The Ethics in Substitution Treatment and Harm Reduction. An Analytical Review

The ethics of opiate substitution treatment (OST) modalities for heroin addiction have been abundantly criticised but also have equally strong supporters. This analytical review addresses three main arguments against such treatments: 1) the social nature of the issue involves a misuse of the medical care; 2) the aim is one of social control (as opposed to a “cure”) and therefore is a perversion health care; and 3) prescribing the very substance (or a substitute) that caused the addiction is ethically questionable. Additionally, the generic criticism against the philosophical/theoretical framework under which they operate, “harm reduction” (HR) as an operational goal of therapy, is also addressed here.

A summary review of the history of addiction supports the argument that, indeed, drug addiction “as a problem” was socially created. Equally clear is that one of the aims of OST and all drug-addition treatments is the social control of individual behaviours. However, neither of these two aspects justifies refusal to provide health and social care. OSTs are legitimate therapeutic options because they comply with the four principles of bioethics—autonomy, nonmaleficence, beneficence and justice. The argument that such treatments and the HR approach, in general, align with the principle of consequentialism—the aim justifies the means—and therefore is ethically questionable is a disingenuous criticism. Consequantialism is based in the implicit assumption that harms are accepted to reach certain objectives as the lesser of two evils. OSTs have been extensively proven as to their safety with benefits margins both at the individual (retention, reduction of illicit drug use and better social adjustment) as well as at the population levels (e.g., HIV incidence reduction). Heroin-substitution based treatment is the latest case of moral resistance to provide patients with the most effective option in spite of sound evidence on its effectiveness and safety. As in other cases of spurious resistance to public health and medical innovations, it is only a matter of time and endurance until such treatments are fully integrated among standard therapeutic options for heroin dependent individuals.