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Supervised Injection Facilities and the Morality of Harm Reduction

photograph of discarded syringe on asphalt

This article has a set of discussion questions tailored for classroom use. Click here to download them. To see a full list of articles with discussion questions and other resources, visit our “Educational Resources” page.

People often support policies that lessen the harms others experience. For instance, proponents of abortion rights often argue that banning abortion does not eliminate abortions, it only makes them unsafe. Some high school sex education programs provide condoms to students to curb the spread of sexually transmitted diseases. Although traditionally alcohol is banned in homeless shelters, some have shifted to a “wet” model allowing residents to use alcohol and in some cases even prescribing alcohol. The rationale here being that it is easier to get one’s sobriety under control in a managed environment and when one has shelter at night.

More recently, some have considered the role harm reduction may play in addressing the U.S. opioid epidemic. According to the Centers for Disease Control, 93,655 Americans died of drug overdoses in 2020, a 30% increase from 2019, and a further 107,622 died of overdose in 2021. One of the leading contributors to this spike in deaths is the increased presence of fentanyl. Because of its potency, lower cost, and addictive potential, fentanyl is often mixed with other powdered drugs or sold in their place. As a result, people who unknowingly consume fentanyl may accidentally overdose, not realizing the strength of the drug they are consuming.

In response, policy makers have been taking measures to reduce the risk of harm fentanyl poses. For instance, although once labeled as “drug paraphernalia” lawmakers across the U.S. have worked to decriminalize fentanyl test strips, hoping to help drug users avoid fentanyl. Some have called for further steps including the creation of Supervised Injection Facilities (SIFs). At these facilities, individuals are permitted to bring in and consume drugs. They are then provided with the means to use these drugs as safely as possible; they receive clean needles, alcohol pads to sterilize injection sites, and medical staff remain on standby to monitor for potential signs of overdose. Additionally, staff can help secure access to resources such as addiction counseling and treatment. The idea is to reduce overall harm by ensuring that those who would otherwise use drugs in public are instead in a private, controlled space with access to resources which can help secure their long-term health. OnPointNYC, the organization running the SIFs, reports they have intervened in 848 overdoses on site and zero deaths have occurred in 68,264 uses.

SIFs, however, are not popular in the U.S. Although other locales have considered opening SIFs, New York City contains the only two officially operating in the U.S. – one in East Harlem and one in Washington Heights. However Representative Nicole Malliotakis of New York’s 11th District has called on the Justice Department to shut down “heroin shooting galleries that only encourage drug use and deteriorate our quality of life.” Pennsylvania’s state senate recently passed a bill banning SIFs by a 41-9 margin. Senator Christine Tartaglione, a Democrat from Philadelphia, stated that her “constituents do not want safe injections site in the neighborhood” and claimed that these sites “enable addiction… [and] we should be in the business of giving these folks treatments.”

These, and other potential objections, warrant further examination. For the purposes of this discussion, I want to consider arguments against harm reduction in the context of SIFs. However, in doing so, these reflections may lead to some insight about harm reduction arguments in other contexts.

One might object to SIFs because they appear to publicly endorse illegal behavior. Yet we may have reason to find this reason uncompelling – the law and morality often diverge. To oppose SIFs because the drugs consumed there are illicit is to merely pass the buck. Why should we regard the use of particular drugs morally objectionable? Why prefer a policy of abstention to moderation? Our focus is better placed on arguments that target SIFs themselves.

The claims by public figures quoted earlier suggest that SIFs fail to prevent harm and instead increase it. There seem to be two purported reasons for this. First, that SIFs enable or even promote drug addiction. Second, that SIFs lead to a deterioration of the surrounding area, encouraging drug users to occupy it, which leads to drug dealing, public drug use, and further threats to the local community.

The available data, however, does not support these arguments. Researchers have found that SIFs lead to lower rates of overdose and decreases in infectious disease rates among drug users. So, SIFs appear to lessen harm to addicts, at least in the short term. Further, SIFs do not seem to impact local crime rates, and, at worst, have no impact on public drug use and needle litter (though there is some evidence that they reduce both).

There is an intuitive argument that these facilities will deteriorate neighborhoods by drawing in drug dealers – the supply may seek out the demand. However, support for this claim is primarily anecdotal. Further, while narcotics arrests have increased in New York neighborhoods with SIFs, these areas now have additional police presence outside of SIFs. It’s at least plausible that an increased police presence is the cause of additional arrests.

Further, there seems to be little, if any, data on the long-term effects of SIFs for overcoming addiction. Perhaps more clarity on long-term consequences of SIFs will come as their impacts are further researched. But currently there seems to be little evidence suggesting they are harmful. They seem to benefit addicts, at least in the short term, and there does not appear to be conclusive evidence that they harm the surrounding community.

But perhaps considering only the consequences misses the point. As I have argued elsewhere, sometimes the consequences of a policy do not seem to matter in the face of other moral objections. Consider, for instance, someone arguing that making cannibalism illegal just produces additional harms – it pushes the market for human meat into the underground, making regulation and oversight impossible, harming both the producers and consumers of human meat. Thus, this person concludes that legalizing cannibalism and regulating human meat consumption would make things safer.

These points, however, fail to resonate as objections to prohibiting cannibalism. This is because harm is just one factor (if even a factor) behind cannibalism’s illegality. Part of the reason why we have laws is to express our attitudes towards a behavior. In this case, eating human flesh simply seems deeply morally wrong to us.

Following this logic, the opponent of SIFs could argue that there is something morally objectionable in drug use, even if SIFs do reduce harm in the long run. That explanation could come in various forms. For instance, in the Groundwork of the Metaphysics of Morals, Immanuel Kant argues that someone who refuses to develop their talents acts immorally by disrespecting her own humanity – she has a potential that she is ignoring in favor of seeking pleasure. Alternatively, one might ground an objection to drug use in virtues. Given the long-term risks associated with drug use, one who regularly uses may fail to demonstrate the virtue of prudence. Thus, one might argue that, if drug use is morally wrong, then facilitating it via SIFs would make one complicit in wrongdoing.

Even if one can give a compelling argument that drug use is in some way immoral (although this may be difficult given the disease model of addiction) there are hurdles this explanation must overcome. Namely, it is unclear whether these concerns are the proper basis of legislation. The government has, at best, a limited prerogative to promote virtue, at least in a society with robust individual rights to self-determination. Further, given the sheer scale of deaths from drug overdoses in the United States, it seems more plausible that reducing harms by participating in or facilitating wrongdoing is a lesser evil than continuing with a status quo that results in tens of thousands of deaths a year. And even still, it is not clear that facilitating a wrong behavior for the sake of minimizing harm is itself wrong.

Opponents of SIFs seem to have two rhetorical options available to them. They may argue that SIFs do not, in fact, reduce harm. But this claim has a tenuous relationship to current data. Alternatively, they may argue that even if they do reduce harms, SIFs are ultimately unjustifiable for moral reasons. There is more flexibility in developing arguments of this nature, but there are still serious theoretical difficulties one must resolve even if they can give a plausible argument for drug use’s immorality. Perhaps this is why opponents of SIFs couch their arguments in terms of the consequences of SIFs, even when they lack the data to support these claims.

Ultimately, if OnPoint’s figures are accurate, SIFs show great promise at limiting deaths from overdose. Even if this is their only benefit, this alone should make us pause before rejecting them. While they may only address the symptoms of the opioid crisis in the U.S., we have compelling moral reason to minimize harms while solving the underlying problems behind addiction.

Re-evaluating Addiction: The Immoral Moralizing of Alcoholics Anonymous

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As of 2019, Alcoholics Anonymous boasts more than 2 million members across 150 countries, making it the most widely implemented form of addiction treatment worldwide. The 12-step program has become ubiquitous within medical science and popular culture alike, to the extent that most of us take its potency for granted. According to Eoin F. Cannon’s The Saloon and the Mission: Addiction, Conversion, and the Politics of Redemption in American Culture, A.A. has “spread its ideas and its phraseology as a natural language of recovery, rather than as a framework with an institutional history and a cultural genealogy . . . A.A.’s deep cultural penetration is most evident in the way the recovery story it fostered can convey intensely personal, experiential truth, largely free from the implications of persuasion or imitation that attached to its precursors.” And yet, medical science continues to debate the effectiveness of A.A., or if it’s even effective at all. Critics have pointed out that the organization’s moral approach to suffering and redemption leaves much to be desired for many addicts.

It’s worth beginning with a basic overview of the social and historical context of A.A. The organization has its roots in the Oxford Group, a fellowship of Christian evangelical ministers who believed in the value of confession for alleviating the inherent sinfulness of humanity. Bill Wilson, who would go on to co-found Alcoholics Anonymous in 1935, was a member of this group, and based many of the founding principles of his organization on the teachings of the Oxford Group. A.A. was also rooted in a much broader historical moment. As Cannon explains, “A.A. embraced the disease concept of alcoholism in an era of rising medical authority and popular psychology. It formulated a spirituality that used the language of traditional Christian piety but was personal and pragmatic enough to sit comfortably with postwar prosperity.” Also crucial was “the evangelical energies and professional expertise of its early members, many of whom were experienced in marketing and public relations.” A.A.’s marketing was so effective at embedding the organization in popular culture that virtually all depictions of addiction and recovery have been colored by the 12-steps-approach, even into the 21st century.

Furthermore, the Great Depression was ending as the group achieved national prominence, and its philosophy was closely aligned with that of the New Deal. As Cannon explains, the pain of the economic crisis (which was characterized by contemporaries as a kind of drunken irresponsibility) was transformed into an opportunity for a moral makeover, a narrative pushed by FDR and the New Deal that A.A. either seized upon or unconsciously imitated. Cannon explains that “recovering narrators described their experiences of decline and crisis drew on the same kind of social material that, writ large, defined the national problem: the bewildering failure of self-reliant individualism, as evidenced in job loss, privation, and family trauma. A.A. narrative, just like FDR’s New Deal story, interpreted this failure as a hard-earned lesson about the limits of self-interest.” In this sense, A.A. is hardly apolitical or ahistorical. It was forged by political and economic currents of the early 20th century, and its ascendancy was hardly natural or inevitable.

The spiritual dimension of A.A. is impossible to ignore. The Oxford Group’s foundational influence is evident in the famous the 12-step program: for example, steps 2 and 3 read,

“2. Came to believe that a Power greater than ourselves could restore us to sanity.

3.. Made a decision to turn our will and our lives over to the care of God as we

understood Him.”

The final step, “Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs,” sounds like a call for religious conversion. Most would agree that medical treatment should be secular, so why is alcoholism an exception?

Furthermore, an emphasis on spirituality doesn’t necessarily make addiction treatment more effective. A 2007 study conducted for the Journal for the Scientific Study of Religion acknowledges that “Studies focusing on religiosity as a protective factor tend to show a weak to moderate relationship to substance use and dependence . . . Studies that have examined religiosity as a personal resource in treatment recovery also tend to report weak to moderate correlations with treatment.” However, the 2007 study takes issue with this data. The researchers argue that most previous studies rely “on the assumption that religiosity, although an outcome of socialization, is an internal attribute that functions as a resource to promote conventional behavior . . . An alternative model to this individualistic, psychological framework is a sociological model where religion is viewed as an attribute of a social group.” In other words, we focus too much on how religion functions for individuals instead of how religion functions in a social context.

Rather, this study uses the “moral community” hypothesis, first articulated by sociologists Stark and Bainbridge, as a framework for understanding addiction treatment. This theory argues that individual interactions with religion (how much importance you place on it or specific beliefs you subscribe to) are not as important as your entrenchment in a religious community, which is the ultimate predictor of long-term commitment to and effectiveness of treatment. The results of the 2007 study seem to support this idea; the data “revealed that an increase in church attendance and involvement in self-help groups were better predictors of posttreatment alcohol and drug use than the measure of individual religiosity.” The study found that “individuals with higher levels of religiosity tended to have higher levels of commitment” to AA, but more broadly, “in some programs religiosity functioned as a positive resource whereas in other programs it served as a hindrance to recovery.” In other words, religion isn’t universally helpful, depending on the person and how easy they find it to assimilate into their moral community. Perhaps those who already have incorporated organized religion into their life will be better equipped for group participation in the context of addiction recovery. What all of this seems to suggest is that A.A. is only effective if you’re already receptive to its framework, which hardly makes it a cure-all for alcoholism. Non-Christians and atheists who drink are more or less left out in the cold.

In fact, there are very few studies that conclusively support A.A. as the best or only treatment plan for alcoholism. As writer Gabrielle Glaser pointed out in an article for The Atlantic, “Alcoholics Anonymous is famously difficult to study. By necessity, it keeps no records of who attends meetings; members come and go and are, of course, anonymous. No conclusive data exist on how well it works.” The few studies that have tested A.A.’s effectiveness tend to find less than impressive results. For example, psychiatrist Lance Dodes estimated in his 2015 book The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry that the actual rate of success for the A.A. program is somewhere between 5 and 8 percent, based on retention rates and long-term commitment. As of 2017, there are 275 research centers devoted to studying alcohol addiction worldwide. The majority of research is conducted in multi-disciplinary research institutions, and nearly half of all research on alcoholism comes out of the U.S, which given how prominent the A.A. approach is here, may skew what facets of addiction are given attention by researchers.

Despite a dearth of proof, A.A. claims to have a 75% percent success rate. According to the movement’s urtext Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism (affectionately referred to as “The Big Book” by seasoned A.A. members),

“Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves . . . They are not at fault; they seem to have been born that way.”

While alcoholism can have a genetic component, the idea that some people are simply doomed to be incurable because of the way they were born (or that any treatment plan for addiction can be “simple”) is deeply troubling. Reading this passage from the Big Book, one can’t help but notice a parallel to early 20th-century eugenicists like Walter Wasson, who argued in 1913 that alcoholics (who he labeled “mental defectives”) should be “segregated and prevented from having children” so as not to pass down their condition and further pollute the gene pool. Eugenicists believed that alcoholism was incurable, and while A.A. ostensibly believes that it can be cured, they still believe that some are genetically destined to always drink. If their treatment plan for you doesn’t work, it’s simply your own fault, and you’ll never be able to get help at all.

Since its post-Depression inception, A.A. has relied on a moral framework that places blame on the individual rather than society at large. Alcoholism is understood as an innate failure of the individual, not a complex condition brought about by a number of economic, social, and genetic factors. As one former A.A. member explained,

“The AA programme makes absolutely no distinction between thoughts and feelings – a key factor in cognitive behavioural therapy, which is arguably a more up-to-date form of mental health technology. Instead, in AA, alcoholism is caused by ‘defects of character,’ which can only be taken away by surrender to a higher power. So, in many ways, it’s a movement based on emotional subjugation . . . anything you achieve in AA is through God’s will rather than your own. You have no control over your life, but the higher power does.”

Many individuals have found comfort and support in A.A., but it seems that the kind of moral community it offers is only accessible to those with a religious bent and predisposition to the treatment plan. For those who drink to escape crushing poverty, racial inequality, or the drudgery of capitalism, A.A. often offers pseudoscience instead of results, moralizing condemnation instead of medical treatment and genuine understanding.

On Providing Safe Spaces for Drug Use

Under new legislation in Maryland, spaces will be provided for illegal narcotics to be ingested in clean facilities under the supervision of medical professionals. There are nearly 100 such facilities worldwide, largely in Europe, where they have existed since the early 1980s. In the United States, where rates of accidental death from opioid overdose have “quadrupled since the late 1990s,” these facilities are still largely a controversial possibility.

Continue reading “On Providing Safe Spaces for Drug Use”