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In recent years, multifetal pregnancy reduction has increasingly been a subject of debate in Norway. The intensity of this debate reached a tentative maximum when the Legislation Department delivered their interpretative statement, Section 2 - Interpretation of the Abortion Act, in 2016 in response to a request from the Ministry of Health that the Legislation Department consider whether the Abortion Act allows for MFPR of healthy fetuses in multiple pregnancies. The Legislation Department concluded that the current abortion legislation [as (...) of 2016] allows for MFPR subject to the constraints that the law otherwise stipulates. The debate has not subsided, and during autumn 2018 it was further intensified in connection with the Norwegian Christian Democratic "crossroads" policy and signals from the Conservatives to consider removing section 2.3c and to forbid MFPR. Many of the arguments in the MFPR debate are seemingly similar to arguments put forward in the general abortion debate, and an analysis to ascertain what distinguishes MFPR from other abortions has yet to be conducted. The aim of this article is, therefore, to examine whether there is a moral distinction between abortion and MFPR of healthy fetuses. We will cover the typical arguments emerging in the debate in Norway and exemplify them with scholarly articles from the literature. We have dubbed the most important arguments against MFPR that we have identified the harm argument, the slippery-slope argument, the intention argument, the grief argument, the long-term psychological effects for the woman argument, and the sorting argument. We conclude that these arguments do not measure up in terms of demonstrating a morally relevant difference between MFPR of healthy fetuses and other abortions. Our conclusion is, therefore — despite what several discussants seem to think — that there is no morally relevant difference between the two. Therefore, on the same conditions as we allow for abortions, we should also allow MFPR. Keywords: abortion, ethics, medical ethics, MFPR, selective MFPR. (shrink)

In recent years, multifetal pregnancy reduction (MFPR) has increasingly been the subject of debate in Norway, and the intensity reached a tentative maximum when Legislation Department delivered the interpretative statement § 2 - Interpretation of the Abortion Act in 2016 in response to the Ministry of Health (2014) requesting the Legislation Department to consider whether the Law on abortion allows for MFPR of healthy fetuses in multiple pregnancies. The Legislation Department concluded that current abortion laws allow MFPR within the (...) framework the law otherwise stipulates. The debate has not subsided, and during autumn 2018, it was further intensified in connection with the Christian Democrat "crossroads" and signals from the Conservatives to consider removing §2.3c and to forbid MFPR. -/- Many of the arguments in the MFPR debate appear seemingly similar to arguments pending in the general abortion debate, and an analysis of what sets MFPR apart from other abortions is wanting. The aim of this article is, therefore, to examine whether there is a moral distinction between abortion and MFPR of healthy fetuses. We will cover the typical arguments of the Norwegian debate, and highlight them with scholarly articles from the literature. The most important arguments against MFPR that we have identified we have dubbed the harm argument, slippery-slope argument, intent argument, grief argument, psychological long-term effects for the woman and sorting argument. We conclude that counter-arguments do not measure up in terms of detecting a morally relevant difference between MFPR of healthy fetuses and abortions. Our conclusion is therefore that—despite what several debaters seem to think—there is no morally relevant difference between the two. Therefore, when we allow abortion, we should also allow MFPR. (shrink)

Elected prosecutors have pledged not to enforce abortion laws, in response to state-level abortion bans. For their pledges to be meaningful, prosecutors must exercise their discretion in cases of individuals who face legal risk, including people who help others self-manage their abortions. With a harm-reduction approach to improving abortion access, prosecutors should aim to reduce abortion helpers’ involvement with the criminal justice system.

Some laws cannot yet be entirely abrogated in a current political situation, though permitting grave injustices against some individuals; for example, unborn and/or disabled individuals. In supporting the passing of new ‘imperfect’ laws that protect only some of those who now lack protection, do we ourselves discriminate unjustly against those remaining unprotected? Or does that depend on factors such as our intentions – including what we intend that others intend? How may we collaborate with colleagues who intend, and perhaps explicitly (...) defend, the continuation of remaining, closely-related injustices, although they are willing to join us in trying to improve some aspects of the status quo? This paper explores the moral constraints on our attempts to extend the law’s protection to some, but not to all, of those individuals currently deprived of such ­protection and at risk of serious harm. (shrink)

A central claim in abortion ethics is what might be called the Harm Claim – the claim that abortion harms the fetus. In this article, we put forward a simple and straightforward reason to reject the Harm Claim. Rather than invoking controversial assumptions about personal identity, or some nonstandard account of harm, as many other critics of the Harm Claim have done, we suggest that the aborted fetus cannot be harmed for the simple reason that it (...) does not occupy any well-being level. (shrink)

A central claim in abortion ethics is what might be called the Harm Claim – the claim that abortion harms the fetus. In this article, we put forward a simple and straightforward reason to reject the Harm Claim. Rather than invoking controversial assumptions about personal identity, or some nonstandard account of harm, as many other critics of the Harm Claim have done, we suggest that the aborted fetus cannot be harmed for the simple reason that it (...) does not occupy any well-being level. (shrink)

Psychedelic Harm Reduction and Integration is a transtheoretical and transdiagnostic clinical approach to working with patients who are using or considering using psychedelics in any context. The ongoing discussion of psychedelics in academic research and mainstream media, coupled with recent law enforcement deprioritization of psychedelics and compassionate use approvals for psychedelic-assisted therapy, make this model exceedingly timely. Given the prevalence of psychedelic use, the therapeutic potential of psychedelics, and the unique cultural and historical context in which psychedelics are (...) placed, it is important that mental health providers have an understanding of the unique motivations, experiences, and needs of people who use them. PHRI incorporates elements of harm reduction psychotherapy and psychedelic-assisted psychotherapy, and can be applied in both brief and ongoing psychotherapy interactions. PHRI represents a shift away from assessment limited to untoward outcomes of psychedelic use and abstinence-based addiction treatment paradigms and toward a stance of compassionate, destigmatizing acceptance of patients' choices. Considerations for assessment, preparation, and working with difficult experiences are presented. (shrink)

The post-confinement phase of the COVID-19 pandemic will require that governments navigate more complex ethical questions than had occurred in the initial, ‘curve-flattening’ phase, and that will occur when the pandemic is in the past. By looking at the unavoidable harms involved in the confinement and quarantine methods employed during the initial phase of the pandemic, we can develop a harm reduction approach to managing the phase during which society will be gradually reopened in a context of managed (...) risk. The principles that are at the heart of such an approach include a reckoning with all of the harms involved in policy choice, including harms that might be given rise to by policy implementation itself; a focus on the harms to which already vulnerable populations are susceptible; and a strong preference for policies that economize on the use of prohibitions and of coercive state enforcement, and that instead emphasize the agency of citizens in realizing health-promoting behavior change. This framework is applied to a policy proposal that has been discussed in policy circles in a number of countries, that of immunity ‘passports’, and to policies that emphasize the creative use of space and time to achieve physical distancing goals. (shrink)

Of the various debates surrounding harm reduction, a conceptual tension that perhaps has the most relevance for the provision of services is that of harm reduction as a technical solution versus a contextualized social practice. The aim of this paper was to examine this conceptual tension. First, the two perspectives will be presented through the use of examples. Second, philosophical drivers that serve to underpin and justify each perspective will be explicated at the level of the (...) knowledge that we privilege; the ideologies that we subscribe to; and the interests that we stand to serve. In this paper, I argue that the existing tension between technical and social approaches to harm reduction is embedded within discord pertaining to ways of knowing, paradigms of inquiry, prevailing ideologies, and notions of harm and risk. Building on these sources of tension, I suggest a means of philosophical reconciliation between the two approaches and ways forward, namely through acknowledging multiple sources of knowledge, through embracing paradigmatic incommensurability, through considering alternative conceptions of people who use drugs as political subjects, through involving service providers and end‐users in shared decision‐making, and lastly through reaffirming people who use drugs as the intended beneficiaries of services. (shrink)

Svirsky, Howard, and Berman’s paper “E-Cigarettes and the Multiple Responsibilities of the FDA” offers a significant contribution to a knowledge domain that might be called “harm reduction e...

Those found liable for negligently injuring others are required to compensate them, but current practices permit most tort feasors to spread the costs of their liability burdens through the purchase of insurance. Those found guilty of criminal offences, however, are not allowed to shift the burdens of their sentences onto others. Yet the reasons for not allowing criminal offenders to shift such burdens – harm reduction, retribution, and moral education – also appear to retain some force in relation (...) to negligent tort feasors. Arguments for and against limiting the abilities of negligent tort feasors to spread such costs, thus imposing a penalty on them, are discussed. The conclusion reached is that further consideration of such a penalty is warranted. (shrink)

The justification for harm reduction as an approach to drug use and addiction is seen by many to be consequentialist in form and it has been claimed that as a deontologist Kant would reject harm reduction. I argue this is wrong on both counts. A more nuanced understanding of harm reduction and Kant shows them compatible. Kant’s own remarks about intoxication reinforce this. Moreover, there is a Kantian argument that harm reduction is (...) not only morally permissible but more consistent with the Kantian duty of respect for autonomy than mandatory abstinence approaches. (shrink)

The target of my discussion is intuitions lay people have about justice in the context of drug policy—intuitions that take on a more or less moral-desert-based shape. I argue that even if we think desert is the right measure of how we ought to treat people, we ought still be in favour of Harm Reduction measures for people who use drugs. Harm Reduction measures are controversial with members of the public, and much of the opposition seems (...) to come from something like an appeal to a desert conception of justice—the notion that a just state of affairs is one in which everybody gets what they deserve, no more, no less. A recent study, for example, found that ‘moral outrage’ predicts a preference for prevalence reduction over Harm Reduction. The thinking seems to be that, since drug use is wrong, letting people who use drugs suffer and/or die as a consequence of their use is just. Aiding their health and safety, while perhaps compassionate, is unjust. I argue that there is a bad desert fit between using drugs and suffering avoidable harm even if using drugs is morally wrong. Many of the possible harms of drug use are socially/policy driven, and much problematic drug use is context dependent, not cleanly attributable to the decisions of the person who uses drugs. This means that even if drug use is wrong, people who use drugs deserve Harm Reduction policies, at minimum. (shrink)

‘Harm reduction’ programs are usually justified on the utilitarian grounds that they aim to reduce the net harms of a behavior. In this paper, I contend that the historical genesis of harm reduction programs, and the crucial moral imperative that distinguishes these programs from other interventions and policies, are not utilitarian; the practical implementation of harm reduction programs is not, and probably cannot be, utilitarian; and the continued justification of harm reduction on (...) utilitarian grounds is untenable and may itself cause harm. Promoting harm reduction programs as utilitarian in the public arena disregards their deeper prioritarian impulses. ‘Harm reduction’ is a misnomer, and the name should be abandoned sooner rather than later. (shrink)

Minor-attracted persons raise multiple ethical and legal challenges. Sexual contact between adults and children is justly prohibited on child welfare grounds. Advances in technology raise the prospect of interventions for minor-attracted persons that have the potential to reduce harm to children by diverting would-be offenders to other endeavors that nonetheless may generate moral disgust This essay examines three of these potential harm reduction technologies (sex robots, haptic devices and synthetic child pornography) and raises the possibility that their (...) use can be justified and their acceptance morally obligatory if doing so reduces harm to real children. (shrink)

One of harm reduction’s most salient features is its pragmatism. Harm reduction purports to distinguish itself from dominant prohibitionist and abstinence-based policy paradigms by being grounded in what is realistic, in contrast with the moralism or puritanism of prohibition and abstention. This is reflected in the meme “harm reduction works”, popular both in institutional and grassroots settings. The idea that harm reduction is realistic and effective has meant different things among the main (...) actors who seek to shape harm reduction policy. Drawing on scholarly literature about harm reduction, as well as examples from recent harm reduction advocacy efforts in relation to drug policy in Canada, this paper argues that harm reduction distinguishes itself through a unique “way of knowing”. Grassroots harm reduction advocates, particularly as they argue through human rights frameworks, do more than simply make claims for the provision of particular services—like needle exchange, safe consumption sites, safe supply and the like—on the basis that these are realistic paths toward the health and well-being of people who use drugs. Rather, as they marshal lived experience in support of these policy changes through peer-driven initiatives in contexts of prohibition, they make particular claims about what constitute valid, methodologically rigorous evidence bases for action in contexts where policies to date have been driven by ideology and have developed in ways that have excluded and marginalized those most affected from policymaking. In doing so, they advocate for the centrality of people who use drugs not only in policy-making processes, but in evidence production itself. (shrink)

There is strong evidence suggesting that harm reduction policies are able to reduce the adverse health and social consequences of drug use. However, in this article I will compare two different countries to demonstrate that some social aspects lead to the adoption or rejection of harm reduction policies. In this case, countries where drugs are seen as a security concern are less likely to adopt these harm reduction policies. For that purpose, I will compare (...) Colombia and Uruguay’s political, normative, and social aspects, which are considered drivers in the adoption of harm reduction policies, as well as how those factors influence the treatments available for substance abuse disorders. (shrink)

Instrumental Stakeholder Theory has begun to suffer from what might be termed “mission drift.” Despite its initial success in creating a foothold for ethics in managerial decision-making, the efficiency arguments which now dominate this research stream have become counterproductive to the original goal of connecting ethics and capitalism. We argue in this paper that the way forward is by re-centering contingency, conversation, and inefficiency in stakeholder theory. To start this process, there needs to be a reckoning of some unintended impacts (...) of the success of the instrumental stream of stakeholder research. For a contrasting approach, we draw on Richard Rorty’s pragmatism and its foundation of ethical “irony,” a state of continuous doubts about the utility of one’s moral vocabulary. We offer a Rortian approach to stakeholder theory, unearthing the possibility for new corporate target functions in the goals of harm reduction, solidarity, and social mobility, the foundational building blocks of an ironist ethical perspective. (shrink)

Patients with severe and enduring anorexia nervosa have a relatively low chance of attaining the symptom-free recovery that traditional eating disorder treatment programs endorse (Bianchi, S...

Zusammenfassung Im illegalen Nierenhandel werden Verkaufer oft uber den Tisch gezogen, sie werden genotigt, es wird ihnen angemessene medizinische Betreuung vorenthalten und sie werden uber die Gefahren und die Illegalitat der Nierenentnahme in die Irre gefuhrt. Die Empfanger bezahlen oft fur qualitativ schlechte Operationen sowie ungesunde oder unpassende Nieren. Einige Autoren argumentieren, es sei die Illegalitat, die dieses Leid und dieses Unrecht verursachen, nicht der Handel an sich. Sie argumentieren, die Legalisierung von Nierenverkaufen wurde das Leid verringern. Dieses Leidensverringerungsargument ist (...) es, das in diesem Aufsatz entwickelt und untersucht wird. Es werden zunachst die ethischen und empirischen Bestandteile einer utilitaristischen Version von Leidensverringerung dargelegt. Und es wird erklart, wie eine Legalisierung das Leiden auf Schwarzmarkten vermutlich verringern wurde, aber auch, warum wir nicht wissen, wie die Legalisierung das Angebot an Organen oder die Anzahl leidvoller Transaktionen auf ‘weisen Markten’ beeinflussen wurde. Kurz gesagt, wir konnen nicht sicher sein, dass seine Legalisierung das Leiden insgesamt verringern wurde. Dennoch versucht dieser Aufsatz zu zeigen, dass die Argumentation zugunsten von einer Legalisierung gestarkt werden kann, wenn man dem utilitaristischen Hauptanliegen des aggregierten Wohlergehens etwas hinzufugt. Den besonderen Anliegen der am schlechtesten Gestellten und dem Unrecht des Verkaufsakts kann man durch Legalisierung besser gerecht werden als durch Kriminalisierung. Das Leidensverringerungsargument entscheidet diese Debatte uber die Legalisierung des Organhandels zwar nicht, aber es ist entscheidender als Kritiker bislang zugestehen wollten. (shrink)

This paper examines the role of clinical practitioners and clinical researchers internationally in establishing the utility of harm-reduction approaches to substance use. It thus illustrates the potential for clinicians to play a pivotal role in health promoting structural interventions based on harm-reduction goals and public health models. Popular media images of drug use as uniformly damaging, and abstinence as the only acceptable goal of treatment, threaten to distort clinical care away from a basis in evidence, which (...) shows that some ways of using drugs are far more harmful than others and that punitive approaches and insistence on total abstinence as the only goal of treatment often increases the harms of drug use rather than reducing drug use. Therefore the leadership and scientific authority of clinicians who understand the health impact of harm-reduction strategies is needed. Through a review of harm-reduction interventions in Canada, the United Kingdom, the United States, Australia, Switzerland, and the Netherlands, we identify three ways that clinicians have helped to achieve a paradigm shift from punitive approaches to harm-reduction principles in clinical care and in drug policy: through clinical research to provide data establishing the effectiveness and feasibility of harm-reduction approaches, by developing innovative clinical programmes that employ harm reduction, and thereby changing the standard of care to include routine use of these evidence-based approaches in their practices. We argue that through promotion of harm-reduction goals and methods, clinicians have unique opportunities to improve the health outcomes of vulnerable populations. (shrink)

Bianchi, Stanley, and Sutander argue in an insightful, cogent manner for the consideration of harm reduction as an ethically-defensible, non-paternal management approach for capable persons...

Talk of harm reduction has expanded horizontally, to apply to an ever-widening range of policy domains, and vertically, becoming part of official legal and political discourse. This expansion calls for philosophical theorization. What is the best way in which to characterize harm reduction? Does it represent a distinctive ethical position? How is it best morally justified, and what are its moral limits? I distinguish two varieties of harm reduction. One of them, technocratic harm (...) reduction, is premised on the fact of non-enforceability of prohibitionist policies. The second, deliberative harm reduction, is premised on the fact of reasonable disagreement, grounded in the fact that reasonable persons disagree about a range of controversial behaviours. I argue that deliberative harm reduction better accounts for some of harm reduction’s most attractive features, and provides a plausible way of accounting for harm reductions’s justificatory grounds and limits. (shrink)

In this paper, I offer a prolegomenon to the philosophy of harm reduction. I begin with an overview of the philosophical literature on both harm and harm reduction, and a brief summary of harm reduction scholarship outside of philosophy in order to make the case that philosophers have something to contribute to understanding harm reduction, and moreover that engagement with harm reduction would improve philosophical scholarship. I then proceed to (...) survey and assess the nascent and still modest philosophy of harm reduction literature that has begun to emerge. I pay particular attention to two Canadian philosophers who have called for the expansion of harm reduction beyond the realm of so-called “vice”. Finally, I sketch some of the most interesting and important philosophical issues that I think the philosophy of harm reduction must grapple with going forward. (shrink)

This paper examines the role of clinical practitioners and clinical researchers internationally in establishing the utility of harm-reduction approaches to substance use. It thus illustrates the potential for clinicians to play a pivotal role in health promoting structural interventions based on harm-reduction goals and public health models. Popular media images of drug use as uniformly damaging, and abstinence as the only acceptable goal of treatment, threaten to distort clinical care away from a basis in evidence, which (...) shows that some ways of using drugs are far more harmful than others and that punitive approaches and insistence on total abstinence as the only goal of treatment often increases the harms of drug use rather than reducing drug use. Therefore the leadership and scientific authority of clinicians who understand the health impact of harm-reduction strategies is needed. Through a review of harm-reduction interventions in Canada, the United Kingdom, the United States, Australia, Switzerland, and the Netherlands, we identify three ways that clinicians have helped to achieve a paradigm shift from punitive approaches to harm-reduction principles in clinical care and in drug policy: through clinical research to provide data establishing the effectiveness and feasibility of harm-reduction approaches, by developing innovative clinical programmes that employ harm reduction, and thereby changing the standard of care to include routine use of these evidence-based approaches in their practices. We argue that through promotion of harm-reduction goals and methods, clinicians have unique opportunities to improve the health outcomes of vulnerable populations. (shrink)

In “The Ethical Defensibility of Harm Reduction and Eating Disorders,” Andria Bianchi et al. defend the use of harm reduction strategies to treat patients with severe and enduring anorexia n...

Eating disorders are mental illnesses that can have a significant and persistent physical impact, especially for those who are not treated early in their disease trajectory. Although many persons w...

Multicultural theory and practice have in recent years been subjected to substantial criticism. While some of these criticisms can be dismissed as grounded in discriminatory attitudes, others are less easily swept aside, as they are underwritten by values that multiculturalists tend to affirm. A harm reduction approach, that recognizes that reasonable citizens can disagree about some multicultural practices while at the same time acknowledging that attempts at prohibition are either exceedingly costly or contrary to the very values that (...) opponents subscribe to, can provide an alternative foundation for some multicultural accommodations to which both opponents and advocates can subscribe. It involved permitting contested behaviours while imposing regulations aimed at minimizing the harms relative to shared values that they can give rise to. (shrink)

In this paper, I will argue that some prominent objections to parental licensing rely on dubious claims about the existence of a very stringent, if not indefeasible, right to parent, which would be violated by licensing. I claim that attaching such stringency to the right only makes sense if we make a number of idealising assumptions. Otherwise, it is deeply implausible. Instead, I argue that we should evaluate parental licensing policies in much the same way we would harm (...) class='Hi'>reduction policies. By adopting this critical perspective, we can see that there are powerful, but quite different, reasons to be cautious about parental licensing relating to our ability to minimize the harmful effects of mass-parenting in a world of minimal surveillance and intervention. (shrink)

Three public opinion studies examined public attitudes toward prevalence reduction (PR; reducing the number of people engaging in an activity) and harm reduction (HR; reducing the harm associated with an activity) across a wide variety of domains. Studies 1 and 2 were telephone surveys of California adults’ views on PR and HR strategies for a wide range of risk domains (heroin, alcoholism, tobacco, skateboarding, teen sex, illegal immigration, air pollution, and fast food). “Moral outrage” items (immoral, (...) disgusting, irresponsible, dangerous) predicted preference for PR over HR, with disgust the most important predictor. In contrast, preferences were not predicted by whether the risk behavior was common, no one else’s business, or harmless. Study 3 explored whether there are domains where liberals might reject HR. A sample of liberal students preferred HR > PR for heroin, but PR > HR for ritual female circumcision; path analysis suggested that this reversal was explained by moral outrage rather than consequentialist judgments of harm to self and harm to others. (shrink)

At first glance, it seems difficult to object to any program that merits the label “harm reduction.” If harm is bad, as everyone recognizes, then surely reducing it is good. What’s the problem? The problem, we submit, is twofold. First, there’s more to “harm reduction,” as that term is typically used, than simply the reduction of harm. Some of the wariness about harm-reduction programs may result from the nebulous “more.” Thus, part (...) of our task is to provide a clear definition of harm reduction. Next, we turn to a second problem: a worry about complicity. Those who object to harm reduction programs fear that participation in such programs would make them complicit in activities they deem immoral. In this paper we argue that this fear is largely unwarranted. We use supervised injection sites —safe spaces for the use of risky drugs—as our paradigmatic case of harm reduction. These SISs are generally offered in the hope of reducing harm to both the drug user and the public. For this reason, our analysis focuses on complicity in harm. We draw upon the work of Gregory Mellema as our framework. Mellema offers three ways one can be complicit in harm caused by another: by enabling, facilitating or condoning it. We argue that one who operates an SIS is not complicit in any of these ways, while also laying out the conditions that must be met if one is to argue that harm reduction entails complicity in non-consequentialist wrongdoing. (shrink)

The original version of this article unfortunately contained a mistake. The fourth sentence of third paragraph under section Do Harm Reduction Programs Condone Harm? Should be “One of us ” instead of “One of us ”. The original article has been corrected.

In this essay, we consider questions arising from cases in which people request medical assistance in dying (MAiD) in unjust social circumstances. We develop our argument by asking two questions. First, can decisions made in the context of unjust social circumstance be meaningfully autonomous? We understand ‘unjust social circumstances’ to be circumstances in which people do not have meaningful access to the range of options to which they are entitled and ‘autonomy’ as self-governance in the service of personally meaningful goals, (...) values and commitments. People in these circumstances would choose otherwise, were conditions more just. We consider and reject arguments that the autonomy of people choosing death in the context of injustice is necessarily reduced, either by restricting their options for self-determination, through their internalisation of oppressive attitudes or by undermining their hope to the point that they despair.Second, should MAiD be available to people in such circumstances, even when a sound argument can be made that the agents in question are autonomous? In response, we use a harm reduction approach, arguing that even though such decisions are tragic, MAiD should be available. Our argument engages with relational theories of autonomy as well as recent criticism raised against them and is intended to be general in application, although it emerges in response to the Canadian legal regimen around MAiD, with a focus on recent changes in Canada’s eligibility criteria to qualify for MAiD. (shrink)

We are unlikely to stop seeking pleasure, as this would prejudice our health and well-being. Yet many psychoactive substances providing pleasure are outlawed as illicit recreational drugs, despite the fact that only some of them are addictive to some people. Efforts to redress their prohibition, or to reform legislation so that penalties are proportionate to harm have largely failed. Yet, if choices over seeking pleasure are ethical insofar as they avoid harm to oneself or others, public health strategies (...) should foster ethical choice by moving beyond current risk management practices embodied in the harm reduction movement. The neuroscience of pleasure has much to offer neuroethics and public health strategies. Distinguishing between ‘wanting’ and ‘liking’ fosters new understandings of addiction. These hold promise for directing the search for pharmacotherapies which prevent addiction and relapse or disrupt associated neuromechanisms. They could inform new research into creating lawful psychoactive substances which give us pleasure without provoking addiction. As the health and well being of human and other animals rests upon the experience of pleasure, this would be an ethical objective within public health strategy. Were ethical and neurobiological obstacles to ending addiction to be overcome, problems associated with excessive consumption, the lure of unlawful psychoactive substances and the paucity of lawful means to achieve pleasurable altered states would remain. Non-addictive designer drugs, which reliably provided lawful access to pleasures and altered states, would ameliorate these public health concerns insofar as they fostered citizens’ informed, ethical choices according to a neurobiological taxonomy of pleasures. (shrink)

Harm-reduction approaches are used to reduce the burden of risky human behaviour without necessarily aiming to stop the behaviour. We discuss what an introduction of harm reduction for doping in sports would mean in parallel with a relaxation of the antidoping rule. We analyse what is ethically at stake in the following five levels: (1) What would it mean for the athlete (the self)? (2) How would it impact other athletes (the other)? (3) How would it (...) affect the phenomenon of sport as a game and its fair play basis (the play)? (4) What would be the consequences for the spectator and the role of sports in society (the display)? and (5) What would it mean for what some consider as essential to being human (humanity)? For each level, we present arguments for and against doping and then discuss what a harm-reduction approach, within a dynamic regime of a partially relaxed antidoping rule, could imply. We find that a harm-reduction approach is morally defensible and potentially provides a viable escape out of the impasse resulting from the impossibility of attaining the eradication of doping. The following question remains to be answered: Would a more relaxed position, when combined with harm-reduction measures, indeed have less negative consequences for society than today9s all-out antidoping efforts that aim for abstinence? We provide an outline of an alternative policy, allowing a cautious step-wise change to answer this question and then discuss the ethical aspects of such a policy change. (shrink)

Harm reduction has been advocated to address a diverse range of public health concerns. The moral justification of harm reduction is usually presumed to be consequentialist because the goal of harm reduction is to reduce the harmful health consequences of risky behaviors, such as substance use. Harm reduction is contrasted with an abstinence model whose goal is to eradicate or reduce the prevalence of such behaviors. The abstinence model is often thought to (...) be justified by ‘deontological’ considerations: it is claimed that many risky behaviors are morally unacceptable, and therefore that we have a moral obligation to recommend abstinence. Because harm reduction is associated with a consequentialist justification and the abstinence model is associated with a deontological justification, the potential for a deontological justification of harm reduction has been overlooked. This paper addresses this gap. It argues that the moral duty to protect autonomy and dignity that has been advocated in other areas of medical ethics also justifies the public health policy of harm reduction. It offers two examples—the provision of supervised injection sites and the Housing First policy to address homelessness—to illustrate the argument. (shrink)

Despite the promise to save every life, the COVID-19 pandemic has exposed social and racial inequalities, precarious living conditions, and engendered an exponential increase in overdose deaths. Although some lives are considered sacred, others are deliberately sacrificed. This article draws on the theoretical work of Foucault and scholars who further developed his concept of biopolitics. While biopolitics aims to ameliorate the health of populations, Foucault never systematically accounted for the unequal value of lives. In the name of saving the biological (...) lives of people who use drugs (PWUD) during the pandemic, the harm reduction movement has emphasized the need for safe supply, decriminalization, and housing; governments have started implementing these measures, which were previously rejected as utopian and unrealistic. Paradoxically, the use of drugs itself, and therefore the increased risk of death from overdose or other medical sequelae, is the only way PWUD can achieve enough visibility to be recognized as a life worth saving. The humanitarian rationale of harm reduction concerns itself with the biological life and stipulates social and political rights in the name of its sacredness. This is what anthropologist Fassin and others called biolegitimacy—the recognition of life reduced to its physiological, biological essence. (shrink)

Unrepresented patients are individuals who lack decision makingcapacity and have no family or friends to make medical decisions for them. This population is growing in number in the United States, particularly within emergency and intensive care settings. While some bioethical discussion has taken place in response to the question of who ought to make decisions for these patients, the issue of how surrogate medical decisions ought to be made for this population remains unexplored. In this paper, we argue that standard (...) applications of surrogate decision making principles in health care are not well suited to many unrepresented patients with long-term mental health diagnosis. We argue that when applied to this population, the substituted judgment standard, designed to preserve patient preferences and values, may lead to the exclusion of their preferences. We argue further that the application of the best interest standard runs the risk of leading to harmful cases of overtreatment or undertreatment. We offer an alternative interpretation of the best interest principle that is better able to promote the well-being of unrepresented patients, especially for those who lack capacity because of mental disorders. This alternative is based on the practices and principles of harm reduction and includes three components: emphasis on considering the expressed preferences of unrepresented patients, a focus on reducing harm as well as the delivery of clinical benefits, and a recognition of the importance of promoting trust. (shrink)

Around a third of men worldwide are circumcised. It is probably the most commonly performed surgical procedure. Circumcision is also one of the oldest forms of attempted human enhancement. It is and has been done for religious, social, aesthetic and health reasons.Circumcision has a variety of benefits and risks, many of which are discussed in this issue. There is some dispute about the magnitude and likelihood of these benefits and risks. Some argue that the risks outweigh the benefits and circumcision (...) should not be performed on children who are not competent to make their own decisions.If the risks of circumcision clearly outweighed the benefits, great harm has been done and is being done globally through this procedure. Around a third of all men would have been harmed. This is an extraordinary public health injury. Presumably, many would be entitled to compensation.The fact that relatively few people think that the situation is as bad as this indicates that most people implicitly believe that circumcision is not generally a significant harm, if a harm at all. One might thus conclude either that: It is not clear from existing evidence whether the risks of properly performed circumcision outweigh the benefits, or vice versa.Or 2. If circumcision is against the interests of an infant or young child, it is only mildly so.In general, people should make their own decisions about body modification and human enhancement when this is possible. Such an approach speaks in favour of waiting until a child becomes an adult to make his or her own decision about circumcision. And procedures which are not clearly in a child's interests should not be performed on that child. However, religious …. (shrink)

As resident physicians practicing Internal Medicine in hospitals within the USA, we are confronted on a daily basis with patients who wish to leave the hospital floor to smoke a cigarette. While many physicians argue that hospitals should do everything in their power to prevent patients from smoking, we argue that a more comprehensive and nuanced approach is needed. In part 1 of this perspective piece, we outline the various forms of smoking bans in hospital settings, applauding the development of (...) indoor smoking bans while questioning the move towards stricter, campus-wide smoking bans. In part 2, we turn to traditional biomedical ethics to guide our approach to the hospitalised patient who smokes. This approach, which is informed by our backgrounds in harm reduction and medical anthropology, takes into account the lived realities of patients and acknowledges the complicated sociohistorical contexts of tobacco use. (shrink)

In a reply to Ross, I argue that, as head injuries often lack external indicators, it is imperative that youth-patient-athletes themselves be convinced to report these injuries. Parents, although part of the pediatric triad, will be no help if the adolescent chooses to conceal the information from them as well. Further, I explain why a more deliberate focus on the role of parents in this relationship does not alter my support of the compromising interpretive model as a harm (...) class='Hi'>reduction strategy. (shrink)