Harm reduction ethics: Acknowledging the values and beliefs behind our actions

In response to the global prevalence of drug-related mortality and premature morbidity from preventable causes, modern harm reduction must span diverse settings and target groups and utilise multiple disciplines and skill sets. The harm reduction sub-specialty of public health has a crucial role in society.

By necessity, harm reduction focuses on health and social issues around which there is often community misunderstanding, stigma, and fear (e.g. in relation to blood-borne viruses, illicit drug use, sexually transmissible infections, mental health etc.). Success in this area depends on novel methods and interventions which may often push the limits of knowledge and accepted moral standards – the implications of which may not always be foreseeable.

In this environment, a range of scientific, political and ethical considerations converge, many of which cannot be resolved by scientific evidence alone. Questions about autonomy, rights, coercion, justice, community, the common good, acceptable norms of research, multi-cultural values, and professional roles are central here.

The emergence of ‘values-based’ health

In this issue of the International Journal of Drug Policy, a series of papers address different topics under the theme of harm reduction ethics. In the last five or so years there has been increasing attention to the ethical underpinnings of contemporary harm reduction.

This recent ‘awakening’ to moral questions and the core values and beliefs behind harm reduction practice (be it service delivery, community development, policy, research or treatment) is not unique to this field. A minor revolution is occurring across many quarters of public health in the form of rapidly growing interest in ‘values-based’ approaches to health policy, research, practice, treatment and care.

Evidence-based policy and practice in public health is of course still a dominant (and important) paradigm, occupying the attention of many in harm reduction. However, opinion leaders in this area are starting to declare that under the huge force of evidence the debate about the scientific worth of harm reduction programmes is over (Wodak, 2007) and, as the papers in this issue of the journal show, explicit values-based approaches are starting to gain recognition as an alternative way to guide and evaluate harm reduction.

With this focus upon the ‘ethics of public health’, and growing willingness by health professionals to identify and align with the core values underpinning their work (as applied resources more so than abstract philosophies), has also come an acknowledgement of the practical ethical decision making and educational needs of the diverse health workforce. The papers on harm reduction ethics in this issue of the journal are therefore particularly timely.

Papers in this issue

We received many more manuscripts than we had the space to accept, and in the end selected papers which deal with practical ethical questions of current importance in the field, and show the breadth of ethical challenges in harm reduction. These papers demonstrate how different ethical frameworks and approaches may guide practice in this field. There are examples of analytic moral philosophy, advocacy ethics, empirical studies of ethical issues, and approaches which focus on professional ethics and the role boundaries and characteristics we might expect of harm reduction professionals.

Pauly’s commentary looks at harm reduction through a social justice framework. It focuses on inequities in health and access to care, arguing for a greater shift in harm reduction to address the social and structural determinants of drug use and the inequitable distribution of ‘harms’.

While Pauly’s call is not new in this area, he seeks to develop the link between this and the exploration of underlying values and ethical frameworks in order to drive harm reduction policies and practices. It takes the social justice and inequities debate into new territory.

In a second commentary in this issue, by Hathaway and Tousaw, the example of the much discussed Vancouver safe injection facility is used to consider the place of evidence and ethics in harm reduction and the differing role expectations of public health and harm reduction professionals. They argue that harm reduction’s silence on moral and value issues (in favour of scientific argument) undermines the movement’s ability to engage critics who would claim that abstinence and law enforcement are the only morally acceptable solutions to drug problems. For Hathaway and Tousaw, the framework of human rights offers a promising way to move harm reduction past old debates about the primacy of scientific evidence. They argue for a greater focus upon the costs and benefits of drug policy interventions to the drug user and wider community.

The commentary by Bruce and Schleifer is a timely piece that engages with an area that has not received adequate attention in the literature to date: the provision of medication-assisted treatment for opioid dependent prisoners. The authors provide a strong argument for reform of prison drug treatment, both in terms of how we understand drug dependence, and the relevant human rights issues. Prison based medical providers have an ethical obligation to ensure prisoners access to medical therapies including substitution therapy for opioid dependence (as they have towards prisoners with insulin dependent diabetes or those on antipsychotic medication). By not allowing access to such treatments, prison officials arguably violate medical ethics as well as their human rights obligation.

The paper raises important policy and ethical questions. What does it mean to provide opioid substitution therapy for incarcerated drug users in settings where the same medical services are not available for opiate dependent person on the outside? Would some drug users desperate to receive substitution therapy be compelled to commit crimes to get into prison to get the treatment they need, similar to some homeless individuals who choose to be purposefully arrested in winter months to avoid living on the streets?

The first of three research papers reports on innovative work by Phillips and Bourne conducted with eight drug workers and 58 clients of the UK Drugs and Homeless Initiative – an exploratory empirical study of the relationship between drug worker values and attributes and the therapeutic relationships and treatment outcomes for their clients. Utilising theory and methods from experimental social psychology, the authors show how the personal values of drug workers can impact client outcomes. This is important research which has a wider relevance for how we might think about the development and evaluation of key ‘harm reduction’ services. It is reminiscent of an earlier study reported in this journal which showed how applied ethics dialogue assisted Geneva drug consumption room staff to better address the ethical dilemmas in their day-to-day work (Solai et al., 2006).

Scott’s research paper asks the question ‘Is respondent driven sampling ethical?’. Respondent driven sampling (RDS) is becoming increasingly popular in harm reduction and the broader field of public health research involving hidden or vulnerable populations. However, as Scott argues, despite its promise as a robust sampling methodology it is not without ethical and practical challenges. To date, a definitive analysis of the ethics of RDS methods has not been written. Scott’s paper does not set out to achieve this, but it presents data from an interesting ethnographic study which serves to raise questions about RDS – the result of which we hope is further constructive debate.

Scott argues that RDS approaches “promoted ethical misconduct on the part of participants”. However, his paper also concedes that a certain level of ‘misconduct’ is expected amongst street based illicit drug market participants which might give us cause to ask ‘Whose ethics matter most in field research?’ and ‘Do current research ethics guidelines accommodate the diversity and complexity of harm reduction research?’. Scott highlights what he argues are significant ethical problems in the implementation of the RDS method as he has studied it, including increased harm and risk to participants that is distributed differently according to an individual’s place in the illicit drug market, and routine breaches of the confidentiality of individual participants. Readers may be interested in the wider literature on the ethical limits of research participant payments in addressing some of these concerns (see for example the recent review paper by Fry, Hall, Ritter & Jenkinson, 2006). Is it possible that the ethical implications of RDS are no different to those for other recruitment and payment methods involving drug users?

Christie, Groark and Sweet’s paper is a good example of how moral philosophers might approach some of the normative ethical questions in harm reduction. They consider the relative fit to harm reduction practice of three very influential ethical frameworks (virtue ethics, deontology and utilitarianism). It is a very different paper next to the others in this issue, but it helps to clarify the difference between ‘top down’ and ‘bottom up’ approaches to ethics. Some aspects of this paper that readers are sure to engage with include: Christie et al’s criticism of ‘applied ethics’ which they characterise as a top down process of “using a set of principles and then intuitively applying them to a problem”; and the author’s ‘harm reduction - abstinence’ dichotomy which may be regarded by some as an ill-fit with the (strategic) notion of modern harm reduction as a broad church that accommodates a continuum of goals and positions on drug use.

The review paper by Patterson and Panessa is a timely examination of the necessity to engage at-risk youth in harm reduction interventions, as an ethical imperative, but also as a more sustainable and effective approach to intervention. The authors build their argument from existing theories and principles guiding youth participation and by presenting a review of the literature on interventions for at-risk youth. They discuss the many challenges of such engagement and call for additional research.

Carter and Hall’s policy analysis concludes the special issue with a topic which sits at one of the new frontiers for harm reduction. Noting the relative lack of research on consent in the treatment of drug dependence, Carter and Hall enter the current debate that is growing around the question of whether opioid addicted individuals can provide free and informed consent to receipt of opioid agonist maintenance treatment. The authors examine empirical evidence from neuroscience and consider the ethical and socio-political factors that impact attitudes towards and the provision of maintenance treatments. While acknowledging that the autonomy of opioid dependent persons is impaired in some cases, Carter and Hall conclude that these individuals should be regarded as able to consent to treatment unless intoxicated or in withdrawal.

Further debate is needed about the evidence of neurobiological bases for addiction, the implications for policy and treatment approaches, and the related identity issues for the drug dependent. The paper presents practical guidelines that should find widespread use in the field, and it would be worthwhile considering how the issues raised by Carter and Hall and their recommended guidelines may be applied in the context of other substance dependencies and associated treatment options.

The democratic ideal of harm reduction ethics

The contributions in this special focus of the journal on harm reduction ethics are not all written by moral philosophers. Nor for the most part, do the articles focus on abstract and inaccessible ideas, as perhaps many come to expect from discussions on ethics.

The moral questions arising in harm reduction practice and the responsibility for ethical problem-solving in this area are matters for all of us. Ethics is not only for ethicists or philosophers any more than politics is only for politicians or health only for health professionals. This special focus of the journal provides the harm reduction field with some much needed signposts, practical methods and resources. These can be utilised in addressing the ethical dilemmas that arise daily in harm reduction work, and also to unselfconsciously argue a moral case in support of harm reduction. Values-based harm reduction has arrived.