The Ethics in Substitution Treatment and Harm Reduction. An Analytical Review

Abstract

The ethics of opiate substitution treatment (OST) modalities for heroin addiction have been abundantly criticised but also have equally strong supporters. This analytical review addresses three main arguments against such treatments: 1) the social nature of the issue involves a misuse of the medical care; 2) the aim is one of social control (as opposed to a "cure") and therefore is a perversion health care; and 3) prescribing the very substance (or a substitute) that caused the addiction is ethically questionable. Additionally, the generic criticism against the philosophical/ theoretical framework under which they operate, "harm reduction" (HR) as an operational goal of therapy, is also addressed here.A summary review of the history of addiction supports the argument that, indeed, drug addiction "as a problem" was socially created. Equally clear is that one of the aims of OST and all drug-addition treatments is the social control of individual behaviours. However, neither of these two aspects justifies refusal to provide health and social care. OSTs are legitimate therapeutic options because they comply with the four principles of bioethics-autonomy, nonmaleficence, beneficence and justice. The argument that such treatments and the HR approach, in general, align with the principle of consequentialism-the aim justifies the means-and therefore is ethically questionable is a disingenuous criticism. Consequantialism is based in the implicit assumption that harms are accepted to reach certain objectives as the lesser of two evils. OSTs have been extensively proven as to their safety with benefits margins both at the individual (retention, reduction of illicit drug use and better social adjustment) as well as at the population levels (e.g., HIV incidence reduction). Heroin-substitution based treatment is the latest case of moral resistance to provide patients with the most effective option in spite of sound evidence on its effectiveness and safety. As in other cases of spurious resistance to public health and medical innovations, it is only a matter of time and endurance until such treatments are fully integrated among standard therapeutic options for heroin dependent individuals.

Accrediting Ethics Competencies in Schools and Programs of Public Health: A Gap in Council on Education for Public Health Criteria

“…34 Published studies connecting ethical issues to public health practice are also coming out of several countries, notably Australia, Europe, India, and Scotland. [35][36][37][38] Public Health Reviews, the official journal of the Association of Public Health in the European region, published 2 themed issues on public health ethics, the most recent one in 2012. 39 It is clear that if a stated goal of the new CEPH accreditation criteria is to better align public health training with the needs of the public health workforce, then public health ethics training is needed by that workforce to meet the needs of accreditation, certification, funders, and everyday public health practice.…”

“…34 Published studies connecting ethical issues to public health practice are also coming out of several countries, notably Australia, Europe, India, and Scotland. 35 –38 Public Health Reviews , the official journal of the Association of Public Health in the European region, published 2 themed issues on public health ethics, the most recent one in 2012. 39…”

Selections of reality: Applying Burke's dramatism to a harm reduction program

“…Within harm reduction programs, then, ethics drive practices because participants are allowed to act in accordance with their preferred life styles (Moore & Fraser, 2006). Aceijas (2012) adds that opiate substitution programs meet the ethical standards of bioethics, while also proving to be effective in improving participants' lives. Hathaway and Tousaw (2008) state that ethical justifications are necessary, because critics often ignore empirical evidence of harm reduction's effectiveness (Buchanan, Ford, & Singer, 2003).…”

Editorial: Why a Theme Issue on Public Health Ethics?

“…25 Carter et al address issues of ethics in health promotion, 26 Coughlin et al consider scientifi c integrity in research in public health, 27 Teutsch and Rechel explore ethics of resource allocation in times of economic austerity, 28 Gray discusses issues of ethics of publication, 29 Edwards et al recount challenges of their experiences with ethical clearance in international health policy and social sciences research 30 and Aceijas argues the ethics of substitution therapy in harm reduction for drug addiction. 31 Legal and ethical issues of mandatory fl uoridation are highlighted by Zusman with Israel as a case study. 32 The alarming neglect and low level of teaching of public health ethics in bachelors and master degree programs curricula in public health in Europe is examined by Aceijas, Brall et al…”