Drug Treatment:

Harm Reduction v Abstinence

Tony Mercer

MANCEPT - Political Theory of Harm Reduction

Tuesday 11th September 2018

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• Public Health Specialist

• Aspiring Philosopher

• Recovered Addict

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1. Background: drugs treatment in UK
2. Abstinence v Harm Reduction
3. Deontological Ethics & Abstinence
4. Utilitarianism & Harm Reduction
5. Irreconcilable differences?
6. Eudaimonia & Recovery

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• 1960 - heroin prescribed by GPs and no. of
addicts reached all time high
• 1960-1964 - prescribing in private clinics
• 1964 - Brain Committee
• 1968 - Dangerous Drugs Act
• 1980s Drug Dependency Units (Injectable
heroin – injectable methadone – oral
methadone/short term prescribing and
detox)

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 ---Cheap Afghani heroin---

• 1985 - Needle exchange

• 1998 - National Drug Strategy
• 2003 - National Treatment Agency
(maintenance prescribing)
• 2006 - Increased recreational use of non opiates
• 2008 - Recovery Agenda

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• Significant funding reductions
• Aging cohort of heroin users
• Increased purity of cocaine & ecstasy
• Novel Psychoactive substances
• Significant increases in drug related deaths

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 Few discussions within the addictions
field have generated more vitriol than
the extremely polarized debates
between advocates of harm reduction
and advocates of abstinence-based
approaches to addiction treatment
and recovery support.

William White et al.(2013)

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 Immanuel Kant
1724 – 1804

• Duty ethics
• Moral absolutes
• Doing the right thing
because it is the right
thing to do

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 We will continue to send a
clear message that drug use is
unacceptable…that we
demand respect for the law
and will not tolerate illegal
behaviour

Home Office (2008)

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 …the fragments of a conceptual
scheme, parts which now lack
those contexts from which their
significance derived

MacIntyre (2013)

It is as if the notion ‘criminal’

were to remain when criminal
law and criminal courts had been
abolished and forgotten

Anscombe (1958)
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 JS Mill
1806 – 1873

• Consequentialism
• Utilitarianism
• Greatest good of the
greatest number

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 …the harm reduction approach will avoid
many negative consequences

harm reduction interventions are clearly

justified on utilitarian grounds because,
based on the evidence, such policies
would produce the greatest good for the
greatest number

Christie et al. (2008)

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 …since abstinence-based policies have many
unintended negative consequences, Mill would
conclude that they would likely not promote the
greatest happiness for the greatest number

Christie et al. (2008)

Kant would not think that the values

guiding harm reduction are ethical
because the justification of harm
reduction interventions focuses
exclusively on examining consequences

Christie et al. (2008)

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…this Enlightenment aspiration went aground
on a multiplicity of moral visions, along with
the inability to choose among them by
sound rational argument

Englehardt (2002)

essentially a conflict
between ‘‘consequentialists’’, more concerned to
evaluate interventions by considering
their impact, while the ‘‘non-consequentialist’’
critics of harm reduction prefer to evaluate
interventions by considering their moral worth

Wodak (2007)
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 There is a recent trend toward
discovery of common ground within
these approaches. Rather than
conceiving these philosophies and
service strategies in either/or terms, a
maturation within all but the most
extreme fringes of both camps seems
to be producing new models of
collaboration

William White (2013)

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 Aristotle
384-322 BC

• Telos (final ends)

• Virtue
• Eudaimonia (human
flourishing)

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 Aristotle
384-322 BC

Eudaimonia (human flourishing)

“…overcoming dependence, reducing risk-taking behaviour and offending,

improving health, functioning as a productive member of society and becoming
personally fulfilled” (NTA (2012)

“a process, not a single event, that may take time to achieve and effort to
maintain” (UKDPC (2008)
 …overcoming dependence, reducing risk-
taking behaviour and offending, improving
health, functioning as a productive
member of society and becoming
personally fulfilled

NTA (2012)

a process, not a single event, that may take

time to achieve and effort to maintain

UKDPC (2008)
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• Different interventions to reach different populations and
reach the same individuals at different stages of their use and
recovery career

• Aim is to reach, engage, and support positive change across a

range of domains

• Changes in drug choice, frequency of use and methods of

administration should be viewed as incremental experiments in
problem resolution

• Resistance and ambivalence are a natural—not pathological—

response to internal and external pressure to change deeply
engrained behaviours
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• Resistance and ambivalence are reduced when people have real
choices and are empowered to choose

• Defining recovery as contingent upon cessation of medications such

as methadone or buprenorphine flies in the face of scientific
evidence and feeds stigma and discrimination

• Ideas matter – innovation is essential

• Drug users must be viewed as allies and participants in their own

individual and collective health

• Multiple points of service entry

• Service delivery within the locations where clients live and use
drugs

• Service duration (beginning and end) defined by the service user

not the service

• Broad service menu encompassing numerous areas of life

functioning

• Goals set by the service user not the service

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 A few questions

• Do we stop using the term “harm reduction”

because of its utilitarian philosophy?

• Do we adopt a “recovery” paradigm based on

“human flourishing” ?

• Could this approach be applied to other areas?

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 References
Anscombe, G. E. M., 1958. Modern Moral Philosophy. Philosophy 33(125): 1–
19

Christie, T., L. Groarke andW. Sweet, 2008. Virtue Ethics as an Alternative to

Deontological and Consequential Reasoning in the Harm Reduction Debate.
International Journal of Drug Policy 19(1): 52–58

Engelhardt, H. T., 2002. Bioethics as a Plural Noun: Competing

Understandings of Morality in Health Care. In H. T. Engelhardt, The
Foundations of Bioethics, 2nd rev. edn, 3–31. Oxford: Oxford University Press

Home Office, 2008. Drugs: Protecting Families and Communities. London:

Home Office

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MacIntyre, A., 2013. After Virtue. London: Bloomsbury, 4th rev. edn.

NTA (National Treatment Agency), 2012. Medications in Recovery: Re-

orientating Drug Dependence Treatment. London: Department of Health

UKDPC (United Kingdom Drug Policy Commission), 2008. A Vision of

Recovery. London: UKDPC

White, W. L., Evans, A. C. and Lamb, R. L. (2013) The Role of Harm Reduction
in Recovery-oriented Systems of Care: The Philadelphia Experience

Wodak, A., 2007. Ethics and Drug Policy. Psychiatry 6(2): 59–62

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