Moral, Prudential, and Political Arguments about Harm Reduction

Abstract

A May 28, 2007 New York Times story profiled Ron Daniels, director of Prevention Works, a syringe exchange in Washington, DC. The front-page story depicted Daniels' journeys through low-income neighborhoods in his Winnebago van, as he distributed sterile syringes and other supplies to injection drug users. Himself infected with HIV from a contaminated syringe, Daniels was operating Washington's only syringe exchange. Local health clinics had provided similar services until 1998, when Congress, which enjoys special authority over the United States' capital city, explicitly forbad the DC government from financing these services.* Defending such stringent policies, Missouri Congressman Sam Groves stated: We need to fight drugs, not show people they can be used in a safe manner.1Why is the United States so resistant to public health strategies that find wide acceptance in many other wealthy democracies? This old question remains pressing. More important, given our history of missed opportunities to reduce the harms connected with HIV/ AIDS, can we do better?In part, American resistance reflects stringent views towards foundational questions of drug policy. Federal sentencing guidelines consider a 5-gram sale of crack to merit greater penalty than attempted second-degree murder that results in serious injury to the victim.2 In some cases, nonviolent firsttime offenders receive mandatory minimum sentences of 25 years or more that exceed penalties imposed for homicide, attempted hijacking, and other violent offenses.34Although few ballot initiatives to allow medical marijuana or to overturn harsh sentencing laws ultimately succeed, their continued popularity suggests that many voters believe that American drug policy has lost its way. So, in more quiet ways, do the majority arguments in recent Supreme Court rulings that grant judges greater discretion to depart from federal guidelines in sentencing crack offenders.5Some critics go further. Mill's harm principle can (but does not have to) be interpreted to support principled objection to government regulation of drug use.67 Most academic researchers are critical of punitive drug policies, but nonetheless accept the right of government to outlaw or to stringently regulate some substances likely to cause severe and likely harm.689Under any feasible policy regime, some citizens will consume heroin, cocaine, or other intoxicating substances. Whether such consumption occurs inside or outside legal boundaries, societies have strong practical reasons to address the accompanying harms. Striking the right balance between deterrence and compassion is an enduring tension in drug policy.This article considers how the public health community might better-address this tension, given the embattled politics that surround efforts to assist substance users. This article mainly focuses on the United States. Several other wealthy democracies have achieved greater success in similar policy domains. I hope that this article reflects lessons learned in European, Canadian, and Australian settings, and that some insights presented here may be useful for other settings. Detailed analysis of harm reduction outside the United States is beyond the scope of the current article.Drawing on terminology advanced by MacCoun and Reuter, this article first describes the term harm reduction, and some of its accompanying complexities. It then describes the political controversy over needle/syringe distribution programs (NSPs) within the United States, and why the term harm reduction and accompanying interventions have proved so politically embattled in this country. It suggests that the public health community has stumbled in its efforts to sidestep the moral and cultural politics of harm reduction, and that more explicit arguments rooted in the humanity of drug users are essential to enact more reflective and humane public policies.Much confusion arises because the single term harm reduction connotes several different things to different authences: a guiding set of questions for policy analysis, a convenient moniker for particular HIV prevention interventions, a unifying slogan of a disparate political movement of activists, public health practitioners, and scholars seeking less punitive drug policies. …