The place of supervised injecting facilities within harm reduction: evidence, ethics and policy

Supervised injecting facilities (SIFs) are commonly defined as legal facilities that enable the consumption of pre-obtained drugs in an anxiety- and stress-free atmosphere under hygienic conditions (Broadhead et al. 2002; Green et al. 2004). While there are now more than 60 SIFs and variants in operation across a number of countries, with a wealth of European experience (for reviews see Dolan et al. 2000; Kimber et al. 2003a; Hedrich 2004), the completion of what is regarded as the world's first comprehensive SIF evaluation trial in Sydney, Australia (Kimber et al. 2003b; MSIC Evaluation Committee 2003; van Beek et al. 2004) and the well-documented progress of similar research in Vancouver (Wood et al. 2004; Kerr et al. 2005), the precise impact of SIFs and the question of the status of the evidence remains unclear. The need for realistic expectations about what SIF outcomes are observable in light of the considerable practical and methodological challenges in SIF trials has been noted (Bammer 2000; Hagan 2002; Hall & Kimber 2005). While evidence is important in public health, as shown by the growing focus on ‘evidence-based’ policy and practice in all areas, we need to be critically aware that what constitutes ‘evidence’ is usually disputed. Further, much less has been said about the ways in which we frame SIFs and assess their value, and what place these considerations have in harm reduction policy and practice generally. In this sense, in the SIF example we can see the hallmarks of a harm reduction approach that has come to prefer technical evidence and professional expertise (in the context of ‘scientific trials’ and ‘medical supervision’), and focuses less explicitly on values and ethics, and the political aspects of consultation and participation in policy development (Hathaway 2002; Fry et al. 2005). In areas of controversial public policy, offering the ‘value-neutral’ perspective of technical experts focused solely on evidentiary issues is not enough. Silence on the political and ethical dimensions of the policy debate, especially where the available evidence is limited and equivocal, can mean that ‘evidence’ becomes a less important issue within policy debates, where dominant interests are also expressed in public opinion (e.g. in the media), through lobby groups, and in partisan politics. In this environment, powerful groups can easily obtain or misrepresent evidence for their arguments. Evidence therefore is necessary, but not sufficient, as the differential policy outcomes across jurisdictions attempting to implement SIF trials shows (e.g. failed attempts to establish SIF trials in the Australian cities of Melbourne and Canberra). By focusing too narrowly on evidential questions about SIF impact, we miss an opportunity to engage with the ethical issues and value questions that are also important in public policy. As a humanitarian approach, harm reduction should be able to articulate and debate the moral and ethical basis of SIF trials (and indeed harm reduction policy, research and practice more generally), and not bypass these issues or assume them as self-evident. A central ethical issue for harm reduction that is especially relevant in the case of SIFs is the tension between the notion of an individual right to use potentially harmful drugs and the State's and community's right to prevent or interfere in this. As some commentators have noted, it is not always clear, even in harm reduction, what form this individual right might take (Hunt 2004, 2005). Is it a right to use drugs only in the manner determined by public health experts? Or is there such a thing as autonomous drug use? Which SIF models (medical or low threshold) best accommodate this? These ethical questions deserve further attention in harm reduction. Important ‘microethics’ questions also exist around the daily operation of SIFs and in their evaluative trials (Fry 2003). These applied ethical issues (e.g. maintenance of client privacy and confidentiality, consent in the case of intoxicated clients, staff role boundaries and duty of care in the case of self-harm through injection) may be considered by some as second-order compared to other clinical and empirical concerns. However, it is through reflecting on and discussing our responses to such issues that it is possible to gain a greater understanding of core values in operation, and opportunities to enhance our current practices (Guilleman & Gillam 2004). The teams involved in SIF operation and evaluation are sure to have encountered a host of interesting ethical challenges in their work. Dissemination of these experiences would be a welcome addition to the rapidly growing SIF literature. Rather than committing us to a punitive moral stance on drugs, discussing the ethical underpinnings of harm reduction can help directly to confront this perspective (Fry et al. 2005). A strict focus on evidence in the SIF policy debate also opens up the possibility for these interventions (if argued for and supported successfully) to be implemented in a manner that is counter to that promised by the usual liberal democratic policy rhetoric around consultation, participation, and evaluation—i.e. impartial and transparent policy processes that are open to autonomous individuals. In an important recent paper, Fischer et al. (2004) suggest in relation to SIFs that ‘little attention has been given to their implications as a substantial shift from the punitive repression of injection drug use (IDU) to the government of drug use as a form of regulated risk consumption and socio-spatial ordering under the guises of public health’ (p. 357). The point is, this policy shift may not displace more punitive measures, but incorporate these in the overall governance (i.e. regulation or control) of drug users, drug use and the associated harms through SIFs. Thus, in this context, drug users who refuse to submit to the tight rules and regulations of SIFs may be excluded from these sites and targeted with harsher measures than originally in place (e.g. saturation policing proximal to new SIFs). Again, by bypassing this political dimension of the SIF issue (and related ethical questions), we sidestep the frameworks through which these issues may be addressed most effectively. Supervised injecting facilities occupy a potentially important place in harm reduction policy and practice in those jurisdictions that have secured community, legal and political approvals for implementation. In addition to representing an opportunity to gather data on operation and outcome variables, with SIF trials also comes a responsibility for harm reduction practitioners to consider a wider set of issues. Our most pressing obligation in relation to the new frontiers of harm reduction is to consider and discuss first the ethical, social and political dimensions of proposed programs and interventions, and in so doing seek the value perspectives and participation of all groups whose interests are affected. In theory, this requires that we allow for the notion of community expertise (in this case drug users and user representative organizations) on its own values and interests as authority in relation to planning and implementing harm reduction innovations. In practice, it requires that ethical and political dimensions be considered explicitly and as equal alongside evidential issues at every stage of a new policy initiative. We are grateful to Nick Crofts for comments on an earlier draft, and Griffith Edwards for editorial input. The opinions expressed by the authors are their own.

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