Families and Friends for Drug Law Reform

committed to preventing tragedy that arises from illicit drug use


ETHICS AT THE AUSTRALIAN DRUG SUMMIT 2000: A REVIEW

by

William Bush

(November 2000)

[Father Dr John I. Fleming, "Drugs and Ethics" & Dr Gregory K. Pike, "Risk Compensation, Needle Exchanges and Bioethics" being papers presented at the Australian Drug Summit 2000 at Parliament House, Sydney 13th Ц 15th June 2000 at http://www.wesleymission.org.au/drugsummit/day1.htm]

Fr John Fleming and Dr Greg Pike of the Southern Cross Bioethics Institute in Adelaide have done a valuable service in presenting in June two papers on ethics and the drug debate at the Australian Drug Summit 2000 in Sydney. The controversy raging in the community on drug policy illustrates the truth of the observation of Alasdair MacIntyre that "we lack . . . any public, generally shared communal mode . . . for putting our politics to the philosophical question." Those such as myself associated with groups advocating "harm minimisation" were not invited to the Summit 2000 but the want of meaningful dialogue about the ethics of drugs goes much deeper than that. There is an incoherence: a babble of people talking past each other. The Prime Minister has couched the provision of drug treatment in terms of "mutual obligation" but, in the absence of an agreed approach to the analysis of the respective duties (and rights) of both the state and the user, the phrase is no more than an opaque statement of political principle.

Those who advocate a drug free society and oppose "legalisation" and the "normalisation" of drugs frequently appeal to morality. The opposing "harm minimisation" camp is inclined to be impatient of "moral" argument believing that the reduction of misery and pain is a self evident justification. There is thus much truth in Fr FlemingТs observation: "That the use of drugs for purely hedonic purposes may be wrong in itself is given little serious consideration. All that remains is the moral requirement to reduce misery and pain." My sense is that this emphasis flows from the imperatives confronting families and carers of the addicted rather than any civil libertarian belief in entitlement to indulge in drugs.

Even so, Fr Fleming is right. We must as a society seriously address our ethical approach to the consumption of drugs for we are engaged in determining a communal response. After all we have a legal regime that incorporates prohibition. Some see this regime as productive of many other extremely serious harms€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€?рррр€р?р?р?рррр?р?ррр?р?р?р?р?р?р?рррррр?р?ррр?р?р?рррррр?р?рррр€ррр€р€ррр?р?ррр?рррррррррр?рррррр€рррр?р€р€р€рр€р€р€р€р€р€р€р€р€рррррррррррррррррррррр?рррррррррррррр€у€срррррррррррррррррррррррррррр€€00рррр€рррррррр?ррр?рррр€рр€€рррррр00рррррррррррр0рррррррр?ррррррррр€рр€€€€р?рр€с€€€€€€€€€€€срррр€€€€€€€€€у€с€сѕ€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€?А€€€€€€ј€€€€€€?А€€€€€€€€€€€€€€€€€€€€€€€П?А€€а€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€гё€€€€€€€г€€€€€я€гјш€€р€cјјјјјјјј@€€ј€г€г€г€€€€€€€€€€€€€€@€€€€а_€€€€€€€€€€€@€€€€€€€€€€€€€€€Г€€€€€€€€€€€ю€€€€€€€€€€€€€€€€€€€€ю€€€€€€€€€€г€€€ью€ч|€€€€€€ш€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€?ш€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€ш€€€€€ѕ€€€€€€€€€€€їю€€€€њюѓ€ѓА€€€€ѓ€€€ыхыы€€ы€€€ш€щю€€Я€ч€ч€њ€€€€ычэп€€€€Р€€р€€€€а€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€чрр€чя€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€lustration, are not wrong in principle. The "stated intention of the programme is to reduce the transmission of infectious disease, and encourage addicts into treatment" and it is unlikely that anyone running it "actually intends that clients use illegal drugs". Where he believes that the programme is probably unethical is that it seems to involve "material cooperation in wrongdoing". This, he writes, "depends on the acceptability of side effects." He rightly judges the issue of side effects to be at the heart of the debate about harm minimisation.

Important ethical questions are whether the various side effects are themselves undesirable and how they rank in gravity. In the public debate, saving of lives from drug overdose deaths is cited as the greatest expected benefit of harm minimisation measures like injection rooms. For some, though, the saving of lives of users would not be a sufficient justification for such measures if, as they assert, the measures would either prolong drug use or encourage others to use. For example, an ACT politician who vetoed the trial of a medically supervised injecting room in Canberra responded on ABC radio that he was not worried that such rooms were likely to save lives. Likewise, Mr Paul Brazier of the Australian Catholic Advocacy Centre seemed to concede that supervised injecting rooms "might save lives", but adds that: "The ChurchТs moral stance can only be understood in light of its supernatural nature and its concern not only with saving peopleТs lives but saving their immortal souls" (Courier Mail, 1/11/99, p. 15). Mr Tony Abbot, the federal Minister for Employment Services, opposes injecting facilities because people who are on drugs are virtually dead anyway. These positions are difficult to reconcile with the overriding importance in other contexts of preserving life, including the life of those who may be in a coma or suffering from senile dementia.

As Dr PikeТs paper illustrates in the context of needle exchanges, controversy abounds in the assessment of side effects. Empirical issues have prominence in this aspect of the drug debate. He makes the incontrovertible point that "reliable information is essential for a complete examination of the ethics of needle exchanges" just as it is for the assessment of other measures. Uncertainty is the main stumbling block. At issue is much information within the realm of the social sciences where scientific proof is notoriously difficult to come by. Whether needle exchanges actually promote drug use, as Dr Pike suggests, is one such question. There are uncertainties also within the biological sciences including the effects on the body of marijuana.

Ethical decision making cannot be left in limbo pending the attainment of certainty. Dr Pike recognises the importance of evidence falling short of proof: "Ethics does not exist in abstraction from the evidence, however, even with limited evidence, it brings a valuable perspective to the debate." As a doctor in physiology he would be well aware of the importance of assessing the weight to be given to evidence. It is undesirable to base action on a mere possibility rather than a reasonable likelihood as determined by those with the technical knowledge that allows them to make an informed assessment of the evidence. The process is part of standard scientific method.

Whether because of emotions surrounding drugs, political sensitivity or otherwise, this process is often derailed when it comes to empirical questions of relevance to drug policy. For example, it is often said that interventions like medically supervised injecting rooms should not be trialled because there is no proof that they will save lives. The Prime Minister used a similarly invalid argument when rejecting renewed calls for a trial of heroin prescription after the release of the report of an expert panel to assess the result of the Swiss heroin trial. The panel acknowledged that the trials produced a large reduction in deaths and crime and improved the health and social integration of the patients but found, because of the trialТs design, that it was not possible to attribute those changes to the prescription of heroin as opposed to the associated psycho-social support. That the trial greatly strengthened the evidence in favour of heroin prescription was ignored.

Similarly, expert opinion that withstands peer scrutiny is frequently discounted in the light of counter views that do not have the same credibility among peers. According equal weight to competing views to achieve "balance" is common in journalism but in science is out of place in the assessment of evidence. A case in point seems to be Dr PikeТs reference to doubts expressed by Dr Lucy Sullivan challenging the generally accepted expert view about the efficacy of the needle exchange programme. The programme was introduced in the late 1980s to limit the spread of blood borne diseases like HIV/AIDS. Since then, she writes, hepatitis C "has spread extensively, [among intravenous drug users] making it clear that the availability of free needles has not prevented bloodborne viral transmission." Three researchers of the Macfarlane Burnet Centre for Medical Research term Dr SullivanТs argument "flawed". They point out that hepatitis C infection among Australian intravenous drug users "predated needle exchange by at least 15 years." Moreover, they affirm that "needle exchange does prevent the spread of HIV". It has been limited to between 2 and 3 per cent. of the intravenous drug using population.

Dr Pike himself cites a major recent study out of context. To support Dr SullivanТs thesis that needle exchanges have been ineffective in limiting the spread of bloodborne disease he mentions that "In one study, the 1997 prevalence of Hepatitis C among users was around 50%, but may be higher . . .". In fact a principal finding of the study was that hepatitis C "prevalence declined significantly from 63% in 1995 to 51% in 1996 and 50% in 1997 (P < 0.001)". In other words the study showed a significant reduction over a 3 year period in hepatitis C infections associated with needle exchanges.

Dr Pike refers to the suppression by the British Department of Transport of the findings of a study it commissioned into the extent to which compulsory seat belts reduced road deaths. The finding went against the given wisdom in that it found that the introduction of the measure had "not led to a detectable change in road deaths". In the United Kingdom there was even an increase in deaths among unbelted users including pedestrians. This appears to be an example of risk compensation. Without evidence, Dr Pike suggests that the same phenomena may be at work with needle exchanges leading to increased drug use.

Dr Pike is quite right that the suppression of inconvenient facts is something that must be guarded against. Discomforting scepticism is at the heart of scientific method. The possibility of risk compensation operating in the case of needle exchanges should be examined if it has not already been. The same scepticism means that we should be alert also to other possibilities. To use the seat belt study as an example, it would hardly be a change for the better if a relaxation of the seat belt law led to more deaths among those who would have worn belts under a compulsory regime. The better approach may be to leave seat belt wearing compulsory and develop other measures to counter risk compensation.

In the drug debate the motives that underpin suppression of inconvenient findings also underpin a reluctance to become informed. The objections to trials can be viewed in that light. If, as argued above, evidence about side effects of measures is crucial in order to come to ethical decisions about those measures, we should be doing everything that we can to become informed. In the light of the social havoc wrought by illicit drugs in spite of substantial existing controls, refusal to conduct trials to gain information about alternative measures lacks credibility. This is particularly so where there exists strong overseas evidence of efficacy.

Finally, we should look to the whole range of likely side effects. Within the compass of their short papers, it is unfair to criticise Fr Fleming and Dr Pike for not doing this. Fr Fleming briefly mentions drug related crime. Dr Pike does not. Neither mentions corruption or family dysfunction brought about by drug addiction nor the tendency of drug abuse to splinter society by alienating youth, which use the drugs, from the rest of the community. Dr Pike mentions the possibility that the needle exchange programme "has the potential to undercut the law". Respect for law is already a casualty of the increasing availability of illicit drugs at cheaper prices. The same scepticism requires us to examine whether our existing responses to drugs Ц including the law itself Ц are responsible for the astronomically high profit margins supplying an addiction driven demand, which support the apparently invulnerable criminal distribution network. Access Economics has estimated that the street value of heroin of 40% purity to be over 3,000 times the farm-gate price of opium.

All of us should agree with Fr Fleming that "insufficient time and attention has been paid to the moral issues at stake in the treatments proposed for addicts". The debate on these is urgent if only for the frighteningly obvious reason that lives and core values of our society are at stake.

Note: The author acknowledges the help of Drs Rod MacQueen, Andrew Byrne, Phyll Dance, Jeff Ward, Alex Wodak and Gabriele Bammer. In particular he wishes to express gratitude to Professor Max Neutze for both his inspiration and careful comments made a few days before his death.