Clinical harm reduction in substance use: An ethics-oriented primer and critique for hospital-based providers.

Abstract

Substance use-targeted harm reduction (HR) has successfully expanded from public health into clinical settings. Hospital-based providers are in positions to encounter, precipitateand/or mediate ethically fraught situations that can arise around clinical HR-informed interventions. We examine why these situations occur and how they might be better addressed. Literature focused on principles, ethics, and clinical implementation of HR are reviewed to identify core elements of this approach. Next, ethical vulnerabilities within those elements are identified and critiqued. A more productive discourse for acknowledging, voicingand addressing ethical dilemmas in HR is sought. Public health orientation and humane concern for substance users, along with a strong anti-stigmatization mission and occasional aversion to a rigid medical model and 'establishment' contributed to HR's successes but can also frame any dissent over its methods as being stigma-fuelled. Practically distilled concepts from moral philosophy and the medical humanities can inform good faith discussions based on common-ground concern for patients. HR's use in the general hospital and other clinical settings is a positive development, but one that brings with it new ethical demands. Broader knowledge of the principles of HR, of the application of those principles to the hospital setting, and of common-ground concepts from outside of HR could help facilitate productive ethical engagement around substance-using patients.