The Ethic of Enabling: A Study of Syringe Exchange Programs
Benjamin GayedIn 2004, IV drug use was responsible for about 1 in every 5 cases of HIV and hepatitis C. Intravenous exposure to infected blood products in a previously healthy person is just about the surest way we know of to transmit blood-borne illness. Syringe exchange programs (SEPs) were started in the late 1980s in an effort to reduce disease transmission from the sharing of dirty needles between intravenous drug users. These programs anonymously provide sterile syringes in exchange for used syringes with the hope that drug users will opt for clean needles if they are available.
A CDC report in 2005 summarized the available data on SEPs. Studies of SEP-using populations have shown reductions in disease transmission, no evidence of increased rates of drug use or recruitment of first-time users, improved tuberculosis and sexually transmitted infection screening in typically hard-to-reach populations, and reductions in other risk-behaviours. SEPs are cost-effective as well associated with an estimated at $4,000-12,000 per case of HIV prevented compared to $190,000 medical bills for each HIV-positive patient (as reported in one analysis).
The transmission rates of HIV and hepatitis might also be reduced by forming concentration camps for infected individuals, but most people would hardly consider this segregation appropriate or acceptable. My point being, the means are not necessarily justified by the end. SEPs look wonderful if you think the studies have shown us the whole picture, but it is my contention that the concept of a SEP is troubling when considered more carefully.
SEPs raise an interesting ethical question which I have referred to as the ethic of enabling. Can the provision of goods or services (sterile syringes) useful for unlawful or immoral activities (illegal drug use) ever be considered appropriate when the provider expects the recipient to use the good or service for an act which the provider considers to be unlawful or immoral? Another way of asking this question is whether the means can ever be justified by the end if the means are legal and morally acceptable but knowingly facilitate an action which is not?
As a side note, the legal issues surrounding SEPs have largely been dealt with already. Laws which prohibited distribution of needles by non-pharmacists or that considered syringes as paraphernalia for illegal drug use have been modified in response to this issue, as well as in response to diseases such as diabetes which requires self-injection of insulin on a daily basis. The ethical aspects of these questions remain.
I cannot think of any example in our society where an illegal or immoral activity is either permitted or facilitated for peripheral benefit while still considering the act illegal or immoral when committed. The closest I can imagine is the exemption to laws (traffic for example) granted to law enforcement agents. But we have created laws releasing these individuals from the regulations to which common citizens are expected to adhere when acting as law enforcement agents. So the action in this case has become legal; it is no longer illegal.
Guilty by commission is a term I have heard used in defense of health care provider refusal to provide patients with information facilitating access to abortion providers when the provider does not consider an abortion morally permissible. The health care provider would hold himself equally culpable for the abortion as he holds the abortion provider by providing access to the abortion service and is lawfully protected from offering services which conflict with his values (the exception being in emergency cases where the patient’s life is in imminent danger). In this example, the physician is protected from liability when asked to perform an act he considers immoral. It only serves our SEP example to show that if the act is considered immoral by extension, there is a legal precedent for precluding the act. While I do attempt to make the argument that the provision of syringes for illegal/immoral activity is itself illegal/immoral, it may be worth considering further in the future. Several other analogous situations come to mind for discussion’s sake: legalization of marijuana as an argument for reducing its abuse and passing out condoms to minors at school dances.
In any of these cases, the provision of any good/service/etc which facilitates an unwanted action is counter-productive to any effort to reduce the same action. The legality of heroin and other IV drug use will not change any time soon. With the goal of reducing and eliminating illegal drug use in mind, passing out syringes is not helpful. Even if SEPs have been shown to have numerous benefits including reductions in disease transmission rates, it is illogical to rebuke a person for using drugs while handing them a sterile syringe to facilitate that activity as long as the activity is illegal.
October 23rd, 2007 at 9:49 pm
I’m not sure that the SEP example is such a straightforward issue of the ends justifying the means. Perhaps it’s just a collision of conflicting policy judgments. We have two largely amoral political judgments at work. One says that drugs ought to be illegal; the other says that we ought to reduce medical care costs for indigents. Those policies collide, politicians decide that reducing costs is more important than placing a small barrier in the path of drug use, and the SEP program is created. SEPs don’t suggest that the goal of health is so powerful that it justifies undermining the drug laws; they suggest only that when forced to choose between the integrity of the drug laws and the medicaid budget, the medicaid budget wins out.
Now, torture of terror subjects seems to present a more direct example of the issue you’re getting at. That’s a true moral dilemma for you.
October 23rd, 2007 at 10:30 pm
But at least for me, Jeremy, my opposition to drug use is moral opposition.
If I were a casuist, I would argue that a program of sterilizing needles doesn’t enable the drug use whereas a program of providing sterile needles does, even if the users would easily procure needles anyway.
October 26th, 2007 at 8:05 am
First point: Asking “Does the end justify the means?” seems to me to be sloppy thinking of the kind that can obfuscate an otherwise clear conversation. In most cases, the answer usually is: of course it does. If my student repeatedly doesn’t do his homework, I give him a paragraph to copy 30 times in order to teach him the importance of doing his homework through doing useless work for an hour (or more, if he doesn’t finish the task by the end of class). The end is his learning to do his homework, which justifies the means of useless copying. And there are many such situations. The question is not, “Does the end justify the means?” — if it were, then Jeremy’s torture example might not be as much of a moral dilemma. The question is, “Does the end justify ANY means?”
Second point: From a public policy perspective, I think Jeremy has the better point. Policy is not just about conflicting moral perspectives — which is what Adam is talking about. It’s about conflicting budgetary priorities, and conflicting bureaucratic priorities, and conflicting personalities, and many other various and sundry things. We can say “I morally oppose SEPs”, but someone else can say, “Well, I oppose swelling the Medicaid budget by 30%, which is what will happen if you stop the SEP and addicts use infected needles and spread HIV/AIDS and Hepatitis C.”
Public policy is more often than not made without clearly thought-through goals in mind — and you’re as likely to see people with a solution shopping around for a problem to justify it as you are to see people earnestly seeking solutions to agreed-upon problems. Given that situation, it’s not at all unlikely that people wouldn’t really consider whether or not they’re enabling addiction through SEPs when they approve them. There’s the justification — which is what Jeremy’s referring to — and then there’s the end result — which is more of what Benji’s discussing. But the one does not necessarily contemplate the other.
October 26th, 2007 at 10:03 am
Paul, there is no problem with the way Benji asked the question. Whenever anyone talks about an “ends justifying the means” problem, it is in the context of a particular example and implies “Does this end justify this means?” Restricting the question to “Does this end justify ANY means?” is a special case of Benji’s question. Benji asks if the sum of the effects of SEPs is positive, and you ask if there is an end that is so good that the sum of effects of any means which achieve that good is positive. The ends justifying the means question usually boils down to the question, “Are we ignoring some significant effects in our sum which would change our resulting conclusion?” We can easily show some positive effects by crunching the numbers and restricting ourselves to monetary concerns. In that case, SEPs look like a no-brainer. But there are more than just monetary concerns to consider when you are measuring the sum of effects of a program or an action. What are the moral effects? What are the psychological effects? If you ignore these effects and they happen to be significantly negative, then you can seriously damage your society.
October 27th, 2007 at 11:48 am
Thanks for the responses. I have learned already.
First: To Jeremy, I see your point, and I agree.
Second: To John, thank you for responding to Paul’s comment more concisely and clearly than I might have.
I find that John’s comment hits the mark as far as my question is concerned, and I am content with Jeremy’s answer. In other words, I am content calculating what we can calculate in terms of the impact of SEPs, starting with money and estimating the less quantifiable effects, and moving ahead with the conclusion that the greatest effect of SEPs will be to free up resources for state. Of course, this assumes the amorality of these policies.
Adam’s comment raises another question. Adam, I would love to hear on what grounds you are morally opposed to SEPs.
October 27th, 2007 at 11:50 am
What I meant to ask was, what is your moral opposition to drug use?
November 5th, 2007 at 8:21 pm
much of public health theory, i find fundamentally amoral and motivated by a thoroughly secular anthropology. (i reject medicine which is amorally motivated. for what benefit a man if he gain a disease-free world, but forfeit his soul?) man is primarily an animal acting on his instincts, and our goal is to maximize health for the species, rather than establish redemptive relationships with individuals. as c.s.lewis said in some article, either the species as a whole is an eternal entity, and individuals are creatures that die, or the species is a creature that dies, and indviduals eternal beings. historically, medicine has been motivated by the latter set of assumptions.
in this question, i believe we are helped by the action theory of St. Thomas Aquinas:
for an action to be morally acceptable, all of its causal components must be good. These components reflect the four Aristotelian causes.
1. Material causes don’t factor much, since there’s no instrinsically evil substance. Every true action has being, and existence is dependent on goodness. So not even contaminated needles, as existant objects, are intrinsically evil. Nor is ethanol, or any ’substance’ for that matter.
2.Formal causes of ethical actions are called the objects of actions. It is wrong to ‘take what belongs to another’. Those who overemphasize this aspect are called moral legalists.
3. Efficient causes are analogous to circumstances. Those who overemphasize this aspect are called moral relativists. But clearly, this is one critical aspect of any good action. The virtuous man acts when he should, where he should, and so in respect of other circumstances.
4. Final causes are analogous to intention, or the ends. Those who overemphasize this aspect are moral subjectivists, such as Kant. But the good in view of which one acts is not always a true good; sometimes it is an apparent good.
Clearly, the provision of condoms in Africa, and needles in the USA, errs on the side of both moral subjectivism and relativism, and abandons the objective species as a necessary component of any action. Ben’s clear thesis was whether it is immoral to participate in such programs. The issue of saving medicaid dollars does not factor into this question. As Ben has said himself, there are limitless immoral ways to save money.