Last week, I opened a discussion on harm reduction policies for drug users. Despite their effectiveness at reducing incidents of disease and death, many harm reduction programs, such as needle exchanges or safe supply to users, remain controversial and underutilized.
Although supporters of harm reduction often portray opponents as lacking in empathy or critical thinking, values analysis exposes a far more complicated moral environment. Opponents of harm reduction often view drugs as inherently dirty and corrupting, so any effort by the government to facilitate drug use would seem morally wrong, even if such efforts would ultimately save lives. As well, drug decriminalization could be viewed as a surrender, with the government basically admitting to its own impotence in battling drug use. But if drugs are inherently bad, then this approach could be viewed as a dereliction of duty.
Moral qualms aside, many jurisdictions continue to implement more harm reduction strategies as the costs and failures of the criminalization of drug use become incontrovertible. The insights of values analysis could illuminate potential avenues for increasing public acceptance of harm reduction measures:
Communications need to be sufficiently respectful towards opponents of harm reduction.
Values analysis shows that natural moral intuitions play a role in the opposition to harm reduction policies. Consequently, suggesting that opponents of harm reduction policies just don’t care about the lives of drug users is unlikely to be an effective communications strategy. This approach was attempted by the journalist Gary Mason in a 2021 Globe and Mail op-ed entitled (condescendingly) “B.C. has a drug overdose crisis. At least try to pretend you care”.The article makes the claim that the continuation of the opioid crisis in BC is primarily the result of public apathy, and Mason seems to want to shame people into action. Pushing for the implementation of safe supply programs, Mason makes the following point:
But even as I type those words I feel a sense of hopelessness. Giving out free drugs such as heroin to “addicts” just seems to be too big a leap for governments and society generally. Allowing people to die from their addictions is easier to accept. Which is just crazy when you think about it. Imagine seeing more than 8,500 people die from a drug overdose in just over five years as easier to accept than making a courageous effort to do something that could really make a difference.
People who already support safe supply, whose moral compasses are primarily based in reducing suffering, are likely to nod their heads along with Mason’s rhetoric, confident in the righteousness of their cause. But this is not a fair illustration of the moral views of opponents of safe supply, so the article is likely to attract outrage from opponents of safe supply programs. Mason is creating a moral strawman and tearing it down, which is not an effective way of bridging a moral gap. This point was raised in a top-rated comment (40 likes) on the article:
I understand where Gary Mason and others are coming from: they see people suffering and dying, and they want to do something. However, they’re missing one important fact: *the drugs are the problem.* These are not safe to use for recreational purposes, and every time access to opioids has been increased in human history, it’s led to a public health crisis. At best, “safe supply”, like safe injection sites before just mitigate some of the side effects of drug use. If you want to suggest bringing back large-scale mental health facilities to get the drug addicted and mentally I’ll off the streets, I’m all ears and it would be worth a tax hike to pay for it.
This is both an intellectually reasonable and morally effective response, as it acknowledges that drugs are inherently damaging, a perspective that Mason doesn’t bother to address. Clearly, the author of this comment was completely unconvinced. So, if Mason was unable to shame this thoughtful individual into changing their opinion, who exactly was he trying to convince? This article was more likely to simply entrench existing views, rather than persuade anyone to support harm reduction policies.
A better communications strategy would directly address the moral issues that underpin the opposition to harm reduction. It would emphasize that the main problem is drug use. It would sell harm reduction as a temporary, regrettable health measure, not a permanent state-of-affairs. It would reaffirm the corrupting nature of narcotics, while humanizing drug users as victim of substance abuse, a medical condition. And it would clearly link harm reduction to long-term success in reducing overall drug use. It would certainly not accuse well-meaning opponents of harm reduction of being cold-hearted, uncaring, or mean. You catch more flies with honey than vinegar.
Set up safe consumption sites in ways that reduce moral outrage.
Values analysis reveals that the moral opposition to drug use is often rooted in concerns about purity and cleanliness. These objections can be partially addressed by deliberately building and operating safe consumption sites in ways that would minimize this moral reaction. To be clear, many of these suggestions remain unsubstantiated by scientific evidence at this time, but values analysis would at least predict that they would increase the public’s acceptance of safe consumption sites:
Make safe consumption sites look as sterile as possible: White floors and walls. Construction materials that resemble hospitals. Consistent and rigorous cleaning standards. Many safe consumption sites already implement such procedures, in part for the safety of users. However, values analysis suggests that these are important steps for building public support as well. The cleaner the area, the less likely the facility will be intuitively connected to uncleanliness and corruption.
Of course, it isn’t enough simply to make safe injection sites look clean; the public needs to be educated about the steps taken too. Publishing photo essays could be useful, such as this one that shows a sterile environment in two Australian safe consumption sites. Offering tours to concerned citizens is another possible way to reduce moral outrage. Such outreach and communications programs have the potential to increase both national and local support for such facilities.
Prioritise the oral administration of drugs when possible: One possibility would be to only offer drugs that could be taken orally, as oral administration of medications is considered normal, while other methods, such as injection or inhalation, are unusual and potentially more grotesque. This may be a reason why alcohol is considered a less morally objectionable drug than heroin, despite its harmful effects. Drinking a drug is better than huffing or injecting it.
I cannot locate any studies that explore the relationship between disgust and different methods of administering drugs, but there is some adjacent evidence to suggest this approach could be effective. First, multiple studies have found that patients prefer oral medications over alternative methods. Certainly, the ease of oral administration is a significant reason for this preference, but moral concerns about injection and inhalation may also play a role. Second, the naming of safe consumption sites has an important impact on the public’s perception. For example, the public is far more likely to support the establishment of “overdose prevention sites” (a term which likely harmonizes with the care/harm value) than “safe consumption sites”, which is morally neutral – or slightly negative. Although it has not been scientifically tested, the term “safe injection site” is likely to attract the least amount of support, as the term “injection” likely prompts images of a morally questionable method of drug administration, which would violate many people’s values. Third, a survey of Canadian adults’ attitudes towards different harm reduction techniques showed that “safe inhalation kits” were the least popular form of harm reduction – though the reason for this was unclear. It may be because “inhalation” is more likely to prompt a negative moral reaction than other forms of drug administration. Admittedly, this is not sufficient evidence to alter the operations of safe consumption sites towards a preference for drugs taken orally at this time, but this is an area where more research should be done.
Offer other hygiene services on site: This suggestion is a bit of a stretch, and I have little evidence to suggest that it will make a difference. Even so, I think it is worth discussing, as our understanding of human morality suggests that it may be effective. If safe consumption sites offered showers, toothbrushes, and other hygiene services for users, it is possible that they would prompt a more positive moral reaction. Imagine the scenario: a drug user enters the safe consumption site in one condition, but leaves looking cleaner and healthier than before. Rather than leaving the person more ‘corrupted’, the safe consumption site serves partially as a centre for physical cleanliness and ‘purification’. This should be an easy sell to pro-harm reduction activists, as the provision of hygiene products and services is helping drug users as well. Again, to my knowledge, this has never been tried, but it might be worth exploring.
Harm reduction efforts require complementary programming that resonate with other values.
Regardless of communications strategies and other tweaks to programming, harm reduction is likely to remain highly resonant with only one value: care/harm (i.e. it is right to help people and wrong to hurt them). This is both a blessing and a curse, as harm reduction is likely to always have a motivated group of supporters – and opponents. To help reduce moral outrage, harm reduction efforts should be tied to other programs that are more acceptable to alternative moral values.
For example, drug decriminalization alone is morally controversial, in part because it can appear like the government is simply giving up the fight, despite the major effects drugs can have on people’s health. However, if decriminalization was advanced in lockstep with mandatory treatment measures for people caught with drugs, the negative reaction to decriminalization would be more muted. It could not be claimed that the government simply surrendered. Rather, the punishment for drug use is simply shifting from an ineffective jail sentence to a useful stint in rehabilitation. This would show that the government continues to take its responsibilities for minimizing drug addiction seriously and would emphasize the corrupting influence of narcotics on otherwise good people. Under this system, treatment must be encouraged with the force of the law, however; it’s an alternative to prison, not a get-out-of-jail-free card.
This is the approach partially taken by Portugal. Following decriminalization in 2001, people who are caught with drugs are not thrown into prison or given a criminal record, but the substances are still confiscated and administrative penalties, such as fines and community service, are applied. They also receive mandatory assessments with councillors to determine their level of risk. People who are caught with drugs multiple times are sometimes designated as “high risk” and referred to specialised treatment services. Drug dealers continue to be prosecuted. This system strikes a balance between harm reduction and perceived government responsibility. The public order element of the reforms is framed in a way that accepts the difficulties faced by drug users, but it is not limp-wristed. The state maintains the power to use police to enforce drug laws and “punish” users, just not through criminal sanctions.
In contrast, the state of Oregon’s decriminalization efforts were tied to a much weaker enforcement system. In 2020, Oregon’s voters overwhelmingly approved a plan to decriminalize small amounts of drugs. If anyone was caught with such substances, they would be given a $100 fine that could be waived with a call to a treatment hotline. Although the structure of this plan resembles Portugal’s approach, the severity of the “punishment” is much lower. In Portugal, drug users mustmeet with a government counsellor in person. This is far more meaningful than an optional call to a hotline to waive a $100 ticket that may or may not be enforced. No wonder early reports suggest that most fines are ignored, the hotline remains quiet, and people are not entering treatment. Overdose deaths are up significantly since decriminalization, and some early reports about the policy of decriminalization are decidedly negative.
Clearly, Portugal’s approach has significant moral advantages over Oregon’s. Both systems harmonize with the care/harm value to some extent, as decriminalization is intended to save lives. But only Portugal’s approach also harmonizes with the authority/subversion value (i.e. it’s morally correct to follow those in positions of rightful authority), because it is clear that the government is living up to its responsibility to use the law to reduce drug use – when necessary. That’s the power of mandatory medical treatment. In contrast, people who are high in the authority/subversion value are likely to oppose Oregon’s system. An ignorable ticket and an optional hotline are ineffective enforcement measures, so the approach appears weak.
Don’t take my word for it. Here’s part of a top-rated comment (net 550 likes) on a Fox News article about Oregon’s decriminalization policy:
One thing I know is that people do not normally change because they see the light, but because they feel the heat. People forced into treatment have virtually the same outcome as those who voluntarily enter a treatment program. Initially motivation is lower, but when they stay… because they have to or go to jail… their motivation gets better and they recover at the same rate or higher rate. So this version of decriminalizing does not work because they will not enter treatment most of the time until they have their backs against the wall.
Whether the details of this comment are true is beside the point; it is morally resonant with a wide audience. Notice that the author of this comment isn’t opposed to decriminalization overall. Rather, they only oppose decriminalization efforts that do not include mandatory treatment as an alternative to punishment, so this person would be far more likely to support Portugal’s model than Oregon’s.
The lesson for policymakers is that decriminalization alone is likely to prompt significant moral outrage. Some people would support no longer throwing drug users behind bars, but such policies are likely to be more acceptable to a wider subset of the population if they also include a strong policy of mandatory treatment for users.
Conclusion
This article has demonstrated that values analysis can lead to important conclusions regarding harm reduction policies. Tailoring programs and communications strategies could likely reduce moral outrage and make harm reduction policies more acceptable to the public. No doubt, more scientific research is needed before harm reduction policies should be completely changed, but values analysis helps outline areas where useful and ground-breaking research could be undertaken.
Values Added will be on hold until mid-September for a summer break, but the work will continue! Here are a few of the projects that I will be focusing on:
- Transforming some of these posts into academic papers for publication;
- Reworking earlier articles to integrate lessons learned from the past nine months of writing;
- Presenting the findings of Values Added at every available opportunity (let me know if you know of any good people to contact); and
- Starting on the next year of Values Added posts.
I’d like to thank everyone who read Values Added in its first year of life. I published 35 articles and over 80,000 words, more than a book’s worth of content. I can’t wait to start publishing again in mid-September!