harm reduction. In Harm reduction: A new direction for drug policies and programs (p. 8). Toronto: University of Toronto Press.

10. Keane, H. (2003). Critiques of harm reduction, morality and the promise of human rights. International Journal of Drug Policy 14: 27.

11. Sometimes the term used is “pragmatic,” though this is less obviously neutral.

12. “Harm reduction policies and practices (where anything goes, if it actually reduces harm) have fundamentally altered our approach to the drugs problem.” Strang, J., Fortson, R. (2004). Commentary: Supervised fixing rooms, supervised injectable maintenance clinics—Understanding the difference. British Medical Journal, 328, 102.

13. See Fry, C. L., Treloar, C., Maher, L. (2005). Ethical challenges and responses in harm reduction research: Promoting communitarian ethics. Drug and Alcohol Review, 24: 449–459; AIVL, National statement on ethical issues for research involving injecting/illicit drug users, http://www.aivl.org.au/files/EthiicalIssuesforResearchInvolvingUsers.pdf.

14. Keane, H. (2005). Moral frameworks, ethical engagement and harm reduction: Commentary on “Ethical Challenges and Responses in Harm Reduction Research: Promoting Communitarian Ethics.”' By C.L. Fry, C. Treloar and L. Maher. Drug and Alcohol Review, 24, 551, citing Race, K. (2005, July). Drug spectacles: Purging the nation. Paper presented at the 1st International Conference of Asian Queer Studies, Bangkok.

15. Buchanan, D., Shaw, S., Ford, A., and Singer, M. (2003). Empirical science meets moral panic: An analysis of the politics of needle exchange.” Journal of Public Health Policy, 24(3–4), 430. Much is said about sending clear and unambiguous moral messages.

16. I will not pursue such issues here. I have, however, endeavored to address some of them in (2005). Thinking ethically about needle and syringe programs. Kleining, J, Substance Use & Misuse 41(6/7): 817–828.

17. Those who are antagonistic to harm reduction in the sense that we are considering it here have often claimed to be doing more for harm reduction by suppressing the underlying behaviors. Although the almost draconian measures sometimes used in the United States have given the lie to this hope, what is almost always left out of account in such claims are the harms of suppression (the lives permanently disrupted by incarceration).

18. Health Outcomes International Pty Ltd, in Association with The National Centre for HIV Epidemiology and Clinical Research and Professor Michael Drummond, Centre of Health Economics, York University. (2002). Return on investment in needle & syringe programs in Australia. Canberra, ACT: Commonwealth Department of Health and Ageing.

19. See U.S. Department of Health and Human Services. (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. http://www.surgeongeneral.gov/library/secondhandsmoke/. A more recent example of a similar phenomenon has been the banning of trans fats from some commercially prepared foods. See http://www.nyc.gov/html/doh/html/pr2006/pr093-06.shtml.

20. See Fry, C., Treloar, C. and Maher, L. (2005). Ethical challenges and responses in harm reduction research: promoting communitarian ethics, Drug and Alcohol Review 24, 449–459. Ethical challenges and responses in harm reduction research. This gets us into another set of ethical issues. What has come to be favored as evidence-based medicine is not without its own ethical challenges. See Jenicek, M. (2006). Evidence-based medicine: Fifteen years later. Golem the good, the bad, and the ugly in need of a review? Medical Science Monitor 12(11): RA241–RA251, http://www.medscimonit.com/pub/vol_12/no_11/9683.pdf.

21. Some critics of harm reduction strategies see them simply as additional expressions of the surveillance state. See Miller, P. G. (2001). A critical review of the harm minimization philosophy in Australia. Critical Public Health, 11(2), 67–78. That is probably taking it too far. See Keane, H. (2003). Critiques of harm reduction, morality and the promise of human rights. International Journal of Drug Policy, 14, 27.Critiques of harm reduction, morality and the promise of human rights. 231.

22. Even the voluntary availability of harm reduction measures is hampered by drug prohibition laws. There needs to be some understanding between law enforcement and harm-reduction programs so that those who wish to avail themselves of such measures can do so without fear of apprehension or arrest. For related discussion, see Fraser, A., George, M. (1992). The role of the police in harm reduction. in P. A. O'Hare, R. Newcombe, A. Matthews, E. C. Buning, E. Drucker (Eds.), The reduction of drug-related harm (pp. 162–171). London: Routledge; Chappell, D., Reitsma, T., O'Connell, D., Strang, H. (1993). Law enforcement as a harm-reduction strategy in Rotterdam and Merseyside. In N. Heather, A. Wodak, E. A. Nadelmann, P. O'Hare (Eds.). Psychoactive drugs and harm reduction: From faith to science (pp. 118–126). London: Whurr Publishers; Hellawell, K. (1995). The role of law enforcement in minimizing the harm resulting from illicit drugs. Drug and Alcohol Review 14(3): 317-322.

23. In 2005, the rate of incarceration was 737 per 100,000. See the work of the Sentencing Project. http://www.sentencingproject.org/Admin/Documents/publications/inc_newfigures.pdf.

24. OECD Health Data. (2005). How does the United States compare. http://www.oecd.org/dataoecd/15/23/34970246.pdf.

25. See, however, note 20.