Safe Injection Sites: A Moral Reflection

Abstract

This article addresses the issue of safe injection sites (SIS) that municipalities in the United States and elsewhere in the world propose to save lives by curbing the instances of fatal overdoses and provide addicts with healthcare services and opportunities for detoxification and social rehabilitation. Drawing on current clinical science and the medical facts regarding substance abuse and addiction, widely accepted bioethical principles, Catholic social teaching, and the common good, it shows the administration and consumption of illicit recreational drugs in an SIS is not a suitable medical intervention and a violation of the core principles of Catholic social teaching and Catholic healthcare ethics. More importantly, municipal governing bodies and the clinicians who staff these facilities cooperate in the evil of illegal drug abuse.

Summary:

Safe injection sites are morally illicit.

Safe injection sites (SIS) are legally sanctioned, medically supervised facilities that are designed to curb drug overdoses and reduce public nuisance from illegal drug use, and provide a sterile and stress-free and supervised space where addicts can consume illicit recreational drugs intravenously without fear of being apprehended by police. These sites are also known as supervised injection sites (SIS), fix rooms, safer injection facilities, drug consumption facilities, and medically supervised injection centers. Proponents of SIS say these facilities save lives by curbing the instances of fatal overdoses and provide addicts with healthcare services and opportunities for detoxification and social rehabilitation.

Proponents of SIS also argue that these facilities offer a compassionate response to a rising epidemic of intravenous drug abuse. But are they overlooking the moral ramifications such facilities present?

The Medical Facts of Substance Abuse and Addiction

It is not the intent of this essay to put forth a particular view as to the genesis of addiction. However, in order to adequately answer the question of the value of SIS to individual addicts and to society, it is necessary to first discuss the nature of addiction. To begin, The American Society of Addiction Medicine Short Definition of Addiction ends with the statement that addiction is progressive and can result in disability or premature death (American Society of Addiction Medicine: Public Policy Statement: Definition of Addiction; August 15, 2011). This is readily evident in considering the link between addictions and death or disability such as the link between smoking and lung cancer, between alcoholism and cirrhosis, between cocaine use and premature heart attack or stroke, and certainly in the ever-rising rate of death from opioid overdose. One might argue, with a certain preciseness, that addiction need not be present to link the use of certain substances to premature death or disability.

However, in consideration of SIS, something more than just an unfortunate outcome of risky behavior by the user is present. One need only to ponder the fact that when one person dies of an overdose, very often, other users will deliberately seek out the same source of drugs, thinking that the potency and value of the drug must be exceptional.

Another characteristic of addiction is that it produces suffering in individual users, in their loved ones, and in society in general. This is seen in the fifth iteration of the Diagnostic and Statistical Manual, 2013 criteria for addiction, which includes a catalog of dangers and harm resulting from addictive use of substances such as repeated use of substances in dangerous circumstances, for instance driving, or repeated use of substances after suffering or causing harm from use of the substance, for example, continued use of intravenous drugs after contracting HIV or Hepatitis C (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders; Section II: Substance-related and Addictive Disorders, 481–591).

In addiction, certain brain processes do not operate correctly. This is seen, for example, in the inability of the brain of a gambler to properly distinguish between a successful outcome and a “near miss.” Another example is seen in the working of an alcoholic’s brain, where the ability to respond to a “Stop” signal after being presented with a “Go” signal is impaired. Another striking example of impaired brain functioning is seen in those afflicted with an addictive disorder who are unable, in neuropsychological tests, to successfully identify and organize the elements needed to carry out a planned action or to achieve a desired goal (Day et al. 2015, 8(1), 26–40).

The nature of addiction can also be more intuitively gained by considering that no user of drugs or alcohol ever plans to become an addict or alcoholic. They may knowingly or in ignorance use dangerous substances for pleasure or to relieve pain but never is this done with the express purpose of becoming enslaved to alcohol or a drug. The impairment of will is evident in this consideration and also in considering that no person caught in addiction ever wakes one morning thinking, “This is a beautiful day to stop drinking/using!”

Finally, the spiritual nature of addiction is elaborated, for those who are curious about such matters, in the Big Book of Alcoholics Anonymous (Bill and Shoemaker 1992, 61). Here is described the spiritual foundation and the primacy of the spiritual in the process of recovery, “...for we have been not only mentally and physically ill, we have been spiritually sick. When the spiritual malady is overcome, we straighten out mentally and physically” ( Alcoholics Anonymous 2001, 64). Any evaluation, then of SIS, must include a consideration as to whether and how SIS address the enslavement and destruction, by drugs, of a person with a divinely inspired soul.

Bioethical Principles

Does the administration and consumption of illicit recreational drugs in an SIS offer reasonable hope of benefit to the addicted user of injection drugs? The first and foremost question that medical professionals ask when determining a medical intervention is as follows: does this treatment offer the patient a reasonable hope of benefit? Ethicists also rely on the answer to this question to determine whether or not the intervention ought to be initiated or licitly terminated. The key word in this question is benefit, which is defined as having a favorable effect on how the patient feels, does this intervention offer symptom relief? It is also defined as having a positive effect on the patient’s anatomical functioning and survival rate.

One might consider that SIS do indeed provide benefit, for risk of transmission of disease is reduced as is the risk of overdose. Also, when one is addicted to opioids, use of an opioid will relieve the suffering of withdrawal. Nonjudgmental staff can also reduce the shame of addiction and allow a certain degree of social interaction that may be perceived as of value to the person suffering from addiction.

However, reasonable hope of benefit applies to the administration and consumption of illicit recreational drugs, not the SIS itself. Thus, the primary question that must be answered by the medical professionals and ethicists is the following: does the consumption of illicit recreational drugs offer reasonable hope of benefit to the drug addict?

The physical organism, although restored by an injection of drugs from the illness of withdrawal, has not been restored to the wholeness. In fact, only a long and difficult withdrawal period, usually months in length, can fully restore the organism to be able to function in a normal fashion without continued administration of the drug. The wide acceptance of maintenance therapy (long-term use of a substitute opioid such as buprenorphine or methadone) as treatment for opioid withdrawal and/or dependency speaks to the difficulty of making a successful transition from being physically dependent on opioids and being physically free from the need to use drugs. SIS then offer a safer way to use deadly substances without providing the necessary conditions to optimally motivate an individual to seek freedom from their underlying addiction and, in a certain sense, provide endorsement of the use of opioids. In fact, data from Vancouver show that less than 7 percent of those utilizing SIS accept referrals to some type of addiction treatment.¹ Thus, SIS may be seen to fail in offering benefit to the drug addict.

Therefore, the argument that the benefit to those suffering from addiction lies in the safe, sterile environment in which to inject the illicit recreational drug is incorrect. They do not offer reasonable hope of benefit to those suffering from addiction.

On another level, the morality of any human act is discovered by considering the three sources of a particular act. These are the dimensions of the human action that constitute a whole but can be distinguished from each other. They are the object that answers the question, “what am I doing”? Is the act that one does or is considering doing good, morally neutral, or intrinsically evil? Acts that are intrinsically evil must never be done. The human action’s object is its “anchor.” Thus, if it is determined that the object of the human action is evil, we do not need to examine either the other two sources or even the consequences of that action.

In this light, the administration and consumption of illicit recreational drugs is an intrinsically evil act. “The use of drugs inflicts very grave damage on human health and life. Their use, except on strictly therapeutic grounds, is a grave offense” (US Conference of Catholic Bishops 2002, Catechism of the Catholic Church #2291).

The second source of the human act is intention. It answers the question, “why am I doing this act”? A good intention cannot make a bad object of a human action good. However, a bad intention can either diminish or eliminate the goodness of the action.

The third source of the human act is circumstance. It answers the question, “how, when, and/or where I do it”? Once again, the circumstances surrounding the execution of the act cannot make a bad object of a human act good. But bad circumstances can either diminish or eliminate the goodness of the action.

Thus, the object, intention, and circumstance must all be good for the act to be good. The object of the SIS is the administration and consumption of illicit recreational drugs, which is an intrinsically evil act. As stated above, if the object of an act is intrinsically evil, nothing can make it good. The intention of SIS is to curb drug overdoses and reduce public nuisance from illegal drug use. Although these are good intentions, they do not change the fact that an intrinsic evil is being committed. The circumstance of SIS is a sterile and stress-free and supervised space where injection drug users can consume illicit recreational drugs intravenously without fear of being apprehended by police. Once again, the provision of a sterile and stress—free environment to commit an intrinsically evil act does not change the moral status of the object.

Therefore, from this vantage point, SIS are not morally correct medical facilities for the treatment of addiction. The question now becomes, do SIS adhere to the four principles of Principlism—beneficence, non-maleficence, justice, and autonomy?

In the Principle of Beneficence, one is obliged to always do the good. This corresponds to the first principle of practical reasoning of Natural Law that is written in the human heart: do good and avoid evil.

No one caught in addiction stops using on their own. Drug users who are able stop the use of opioids on their own, by definition, have never had the central nervous system impairments that characterize addiction, since impaired planning is inherent in the nature of addiction. Physicians and other health professionals impaired by addiction, who are participating in a Recovery Monitoring Program, have a five-year recovery rate of 85 percent. Participants in these types of programs typically have the support of a therapist, a physician skilled in addiction, peer support groups, a worksite monitor, and the monitoring program itself to provide support for recovery-oriented planning and strategizing. To provide less treatment to anyone else is to say, essentially, that they are not worth the resources they need to get well. Thus, beneficence is not served by SIS despite the apparent compassion in helping to both reduce suffering in society and in helping the drug user by reducing the risk of overdose and death, transmission of disease, and other good goals.

First do no harm, the Principle of Non-maleficence, dates back to the ancient Greek practice of medicine and the Hippocratic Oath. It obliges the medical practitioner to do nothing that would be detrimental to the health and well-being of the patient.

Injecting drugs is not a procedure without risk. The intrinsically destructive nature of addiction is a source of great harm to the individual, their family, and to society. Codifying and facilitating the course of a destructive illness is harm. Advocates of SIS propose that there is less risk to the user if he or she injects in a clean facility, using clean needles, with trained personnel present to intervene in the event of overdose, and so on. However, the desire to reduce harm in this instance with the least financial and human effort results in the restriction of human and financial resources for other means of reducing harm, such as incentives for vaccination programs.

There is literature to show that addicts who utilize SIS are open to interventions supporting addiction treatment. However, it is never good to do evil so that good can come from it, which is the case in this instance. This is classic proportionalist/consequentialist ethical methodology that is not consistent with authentic Catholic healthcare ethics.

The Principle of Autonomy is intimately linked to human freedom. It obliges the medical practitioner to always respect wishes of the free and competent individual and to treat them as autonomous agents. They must be fully informed of the intervention, its risks, benefits, and any possible alternatives and give free consent to the intervention. Most importantly, persons with diminished autonomy must be provided with special protections and have the ability to have others speak on their behalf. There is to be no coercion to consent directed toward the individual.

Because addiction impedes freedom, there exists a certain diminished autonomy with respect to making decisions analogous to that seen in other mental health disorders such as schizophrenia or severe depression. An individual in the grip of an addictive disorder, although starving, with a family starving at home, will spend money that could be used for food to purchase drugs. The drive to use drugs is of the nature of the drives of hunger, thirst, sleep, sex. Studies show that the drive to use drugs can take primacy over these natural drives. SIS by the very nature of their design encourage the primacy of drug use. In contrast, places that supply food, clothing, shelter, professional counseling, and peer support are known as treatment centers where those willing to leave the cycle of addiction learn to reorder the primacy of the drives of the human soul.

The Principle of Justice pertains to the healthcare delivery system. It requires that the benefits and burdens of the system be shared fairly. The Catholic understanding of the concept of justice as it relates to SIS will be more fully discussed in Catholic Social Teaching.

However, this leads to another question. Can the money that funds these sites be used more wisely and efficiently by diverting them to drug rehab centers and social services to help get people free of drug dependency and by making it more possible for them to lead a truly human life?

Yes, the benefit of treatment programs such as those designed for airline pilots or health professionals is clearly documented. Monies used to establish and maintain SIS potentially drain resources that otherwise could be used to develop treatments based on established evidence-based practices that would be available to those wishing to break free of addiction.

Catholic Social Teaching

It is important to note that bioethics from a Catholic perspective is a subset of Catholic social teaching in general and the common good in particular. The foundational principle of Catholic Social Teaching is the sacredness of human life and the dignity of all persons. Catholic bioethics will incorporate the secular bioethics noted above when appropriate and when they do not conflict with Catholic moral teaching. With this in mind, a question that must be addressed is as follows: do SIS threaten or enhance the life and dignity of the person using drugs?

The dignity of the human person is rooted in his creation in the image and likeness of God…; it is fulfilled in his vocation to divine beatitude…It is essential to a human being freely to direct himself to this fulfillment…(US Conference of Catholic Bishops 2002, Catechism of the Catholic Church #1700)

Human dignity is enhanced by freedom, the power that is embedded in reason and will, to act or not act in any particular way. In freedom, a person shapes his own life for the good or for the bad. It is the source of growth or digression, maturity in the truth, or stagnant immaturity. So, the questions become do SIS allow one suffering from addiction to exercise his or her natural freedoms, freedoms that are indispensable for them to develop his or her vocation to social responsibility, and to participate positively in society?

In Addiction Medicine, it is never the case that a person with an addiction wakes up one morning and says, “What a great day to enter treatment or go to an AA meeting!” The darkness of addiction can motivate the addict or alcoholic to seek light, especially if there is a loving, compassionate voice, rooted in the truth, to accompany them. In this understanding, SIS actually hinder the exercise of natural freedoms. These are essentially interventions of despair, which make the statement that treatment is not worthwhile, does not work and that the addict is not worth the time and effort and financial resources needed to heal. What message do SIS send to these persons who are looking for help, that what is offered to them by society is a way to go forward that causes minimal disruption to society?

The message sent is that continued use of drugs is supported as, despite what verbal messages may be given, the very concept of an SIS is to support the continued use of drugs. In continuing use, the family of one caught in addiction continues to lose their son or daughter or husband or wife or parent, society continues to lose the full potential of its members and suffers the loss of revenues and work which go to subsidizing both SIS and the drugs used there.

Another question that needs to be addressed is as follows: do SIS establish harmony and equality between the injection drug user and the common good? To answer this question, we must first further examine justice as a virtue in its relation to the rights of those using drugs and the rights of the community.

Justice is the moral virtue that consists in the constant and firm will to give their due to God and Neighbor. Justice toward God is called the ‘virtue of religion’. Justice toward men disposes one to respect the rights of each and to establish in human relationships the harmony that promotes equality with regard to person and to the common good.…(US Conference of Catholic Bishops 2002, Catechism of the Catholic Church #1807)

For the purpose of this essay, it is important to highlight the following key words: rights, human relationships, equality, and the common good. To act justly, one must always respect the rights of others. Human rights are not determined by the state. Nor are they determined by social contract or popular vote. Nor are they determined by an individual. Human rights are given by God and made known to each human person through the Natural Law that forms the foundation of all human rights and their corresponding duties.

“Justice, in fact, is not merely a simple human convention, because it is not first determined by the law but by the profound identity of the human being” (Compendium of Social Doctrine of the Church #202). So what is the identity of the human being? As the Imago Dei, the human person is not just something to be used, enjoyed or discarded, or relegated to subhuman status, but someone who “is capable of self-knowledge, of self-possession and of freely giving himself and entering into communion with other persons” (Compendium of Social Doctrine of the Church #202).

Because rights are God given, they are immutable and universal to all persons. This is in contrast to the popular notion that rights are anything the culture decides them to be. These are known as rights of desire. For instance, some desire to smoke marijuana on a recreational basis. They do so illegally in some jurisdictions. The more acceptable that becomes socially the more people openly do so. The more socially acceptable recreational use of marijuana becomes, the more those who desire to do this petition the government to legalize it. This happened recently in Mexico. In 2015, the Mexican Supreme Court created a right to smoke marijuana based on “free development of the personality granted protection to grow and use cannabis for personal use” (Aguinaco and Barra 2017, 9–10).

Having stated this, are SIS a human rights issue? Proponents argue that harm reduction is a basic human right. In this regard, they are correct. The common good demands peace and security of the community and its members. From their perspective, the human right of harm reduction is accomplished by SIS. Thus, by default, these sites are a basic human right. The designation of a human right belongs to harm reduction, not to SIS. But can harm reduction from the administration and consumption of illicit recreational drugs be accomplished in ways other than the establishment of SIS? This essay will not attempt to enumerate every harm resulting from the administration and consumption of illicit recreational drugs, but it will offer the following considerations as examples of alternative approaches of harm reduction that would not involve providing SIS.

One method of reducing harm would be to support and expand places that provide necessities of life to addicts and alcoholics, places where they are welcomed but their addiction is not. An excellent example of such services are the many centers sponsored and run by the Salvation Army.²

Another method of harm reduction would be to support and expand places that provide affordable help to family and friends of addicts and alcoholics, as their love and care can be strengthened through education and counseling. An excellent example of such services is provided by Catholic Charities of Shiawassee and Genesee Counties in Michigan.³

Another method of reducing harm would be to expand funding for vaccines to protect against Hepatitis. Safe and effective vaccines already exist for Hepatitis B. Good programs to deliver the needed vaccinations to injection drug users and other vulnerable populations need to be readily identifiable and financed to reach those in need. Hepatitis C has no effective vaccine, although ongoing trials show promise. Efforts to continue to develop a good vaccine ought to be adequately financed and encouraged. Efforts to reduce harm must be strongly encouraged, both the harm from addiction itself and the health consequences that result from addiction.

The Common Good

Do the governments that sanction SIS embrace their role to ensure as far as possible the common good of the society and afford to the citizenry social stability and security of a just order as the common good demands of them? It is well-documented that SIS offer safety and security to users of injection drugs. As stated above, harm reduction is the stated purpose and goal of these sites. However, lost in this discussion is the safety of the community and its members.

To review, the Principle of Justice presents a moral obligation to equality and equity when adjudicating competing claims. In this instance, one claim is the safety of drug users and their right to be protected from any further harm which the administration and consumption of illicit recreational drugs presents them. The competing claim is the protection of the community from the unintended negative consequences of providing this type of service.

According to FactCheck, a service of the Irish Publication, The Journal, there was no significant increase or decrease in drug-related crime in Europe and Australia where SIS exist. They concluded, “On the whole, our research uncovered some evidence, but no clear pattern, of reductions in drug-related crime after the opening of a SIF (Safe Injection Facility)” (MacGuill 2017).

They also concluded, “It should be noted that studies on this subject are marked by a widespread reluctance on the part of researchers to causally attribute any increases or decreases in drug-related crime to the opening of a SIF”(MacGuill 2017).

Such reluctance is understandable since behaviors that produce crime, such as stealing money or goods to finance drug use, are not affected by the provision of an SIF.

Cooperation in Evil

Do SIS cause governments and clinicians to cooperate in the evil of drug abuse? If one understands addiction as a disease process, which ultimately leads to physical and spiritual death, the question of cooperation with evil is one, which needs careful consideration. We must make sure that in our interventions, we do not facilitate the evil act of the administration and consumption of illicit recreational drugs and thereby incur moral culpability for that act. Therefore, it is important that the Principle of Cooperation in Evil be adequately defined. It is even more important for this principle to be properly applied to issue of SIS. This section will review some specific applications of this principle to SIS.

To begin, a variety of persons are involved in the operation of SIS. Depending on the structure of the SIS, there may be costs for the building; costs for water, electricity, heating/cooling; supplies, including supplies for injecting drugs (needles, syringes, alcohol pads, etc.); and personnel. Depending, again, on the nature of the specific SIS, the staff may perform different functions such as building upkeep, counseling, nursing, and/or medical care. It is also likely that there may be instances in which the user of illicit recreational drugs is unable to inject himself or herself and needs assistance doing so. In all these situations, it is important to consider whether one involved in establishing or maintaining an SIS may be cooperating with evil.

The person who commits an evil act is called the principal agent or the evildoer. The principal agent is fully culpable for evil act. It is the person who uses the illicit recreational drug in the context of the SIS who is the principle agent in this intrinsically evil act. However, various factors, such as economic pressures to change from use of oral forms of illicitly used drugs to initially cheaper intravenous forms of those drugs, may affect moral culpability for initiating the use of injection drugs. In addition, it is evident that there is a different culpability in the person afflicted with an addiction that started with licitly prescribed and appropriately used medications compared with an addiction that develops as a result of intentional use of an addicting drug for recreational purposes in spite of full knowledge of the risks inherent in such use. In like manner, physical dependency on a drug, the compulsion to use a drug, and the altered value system inherent in addiction may also mitigate culpability for the addictive or compulsive act in someone who is suffering from an established addiction. Although the culpability for making the freewill decision to take drugs that may lead to addiction may be mitigated by various factors, the act of injecting illicit recreational drugs remains a grave evil under all circumstances. Therefore, one who uses injections drugs is always the principal agent in committing a gravely evil act.

Circumstances may arise in which someone is associated to some degree with someone else who commits an evil act. One who is associated with the principal agent is called the cooperator—one who “operates along with” the principal agent (Grisez 1997, 440). In the context of an SIS, persons who establish, support, maintain, and staff such facilities are cooperating with the principal agent. There are two categories of cooperation, formal cooperation and material cooperation.⁴

A formal cooperator intends the evil act to occur for its own sake or as a means to some other end (Grisez 1997, 440). He or she does not necessarily have to be essential for its commission. Persons in the public or private sector who support and help establish SIS, whatever good is intended, are helping to facilitate continued use of illicit intravenous drugs, a gravely evil act. They are formal cooperators and, as such, are equally culpable for the evil act committed. Thus, first and foremost the governmental leaders who initiate, pass, and sign legislation to allow for an SIS to exist in their jurisdiction are formal cooperators in the use of illicit intravenous drugs. Although their purpose in doing so is to curb drug overdoses and reduce public nuisance, this is an illicit means to a good end. This purpose is known as implicit formal cooperation since “the evil act is neither desired nor openly acknowledged but is an intended means for attaining other beneficial ends” (Di Camillo 2013).

A material cooperator provides the “material” for the evil act to occur. However, the material cooperator does not intend the evil act to happen. Material cooperation is divided into two categories: immediate and mediate cooperation (Grisez 1997, 440).

The immediate material cooperator is indispensable for the commission of the evil act. Who would be considered immediate material cooperators in regard to SIS? Healthcare professionals whose participation is indispensable for the commission of the evil act of illicit intravenous drug use are considered immediate material cooperators. Such persons are involved in providing the sterile needles and in certain situations, in activities such as preparing a site on the body for the injection of a drug, filling a syringe with drug to be used in the injection or actually injecting drug for the user. Immediate material cooperation is never licit because it is so intimately linked with the principle agent’s evil act that they are nearly indistinguishable. One must note that if the healthcare professional person intends use of illicit intravenous drugs, even with the goal to curb drug overdoses and reduce public nuisance, this person becomes an implicit formal cooperator. In either case, his or her participation is so closely linked to the evil act of the principal agent that they incur the same culpability for the evil act as that which the principal agent incurs.

According to Scott R. Lefor, PhL, who is a member of the Catholic Studies faculty at Mary College at Arizona State University in Tempe, Arizona, explores this question in his article, “Safe Injection Sites and the Ethic of Harm Reduction” (Ethics and Medics, Volume 44, Number 5; May 2019). He gives consideration to the argument that SIS and the provision of equipment is mediate material cooperation rather than immediate. Proponents of this argument state that the addicted person will find a way of getting the equipment needed to abuse drugs regardless of the presence of SIS. However, he states that this argument does not provide sufficient evidence to arrive at this conclusion.

While it is true that addicts find access to this equipment without it being provided by safe injection facilities, it is clear that they often must go to great lengths to do so.…Furthermore, in determining the level of the cooperator’s participation, whether there is any possible way for the principal agent to carry out the act without the cooperator’s assistance does not seem to be a reasonable standard. Rather the fact that ought to be focused on is that the safe injection site purchases, ensures the sterility of, and provides the necessary equipment to the addict in order for the addict to inject. This seems to meet a reasonable standard of immediate material cooperation and, as such is morally illicit cooperation. (Lefor 2019, 3)

The mediate material cooperator is not indispensable for the evil act to occur. However, his or her action can lead to the commission of the evil act (Grisez 1997, 440). An example of this is the administrative staff who communicates with patients, scheduling, electronic medical coding, maintaining records, and financial accounting. The action that the cooperator performs may be good or neutral in itself and yet also supplies some assistance, means, or preparation for the immoral action of another. In other words, the mediate material cooperator provides the material that can lead to the occurrence of the immoral act.

In 1999, the Archdiocese of Sidney Australia the Sisters of Charity Health Service (SCHS) agreed to conduct the first legal trial in Australia of medically supervised injecting rooms in Sidney. The Sisters noted that they did not have the goal of perpetuating drug abuse rather to discourage it and reduce harm. The Cardinal Archbishop of Sydney, Edward Clancy, referred this proposal to the Congregation of the Doctrine of the Faith. The Congregation, headed by Josef Cardinal Ratzinger, opined against the proposal. According to Anthony Fisher, author of Catholic Bioethics for a New Millennium, the full document was never made public. However, he stated that excerpts of the ruling were published in the Archdiocesan weekly newspaper, Catholic Weekly on November 7, 1999, entitled The Debate on Medically Supervised Injecting Rooms: Cardinal Explains the Holy See’s Decision.

It apparently gave the SCHS the benefit of the doubt in assuming that none of those involved would cooperate formally in drug taking. It nonetheless opposed the plan for reasons such as:

• The intrinsic immorality and extrinsic harmfulness of drug abuse, which impedes the ability of the human person to think, will and act responsibly; which destroys bodies, minds and lives; and which harms families and communities (CCC2291);

• The lack of a focus on freeing people from drug abuse and addiction because supervised injecting rooms, in order to attract clients, avoid any strong message about abstinence and rehabilitation and even imply despair of such outcomes;

• The risk that the injecting room would actually encourage drug abuse by offering a secure venue for the practice;

• The danger that drug-trafficking might also be encouraged, by giving dealers and users a police—free location for their trade;

• The risk of (theological) ‘scandal’ in the sense of leading people into sin;

• Serious doubts about the efficacy of such programmes [sic];

• Fear that state and church sponsored injecting rooms would represent a step towards decriminalization and ‘normalization’ of drug taking;

• The risk of compromising that clear Gospel witness which Catholic agencies should always give;

• The danger that an injecting room would undermine respect for law, further degrade social mores and mask inaction by government and the community to reduce drug abuse. (Fisher, 80–83)

One final question to be considered in this discussion involves the level of cooperation, if any, that social workers or therapists experience who work at a specific SIS. The answer to this question lies in the specific role of these caseworkers. If they are employed in order to motivate persons using these facilities for illicit drug use to enter treatment centers or to receive other services that will help them legitimately overcome their addiction, then their act is a good one and very necessary for the health and well-being of both persons suffering from addiction and the greater municipality. They are not intending the evil act to take place because they are not advocating use of illicit drugs. Nor are they providing the material necessary for the evil act to occur. Nor do the services they provide lead to the occurrence of the evil. Quite the contrary. Thus, their presence at the SIS is not an example of cooperation in evil. Rather, it is an example of beneficence.

Conclusion

Drawing on current clinical science and the medical facts regarding substance abuse and addiction, widely accepted bioethical principles, Catholic social teaching, and the common good, SIS are not morally licit. Municipal governing bodies and the clinicians who staff these facilities cooperate in the evil of illegal drug abuse.

Biographical Notes

Steven Bozza, PhD candidate, is the director of the Office for Life and Family for the Archdiocese of Philadelphia. He is also professor of Catholic healthcare ethics and moral theology at Catholic Distance University in West Virginia and adjunct professor of the same subjects at Immaculata University in Immaculata Pennsylvania. He is a member of the Philadelphia Guild of the Catholic Medical Association. He received his BA from Glassboro State College (now Rowan University) and his MA from St. Charles Borromeo Seminary/School of Religious Studies. He currently finished his coursework and writing his dissertation for a PhD in Bioethics from the Pontificio Ateneo Regina Apostolorum/School of Bioethics in Rome, Italy. He has written extensively on bioethical issues and produced several videos on end of life issues.

Jeffrey Berger, MD, earned his medical degree at Wayne State University. He took his Internship in Internal Medicine at Thomas Jefferson University Hospital in Philadelphia, PA, then finished his Residency in Internal Medicine at Detroit General Hospital in Detroit, MI. Shortly after joining the medical staff at Henry Ford Hospital in Detroit as an Internist, he became interested in addiction medicine. He has practiced addiction medicine for more than thirty-five years. He has served as medical director at Brighton Hospital, is now medical director at Guest House, an addiction treatment center in Lake Orion, MI, for Catholic clergy and religious and seminarians. He is boarded in both internal medicine and addiction medicine.