Opioids & The Ethics of Harm Reduction

Start with Safe
Jesse Harvey, the founder of the Church of Safe Injection, gives out naloxone to anyone in need of it outside of his parked car near Kennedy Park in Lewiston, Maine. (Brianna Soukup / Portland Press Herald via Getty Images)

Jesse Harvey describes himself as “in recovery.” He has been involuntarily committed five times for substance-abuse disorders—principally addictions to methamphetamine, alcohol, and tranquilizers. He has also used opioids, though he is not addicted to them. He tried to commit suicide before his third involuntary commitment. The treatment facility in Pennsylvania summarily discharged him onto the street with no follow-up plan. Just recently, Harvey relapsed again, was arrested, and checked himself into another treatment program.

The road to recovery is rocky and long. Harvey, who is twenty-seven and lives in Portland, Maine, claims the reason he’s not dead is that he’s had access to sterile syringes and needles and fentanyl testing strips. In 2016, after his fifth involuntary commitment, Harvey founded the nonprofit Journey House, which now oversees four recovery houses in Maine. He became a state-certified recovery coach. He also began distributing, out of the back of his car, sterile syringes and needles, tourniquets, alcohol swabs, fentanyl testing strips, biohazard disposal bins, and the opioid “antagonist” naloxone. It is illegal to distribute syringes in Maine unless one does it under the auspices of a needle-exchange program certified by the state’s Centers for Disease Control. There are only six such programs. According to the National Institute on Drug Abuse, Maine had 360 overdose deaths in 2017, which came to a rate of 29.9 deaths per 100,000 people—well above the national average. Harvey operated his uncertified needle exchange as part of another nonprofit he founded in 2018, the Church of Safe Injection (CoSI), which has a board comprised of clergy, physicians, nurses, counselors, people in recovery, and people who use drugs. The police in Portland decided to turn a blind eye when Harvey made his distributions there, but the police in Lewiston threatened him, albeit politely, with arrest.

CoSI is dedicated to what Harvey calls “the harm-reduction gospel” and has as its foundational belief that, as he put it in an interview with me, “people who use drugs don’t deserve to die, especially when we have decades of evidence-based solutions.” As its name suggests, CoSI advocates for safe-injection sites, also known as supervised injection facilities, as one of those solutions, along with needle exchanges. Fundamentally, safe-injection sites, of which there are around a hundred worldwide, aim to keep people who use drugs alive in the hope that they might eventually seek treatment. CoSI, which currently has twenty chapters across nine states, does not itself operate a safe-injection site—they are illegal under U.S. federal law—but one of Harvey’s aims for the organization is “to leverage our collective First Amendment right to gain protection against counterproductive drug laws.” He has sought legal advice and has a letter to the Drug Enforcement Administration ready to go. According to Harvey, the U.S. government’s “war on drugs” is “oriented toward killing drug users.” Stigmatized as addicts or junkies, they are cast aside as human trash whose lives are not worth saving. Harvey knows this from experience.

Harvey is a provocateur. Though soft-spoken, he’s not averse to publicity—he and CoSI have been the subject of stories by NBC, NPR, and Huffpost—and he acknowledges that he is drawn to guerilla-theater tactics. He likes to cite Matthew 5:10, “Blessed are they who are persecuted for the sake of righteousness, for theirs is the kingdom of heaven,” and he calls naloxone CoSI’s sacrament. Harvey is also, however, morally serious. Commenting on Matthew 5:10 (with an eye to Luke 10), he wrote me that he is “sure we will be judged not by how many politicians and bureaucrats we mollycoddled or placated, but by how many times we did the right thing when we had the opportunity to, when we acted as the Good Samaritan when nobody else would.” He cites, among his inspirations, Dorothy Day. He hadn’t known of the Berrigan brothers when we first spoke, but later wrote me to express amazement and admiration that Daniel Berrigan had been arrested for civil disobedience at least 250 times. (I should add here that Harvey is a 2014 summa cum laude graduate of King’s College, where I teach, though he was never my student and I did not meet him until 2019. It also should be noted that, after his recent relapse, Harvey is trying to focus more on his own recovery program.)

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A branch of Catholic Charities in the diocese of Albany, New York, has been operating a needle-exchange program called Project Safe Point since 2010, so harm reduction is not unknown in Catholic health care. Nevertheless, such programs remain both rare and controversial—there are fewer than two hundred of them in the whole country.  This is partly because they may not be supported with federal funds. One of Project Safe Point’s directors told me that their program was launched in anticipation of the second wave of opioid addiction, when deaths from abuse of prescription drugs were compounded by deaths from abuse of heroin. Predictably, Project Safe Point generated a blizzard of commentary when it was announced a decade ago, as did the 1999 announcement of a safe-injection site that the Sisters of Charity planned to run at St. Vincent’s Hospital in Sydney, Australia. That plan had to be abandoned after the Vatican’s Congregation for the Doctrine of the Faith warned the Sisters of Charity that operating a safe-injection site was “extremely proximate material cooperation in the grave evil of drug abuse.”

And there lies the heart of the controversy over both needle-exchange programs and safe-injection sites. Do such harm-reduction strategies enable and even encourage drug abuse? When I asked Jesse Harvey whether he has any qualms about his work, he told me that he did find it hard to read the NPR story about CoSI. There a man is characterized as “conflicted about whether getting these supplies makes it easier for him to use drugs.” Harvey quickly added that “the science demonstrates” that people don’t use drugs, or use more drugs, because of needle-exchange programs. Still, he acknowledged that it’s difficult to keep the science in mind “when you’re handing someone a needle.”

Pope Francis has famously likened the Roman Catholic Church to “a field hospital after battle.” He added, “It is useless to ask a seriously injured person if he has high cholesterol and about the level of his blood sugars! You have to heal his wounds. Then we can talk about everything else.” Over the past year, the church in the United States has itself become one of the walking wounded, especially here in Pennsylvania. In the wake of this latest annus horribilis, it hardly needs repeating that the church’s moral authority has been deeply compromised. But the church would not be the body of Christ in history if it turned in on itself and gave up on its healing mission. How, then, should Catholics think about needle-exchange programs and safe-injection sites? Should Catholics join CoSI, and others, in advocating for and seeking to implement such harm-reduction strategies? Meeting Jesse Harvey raised those questions for me.

 

It is all but impossible for some people addicted to opioids to give them up all at once: they need to keeping taking the drug just to function.

Before one assesses the arguments about needle-exchange programs and safe-injection sites, it helps to know some basic facts. First, there are the facts about the opioid crisis itself. Is there a family that has not been affected? According to the Centers for Disease Control (CDC), more than 700,000 Americans died from a drug overdose between 1999 and 2017; nearly 400,000 died from overdosing on opioids. The number of deaths from opioids increased dramatically from 1999 to 2017. In 2017, around 68 percent of the 70,200 drug-overdose deaths involved opioids. That’s an average of 130 deaths caused by opioid overdoses per day. In 2017, drug overdose was, incredibly, the leading cause of death for people under the age of fifty-five. A recent study commissioned by the New York City Department of Health and Mental Hygiene observed that “someone dies from a drug overdose in New York City every seven hours, and more people died from overdose in New York City in 2017 than from suicide, homicide, and motor vehicle accidents combined.” And these are just the numbers for overdose deaths; they do not indicate the full extent of the damage—the lives ruined, families devastated, communities broken by opioid abuse. It’s estimated more than 650,000 Americans are addicted.

The CDC distinguishes three waves in the rise of opioid deaths. The first began in the 1990s with increased prescription of opioids like Purdue Pharma’s OxyContin; the second began in 2010, with rapid increase in the abuse of heroin; and the third began in 2013, with the circulation of deadly synthetic opioids like fentanyl. The New York City study attributes that city’s dramatic increase in overdose deaths since 2014 to fentanyl. As for the causes of the crisis, the moral theologian Joel Shuman—a colleague of mine at King’s College who spent the last academic year working at Duke University on a project related to the opioid crisis—has argued that several factors must be taken into account. To begin with, since the early 1980s, there has been a trend within the medical professions toward elevating the relief of pain as a goal no less important than the treatment of disease. U.S. residents, Shuman reports, consume 80 percent of the world’s manufactured analgesics, while constituting only 5 percent of the global population. Treating the relief of pain as an end of medicine is not problematic in itself, and, as Shuman observes, under the medical paternalism of old “patients were frequently denied a voice in their care [and] their suffering was frequently ignored.” But consider the social and economic context for this change in the understanding of medical practice. In the consumer capitalism of late-twentieth- and early-twenty-first-century America, the patient has come to be treated more and more like a customer, with “patient-satisfaction scores” determining how much hospitals get reimbursed and doctors get paid. At the same time, health-insurance companies have tried to save money by pushing cheap and addictive opioids instead of more costly, less addictive alternatives, while pharmaceutical companies continued to market opioids aggressively after evidence of their addictiveness became conclusive. Finally, there is the disaster of the war on drugs, which casts addiction as a crime rather than a disease.

Needle-exchange programs and safe-injection sites might seem like counterintuitive ways to counter opioid addiction. They begin to make sense only when it’s understood what opioid addiction does to a person. By definition, addiction involves compulsion, compromising a person’s capacity to make voluntary choices. Opioids flood the body with feelings of euphoria, while suppressing pain. It is no wonder, then, that people with a history of mental illness, trauma, or abuse are at high risk of addiction to this category of drugs. Chronic use of opioids changes the chemistry of the brain, affecting the expression of genes involved in neurotransmission. Users gradually develop greater tolerance of the drug, so that they need more of it in order to get high and to escape debilitating symptoms of withdrawal, including muscle cramping, diarrhea, and anxiety. This makes it all but impossible for some people addicted to opioids to give them up all at once: they need to keeping taking the drug just to function. Unsurprisingly, after the over-prescription of drugs like OxyContin was finally slowed by regulation, the number of heroin overdoses began to spike. When fentanyl hit the streets, people began dying in yet greater numbers.

 

There is nothing theological about the ethics of cooperation, though it was first developed by Roman Catholic moral theologians.

The rationale for needle-exchange programs and safe-injection sites is that some people will inject opioids—heroin or synthetics like fentanyl—no matter how much others plead with them not to do so, or how much those who are addicted hate what they’re doing, or how likely they are to get arrested, or to overdose. Given that people are intent on injecting opioids despite these considerable risks, it might seem there’s a case to be made that providing sterile syringes and needles, and perhaps even legally sanctioned, medically supervised places to inject drugs, is justifiable under the longstanding principle of the lesser evil. Studies have found that people are more likely to share syringes and needles when they fear arrest for carrying drug paraphernalia, and sharing syringes and needles leads to significant risk of contracting HIV, hepatitis B and C, and bacterial infections. As it happens, the diocese of Albany invoked the principle of lesser evil in explaining its decision to establish Project Safe Point. In the commentary that followed, the Jesuit moral theologian James Bretzke, who teaches at Boston College, noted that the diocese was drawing here on the thinking of Thomas Aquinas and went on to say, “When you cannot reasonably expect a person to avoid the moral evil itself, you can counsel them at least to lessen or mitigate the potential damage of their action and can even help them in doing that.”

This is where the controversy starts. While Bretzke can cite authorities like Aquinas and even recent popes like Paul VI and Benedict XVI in support of the claim that it’s morally permissible to counsel and tolerate the lesser of two evils when a person is intent on doing evil no matter what, the claim that is morally permissible to help a person do the lesser evil remains controversial within the Catholic tradition, as Bretzke well knows. Here we cross over into the ethics of cooperation in evil, which introduces a notoriously difficult set of considerations.

A person cooperates with another when she knowingly and freely facilitates the other’s intended action. For example, imagine that the flight instructors of the 9/11 terrorists had known what the men intended to do and freely agreed to provide the necessary instruction. In that case, the flight instructors would have cooperated—impermissibly—in evil. But there are many shades of cooperation, and some of them may be morally permissible. I take the following example from the philosopher Thomas Cavanaugh at the University of San Francisco: A hardware-store owner whose store is by the sea stocks and sells a kind of spray paint that boaters use because it adheres well in a marine environment. The spray paint is also favored, however, by graffitists, who use it to vandalize property. The hardware-store owner suspects—if she is honest with herself, she even knows—that some of her customers buy the paint with the intention of using it for graffiti. She doesn’t stock and sell the spray paint with the intent of cooperating with the graffitists; she disapproves of what they do and wishes there were some reliable way to recognize them before they purchased her paint, but she judges, perhaps correctly, that the good the spray paint does for her other customers justifies the harm it enables the graffitists to do. Of course, if that harm were truly great, she might have to reconsider that judgment. And if she were unwilling to reconsider it, there would be reason to wonder whether she didn’t in some sense share the graffitists’ intent after all.

Cooperation is always blameworthy when the cooperator shares the principal actor’s wrongful intention. This is called formal cooperation: in such cases, the cooperator’s will is shaped or informed by the very same object that the principal actor has in mind. Had the flight instructors of the 9/11 terrorists known what the men intended to do and freely agreed to help, they would have been formally cooperating in evil, and we would have been justified in holding them accountable for what happened. By contrast, the case of the hardware-store owner, as I told it, is an example of what is called material cooperation. In such cases, the cooperator does not share the wrongful intention of the principal actor, but nonetheless contributes materially to the action, here by supplying something that makes the action possible.

Material cooperation may be permissible or impermissible depending on a number of factors. One has to do with the nature of the harm the principal actor intends: the greater the harm, the harder it is to justify material cooperation. If the graffitists were, say, white supremacists who painted words or symbols designed to intimidate minorities and foment violence against them, the hardware-store owner might reach a different conclusion about whether making spray paint available to boaters justified the risk of its being used by graffitists.

Another factor has to do with whether the cooperation is “remote” or “proximate.” Material cooperation is proximate rather than remote when what the cooperator does provides a probable instrument of wrongful use for the principal actor. As the philosopher David Oderberg has remarked, the question here is about “how close the cooperator is, causally speaking, to the primary act itself.” The closer the cooperator’s action is in the causal chain that leads to the principal’s action, the harder it is to justify the cooperation. A final factor has to do with whether the material cooperation is “immediate, ” as opposed to “mediate” or “non-immediate.” It is immediate when the cooperator’s action overlaps with the principal’s action.

Take the following two cases. If I were to agree to drive the getaway car in a bank robbery, I would be formally cooperating in evil. But imagine I “drove with Uber,” as the company puts it, to make a little extra money. Imagine further that I got a call to pick up someone who was escaping from a crime scene, but that I discovered that he was escaping only after he was in the car and we were on our way. There is nothing wrong, in itself, with providing livery service, but what I am doing in this case overlaps with the criminal’s escape. What’s more, it is necessary to his escape, and the more a particular act of cooperation is necessary for the principal action to come to pass, the harder it will be to justify. In this case, the justification for proceeding had better be awfully great: a lot of money wouldn’t do; a threat to my life probably would. Moreover, if I did agree to proceed on the condition of being paid a lot of money, that would make me a formal cooperator, since it could hardly be denied, in the circumstances, that I had come to share the criminal’s intention of escaping. (I wouldn’t get paid otherwise!) By contrast, my proceeding lest the criminal kill me would be an instance of immediate material cooperation under duress. For, in that case, it would not make sense to say that my intention was to help the criminal escape. I would be greatly relieved if the police caught him and saved me!

It is worth pointing out that there is nothing theological about the ethics of cooperation, though it was first developed by Roman Catholic moral theologians who looked back to Aquinas and beyond him to Aristotle. The difficult issues in the ethics of cooperation are philosophical in nature: they are about the meaning of basic concepts we use to try to make sense of ourselves and our world.

 

Safe-injection sites are under consideration or in the works in a number of U.S. cities, including Philadelphia, New York, Seattle, and San Francisco.

The diocese of Albany invoked “the principles of permissible cooperation in evil” when it explained its decision to establish Project Safe Point. The controversy that followed centered on the right understanding of the ethics of cooperation. The controversy over the plan to establish a “supervised injecting room” at St. Vincent’s Hospital in Sydney also centered on the ethics of cooperation. Recall that the CDF warned the Sisters of Charity that operating such a facility would constitute “extremely proximate material cooperation in the grave evil of drug abuse.”

Edward Peters, a professor of canon law at Sacred Heart Major Seminary in Detroit, judged Project Safe Point to be formal cooperation in evil, on the grounds that supplying syringes and needles to people who inject opioids is done with the intent that those people use that equipment to abuse drugs. In a position paper on cooperation prepared in 2013, the National Catholic Bioethics Center in Philadelphia likewise judged needle-exchange programs to be formal cooperation in evil, on the somewhat subtler grounds that it is “impossible to separate [the] intention for [drug users’] good health from the intention that harmful drugs be injected.” Six years later, in 2019, one of the ethicists at the Bioethics Center judged safe-injection sites to be instances of immediate moral cooperation in evil, on the grounds that acts of purchasing and providing sterile equipment to people who inject opioids are of a piece with the act of using the drugs. In 1999, an Australian physician, Joseph Santamaria, made the same argument in the journal Bioethics Research Notes. He even claimed that a Catholic hospital’s operating a safe-injection site would be “similar in kind to providing abortion facilities for an abortionist so that women may have their abortions in a clinically safe environment and in the hope that some women may be deterred from having the abortion or from having further abortions in the future.”

On the other side of the question, the moral theologian Germain Grisez, professor emeritus at Mount Saint Mary’s University in Maryland, was characterized in a 2010 news article on Project Safe Point as holding that “supplying addicts with clean syringes is not necessarily wrong if the intention is to limit the spread of disease.” Grisez went on to claim, though, that the Catholic Church should focus its resources on combating addiction, apparently not realizing that one of the aims of harm-reduction strategies like needle exchange programs is, as Project Safe Point explains on its website, “to develop non-judgmental, meaningful relationships with people who use drugs” and “through these relationships…provide a vital link to the resources people need or want.” Similarly, in 1999, Gerald Gleeson, an ethicist at the Plunkett Centre for Ethics at Australian Catholic University, claimed that “nothing in the establishment of [a supervised injecting room] must imply that those who operate it are in the business of endorsing drug taking as such.” To the contrary, “those responsible for the room can simply be intending that help be available should a person’s life be endangered, and that rehabilitation be encouraged.” In 2017, several ethicists working in Catholic health care in the United States agreed with that judgment in an article published in the Catholic Health Association’s Health Care Ethics USA. There is no reason operators of a safe-injection site could not intend simply to “limit the risk of infection, prevent possible overdoses, eliminate hazardous street waste…. and create an environment” conducive to trust and encouraging of rehabilitation. Providing sterile injection equipment and medical supervision certainly facilitates drug abuse, but it counts, according to these ethicists, as non-immediate material cooperation, which they judge to be morally permissible in the circumstances.

Who is right? To answer this question, we have to consider one more distinction. Traditionally, philosophers have distinguished between effects of action that are intended and effects that, though brought about voluntarily, are not intended but merely foreseen. Let’s return to the example of the Uber driver threatened with death. Does the Uber driver intend to help the criminal escape? It would be strange to say so, even though his driving the car as the criminal directs him to does have the effect of helping the criminal escape. The important point is that helping the criminal escape isn’t what the driver intends. His intention in driving the car as the criminal directs him to is to save his own life, and keeping the criminal satisfied by helping him escape is the means to that end. So helping the criminal escape, though it is undeniably something that the driver does, falls outside his intention. He is not a formal cooperator in evil.

And neither, for the same reason, is the operator of a needle-exchange program or safe-injection site, as long as the operation isn’t corrupt. Drug abuse isn’t one of the ends of these programs; their ends are to reduce infections, save lives, build relationships with the marginalized, and encourage rehabilitation. It is undeniable that one foreseeable effect of both needle-exchange programs and safe-injection sites is to facilitate the use of drugs. But, carefully considered, that effect falls outside the programs’ intention.

Is providing sterile equipment and a medically supervised space so close to the act of abusing drugs that it should be considered immediate material cooperation? I doubt whether the answer to that question matters morally. What seems much more important is how “close” the people who use needle-exchange programs and safe-injection sites are to doing significant harm to themselves—harm these operations exist to reduce. Much as the threat of death in the Uber example mitigates the driver’s blameworthiness, the risk that those addicted to drugs will overdose or contract a life-threatening infection renders permissible an action that would otherwise be immoral. No morally upstanding person would countenance distributing syringes, needles, and the like to people beginning to experiment with drugs. That would simply encourage drug abuse. But the circumstances in which needle-exchange programs and safe-injection sites operate are radically different. Replace the gun at the head of the driver with an infected needle, or a syringe loaded with a lethal dose of fentanyl. Supplying a clean needle and providing medical supervision may or may not be “of a piece” with the injection of drugs, but no one can reasonably claim that these things are done in order to facilitate drug abuse—or done without a very strong reason.

Providing sterile equipment and a medically supervised space does appear to be proximate cooperation, as the Congregation for the Doctrine of the Faith claims. There is no way around the fact that giving someone a syringe and a needle is quite close in the causal chain to that person’s injecting drugs. Likewise, there is no way around the fact that providing someone a legally sanctioned, medically supervised space in which to inject drugs is causally close to his or her doing so. But, again, this doesn’t seem to matter morally in the circumstances. The point to keep in mind is that the people who use needle-exchange programs and safe-injection sites are intent on abusing drugs no matter what. They are in the grip of addiction, with little power to resist. That is the unfortunate reality to which harm-reduction strategies respond. They are acts of charity toward people whose freedom of will has been severely compromised. Part of the grave evil of drug abuse, to use the Vatican’s language, is that it destroys persons as persons: they become more acted upon than agents themselves.

Safe-injection sites are under consideration or in the works in a number of U.S. cities, including Philadelphia, New York, Seattle, and San Francisco, but they still face opposition from the federal and state governments. Even proponents recognize that, as the New York City study states, there is a critical need for “meaningful community engagement and education” to win over skeptics. Scientific studies of both needle-exchange programs and Vancouver’s safe-injection site, which has been operating since 2003, provide evidence that these harm-reduction strategies save lives, decrease infections, and increase the number of people who end up getting treatment. Health-care professionals have already been won over. In 1997, the American Medical Association called on Congress to revoke the ban on using federal funds to support needle exchanges; in 2017, it called for pilot safe-injection sites. Law enforcement officials and politicians have been slower to come around.

There are still a number of practical matters to consider, such as ensuring that harm-reduction programs don’t draw away funds for prevention and rehabilitation, or overburden communities that already host multiple social services. Nevertheless, I’ve come to the conclusion that there is no reason, in principle, to oppose these programs. To the contrary, they are precisely what love of neighbor enjoins in the circumstances. The Catholic Church—meaning lay people as well as the hierarchy—should support initiatives like Project Safe Point and deploy what moral authority we still have to support the basic strategy, if not always the tactics, of activists like Jesse Harvey.

Published in the November 2019 issue: 

Bernard G. Prusak is professor of philosophy and director of the McGowan Center for Ethics and Social Responsibility at King’s College in Wilkes-Barre, Pennsylvania. His books include Catholic Moral Philosophy in Practice and Theory: An Introduction, published by Paulist Press in 2016.

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