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Virtue ethics as an alternative to deontological and consequential reasoning in the harm reduction debate
Abstract
There is strong evidence that harm reduction interventions such as Supervised Injection Sites and Needle Exchange Programs prevent many of the negative consequences of problematic substance use. Yet many governments, including the United States and Canada, still do not endorse these interventions, claiming that they do not get people off of drugs and send a mixed message.
This paper will analyze objections to harm reduction in light of the ethical theories of John Stuart Mill, Immanuel Kant and Aristotle.
The most important ethical issue in the abstinence vs. harm reduction debate is whether harm reduction - because it does not require individuals to either reduce their consumption of illicit substances or to abstain from illicit substance use - can be ethically justified.
Harm reduction interventions are clearly justified on Utilitarian grounds because, based on the evidence, such policies would produce the greatest good for the greatest number. However, Kant would not think that the values guiding harm reduction are ethical because the justification of harm reduction interventions focuses exclusively on examining consequences. Virtue Ethics seeks to find the proper balance between harm reduction and abstinence. We claim that the virtue of compassion would provide a defense of harm reduction.
... Theories of deontology emphasise the existence of basic ethical rules which must be observed regardless of the result. Immanuel Kant is credited with inventing deontology (Christie, 2008). In this context, individual laws are the subject of deontological ethics (Hoover and Pepper, 2014, p. 607). ...
... Kant goes on to claim that certain acts inspired by a sense of obligation hold moral meaning, and this obligation is thus characterised as behaving in conformity with the general rule (Christie et al., 2008). The Categorical Imperative (CI), as Kant calls it, can be classified as follows: ...
... • Act just on the principle that you are building at the very same moment with the intention of it being a law of the universe, and • Act in such a manner that you regard humanity, either in your own person or in the position of another, as a purpose in itself, never as a means to an end (Christie et al., 2008). ...
... Virtue ethics theory is one the three main normative theories of ethics, the other two being deontological ethics theory and consequential ethics theory (Christie et al., 2008). Virtue ethics theory differs from the other two in that it argues for the need to focus on the actors and not just the acts in examining morality (Christie et al., 2008). ...
... Virtue ethics theory is one the three main normative theories of ethics, the other two being deontological ethics theory and consequential ethics theory (Christie et al., 2008). Virtue ethics theory differs from the other two in that it argues for the need to focus on the actors and not just the acts in examining morality (Christie et al., 2008). Deontological ethics theory, on the other hand, focuses on acts defined as inherently right or wrong irrespective of context, while consequential ethics theory argues for the need to consider the consequences of actions in examining morality (Kindsiko, 2013;Christie et al., 2008). ...
... Virtue ethics theory differs from the other two in that it argues for the need to focus on the actors and not just the acts in examining morality (Christie et al., 2008). Deontological ethics theory, on the other hand, focuses on acts defined as inherently right or wrong irrespective of context, while consequential ethics theory argues for the need to consider the consequences of actions in examining morality (Kindsiko, 2013;Christie et al., 2008). Virtue ethics theory has its roots in ancient Greek philosophy, particularly the works of Plato and Aristotle, who argued that the purpose of ethics was to become good and not only know good (Hursthouse and Pettigrove, 2016). ...
... What does Kantian ethics require of us in relation to the consumption of psychoactive substances? Some applied ethics literature implies the answer is: abstinence, and by implication public policies regarding psychoactive drugs based on prohibition [1]. On the other hand, harm reduction approaches, those characterized by not requiring abstinence, are, this literature equally implies or asserts, the province of consequentialists and virtue ethicists [1,5,7]. ...
... Some applied ethics literature implies the answer is: abstinence, and by implication public policies regarding psychoactive drugs based on prohibition [1]. On the other hand, harm reduction approaches, those characterized by not requiring abstinence, are, this literature equally implies or asserts, the province of consequentialists and virtue ethicists [1,5,7]. If, after all, what is motivating your interventions into people's drug use is reducing harms you must be focusing on consequences, something that cannot be countenanced by a Kantian deontological moral theory. ...
... Thus Christie et al. claim that on a Kantian account of morality "this type of instrumental reasoning does not meet the relevant ethical standard" (p.56) and that "Kant would not think that the values guiding harm reduction meet the appropriate ethical standard, because the "raison d'ˆetre" of harm reduction is exclusively to prevent negative consequences" (p. 58) [1]. Christie et al. present two interconnected but distinct Kantian arguments against harm reduction. ...
The justification for harm reduction as an approach to drug use and addiction is seen by many to be consequentialist in form and it has been claimed that as a deontologist Kant would reject harm reduction. I argue this is wrong on both counts. A more nuanced understanding of harm reduction and Kant shows them compatible. Kant’s own remarks about intoxication reinforce this. Moreover, there is a Kantian argument that harm reduction is not only morally permissible but more consistent with the Kantian duty of respect for autonomy than mandatory abstinence approaches.
... Virtue ethics theory is one the three main normative theories of ethics, the other two being deontological ethics theory and consequential ethics theory (Christie et al., 2008). Virtue ethics theory differs from the other two in that it argues for the need to focus on the actors and not just the acts in examining morality (Christie et al., 2008). ...
... Virtue ethics theory is one the three main normative theories of ethics, the other two being deontological ethics theory and consequential ethics theory (Christie et al., 2008). Virtue ethics theory differs from the other two in that it argues for the need to focus on the actors and not just the acts in examining morality (Christie et al., 2008). Deontological ethics theory, on the other hand, focuses on acts defined as inherently right or wrong irrespective of context, while consequential ethics theory argues for the need to consider the consequences of actions in examining morality (Kindsiko, 2013;Christie et al., 2008). ...
... Virtue ethics theory differs from the other two in that it argues for the need to focus on the actors and not just the acts in examining morality (Christie et al., 2008). Deontological ethics theory, on the other hand, focuses on acts defined as inherently right or wrong irrespective of context, while consequential ethics theory argues for the need to consider the consequences of actions in examining morality (Kindsiko, 2013;Christie et al., 2008). Virtue ethics theory has its roots in ancient Greek philosophy, particularly the works of Plato and Aristotle, who argued that the purpose of ethics was to become good and not only know good (Hursthouse and Pettigrove, 2016). ...
... 3 The defining feature of harm reduction is a focus on prevention of harm rather than prevention of drug use itself. 4 Narrow definitions of harm reduction do not include abstinence-based programs; whereas, broad definitions do include abstinence-based programs as long as the programs include measures to decrease harms for those who continue to use drugs. 5 Harm reduction focuses on maximizing the well-being of persons who use drugs who are unable or unwilling to stop using drugs. ...
... HIV and hepatitis C), injection-related bacterial infections (local and systemic), and overdose complications, including death. 4 The indirect social harms of drug use are complex and difficult to quantify, but multiple studies have proven associations of drug use with violence, homicide, property crime, involvement in the sex trade, public stigmatization, homelessness, and incarceration. 4,6 The US has been resistant to adopt harm reduction policies for drug use. ...
... 4 The indirect social harms of drug use are complex and difficult to quantify, but multiple studies have proven associations of drug use with violence, homicide, property crime, involvement in the sex trade, public stigmatization, homelessness, and incarceration. 4,6 The US has been resistant to adopt harm reduction policies for drug use. Resistance to harm reduction has largely been driven by a culture that values abstinence from illicit drugs. ...
The US is facing dual public health crises related to opioid overdose deaths and HIV. Injection drug use is fueling both of these epidemics. The War on Drugs has failed to stem injection drug use and has contributed to mass incarceration, poverty, and racial disparities. Harm reduction is an alternative approach that seeks to decrease direct and indirect harms associated with drug use without necessarily decreasing drug consumption. Although overwhelming evidence demonstrates that harm reduction is effective in mitigating harms associated with drug use and is cost-effective in providing these benefits, harm reduction remains controversial and the ethical implications of harm reduction modalities have not been well explored. This paper analyzes harm reduction for injection drug use using the core principles of autonomy, nonmaleficence, beneficence, and justice from both clinical ethics and public health ethics perspectives. This framework is applied to harm reduction modalities currently in use in the US, including opioid maintenance therapy, needle and syringe exchange programs, and opioid overdose education and naloxone distribution. Harm reduction interventions employed outside of the US, including safer injection facilities, heroin-assisted treatment, and decriminalization/legalization are then discussed. This analysis concludes that harm reduction is ethically sound and should be an integral aspect of our nation's healthcare system for combating the opioid crisis. From a clinical ethics perspective, harm reduction promotes the autonomy of, prevents harms to, advances the well-being of, and upholds justice for persons who use drugs. From a public health ethics perspective, harm reduction advances health equity, addresses racial disparities, and serves vulnerable, disadvantaged populations in a cost-effective manner.
... Consequential ethics theory is the dominant theory in marketing practice (Batra & Klein, 2010). Its origin is attributed to the works of the 19th century English philosophers Jeremy Bentham and John Mills, who promoted the ideas of liberalism and utilitarianism to analyze actions from an ethical perspective (Christie, Groarke, & Sweet, 2008). The theory argues that moral agents should be free to act as they wish, as long as such acts result in positive consequences (Christie et al., 2008). ...
... Its origin is attributed to the works of the 19th century English philosophers Jeremy Bentham and John Mills, who promoted the ideas of liberalism and utilitarianism to analyze actions from an ethical perspective (Christie, Groarke, & Sweet, 2008). The theory argues that moral agents should be free to act as they wish, as long as such acts result in positive consequences (Christie et al., 2008). Where an action has both positive and negative consequences, consequentialism argues that agents be allowed to pursue such acts as long as the benefits outweigh the drawbacks. ...
... This theory argues that actions have their own intrinsic qualities that make them inherently right or wrong, irrespective of their consequences (Kindsiko, 2013). The proponent of this theory, Emmanuel Kant, argues for an abstinence-based approach to acts that are not in line with duty, because engaging in such acts entails being unethical (Christie et al., 2008). Duty, according to Kant, is rooted in three main categorical imperatives of the universality of moral rules: the applicability of rules in all situations, regardless of the consequences; the dignity of humans, shown in always treating humans as the end and not just the means to an end; and doing the right for its own sakethat is, because it is right to do right (Bowen & Prescott, 2015). ...
The practice of mobile behavioral advertising, which involves monitoring and analyzing customer mobile browsing behavior and location in order to provide behavior-based personalized advertisements, is on the increase. This study investigated consumer perceptions of the ethical value of the brands advertised using mobile behavioral advertising, and the precursors and outcomes of these perceptions. Data was collected in Gauteng, South Africa from 500 consumers who indicated that they had previously been targeted by mobile behavioral advertising. Structural equation modeling was used to analyze the data. The results suggest that perceived privacy control, desire for privacy, privacy concerns, and attitude towards mobile behavioral advertising exert a significant influence on consumers’ perception of brand ethical value. Perceived brand ethical value was found to affect advertisement avoidance and brand customer relationship quality as denoted by brand romance. Marketers can use the study's findings to manage their mobile behavioral advertising practices better.
... Utilitarianism, pioneered by Jeremy Bentham and John Stuart Mill, teaches that an action is moral if it maximizes the happiness within a society. 12 Utilitarianism is sometimes considered under the broader theory of consequentialism. In judging the morality of an action or policy, consequentialism considers the widespread impact of an action on all stakeholders as well as society at large. ...
... 14 Therefore, deontology judges morality by inherent goodness and whether actions are motivated by duty, irrespective of the consequences. 12 Inherent goodness is often evaluated by whether an action or policy can conform to the categorical imperative, which poses that inherently moral actions could be prescribed as a universal law. 12 supervised injection facilities maximize good for more drug users An ideal utilitarian approach to the issue of substance abuse would bring about the most happiness for the greatest number of people. ...
... 12 Inherent goodness is often evaluated by whether an action or policy can conform to the categorical imperative, which poses that inherently moral actions could be prescribed as a universal law. 12 supervised injection facilities maximize good for more drug users An ideal utilitarian approach to the issue of substance abuse would bring about the most happiness for the greatest number of people. However, many of the current approaches to treatment for substance abuse are rooted in an abstinence-only philosophy whereby help is provided to those willing to completely cease use. ...
Novel approaches are needed to address the issue of injection drug use in Canada, which can have negative consequences for drug users and society. Supervised injection facilities (SIFs) are legally sanctioned facilities in Canada where drug users can receive sterile drug paraphernalia, referral to cessation programs and timely medical care if necessary. SIFs operate under the principle of harm reduction, which aims to reduce rates of infection and death due to overdose among drug users. SIFs are largely driven by the utilitarian ideal of maximizing benefit for the greatest number of people, through supervision of active drug users and appropriate referral for those wishing to quit. Deontological theory may support SIFs depending on how one applies the categorical imperative. Studies of the first SIF in North America, Insite, have shown demonstrable reductions in adverse health and societal consequences of injection drug use, rationalizing their implementation under consequentialism. SIFs are, therefore, suitable for greater adoption by the healthcare system.
... This study, however, is situated within the virtue theory for the following reasons. In contrast to consequentialist theory, the emphasis of virtue ethics is not on isolated acts of agents but on the character of the agent, such as honesty, loyalty, courage, compassion, kindness and fairness (Christie et al., 2008). In the view of Aristotle, politics and morality are inseparable; for politics seeks to have a good society inhabited with morally upright citizens. ...
... Furthermore, ethics interventions are not made in self-interest or to satisfy one's duty to escape retribution (Christie et al., 2008). Rather, accounting educators see themselves as responsible for preparing graduates who are socially appropriate and ready to function in a global environment without barriers. ...
The paper explores curriculum design and drivers of ethics in universities and the professional accounting bodies in Ghana. Data were collected through individual face-to-face interviews. The study revealed that ethics in the curricula of universities and professional bodies are integrated within and across subjects and within all levels of programmes. Also, ethics is integrated using a combination of stand-alone, embedded and narrative approaches. Factors such as faculty initiative, industry demand, international benchmarking and modernisation are some of the drivers of ethics in the universities and the professional accounting bodies. Accounting educators need to understand the nature and drivers of ethics in the design of accounting curricula in order to improve the ethical practices of accounting graduates. The study is among the few that adopt an in-depth qualitative approach in highlighting the nature of ethics curriculum design for universities and professional bodies.
... In Canada, for example, it became a term commonly used by Jane Philpott, Justin Trudeau's first Health Minister, 1 and it is arguably operative in a trio of decisions of the Supreme Court of Canada, to do with safe injection sites, sex work, and medical assistance in dying. 2 The horizontal expansion has had to do with the range of practices to which talk of harm reduction has been seen by some to be appropriate. No longer confined solely to drug use, harm reduction has been seen by some as an appropriate approach to adopt across a wide range of practices, including sex work [3], female genital cutting [20], domestic violence [7], medical assistance in dying [9,15], abortion [4], and even risky behaviour in the context of the COVID-19 pandemic [13]. ...
... This expansion in the presence of harm reduction talk across a wide range of policy domains and contexts has thus far not been met by a concomitant increase in theoretical discussion of the concept. Philosophical attention in particular has been scant [2,4,12,17]. ...
Talk of harm reduction has expanded horizontally, to apply to an ever-widening range of policy domains, and vertically, becoming part of official legal and political discourse. This expansion calls for philosophical theorization. What is the best way in which to characterize harm reduction? Does it represent a distinctive ethical position? How is it best morally justified, and what are its moral limits? I distinguish two varieties of harm reduction. One of them, technocratic harm reduction, is premised on the fact of non-enforceability of prohibitionist policies. The second, deliberative harm reduction, is premised on the fact of reasonable disagreement, grounded in the fact that reasonable persons disagree about a range of controversial behaviours. I argue that deliberative harm reduction better accounts for some of harm reduction’s most attractive features, and provides a plausible way of accounting for harm reductions’s justificatory grounds and limits.
... The evaluation of whether this research crossed ethical boundaries depends, in part, on guidelines available at the time (APA, 1959) and the moral philosophical position taken (Miller, 1986; for a discussion on the ethics of harm avoidance, see : Bradley, 2012;Christie et al., 2008;Miller, 1986). For example, inflicting minimal harm to gain insights into how people speak-up within malevolent scenarios may be considered universally undesirable in a deontological view (e.g., because it crosses a general principle of non-maleficence; Sharpe, 1997), acceptable in a utilitarian/consequentialist perspective (e.g., because the minimal harm weighs up against the benefit of applying new insights to prevent many accidents), or honourable within a virtue-ethics perspective (e.g., because the motive for increasing safety was appropriate for its context; Bolsin et al., 2005). ...
... For example, inflicting minimal harm to gain insights into how people speak-up within malevolent scenarios may be considered universally undesirable in a deontological view (e.g., because it crosses a general principle of non-maleficence; Sharpe, 1997), acceptable in a utilitarian/consequentialist perspective (e.g., because the minimal harm weighs up against the benefit of applying new insights to prevent many accidents), or honourable within a virtue-ethics perspective (e.g., because the motive for increasing safety was appropriate for its context; Bolsin et al., 2005). Safety voice research appears to incorporate a utilitarian perspective in researching safety voice because concepts for safety voice have incorporated utilitarian principles (e.g., trade-offs between cost and benefits of speaking-up; Morrison, 2014;Schwappach & Gehring, 2014d), and the need for investigating safety voice is typically justified through its contribution to harm-avoidance (e.g., see the introduction to this thesis), which implicitly appeals to the consequences of the behaviour (e.g., Christie et al., 2008). ...
Background: The concept of ‘safety voice’ captures the extent to which individuals speak-up about safety. The behaviour is deemed important for preventing accidents, yet interventions are needed because people often fail to speak-up (‘safety silence’), thus contributing to harmful outcomes across safety-critical domains. However, the concept remains disintegrated and grounded in limited evidence and methodologies. Thus, the utility of ‘safety voice’ for safety management remains unclear, prohibiting effective interventions. This thesis therefore aims to evaluate how the behavioural nature of safety voice may be optimally conceptualised, assessed and intervened on. Approach: Four articles presented a systematic literature review (n = 48 publications), twelve experimental studies (ntotal = 1,222) and an analysis of Cockpit Voice Recorder (CVR) transcripts across 172 aviation accidents (1962-2018; n = 14,128 conversational turns). Article 1 synthesised evidence from across theoretical domains. Article 2 presented the first experimental paradigm for safety voice (‘Walking the Plank’) to address nine methodological challenges. Article 3 observed safety silence in the laboratory to establish and conceptualise how the behaviour manifests in relationship to safety voice and interventions. Article 4 captured safety voice during real-life safety accidents, and investigated how risk, safety listening, power distance and CRM training impact on safety voice. Findings: Safety voice is a distinct concept that is highly ecological and situated, and that is important for understanding how safety voice contributes to accidents. A methodological reliance on self-reports and post-hoc methodologies was identified and addressed through the Walking the Plank paradigm. Safety silence, identifiable through assessing safety concerns, was scalable based on the degree of safety voice speech, with interventions uniquely impacting on five safety themes and hazard stages. Safety voice was found to occur frequently during real accidents, with the developed Threat Mitigation Model underscoring that safety concerns, safety voice and safety listening all contribute to preventing harm.
... This well-known tension between deontological and utilitarian ethical outlooks is at the base of many ethical dilemmas in medicine, including that of the justification of harm reduction. It has been proposed that an alternative to this narrow deontologicalutilitarian dichotomy is the school of virtue ethics, most commonly associated with Aristotle (36). Virtue ethics do not focus on isolated acts but rather on the character of the agent (i.e., compassion, honesty, kindness, etc.). ...
... Virtue ethics thus takes into account context and consequences, without reducing ethics into a simple matter of promoting pleasure, reducing pain or doing one's duty. In the case of harm reduction, it is proposed that the necessary character trait for policy makers and practitioners is that of compassion, which should be balanced between aiding a particular act as opposed to encouraging it (36). This form of virtue-based morality can provide an ethical foundation for some harm reduction policies without resorting to utilitarianism. ...
Harm reduction is a general term for pragmatic interventions aimed at reducing problematic behaviors. Emerging from addiction treatments, it is based on the understanding that people will continue to behave in ways that pose a risk to them and their communities, and that an important goal of any treatment program is to minimize the harm associated with these behaviors. Despite its evidence based background, harm reduction is not readily applied in general psychiatry. This is mainly due to the complex ethical dilemmas arising within harm reduction practices, as well as a lack of scientific knowledge and theoretical frameworks essential for dealing with such ethical dilemmas. In this paper we introduce the fundamental theoretical and scientific base of harm reduction strategies, and present three clinical examples of the complex ethical dilemmas arising when working within a harm reduction practice. We finally present a theoretical framework for dealing with the ethical dilemmas and argue this may make harm reduction strategies more accessible in general psychiatry.
... Harm reduction is a framework for public health intervention that focuses on a pragmatic and compassionate approach to reduce harms from unhealthy behaviors (Erickson, 1995). It was originally focused on reducing harms from drug use but can be extended to include other stigmatized harmful behaviors (Christie, Groarke, & Sweet, 2008;Erickson, 1995;Marlatt, 1996). Harm reduction focuses on the consequences of behaviors rather than making a moral judgment about the behaviors themselves and encourages providers to use a collaborative and compassionate approach to help patients reduce harm from their behaviors (Christie et al., 2008;Marlatt, 1996). ...
... It was originally focused on reducing harms from drug use but can be extended to include other stigmatized harmful behaviors (Christie, Groarke, & Sweet, 2008;Erickson, 1995;Marlatt, 1996). Harm reduction focuses on the consequences of behaviors rather than making a moral judgment about the behaviors themselves and encourages providers to use a collaborative and compassionate approach to help patients reduce harm from their behaviors (Christie et al., 2008;Marlatt, 1996). ...
Methamphetamine use has increased substantially in the United States since the 1990s. Few studies have examined the healthcare service needs of women who use methamphetamine. This study describes unmet medical needs in a community-based sample of women who use methamphetamine in San Francisco, CA. Women who use methamphetamine were recruited in San Francisco and participated in a computer-assisted survey (N = 298 HIV-negative women). Multivariate analysis was performed to explore associations among sociodemographic variables, drug use, use of health and social services, and unmet healthcare need across three domains: chronic health problems, dermatologic problems, and women's preventive healthcare. Sixty-nine percent of participants reported a need for care for a chronic health condition, and 31% of them had an unmet need for care, in the last six months. Thirty-five percent of participants reported a need for dermatologic healthcare, and 66% had an unmet need for care in the last 6 months. Ninety-two percent of participants reported a need for women's preventive healthcare and 46% had an unmet need for care in the last year. Women who reported having a healthcare provider had lower odds of reporting an unmet need for a chronic health condition or women's preventive healthcare. Women who used a case manager had lower odds of having an unmet need for dermatologic care. A significant proportion of women who use methamphetamine in this sample had an unmet need for women's preventive healthcare, and overall these women had a significant unmet need for healthcare. These findings suggest that contact with a healthcare provider or a caseworker could help to expand access to healthcare for this vulnerable population.
... There is a growing body of evidence supporting the use of harm reduction strategies for the pragmatic purposes of saving lives and preventing disease [7][8][9]. Harm reduction can also be justified as a means of relieving human suffering through acts of compassion [10], as a tool of social justice [11], a mechanism to address inequities and an effective means of countering stigmatizing beliefs about PWLE [12]. Harm reduction has been endorsed by the Canadian Nurses Association [13], Doctors of BC [14], and the Canadian Public Health Association [15]. ...
Background
The Compassion, Inclusion and Engagement initiative (CIE) was a social contact intervention that operated in British Columbia between 2015 and 2021. The primary objective of CIE was to increase the participation of people with lived experience of substance use (PWLE) in the planning, design, implementation, and evaluation of harm reduction supports and services.
Case presentation
CIE used the developmental evaluation methodology outcome mapping to define and measure progress towards its goals. Developmental evaluation emphasizes learning in contrast to other forms of evaluation which are often more focused on determining the value or success of a project or programme based on predetermined criteria. Outcome mapping is a relational practice which acknowledges that change is achieved by an initiative’s partners and the role of the initiative is to provide access to resources, ideas and opportunities that can facilitate and support change.
Conclusions
Through the implementation and evaluation of CIE, it became clear that directly supporting PWLE facilitated more meaningful and lasting change than solely working to improve the health and social services that supported them. The impacts of the CIE initiative extend far beyond the outcomes of any of the dialogues it facilitated and are largely the result of an increase in social capital. CIE engagements created the opportunity for change by inviting people most affected by the toxic drug supply together with those committed to supporting them, but their ability to bring about systemic change was limited. Both PWLE and service providers noted the lack of support to attend CIE engagements, lack of support for actions that came from those engagements, and lack of PWLE inclusion in decision-making by health authorities as limiting factors for systemic change. The lack of response at a systemic level often resulted in PWLE carrying the burden of responding to toxic drug poisonings, often without resources, support, or compensation.
... Beliefs about relationships between addiction and autonomy, capacity, or free-will are complex and contested, especially under the biomedical framing of the "brain disease model of addiction" [41][42][43]. MAPs are informed by a harm reduction philosophy, which promotes autonomy, choice, and compassion [4,14,[44][45][46][47][48][49]. Regarding the ethical principle of justice, MAP was compatible with Mr. S' rights and the law. ...
Managed alcohol programs aim to reduce health and social harms associated with severe alcohol use disorder. Here, we describe a young man with severe alcohol use disorder enrolled in a managed alcohol program, who was admitted to hospital with acute liver injury. Fearing that alcohol was contributing, the inpatient care team discontinued the managed alcohol dose in hospital. He was ultimately diagnosed with cephalexin-induced liver injury. After consideration of risks, benefits, and alternative options, the patient and care team jointly decided to restart managed alcohol after hospital discharge. With this case, we describe managed alcohol programs and summarize the emerging evidence-base, including eligibility criteria and outcome measures; we explore clinical and ethical dilemmas in caring for patients with liver disease within managed alcohol programs; and we emphasize principles of harm reduction and patient-centered care when establishing treatment plans for patients with severe alcohol use disorder and unstable housing.
... It is estimated that harm reduction There is a growing body of evidence supporting the use of harm reduction strategies for the pragmatic purposes of saving lives and preventing disease (Magwood et al., 2020), (Gowing et al., 2011), (Platt et al., 2017). Harm reduction can also be justi ed as a means of relieving human suffering through acts of compassion (Christie et al., 2008), as a tool of social justice (Pauly, 2008), a mechanism to address equity and an effective means to counter stigmatizing beliefs about PWLE (Perera et al., 2022). Harm reduction has been endorsed by the Canadian Nurses Association (Canadian Nurses Association, 2018), and Doctors of BC (Doctors of BC, 2021), psychoactive substances (Canadian Public Health Association, 2017). ...
Background: The Compassion, Inclusion and Engagement initiative (CIE) was a social contact intervention that operated in British Columbia between 2015 and 2021. The primary objective of CIE was to increase the participation of people with lived experience of substance use (PWLE) in the planning, design, implementation, and evaluation of harm reduction supports and services. Case presentation: CIE used the developmental evaluation methodology Outcome Mapping to define and measure progress toward it’s goals. Developmental evaluation emphasizes learning in contrast to other forms of evaluation which are often more focused on determining the value or success of a project or program based on predetermined criteria. Outcome Mapping is a relational practice which acknowledges that change is achieved by an initiative’s partners and the role of the initiative is to provide access to resources, ideas and opportunities that can facilitate and support change .Conclusions: Through the implementation and evaluation of CIE, it became clear that directly supporting PWLE facilitated more meaningful and lasting change than solely working to improve the health and social services that supported them. The impacts of the CIE initiative extend far beyond the outcomes of any of the dialogues it facilitated and are largely the result of an increase in social capital. CIE engagements created the opportunity for change by inviting people most affected by the toxic drug supply together with those committed to supporting them, but their ability to bring about systemic change was limited. Both PWLE and service providers noted the lack of support to attend CIE engagements, lack of support for actions that came from those engagements, and lack of PWLE inclusion in decision-making by health authorities as limiting factors for systemic change. The lack of response at a systemic level, often results in PWLE carrying the burden of responding to toxic drug poisonings, often without resources, support, or compensation.
... Beim Ansatz der Schadensminderung erscheinen folgende Tugenden besonders relevant (Christie et al. 2008;Westermair et al. 2021 ...
Der Ansatz der Schadensminderung in der Suchtmedizin wird oft als wertfrei oder ethisch neutral beschrieben. Dabei ist «Schaden» per se bereits ein normativer, also bewertender Begriff. Häufige Rechtfertigungen für Schadensminderung bedienen sich der ethischen Theorie des Utilitarismus. Zudem basiert der Ansatz der Schadensminderung auf humanitären und liberalen Werten. Eine explizite ethische Auseinandersetzung mit dem Ansatz der Schadensminderung kann helfen, in herausfordernden Einzelfällen gute Entscheidungen zu treffen und die politische und gesellschaftliche Unterstützung für Schadensminderung sowie die Weiterentwicklung des Ansatzes zu fördern.
... What is important is that normative theories have been consistently applied in evaluating public health interventions throughout the brief history of public health ethics as a subdiscipline. Some commentators apply moral and political theory to public health ethics in general (Holland 2015); more frequently, specific moral or political theories are applied to discrete public health interventions or policy issues (Christie, Groarke, and Sweet 2008;Rajczi 2008). At the time of writing, the flow of papers applying normative theories to Covid measures is predictably and steadily increasing, as one commentator drily observes: 'All standard ethical theories made cameo appearances in the discussion' (Häyry 2021). ...
This paper presents, defends and applies a conception of public health ethics as focused on liberty-limiting public health action. This approach has been persistently criticised, but the criticism is ambiguous between two challenges: that the focus on liberty makes an objectionable presumption in favour of liberal values and that the focus on liberty fails to address institutionalised social injustice. Part One of the paper addresses both challenges to show they can be met by a nuanced account of a liberty-oriented public health ethics. Part Two establishes that debates about policy responses to the current Covid-19 pandemic illustrate and vindicate this conception of public health ethics as focused on liberty-limiting public health action. The discussion then turns to the methodological question as to how public health policies are to be evaluated, focusing particular on the role of normative theory in such evaluations. The methodology of ‘wide reflective equilibrium’ is described and endorsed; the paper ends with a case study to illustrate this evaluative methodology, focused on the ethics of Covid-19 immunity passports.
... These deontological ethical principles stress that doing no harm at an individual level takes precedence over risking individual harm to potentially improve aggregate wellbeing. On the other hand, business and marketing tend to emphasize consequentialist or utilitarian ethics which favor decisions when aggregate benefits outweigh costs and will tolerate outcomes that may harm individuals if they improve the greater good (Christie et al., 2008;Ferrell et al., 2019;Gustafson, 2013). Thus, pharmaceutical marketing practices that provide overall health and economic benefits or promote the good of the many over that of the few might be viewed positively by marketing and other business scholars and practitioners, but researchers in medical fields might see these same practices as ethically problematic. ...
This systematic review of cross-disciplinary peer-reviewed quantitative research into pharmaceutical marketing ethical issues from 1990 to 2021 reveals a focus on direct-to-consumer advertising and physician-directed promotion. This review documents inconsistent findings across studies due to discrepancies and limitations in research designs, study populations, sampling procedures, and analytical approaches as well as discipline-specific biases and normative ethical ideologies. We present a comprehensive taxonomy of ethical issues from the systematic review, additional scholarly and industry publications, and expert interviews. We recommend that future research test causal inferences, use rigorous research designs, explore under-researched topics, resolve conflicting findings, and incorporate ethical theories.
... To be clear, harm reduction approaches do not abrogate clinicians' interest in finding definitive cures or in motivating patients to participate in useful treatments. Nor do they "aid or abet" illness behavior (Christie, Groarke, and Sweet 2008) by simply going along with the patient's desires to continue unabated self-harm or by denying possibilities of improvement. Rather, in a utilitarian fashion, harm reduction approaches are implemented while clinicians wait for better treatments. ...
... As Christie et al. note, harm reduction is generally characterized as a consequentialist or utilitarian response to prohibitionist approaches that identify particular behaviors as wrong and seek to eliminate them: implicit in the reasoning of harm reduction advocates is a Utilitarian argument, which holds that the key guideline in ethics is that if negative consequences can be avoided they should be avoided. Abstinence advocates, however, generally seem to employ a Deontological ethic, which maintains that the moral worth of one's actions has nothing to do with the consequences of those actions but, rather, is determined by the intention of the actors [4]. ...
‘Harm reduction’ programs are usually justified on the utilitarian grounds that they aim to reduce the net harms of a behavior. In this paper, I contend that (1) the historical genesis of harm reduction programs, and the crucial moral imperative that distinguishes these programs from other interventions and policies, are not utilitarian; (2) the practical implementation of harm reduction programs is not, and probably cannot be, utilitarian; and (3) the continued justification of harm reduction on utilitarian grounds is untenable and may itself cause harm. Promoting harm reduction programs as utilitarian in the public arena disregards their deeper prioritarian impulses. ‘Harm reduction’ is a misnomer, and the name should be abandoned sooner rather than later.
... abstinence-only sex-education policies do not reduce teenage pregnancy rates [2]. Third, harm reduction is said to offer a 1 As a result, others have argued for a 'virtue ethics' justification of harm reduction [3,15]. 2 In an unpublished manuscript, "'Harm Reduction' is Neither," Nick King also argues against a consequentialist justification of harm reduction. He claims that harm reduction policies in fact operate to benefit the least well off and therefore that a justification that employs principles of justice may be promising. ...
Harm reduction has been advocated to address a diverse range of public health concerns. The moral justification of harm reduction is usually presumed to be consequentialist because the goal of harm reduction is to reduce the harmful health consequences of risky behaviors, such as substance use. Harm reduction is contrasted with an abstinence model whose goal is to eradicate or reduce the prevalence of such behaviors. The abstinence model is often thought to be justified by ‘deontological’ considerations: it is claimed that many risky behaviors are morally unacceptable, and therefore that we have a moral obligation to recommend abstinence. Because harm reduction is associated with a consequentialist justification and the abstinence model is associated with a deontological justification, the potential for a deontological justification of harm reduction has been overlooked. This paper addresses this gap. It argues that the moral duty to protect autonomy and dignity that has been advocated in other areas of medical ethics also justifies the public health policy of harm reduction. It offers two examples—the provision of supervised injection sites and the Housing First policy to address homelessness—to illustrate the argument.
... Ethical practice: Underlying theory Central to ethics is the question of what constitutes moral conduct . The theory informing this study is the deontological ethical theory, which has its origins in the work of the 18th century German philosopher Emmanuel Kant (Christie et al., 2008). Kant argues that morality is a matter of duty in that humans have the moral duty to do what is right and not to do what is wrong (Darwall, 2018). ...
Purpose
The purpose of this study is on the top 500 companies in South Africa (as per the TopCo, 2014 list) that have a code of ethics, to see the current state of development in this area after 20 years of focus by the government and business on making corporate South Africa a more ethical environment, in which to conduct business.
Design/methodology/approach
A structured questionnaire survey method was used to gather the data and it was directed to the company secretaries of these top 500 companies.
Findings
Many companies in South Africa have a well-established set of protocols to enact the ethos of their code of ethics, indicating that they are becoming increasingly aware of the benefits to them of having a code. South African companies are, therefore, implementing both a code of ethics and strategies that contribute to creating an ethical corporate culture.
Research limitations/implications
This study provides an opportunity to further research assessing and comparing other companies in non-Western and emerging economies.
Practical implications
After 20 years of endeavours by business people and lawmakers to improve the ethical framework of South African business, there is still plenty of work to be done, as so many top companies do not appear to have a code of ethics.
Originality/value
There have been limited studies in the area of business ethics in South African companies. This study is the first of its kind in the South African context and establishes the current practice 20 years after the King I report.
... Ethical practice: underlying theory Central to ethics is the question of what constitutes moral conduct (Kindsiko, 2013). The theory informing this study is the deontological ethical theory, which has its origins in the work of the eighteenth-century German philosopher Emmanuel Kant (Christie et al., 2008). Kant argues that morality is a matter of duty in that humans have the moral duty to do what is right and not to do what is wrong (Darwall, 2018). ...
... Such thinking calls into question the 'virtue' of being virtuous, or as Kant might put it, the moral worth of the action taken when the primary motivation is instrumental or in the best interest of the actor. Under this accounting of what makes ethics ethical, if the aim of the COE is avoiding negative consequences, it unwittingly undermines the values that it holds in high regard (Christie, Groarke, & Sweet, 2008). indiscretion; 2) where a COE is intended to specify the moral and ethical constraints of the profession, it is largely a bureaucratic boilerplate document that exists only in the abstract-that is, it applies without practice understanding; and 3) no system of rules, however imbued with talk of principles and virtues, can overcome the highly theoretical nature of what makes something "the right thing to do". ...
Ethical codes have long been considered indispensable tools in defining the proper conduct of counseling professionals. Revisions reflect the ideals of the industry to accommodate the evolving needs of clients and trends in treatment models, but the essence of the code is to convert principles befitting of the profession into concrete actions or considerations that abet professional decision-making. Acculturation into the profession involves ethics training intended to improve professionals’ ability to apply the code to situations that might arise in their practices, resulting in the most ethically appropriate action. However, such assumptions may be problematic. The idea of ethical competency and improvement in the code itself should be qualified to reflect the uncertainty of moral truths, including counselor training tailored to test competency, both before and during professional practice. In this article, the consideration that morals and ethics are distinct is spelled out and then challenged by drawing on Jean Paul Sartre’s existentialist critique of moral decision-making reality. In light of this critique and John Stuart Mill’s argument regarding the value of vigorous debate over philosophical ideas, suggestions are made regarding a potential approach to ethics competency education.
... And we should not see this as a failure to be good as a social worker, or as indicating a lack of professional virtues. Social workers can perform their function in ways that are 'good enough' in a virtue-ethical sense (McBeath & Webb, 2002) and that are duly sensitive to context and consequences (Christie, Groarke, & Sweet, 2008) prescribe forms of toleration the social worker deems inappropriate (e.g., they might prescribe toleration as a matter of merely putting up with diversity where the social worker takes it that respect-toleration or esteem-toleration is in place). It is important to discuss what, in a given context and all things considered, might be the best course of action to take in cases of such conflicts. ...
Toleration is one of many responses towards diversity and difference. With the growing diversity, the theme of toleration has often taken centre stage in discussions of multiculturalism and social pluralism. Nonetheless, it has not received much attention in the social work profession. Social workers often encounter situations in which they face a choice between tolerating and not tolerating. We argue that toleration is a legitimate and relevant topic in social work discourse. To make this point, first, this paper discusses different conceptions of toleration. Then, it demonstrates its relevance to social work and explores a potential benefit of including the idea of toleration in social work discourse. Social work codes of ethics implicitly support toleration, or at least respect-toleration and esteem-toleration. Incorporating toleration in social work discourse may help social workers to better cope with or reduce ethical stress and disjuncture.
... One benefit of harm reduction research is its contribution to developing and sustaining evidence-informed programs. In a climate where it is important to attend to personal values and critiques of science (Christie et al., 2008), these studies also provide valuable information for funders and decision-makers interested in learning more about how best to engage and support people who use drugs. Perhaps more importantly, research and evaluation can be used by community and drug user organizations to learn from each other. ...
People who inject drugs have been central to the development of harm reduction initiatives. Referred to as peer workers, peer helpers, or natural helpers, people with lived experience of drug use leverage their personal knowledge and skills to deliver harm reduction services. Addressing a gap in the literature, this systematic review focuses on the roles of people who inject drugs in harm reduction initiatives, how programs are organized, and obstacles and facilitators to engaging people with lived experience in harm reduction programs, in order to inform practice and future research.
This systematic review included searches for both peer reviewed and gray literature. All titles and abstracts were screened by two reviewers. A structured data extraction tool was developed and utilized to systematically code information concerning peer roles and participation, program characteristics, obstacles, and facilitators.
On the basis of specific inclusion criteria 164 documents were selected, with 127 peer-reviewed and 37 gray literature references. Data extraction identified key harm reduction program characteristics and forms of participation including 36 peer roles grouped into five categories, as well as obstacles and facilitators at systemic, organizational, and individual levels.
Research on harm reduction programs that involve people with lived experience can help us better understand these approaches and demonstrate their value. Current evidence provides good descriptive content but the field lacks agreed-upon approaches to documenting the ways peer workers contribute to harm reduction initiatives. Implications and ten strategies to better support peer involvement in harm reduction programs are identified.
Copyright © 2015. Published by Elsevier Ireland Ltd.
... Because several economic, social, and health care factors affect the epidemic of addiction and control of STD among PWUD (Latkin et al. 2010), it is necessary to offer evidence-based services (Kass 2001). Services based on scientific evidence (Christie et al. 2008; Cohen and Csete 2006; Pauly 2008; Uchtenhagen 2010), human rights (e.g., right to health), and ethics (e.g., principles of respect of persons, beneficence, and justice) can be effective. These services need to operationally protect the rights of PWUD in ways similar to those used to protect the rights of people with other health conditions (Griffiths 2005; Jurgens et al. 2010; Semaan et al. 2011a ...
Background:
Herpes simplex virus type 2 (HSV-2) affects HIV acquisition, transmission, and disease progression. Effective medications for genital herpes and for HIV/AIDS exist. Parenteral transmission of HIV among persons who inject drugs is decreasing. Reducing sexual transmission of HIV and HSV-2 among persons who use drugs (PWUD; i.e., heroin, cocaine, "speedball", crack, methamphetamine through injection or non-injection) necessitates relevant services.
Methods:
We reviewed HSV-2 sero-epidemiology and HSV-2/HIV associations in U.S.-based studies with PWUD and the general literature on HSV-2 prevention and treatment published between 1995 and 2012. We used the 6-factor Kass framework to assess relevant HSV-2 public health strategies and services in terms of their goals and effectiveness; identification of, and minimization of burdens and concerns; fair implementation; and fair balancing of benefits, burdens, and concerns.
Results:
Eleven studies provided HSV-2 serologic test results. High HSV-2 sero-prevalence (range across studies 38-75%) and higher sero-prevalence in HIV-infected PWUD (97-100% in females; 61-74% in males) were reported. Public health strategies for HSV-2 prevention and control in PWUD can include screening or testing; knowledge of HSV-2 status and partner disclosure; education, counseling, and psychosocial risk-reduction interventions; treatment for genital herpes; and HIV antiretroviral medications for HSV-2/HIV co-infected PWUD.
Conclusions:
HSV-2 sero-prevalence is high among PWUD, necessitating research on development and implementation of science-based public health interventions for HSV-2 infection and HSV-2/HIV co-infections, including research on effectiveness and cost-effectiveness of such interventions, to inform development and implementation of services for PWUD.
Widely used policy development processes rarely systematically consider differing moral values, which can lead to overlooked risks, ineffective communications and suboptimal policy design. This article introduces morality analysis, a policy tool that draws on moral foundations theory to optimize policy and program design, build public support for policies and present key advice to decision‐makers. Morality analysis is used to examine the case of a controversial vaccination incentive program introduced by the Government of Alberta in late 2021 and identify policy options that would likely have prompted less public backlash. This article suggests that morality analysis should supplement the policy analysis toolkit.
Au Québec, les intervenants qui exercent leur mandat à l’intérieur de sites d’injections supervisées sont souvent confrontés à des enjeux éthiques qui touchent une population vulnérable et marginale. Les intervenants sont coincés entre le désir de soutenir les usagers et l’importance du respect des règlements pour assurer le bon fonctionnement du service et la sécurité des usagers dans un souci d’offrir un accès équitable. À partir d’un cas fictif, qui illustre le soi-disant manque de collaboration d’un usager ayant un comportement perturbateur et menaçant, il s’agit de décrire la difficulté et les tensions entre différentes perspectives dans le champ de l’intervention sociale. Notre démarche est phénoménologique et herméneutique avec une visée pragmatique. Les cadres théoriques d’Aristote et de Ricoeur nous serviront d’appui. Nous proposons l’idée que les sites d’injections supervisées offrent un lieu de partage, d’écoute et de dialogue, voire un lieu de réflexion, de délibération et de prise de décision à l’intérieur d’une communauté de recherche, au sein de laquelle les usagers, même en état d’intoxication, ont un rôle social à jouer dans une résolution d’un problème éthique.
Our goal was to examine the relationship between biological and sociocultural factors that predict utilitarian moral judgment. Utilitarian moral judgments occur when a specific action is based on the outcome rather than its consistency with social norms. We predicted that (1) individuals with higher levels of dopamine will make more utilitarian decisions and (2) individuals who express greater religiosity will make less utilitarian judgments. We measured dopamine using spontaneous eyeblink rate, an indirect measure associated with striatal dopaminergic transmission. A total of 96 participants completed a utilitarian moral judgment task where they made judgments regarding nonmoral, impersonal, personal low-conflict, and personal high-conflict moral dilemmas (Koenigs et al., 2007). Then, participants completed a questionnaire measuring religiosity (Huber & Huber, 2012). We found a negative relationship between religiosity and the proportion of “yes” judgments participants made in the high-conflict personal dilemmas, which was consistent with our second hypothesis. None of our other hypotheses were supported. Understanding biological and cultural factors that relate to utilitarian moral judgment may also help in developing artificial intelligence that more closely mimic human behavior.
Eating disorders are mental illnesses that can have a significant and persistent physical impact, especially for those who are not treated early in their disease trajectory. Although many persons with eating disorders may make a full recovery, some may not; this is especially the case when it comes to persons with severe and enduring anorexia nervosa (SEAN), namely, those who have had anorexia for between 6 and 12 years or more. Given that persons with SEAN are less likely to make a full recovery, a different treatment philosophy might be ethically warranted. One potential yet scarcely considered way to treat persons with SEAN is that of a harm reduction approach. A harm reduction philosophy is deemed widely defensible in certain contexts (e.g. in the substance use and addictions domain), and in this paper we argue that it may be similarly ethically defensible for treating persons with SEAN in some circumstances.
This paper reflects on approaches to conducting “ethical research” on architecture and urban (in)equality in cities in the global south. It focuses on two themes: the formalization of institutional ethics procedures and protocols for conducting such research, and the need to move away from ethical frameworks that emerge from western structures for knowledge production. The paper will question whether ethical principles are universal or specific, and how they affect the possibility of knowledge co-production and its potential to generate pathways to urban equality. These questions arise from the history of contemporary research ethics procedures, which are rooted in the social norms of western modernity that views researchers and research participants as “autonomous individuals.” The paper will suggest that exploring the relation of the individual to the collective and understanding social existence as relationality, is fundamental in formulating an alternative type of ethics methodology.
This paper considers the ethical justification for the use of harm minimisation approaches with individuals who self-injure. While the general issues concerning harm minimisation have been widely debated, there has been only limited consideration of the ethical issues raised by allowing people to continue injuring themselves as part of an agreed therapeutic programme. I will argue that harm minimisation should be supported on the basis that it results in an overall reduction in harm when compared with more traditional ways of dealing with self-injurious behaviour. It will be argued that this is an example of a situation where healthcare professionals sometimes have a moral obligation to allow harm to come to their patients.
Harm-reduction approaches are used to reduce the burden of risky human behaviour without necessarily aiming to stop the behaviour. We discuss what an introduction of harm reduction for doping in sports would mean in parallel with a relaxation of the antidoping rule. We analyse what is ethically at stake in the following five levels: (1) What would it mean for the athlete (the self)? (2) How would it impact other athletes (the other)? (3) How would it affect the phenomenon of sport as a game and its fair play basis (the play)? (4) What would be the consequences for the spectator and the role of sports in society (the display)? and (5) What would it mean for what some consider as essential to being human (humanity)? For each level, we present arguments for and against doping and then discuss what a harm-reduction approach, within a dynamic regime of a partially relaxed antidoping rule, could imply. We find that a harm-reduction approach is morally defensible and potentially provides a viable escape out of the impasse resulting from the impossibility of attaining the eradication of doping. The following question remains to be answered: Would a more relaxed position, when combined with harm-reduction measures, indeed have less negative consequences for society than today's all-out antidoping efforts that aim for abstinence? We provide an outline of an alternative policy, allowing a cautious step-wise change to answer this question and then discuss the ethical aspects of such a policy change.
Abstract: Sex trafficking, where individuals are traded for sex purposes and abused sexually, physically, mentally, and economically leading to repercussions in individual liberty, social life, and health and well-being, is one of the worst forms of infringement of human rights. Despite the growing global concern against sex trafficking, thousands of individuals, mostly girls and women, are trafficked annually, especially from low- and middle-income countries like Nepal. This article discusses the public health issues related to sex trafficking and the different ethical approaches – libertarianism, paternalism, stewardship, and virtue ethics – on perspectives concerning combating sex trafficking in Nepal. Along with the legal standpoint, awareness-raising activities, transit monitoring, and limited rehabilitative programs, Nepal also needs to enhance its stewardship approaches by addressing the gender-sensitive nature of the problem through empowerment and livelihood programs for girls and women from vulnerable communities to combat sex trafficking effectively.
A sixteen-year-old female presented at the Emergency Department with left hip pain and the left leg in external rotation after having felt dizzy and collapsing at home. The orthopaedic surgeon wanted to see a hip x-ray immediately with the suspicion of femoral neck fracture and stressed the importance of early treatment for that possible orthopaedic emergency. When the patient was alone with the orthopaedic surgeon, she told him that she was pregnant. According to the current legal regulations, minors need to have parental approval for x-rays and other medical procedures in such situations, so doctors need the parents' informed consent. However, the patient stated "if my parents learn of my situation they will kill me in the name of honour." So, she asked the orthopaedic surgeon not to inform her family of her pregnancy, otherwise she would refuse treatment.
This study examines the ways in which the moral community is "talked into being" in relation to crime, and the objects of concern that typically occupy its attention. It maps the imagined moral universe of the virtuous and the criminal and charts the relations between these two groups in the "history of the present." It examines the calls to action which symbolically endow the moral community with power. And it looks at the character and content of collective moralizing. The source materials are commentaries about crime and criminal justice appearing in selected newspapers across the Americas. The moral "talk" found there is stylized, routine, trivial and occasionally dramatic. It looks nothing like the weightier renderings of morality that derive from the reconstruction of a particular "ethic" or from the systematic probing of values and moral reasoning. And its fuzzy, offhand, unexceptional and frequently unsystematic nature makes it a difficult candidate for explaining either stability or change in crime policies. But moral talk has intrinsic importance as the creator and sustainer of an imagined moral community, a community that symbolizes the existence and vigor of morality itself and confers a crucially important identity on its self-proclaimed members. And moral talk reveals inherent intersections between normative, empirical and technical discourses, highlighting the relationships between morality, science and social engineering. Thus, a prosaic, instrumental, model of morality is particularly strong in North America, but only found in a more abstract form in Latin America, where it sits alongside a stirring vision of morality, more directly anchored in virtue. Research on social problems, moral panics and the sociology of morality has largely overlooked the type of moral discourse studied here. While emphasizing the culturally contingent nature of the findings, the conclusion reflects on their significance for understanding the nature of moralizing, the artifacts of talk and the construction of identity.
This paper proposes that SMEs managers should include a consideration to virtue of human character as a full complement to ethical judgment according to a deontological focus on obligation and duty to act and the utilitarianism focus on consequences. Virtue ethics provide the substantial benefits of applying human character perspective in conjunction with imperfect-act-oriented perspectives. An interactive symbiosis approach is superior in meeting the complex requirements of applied ethics. To illustrate how deficiencies of utilitarianism and deontological approaches, virtuous character formulation can be injected into the paradigm of ethical judgment since it can highlights a dynamics leadership in SMEs. This paper also compares the ethical orientation realms of utilitarianism, deontology and virtue ethics as well underline the danger inherent in each. Effective application of such an ethics approach in contemporary organizations with requires further empirical research to develop a greater understanding of the moral characters that actually practiced. Meeting the IJRMEC Volume2, Issue 7(July 2012) ISSN: 2250-057X International Journal of Research in Management, Economics and Commerce www.indusedu.org 60 challenge will allow academicians better assist practicing SMEs managers lead ethical judgement dynamics.
This paper begins by examining the ethical issues in public health and attempts to resolve them. It then considers three different paradigms responding to heroin addiction and their underlying moral philosophy. Firstly it examines prohibition and abstinence only treatment as an example of deontological ethics and harm reduction approaches as an example of a utilitarian ethics. Policy and practice problems resulting from weaknesses in the underlying philosophies are examined along with the futile debate between abstinence only and harm reduction approaches. A third paradigm, 'recovery' is examined as an example of Aristotelian virtue ethics. The paper concludes by considering the wider implications of this case study in terms of the need for further bioethical enquiry in public health and proposes virtue ethics as a paradigm within which ethical issues can be identified and debated.
The aim of the present study is to offer a validated decision model for casino enterprises. The model enables those users to perform early detection of problem gamblers and fulfill their ethical duty of social cost minimization. To this end, the interpretation of casino customers' nonverbal communication is understood as a signal-processing problem. Indicators of problem gambling recommended by Delfabbro et al. (Identifying problem gamblers in gambling venues: final report, 2007) are combined with Viterbi algorithm into an interdisciplinary model that helps decoding signals emitted by casino customers. Model output consists of a historical path of mental states and cumulated social costs associated with a particular client. Groups of problem and non-problem gamblers were simulated to investigate the model's diagnostic capability and its cost minimization ability. Each group consisted of 26 subjects and was subsequently enlarged to 100 subjects. In approximately 95 % of the cases, mental states were correctly decoded for problem gamblers. Statistical analysis using planned contrasts revealed that the model is relatively robust to the suppression of signals performed by casino clientele facing gambling problems as well as to misjudgments made by staff regarding the clients' mental states. Only if the last mentioned source of error occurs in a very pronounced manner, i.e. judgment is extremely faulty, cumulated social costs might be distorted.
Drawing on other ethics scales which are grounded in virtue, deontology, utilitarianism and justice principles, we developed a four-partite integration ethics scale. Other ethics scales emphasized on people classification according to their beliefs based on criterion used to make ethical decision and the ethicality of decisions. We suggested that our four-partite integration ethics scale could provide a complimentary role in terms of rules to follow; utilitarianism endow with cost benefit analysis to bestow justice in dealing business with virtuous characters. The integration enables for the expansion of scope and understanding of ethical analyses in order to help business people to solve specific problems in specific situation and context in volatile business environment; in which widely open to constraints and complexities.
Kenneth Burke's dramatistic perspective is applied to accounts told by staff members working in methadone maintenance treatment centers in Copenhagen, Denmark. As a harm reduction strategy, methadone maintenance is designed to reduce the costs and dangers of chronic long-term drug use by providing substitution (methadone) treatment to users. Burke's dramatistic perspective calls attention to the recurring relationships among rhetorical elements within accounts of social reality. The elements form a pentad: scene, purpose, agent, agency and acts. Our analysis examines how the ideal of governmentality is constructed by staff members to justify and criticize the operations of the Copenhagen methadone maintenance program. For Burke, social criticism involves rearranging pentadic elements to produce new meanings and justify alternative actions. We discuss how Burke's perspective might be developed by sociologists as a critical dramatism of social policies and programs.
In response to the mounting number of HIV/AIDS and overdose deaths directly attributable to intravenous drug use during the 1980 and 1990’s, governments across the world began considering alternatives to traditional prohibitionist drug policies. These alternatives, generally described as harm reduction strategies involving needle exchange programs and safe injection sites, rapidly gained acceptance across Europe. By contrast, they encountered significant opposition in North America. This thesis summarily traces the history of Canadian drug law, describing the development and impact of the harm reduction movement in Canada and the establishment of the first and only safe injection site (SIS) in North America (Insite). Employing a repressive formalist analysis of the application of federal drug laws, I then examine the role of the current Conservative government in contesting harm reduction strategies and refusing full legalization of Insite. I illustrate that through the strategic manipulation and discriminatory enforcement of drug laws and political gamesmanship relating to the criteria grounding Insite’s exemption from current drug laws, the government has failed to fulfill a set of fundamental social values with respect to Insite’s users and members of the downtown eastside of Vancouver. Interviews with injection drug users, workers at Insite and residents of the local community provide empirical support for the beneficial effects of safe injection sites, and expose the politics of the struggle for Insite’s continued existence. I also show how the Conservative anti-drug ideologues have led a resistance against classifying drug addiction as a health-related rather than criminal problem, despite significant scientific evidence to the contrary, and how this resistance has resulted in the further marginalization of injection drug users.
Safer injection facilities (SIFs) reduce risks associated with injecting drugs, particularly public injection and overdose mortality. They exist in many countries, but do not exist in the United States. We assessed several ethical, operational, and public health considerations for establishing SIFs in the United States.
We used the six-factor Kass framework (goals, effectiveness, concerns, minimization of concerns, fair implementation, and balancing of benefits and concerns), summarized needs of persons who inject drugs in the United States, and reviewed global evidence for SIFs.
SIFs offer a hygienic environment to inject drugs, provide sterile injection equipment at time of injection, and allow for safe disposal of used equipment. Injection of pre-obtained drugs, purchased by persons who inject drugs, happens in a facility where trained personnel provide on-site counseling and referral to addiction treatment and health care and intervene in overdose emergency situations. SIFs provide positive health benefits (reducing transmission of HIV and viral hepatitis, bacterial infections, and overdose mortality) without evidence for negative health or social consequences. SIFs serve most-at-risk persons, including those who inject in public or inject frequently, and those who do not use other public health programs. It is critical to address legal, ethical, and local concerns, develop and implement relevant policies and procedures, and assess individual- and community-level needs and benefits of SIFs given local epidemiologic data.
SIFs have the potential to reduce viral and bacterial infections and overdose mortality among those who engage in high-risk injection behaviors by offering unique public health services that are complementary to other interventions.
The coming decades will see exciting breakthroughs in the treatment of SUDs, such as further elucidation of the genetic mechanisms of addiction. Yet if the past is any guide to the future, each new discovery will bring with it new challenges to the core ethical obligations of honoring informed consent, protecting confidentiality, and respecting justice, while also protecting the public from harm and ensuring the good of the individual patient. For the emerging scientific shift to a biobehavioral model of addiction to transform cultural attitudes and enhance treatment and research will require the scientifically rigorous and ethically sound agency of ethicists and addiction professionals to influence public policy. The growing body of neurobiologic evidence that contests traditional assumptions about free will and responsibility will evoke more deliberate and nuanced approaches to informed consent and treatment participation and dispute the forensic orientation in drug policy. If this unprecedented paradigm change can influence health care decision making in a reasoned and balanced fashion, there is real hope that the cultural stigma, which has warranted highly stringent confidentiality protections, and the disenfranchisement underlying health disparities in addiction treatment may move in the direction of compassionate and competent care for all those who suffer from addiction.
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.
An exploratory study of men having sex with men (MSM) was conducted in central and southern Malawi in order to understand their socio-demographic characteristics, sexual behaviours, and perceptions about confidentiality and stigma. A total of 97 men participated in the study of whom 84 (86.6%) were in the age group 17-32 years. The majority, 73 (75.3%) of MSM had never married, 26 (32.5%) reported not always using condoms
during sexual intercourse, and 23 (23.7%) had ever received money or gifts in exchange of sex. Only 17 (17.5%) of the participants reported being exposed to HIV prevention messages targeted at MSM. Fear of sexual orientation disclosure and discrimination were reported by 27 (30.7%) of MSM. Many of the study participants reported that
HIV intervention programmes are not accessible to them. In conclusion, HIV intervention programmes may not be reaching out to the majority of MSM. We suggest an exploration of the feasibility of HIV prevention interventions targeting MSM in this country where the practice is illegal.
This study was undertaken to identify factors associated with entry into detoxification among injection drug users (IDUs),
and to assess the role of needle-exchange programs (NEPs) as a bridge to treatment. IDUs undergoing semiannual human immunodeficiency
virus (HIV) tests and interviews were studied prospectively between 1994 and 1998, during which time an NEP was introduced
in Baltimore. Logistic regression was used to identify independent predictors of entry into detoxification, stratifying by
HIV serostatus. Of 1,490 IDUs, similar proportions of HIV-infected and uninfected IDUs entered detoxification (25% vs. 23%,
respectively). After accounting for recent drug use, hospital admission was associated with four-fold increased odds of entering
detoxification for HIV-seronegative subjects. Among HIV-infected subjects, hospital admission, outpatient medical care, and
having health insurance independently increased the odds of entering detoxification. After accounting for these and other
variables, needle-exchange attendance also was associated independently with entering detoxification for both HIV-infected
(adjusted odds ratio [AOR]=3.2) and uninfected IDUs (AOR=1.4). However, among HIV-infected subjects, the increased odds of
detoxification associated with needle exchange diminished significantly over time, concomitant with statewide reductions in
detoxification admissions. These findings indicate that health care providers and NEPs represent an important bridge to drug
abuse treatment for HIV-infected and uninfected IDUs. Creating and sustaining these linkages may facilitate entry into drug
abuse treatment and serve the important public health goal of increasing the number of drug users in treatment.
Using cost-of-illness methodology applied to a comprehensive survey of 114 daily opiate users not currently in or seeking treatment for their addiction, we estimated the 1996 social costs of untreated opioid dependence in Toronto (Ontario, Canada). The survey collected data on social and demographic characteristics, drug use history, physical and mental health status, the use of health care and substance treatment services, drug use modality and sex-related risks of infectious diseases, sources of income, as well as criminality and involvement with the law enforcement system. The annual social cost generated by this sample, calculated at Canadian $5.086 million, is explained mostly by crime victimization (44.6%) and law enforcement (42.4%), followed by productivity losses (7.0%) and the utilization of health care (6.1%). Applying the $13,100 cost to the estimated 8,000 to 13,000 users and 2.456 million residents living in Toronto yields a range of social cost between $43 and $69 per capita.
1 Illicit drug injection is as- sociated with significant health and social consequences for drug users, their families and communities. The conse- quences include injection-related infections, overdose, bloodborne disease transmission, exposure to discarded needles, violence, property crime and sex trade. Two articles in this issue of CMAJ highlight the contin- uing unsafe injection practices 2 and the health-related con- sequences 3 that are occurring in a cohort of IDUs in Van- couver despite the availability of a large needle-exchange program. 4,5 In the first report (page 405), 214 (27.6%) of 776 participants from the Vancouver Injection Drug User Study (VIDUS) stated that they had recently shared nee- dles. 2
Many injection drug users (IDUs) seek care at emergency departments and some require hospital admission because of late presentation in the course of their illness. We determined the predictors of frequent emergency department visits and hospital admissions among community-based IDUs and estimated the incremental hospital utilization costs incurred by IDUs with early HIV infection relative to costs incurred by HIV-negative IDUs.
The Vancouver Injection Drug User Study (VIDUS) is a prospective cohort study involving IDUs that began in 1996. Our analyses were restricted to the 598 participants who gave informed consent for our study. We used the participants' responses to the baseline VIDUS questionnaire and, from medical records at St. Paul's Hospital, Vancouver, we collected detailed information about the frequency of emergency department visits, hospital admissions and the primary diagnosis for all visits or hospital stays between May 1, 1996, and Aug. 31, 1999. The incremental difference in hospital utilization costs by HIV status was estimated, based on 105 admissions in a subgroup of 64 participants.
A total of 440 (73.6%) of the 598 IDUs made 2763 visits to the emergency department at St. Paul's Hospital during the study period. Of these 440, 265 (160.2%) made frequent visits (3 or more). The following factors were associated with frequent use: HIV-positive status (seroprevalent: adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.2-2.6; seroconverted during study period: adjusted OR 3.0, 95% CI 1.6-5.7); more than 4 injections daily (adjusted OR 1.5, 95% CI 1.1-2.1); cocaine use more frequent than use of other drugs (adjusted OR 2.0, 95% CI 1.2-3.6); and unstable housing (adjusted OR 1.5, 95% CI 1.1-2.2). During the study period 210 of the participants were admitted to hospital 495 times; 118 (56.2%) of them were admitted frequently (2 or more admissions). The 2 most common reasons for admission were pneumonia (132 admissions among 79 patients) and soft-tissue infections (cellulitis and skin abscess) (90 admissions among 59 patients). The following factors were independently associated with frequent hospital admissions: HIV-positive status (seroprevalent: adjusted OR 5.4, 95% CI 3.4-8.6; seroconverted during study period: adjusted OR 2.9, 95% CI 1.4-6.0); and female sex (adjusted OR 1.8, 95% CI 1.1-3.1). The incremental hospital utilization costs incurred by HIV-positive IDUs relative to the costs incurred by HIV-negative IDUs were $1752 per year.
Hospital utilization was significantly higher among community-based IDUs with early HIV disease than among those who were HIV negative. Much of the hospital use was related to complications of injection drug use and may be reduced with the establishment of programs that integrate harm reduction strategies with primary care and addiction treatment.
Many cities throughout the world are experiencing ongoing infectious disease and overdose epidemics among illicit injection drug users (IDUs). In particular, HIV and hepatitis C virus (HCV) have become endemic in many settings and bacterial infections, such as endocarditis, have become extremely common among this population. In an effort to reduce these public health concerns, in September 2003, Vancouver, Canada, opened a pilot medically supervised safer- injecting facility (SIF), where IDUs can inject pre-obtained illicit drugs under the supervision of medical staff. Before and since the facility's opening, there has been a substantial misunderstanding about the rationale for evaluating SIF as a public-health strategy. This article outlines the evidence and rationale in support of the Canadian initiative. This rationale involves limitations in conventionally applied drug-control efforts, and gaps in current public-health policies in controlling the spread of infectious diseases, and the incidence of overdose among IDUs.
North America's first medically supervised safer injecting facility for illicit injection drug users was opened in Vancouver on Sept. 22, 2003. Although similar facilities exist in a number of European cities and in Sydney, Australia, no standardized evaluations of their impact have been presented in the scientific literature.
Using a standardized prospective data collection protocol, we measured injection-related public order problems during the 6 weeks before and the 12 weeks after the opening of the safer injecting facility in Vancouver. We measured changes in the number of drug users injecting in public, publicly discarded syringes and injection-related litter. We used Poisson log-linear regression models to evaluate changes in these public order indicators while considering potential confounding variables such as police presence and rainfall.
In stratified linear regression models, the 12-week period after the facility's opening was independently associated with reductions in the number of drug users injecting in public (p < 0.001), publicly discarded syringes (p < 0.001) and injection-related litter (p < 0.001). The predicted mean daily number of drug users injecting in public was 4.3 (95% confidence interval [CI] 3.5-5.4) during the period before the facility's opening and 2.4 (95% CI 1.9-3.0) after the opening; the corresponding predicted mean daily numbers of publicly discarded syringes were 11.5 (95% CI 10.0-13.2) and 5.4 (95% CI 4.7-6.2). Externally compiled statistics from the city of Vancouver on the number of syringes discarded in outdoor safe disposal boxes were consistent with our findings.
The opening of the safer injecting facility was independently associated with improvements in several measures of public order, including reduced public injection drug use and public syringe disposal.
Estimated and potential medical costs of treating patients infected with human immunodeficiency virus (HIV) in urban areas of high HIV prevalence have not been well defined. We estimated the total medical cost of HIV disease among injection drug users in Vancouver, British Columbia, Canada, assuming stable and increasing HIV prevalence. Total medical costs were estimated by multiplying the average lifetime medical cost per person by the number of HIV-infected individuals. We assumed the cost of each HIV infection to be 150,000 Canadian dollars, based on empirical data, and HIV prevalence estimates were derived from the Vancouver Injection Drug Users Study (VIDUS) and external data sources. By use of Monte Carlo simulation methodology, we performed sensitivity analyses to estimate total medical cost, assuming the HIV prevalence remained stable at 31% and under a scenario in which the prevalence rose to 50%. Expected medical expenditures based on current HIV prevalence levels were estimated as 215,852,613 Canadian dollars. If prevalence rises to 50% as reported in other urban centers, the median estimated medical cost would be approximately 348,935,865 Canadian dollars. This represents a difference in the total costs between the two scenarios of 133,083,253 Canadian dollars. Health planners should consider that predicted medical expenditures related to the HIV epidemic among injection drug users in our setting may cost an estimated 215,852,613 Canadian dollars. If funding cannot be found for appropriate prevention interventions and the prevalence rises to 50%, a further 133,083,253 Canadian dollars may be required.
Illicit use of injected drugs is linked with high rates of HIV infection and fatal overdose, as well as community concerns about public drug use. Supervised injecting facilities have been proposed as a potential solution, but fears have been raised that they might encourage drug use.
A before and after study. Participants and setting 871 injecting drug users recruited from the community in Vancouver, Canada.
Rates of relapse into injected drug use among former users and of stopping drug use among current users.
Local health authorities established the Vancouver supervised injecting facility to provide injecting drug users with sterile injecting equipment, intervention in the event of overdose, primary health care, and referral to external health and social services.
Analysis of periods before and after the facility's opening showed no substantial increase in the rate of relapse into injected drug use (17% v 20%) and no substantial decrease in the rate of stopping injected drug use (17% v 15%).
Recently reported benefits of supervised injecting facilities on drug users' high risk behaviours and on public order do not seem to have been offset by negative community impacts.
Injection drug users (IDUs) are vulnerable to serious health complications resulting from unsafe injection practices. We examined whether the use of a supervised safer injection facility (SIF) promoted change in injecting practices among a representative sample of 760 IDUs who use a SIF in Vancouver, Canada. Consistent SIF use was compared with inconsistent use on a number of self-reported changes in injecting practice variables. More consistent SIF use is associated with positive changes in injecting practices, including less reuse of syringes, use of sterile water, swabbing injection sites, cooking/filtering drugs, less rushed injections, safe syringe disposal and less public injecting.
On the basis of the harm reduction movement's founding texts from the beginning of the 1990s, this paper reflects the movement's self-understanding in contrasting itself with the system of punitive prohibition. Following this is a discussion of the implications for drug users of harm reduction claims-making. The paper concludes that the principles of the harm reduction movement resonate extremely well with the moral sensibilities of our contemporary societies, and but that the movement's claims for an amoral, rational, just, and emancipating approach to drug use are to be seen rather as a powerful rhetorical intervention in the highly moralised landscape of drug debate than something that would be achieved in practice.
During the 20th century, support for a deontological approach to illicit drugs grew steadily. As a deontological framework was invoked, how goals were accomplished was considered more important than what was achieved. Accordingly, global drug prohibition was considered right even though illicit drug production and consumption, deaths, disease, crime and official corruption increased steadily. In the last decades of the 20th century, consequentialist approaches to drugs began to receive increasing support. Drug policy was now considered morally right if it produced predominantly beneficial consequences. The advent of an HIV pandemic in the last quarter of the 20th century changed the nature of injecting drug use irrevocably, just as injecting drug use changed the course of the HIV epidemic. HIV spread among injecting drug users led to increased support for ‘harm reduction’. The scientific debate about harm reduction, which is now over, has essentially been between consequentialists and their deontological critics. The paramount aim of harm reduction is to reduce the health, social and economic costs of drug use. Reducing drug consumption can be a means to this end. Harm reduction strategies have been recognized as being effective, safe and cost-effective for at least 15 years. The paramount need now is to overcome the conventional reliance on drug law enforcement, the major barrier to implementing harm reduction strategies in time and on sufficient scale. Because of the limited benefits, high costs and severe unintended negative consequences of global drug prohibition, increasing consideration is being given to possible alternative arrangements for drugs.
There are few circumstances among those which make up the present condition of human knowledge, more unlike what might have been expected, or more significant of the backward state in which speculation on the most important subjects still lingers, than the little progress which has been made in the decision of the controversy respecting the criterion of right and wrong. From the dawn of philosophy, the question concerning the summum bonum,1 or, what is the same thing, concerning the foundation of morality, has been accounted the main problem in speculative thought, has occupied the most gifted intellects, and divided them into sects and schools, carrying on a vigorous warfare against one another. And after more than two thousand years the same discussions continue, philosophers are still ranged under the same con-tending banners, and neither thinkers nor mankind at large seem nearer to being unanimous on the subject, than when the youth Socrates listened to the old Protagoras,2 and asserted (if Plato’s dialogue be grounded on a real conversation) the theory of utilitarianism against the popular morality of the so-called sophist.
To provide an empirical examination of the effect that chronic illicit drug use has on emergency room (ER) utilization, controlling for the potential biases introduced by correlation between unobservable determinants of chronic illicit drug use and ER utilization.
From the National Household Survey on Drug Abuse 1994 (NHSDA94).
Chronic illicit drug use and ER utilization are analyzed for 5,384 females and 4,177 males in 1994. The study uses a two-stage estimation technique. In the first stage, sociodemographic, drug use history, and drug use risk variables are used to estimate the probability that the subject is a chronic illicit drug user (CDU). In the second stage, the first-stage estimates provide information needed to test for the possibility of bias in the estimation of ER utilization. This bias is the result of the correlation between unobservable influences on the probability that the person is a CDU and the probability that he or she uses an ER.
The data were collected through a multistage stratified sampling design. With the use of this methodology, the resulting data set provides the most comprehensive information on household drug use.
Without a correction for the possibility of endogeneity bias, chronic illicit drug use is a positive (for both males and females) and a significant (for females only) determinant of the probability of using an ER for medical treatment. After a correction for endogeneity, the influence of chronic drug use remains positive and significant for females and becomes significant for males. The corresponding change in probability for females is from 6 percent to 30 percent, while for males the increase is from an insignificant 0.1 percent to a significant 36 percent change.
We estimate that chronic drug-using females and males, after adjustments for bias, increase the probability that they use an ER by more than 30 percent compared to their casual or non-drug-using counterparts. Therefore, policymakers and health services providers may consider designing programs to bring primary care and prevention services to facilities where drug users are more likely to seek access to care, within an ER setting.
The association between needle exchange, change in drug use frequency and enrollment and retention in methadone drug treatment was studied in a cohort of Seattle injection drug users (IDUs). Participants included IDUs classified according to whether they had used a needle exchange by study enrollment and during the 12-month follow-up period. The relative risk (RR) and the adjusted RR (ARR) were estimated as measures of the association. It was found that IDUs who had formerly been exchange users were more likely than never-exchangers to report a substantial (> or= 75%) reduction in injection (ARR = 2.85, 95% confidence limit [CL] 1.47-5.51), to stop injecting altogether (ARR = 3.5, 95% CL 2.1-5.9), and to remain in drug treatment. New users of the exchange were five times more likely to enter drug treatment than never-exchangers. We conclude that reduced drug use and increased drug treatment enrollment associated with needle exchange participation may have many public health benefits, including prevention of blood-borne viral transmission.
Currently Canada is experimenting with the implementation of drug treatment courts. Pilot projects are underway in both Toronto and Vancouver. In the U.S., drug courts emerged as a response to the overcrowding of the prison system, the end product of the revolving door of substance dependent people moving through the court system. However, this expansion was not accompanied by any rigorous evaluation or critical reflection as to whether drug treatment courts can achieve their desired outcomes or if they are appropriate for dealing with substance dependent offenders. The purpose of this article is to take a critical look at this phenomenon and to discuss whether the drug court model is suitable for Canada.
In Western Europe and elsewhere, medically supervised safer injection facilities (SIFs) are increasingly being implemented for the prevention of health- and community-related harms among injection drug users (IDUs), although few evaluations have been conducted, and there have been questions regarding SIFs' ability to attract high-risk IDUs. We examined whether North America's first SIF was attracting IDUs who were at greatest risk of overdose and blood-borne disease infection.
We examined data from a community-recruited cohort study of IDUs. The prevalence of SIF use was determined based on questionnaire data obtained after the SIF's opening, and we determined predictors of initiating future SIF use based on behavioral information obtained from questionnaire data obtained before the SIF's opening. Pearson's chi-square test was used to compare characteristics of IDUs who did and did not subsequently initiate SIF use.
Overall, 400 active injection drug users returned for follow-up between December 1, 2003 and May 1, 2004, among whom 178 (45%) reported ever using the SIF. When we examined behavioral data collected before the SIF's opening, those who initiated SIF use were more likely to be aged <30 years (odds ratio [OR]=1.6, 95% confidence interval [CI]=1.0-2.7], p=0.04); public injection drug users (OR=2.6, 95% CI=1.7-3.9, p<0.001); homeless or residing in unstable housing (OR=1.7, 95% CI=1.2-2.7, p=0.008); daily heroin users (OR=2.1, 95% CI=1.3-3.2, p=0.001); daily cocaine users (OR=1.6, 95% CI=1.1-2.5, p=0.025); and those who had recently had a nonfatal overdose (OR=2.7, 95% CI=1.2-6.1, p=0.016).
This study indicated that the SIF attracted IDUs who have been shown to be at elevated risk of blood-borne disease infection and overdose, and IDUs who were contributing to the public drug use problem and unsafe syringe disposal problems stemming from public injection drug use.
Safer injection facilities provide medical supervision for illicit drug injections. We aimed to examine factors associated with syringe sharing in a community-recruited cohort of illicit injection drug users in a setting where such a facility had recently opened. Between Dec 1, 2003, and June 1, 2004, of 431 active injection drug users 49 (11.4%, 95% CI 8.5-14.3) reported syringe sharing in the past 6 months. In logistic regression analyses, use of the facility was independently associated with reduced syringe sharing (adjusted odds ratio 0.30, 0.11-0.82, p=0.02) after adjustment for relevant sociodemographic and drug-use characteristics. These findings could help inform discussions about the merits of such facilities.
North America's first government sanctioned supervised injection facility (SIF) was opened in Vancouver in response to the serious health and social consequences of injection drug use and the perseverance of committed advocates and drug user groups who demanded change. This analysis was conducted to describe the attendance, demographic characteristics, drug use patterns, and referrals made during the first 18 months of operation.
As part of the evaluation strategy for the SIF, information is collected through a comprehensive on-site database designed to track attendance and the daily activities within the facility. All users of the SIF must sign a waiver form and are then entered into a database using a unique identifier of their choice. This identifier is used at each subsequent visit to provide a prospective record of attendance, drug use, and interventions.
From 10 March 2004 to 30 April 2005 inclusive, there were 4764 unique individuals who registered at the SIF. The facility successfully attracted a range of community injection drug users including women (23%) and members of the Aboriginal community (18%). Although heroin was used in 46% of all injections, cocaine was injected 37% of the time. There were 273 witnessed overdoses with no fatalities. During just 12 months of observation, 2171 individual referrals were made with the majority (37%) being referred for addiction counseling.
Vancouver's SIF has successfully been integrated into the community, has attracted a wide cross section of community injection drug users, has intervened in overdoses, and initiated over 2000 referrals to counseling and other support services. These findings should be useful for other settings considering SIF trials.
To examine the nature and extent of the association between workplace drug testing and worker drug use.
Repeated cross-sections from the 2000 to 2001 National Household Surveys on Drug Abuse (NHSDA) and the 2002 National Survey on Drug Use and Health (NSDUH).
Multivariate logistic regression models of the likelihood of marijuana use are estimated as a function of several different workplace drug policies, including drug testing. Specific questions about penalty severity and the likelihood of detection are used to further evaluate the nature of the association.
Individuals whose employers perform drug tests are significantly less likely to report past month marijuana use, even after controlling for a wide array of worker and job characteristics. However, large negative associations are also found for variables indicating whether a firm has drug education, an employee assistance program, or a simple written policy about substance use. Accounting for these other workplace characteristics reduces-but does not eliminate-the testing differential. Frequent testing and severe penalties reduce the likelihood that workers use marijuana.
Previous studies have interpreted the large negative correlation between workplace drug testing and employee substance use as representing a causal deterrent effect of drug testing. Our results using more comprehensive data suggest that these estimates have been slightly overstated due to omitted variables bias. The overall pattern of results remains largely consistent with the hypothesis that workplace drug testing deters worker drug use.
About three-quarters of the resources of Canada's Drug Strategy are directed towards enforcement-related efforts, despite a lack of scientific evidence to support this approach and little, if any, evaluation of the impacts of this investment. In this feature article, Kora deBeck, Evan Wood, Julio Montaner and Thomas Kerr report on a study that examined expenditures and activities related to the Drug Strategy as renewed in 2003. The article reviews the effectiveness of the Strategy in light of current scientific evidence pertaining to the reduction of drug-related harm. The authors find that although the Drug Strategy promised to remain accountable and regularly report its progress, information pertaining ot the evaluation of teh Strategy remains limited. Further, Canada's Drug Strategy has not seized the opportunity to promote a national standard of care that reduces the most deadly harms associated with illicit drug use. The authors conclude that from a scientific perspective, Canada's Drug Strategy should make it a priority to ensure that federal funds are directed towards cost-effective, evidence-based prevention, treatment and harm reduction services, and that these services should be available to all Canadians.
Interpretingtherelationbetweeninjectiondruguseand harm: A cautionary note
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