There’s a lot of agreement around harm reduction. So why aren’t we doing more of it?

Something interesting is happening in response to America’s drug overdose crisis: various experts are coming out more and more strongly in support of harm reduction services, and yet many such services continue to be vehemently opposed by politicians and a portion of the public. I was very happy to see that in response to my essay in this issue, all three respondents supported broad harm reduction efforts. And yet we are far from meeting the demand for sterile syringe exchange and sufficient supplies of naloxone, and we have yet to open the first American safe injection site.

Why this sluggish response to expert-supported, evidence-based policy?

Earlier this summer, I wrote for USA Today that I have a hypothesis about this failure of Americans to embrace harm reduction, and I thought I would use this opportunity to expand a bit on that idea. In short, I think that citing the evidence in favor of harm reduction does not change the mind of every American because at least sometimes, their objections are moral rather than empirical. That is: not everyone objects to harm reduction services because they don’t believe such services can save lives; rather, they sometimes object because, whether they save lives or not, they think it’s wrong for the state to spend resources on harm reduction. And the reason they think it’s wrong is because harm reduction—by not focusing on eliminating drug use, but instead on reducing the harms of drug use—can feel like enabling what some see as bad behavior.

This sort of reasoning can be seen when a politician denounces opioid agonist treatment as “substituting one opioid with another,” or when a frustrated sheriff laments repeat uses of naloxone for the same person, saying, “It’s just reviving somebody who’s going to go back and get high the same day.” When someone complains that a safe-injection site will essentially be a state-sponsored “shooting gallery,” the same worry is being echoed.

As a moral philosopher, I hear these sorts of condemnations as laced with a particular account of ethics: one that focuses on individual responsibility. And it is often combined with a particular view of drug use: that it is morally bad. Combined—without any further views about addiction to complicate the picture—we can see the old, harmful, stigmatizing view of addiction as a moral failure: drug use is bad, and people are responsible for their choices. So if they choose to do drugs, they should live with the consequences, and enacting harm reduction policies would actually be quite problematic, as they would be helping these people to do the morally wrong thing.

I take this view to be tragically, catastrophically mistaken; but I also want people (including my allies in support of harm reduction) to notice how understandable the view looks if you have certain beliefs. Because if my experience is any indication, and if this is really one of the significant obstacles to embracing harm reduction, we must tackle this view head-on, rather than simply continuing to tell our opponents that harm reduction is evidence-based.

We could take issue with the high-level moral philosophy being invoked and argue that whether or not an individual is responsible for her actions is not actually all that morally important. For transparency’s sake, I’ll note that this is actually my own inclination. But I also think it’s both philosophical overkill and unlikely to be effective. Because anyone with strong intuitions about moral responsibility is unlikely to be convinced, and we can respond to the more specific challenge for drug policy with less grand claims. These more modest claims are: 1) that even if moral responsibility is a good foundation for ethics and policy, it doesn’t work well in cases of compromised integrity (like with addiction); and 2) that even if moral responsibility is a good foundation for ethics and policy and if addiction didn’t compromise integrity, healthcare isn’t (and shouldn’t be) organized around a principle of personal responsibility.

Regarding 1: addiction is a health condition characterized by injury to the will. That is, the precise effects on the brain that define addiction result in cravings and compulsive behavior, even in the face of adverse consequences. What it means to be addicted is to fail to be able to fully regulate one’s will. And when someone’s will is compromised, that changes our evaluation of their responsibility. This is true for children, those with other mental health conditions, or someone being controlled or coerced. It is a foundational view of moral philosophies that focus on personal responsibility that certain conditions must be met in order for ascriptions of responsibility to be appropriate. But addiction undermines full autonomy, and so the focus on responsibility for one’s actions when suffering from addiction is unhelpful and incomplete. We should note that this does not mean that someone who is addicted to a substance has no responsibility for their actions—having an addiction does not turn one into a robot or a zombie—but it does compromise one’s responsibility.

Further, argument 2 notes that even if someone suffering from addiction has sufficient autonomy to be fully responsible for her actions, the proper goal of healthcare is not to reward good behavior and punish bad behavior. Many health outcomes are related to personal choices to some degree. As Dr. Singer notes, overweight and sedentary patients are regularly treated with medications for conditions that are partially related to lifestyle choices. For another example, joint replacements are incredibly common in the United States, and they can be the result of activity choice, weight, or both. Even the common broken bones and trauma resulting from everyday activities like playing sports, hiking, skiing, or driving are health conditions that result from our free and informed choices.

Focusing especially on the case of injury from sports (and how I have never heard anyone suggest that athletes should be forced to live with consequences of their risky choices), it becomes clear that a lot of the force of the moral responsibility argument is being carried by a stigmatizing view of drug use. If athletics is good and drug use is bad, then we can separate out healthcare for those suffering from addiction as unjustified. But now it becomes clear that the view is not a rigorous moral philosophy, but an individual view about what behaviors are good and bad.

Do we really want healthcare policy to be based on what some group of people thinks is bad behavior?

I certainly don’t. I have moral objections to American football, but I certainly want all football players to have access to healthcare. And as a past motorcyclist, I was told many times in my life that I was a bad person for taking such risks when I had a family. Having now paid the price for my decision to ride, I see the wisdom in their comments, but am eternally grateful that I wasn’t denied healthcare because of my lifestyle.

The goal of healthcare is to promote health, not to reward or punish certain lifestyles and choices. We can promote the health of people who use drugs through harm reduction services, so let’s recognize that as consistent with the ideal of healthcare, even if some people disagree with their lifestyle.

Also from this issue

Lead Essay

  • American pain medicine is desperately broken, says bioethicist Travis N. Rieder. To fix it, we must avoid swinging the pendulum too far toward over-medication—and too far toward under-medication. Either of these mistakes can drive patients toward the dangerous illicit opioid market. Instead, Rieder recommends harm reduction strategies, including safe injection sites and even prescriptions for pharmaceutical grade opioids to minimize the harms of addiction.

Response Essays

  • Jeffrey A. Singer agrees that pain is individualized and thus difficult to assess. The War on Drugs has made practicing medical pain management much more difficult, because doctors have grown averse to prescribing opioids, particularly in high doses. But it was not doctors prescribing too freely that prompted the recent crisis, and when doctors withdrew these medications, many patients turned to the streets.

  • Gail D’Onofrio says that clinicians have a good idea of what works in fighting opioid addiction and dependency. She calls for a multifaceted approach that involves medication, more treatment professionals, and ending the stigma of seeking treatment, which can often drive away people who would otherwise seek help. She outlines a variety of legislative and clinical practice reforms that she believes will help prevent and treat substance use disorders in the future.

  • “The chronic and relapsing nature of addiction—the very symptoms of addiction—are punished and criminalized,” writes Regina LaBelle, who argues that this punishment is counterproductive. The criminal justice system has become the default primary care provider for many and perhaps most addicts, and this situation helps no one in society, not even those who never use drugs at all.