The Pharmaceutical Journal
Vol 269 No 7211 p214
17 August 2002

This article
Reprint
Photocopy

PDF* 35K

Are needle exchange schemes ethical?

By Philip Bates

The concept of needle exchange was first introduced in Amsterdam in 1984 as a pragmatic answer to the risks of HIV and hepatitis in intravenous drug misusers who share injecting equipment. The philosophy is that if other drug policies cannot stop the misuse of drugs at least the risks to users and the public can be reduced. Needle exchange is an example of a public health measure, not only to manage harm in the individual, but as an intervention that targets one group to protect the rest of the population. It operates in many pharmacies in the United Kingdom, there are guidelines for practice and it is funded by local National Health Service trusts. The code of ethics for pharmacists states: "at all times pharmacists must act in the interests of patients and other members of the public and seek to provide the best possible health care for the community ...". This statement embraces elements of public health and should include drug misusers as patients. Pharmacists should therefore consider their own ethical justification for providing a needle exchange service.

In the UK there was initial opposition to needle exchange and from 1982 to 1986 the Royal Pharmaceutical Society advised pharmacists that it was not ethical to be involved in the supply of needles or syringes to known drug injectors. In the United States, a public health and ethics debate is still raging on whether science shows that needle exchange works and whether it condones drug abuse, and vital funding and research for needle exchange was prohibited by the Surgeon General in 1995 until it was proven to be effective. There is presently a polarisation between the pragmatists who believe needle exchange benefits overall public health and those that oppose both its effectiveness and its ethics.

Opposition

Opponents of needle exchange do not agree that it is harm reduction because addicts are not responsible enough to use clean needles and dispose of them properly, which only exacerbates the public health risks. The case against needle exchange was strengthened by studies in Canada that suggested that it increased, rather than decreased, the frequency of HIV and hepatitis in intravenous drug users.

The perceived danger of introducing needle exchange in some circumstances is that the availability of clean equipment may promote a transition from non-injected to injected drugs in the drug-taking population. Opponents argue that it is unethical because illegal drug use is perceived to be wrong and should be discouraged at all costs. Instead, other treatment and advice should be provided to help people to stop using drugs and the force of law applied if they do not.

Research into the effectiveness of needle exchange is confounded by the often unpredictable behaviour of drug users and this has been recognised by the authors of the Canadian studies. The authors of one study admit they may have inadvertently selected "riskier" users for needle exchange and in conclusion do not reject needle exchange, only say that it should be "fine-tuned" to fit into the specific community. However, opponents use the results of these studies to support their own moral stance. Until there is irrefutable evidence that needle exchange reduces the incidence of infectious disease in drug users, it will always be criticised on ethical grounds, and probably still even then.

Advocates of needle exchange point to evidence that suggests infectious disease in intravenous drug users has decreased in cities with schemes while recognising factors that confound the data. With good evidence, needle exchange can be ethically defended on the grounds of utilitarian consequentialism: the rightness or wrongness of an action is judged by the consequences resulting from that action and the overall sum of the positive consequences outweighs the possible risks and concerns. However, the scientific evidence is not as strong as it could be. The ethical question arises of how strong the scientific evidence must be to overcome the concerns of needle exchange, or is the perceived need in itself justification enough? The introduction of needle exchange in Amsterdam was justified at the time because the predicted AIDS epidemic was a potential public health emergency which overrode any possible ethical concerns. Therefore, despite any ethical misgivings of condoning drug use, it is ethically justified on the basis that it reduces harm to drug users, protects the rest of the community and assumes it does not make the drug situation worse.

However, seeking irrefutable evidence is complicated by the other unsafe practices that drug users might participate in, such as sharing drug preparation equipment and risky sexual behaviour. Without needle exchange, contaminated needles would still be found discarded in public places but would pose an even greater risk than if needle exchange schemes were operating since the discarded needles are likely to have been shared by more users. It could be argued that needle exchange imposes a code of behaviour or ethics on the drug user to use needles responsibly in the same manner as condoms are used for safe sex.

When there is insufficient money in the NHS available to pay for every drug and surgical procedure, is it ethical to use funds to provide drug addicts with the means to inject? Needle exchange may be justified on economical grounds if drug users are predicted to have a reduced chance of contracting, and therefore requiring expensive therapy for, hepatitis and AIDS. It may be questioned whether drug users merit an equal claim to the resources available as a person who leads a healthy lifestyle and falls ill as a result of events out of their control. Does someone who places dependence on a drug above all else deserve the same human rights as someone who has respect for themselves, the community and the environment in which they live? Should the individual be responsible for protecting their own health and that of others, or is it the responsibility of the state? Abstinence from drugs is a high moral standpoint but opponents of needle exchange are judging drug users by their own virtues and probity. How different is needle exchange to prescribing nicotine replacement products to smokers? Drug users have a right to protect themselves and others from disease and the ethics of public health oblige us to provide needle exchange.

Pharmacy involvement

There are concerns about whether it is appropriate to operate needle exchange in the setting of a pharmacy, instead of restricting all services to a drug treatment centre. A concern of pharmacists is that drug misusers attracted by a needle exchange scheme may shoplift, deal in drugs and offend other customers. It may be considered unethical to mix the proper medicinal use of drugs with any association with their misuse, and pharmacists should be the last people appearing to condone illegal drugs.

The use of "safe" acids such as citric acid or ascorbic acid to dissolve heroin before injecting is recommended by harm reduction campaigns. Under the same principle that pharmacists provide needle exchange, it should then follow that it is also ethical to sell these items to drug misusers. This may be a step too far and promote drug injection to the point that pharmacies become "sweet shops" for drug misusers. In favour of pharmacy involvement is the fact that drug misusers can visit a pharmacy that is local to them where the pharmacist can be a source of advice and support.

Public health and ethics inevitably clash when the people who decide public health policy have different ethical values and when opposing sides claim their idea of public health is ethical. Public health policy makers have an ethical duty to improve the health of the population, which includes those who may be socially discriminated against such as drug users. Ethics in public health today is more than just about utilitarian principles. An ethics framework for public health should retain the traditional aims of public health to improve the health of populations while respecting individual autonomy and justice by clearly identifying the benefits and burdens of an intervention and ensuring that it is fair and acceptable.