The war on drugs is surrounded in controversy from drug-control policy and recreational drug use to treatment of addicts and rising healthcare costs. Most countries have strict zero tolerance policies with society’s support – deeming the subject taboo and unethical, drugs as evil, and addicts as “bad” people. Canada as taken alternative measures in Vancouver’s Downtown East, which had “astronomical levels of HIV and drug overdose.” INSITE is a legal, supervised injection site offering a safe environment to use illicit drugs and to connect with healthcare services. The Canadian facility allows drug users to shoot-up safely without fear of arrest and with on-site medical assistant. The government-funded injection site is the only facility of its kind in North America. There is sufficient evidence that INSITE has public health benefits by lowering HIV and AIDS rates, but the subject is still controversial. Critiques argue harm reduction practices encourage drug users, perpetuate a problem, and give the “green light” on illicit drug use. Advocates claims INSITE saves lives, reconnects marginalized drug addicts with the community, has financial benefits to healthcare costs, and is overall beneficial to society. In first applying consequentialism to INSITE, it is clear the facility provides public health benefits for the larger community. When delving deeper, one must ask who are the beneficiaries of INSITE? Do harm reduction programs really help addicts or the general public? Is the action of opening INSITE causing unintended consequences? This paper will seek to understand INSITE and the consequential ethics behind it.

INSITE opened its doors in 2003 as a three-year trial period for scientific research on reducing HIV levels in Downtown Eastside Vancouver, which had rates similar to developing countries (Figure 1 and 2).

Figure 1 Patterns of injection-related HIV risk behavior among people who use illicit drugs in Vancouver, 1996-2011

Figure 2 Incidence of HIV and HCV infections among people who use illicit drugs in Vancouver, 1996-2011

**All figures were taken from the Urban Health Research Initiative of the British Columbia Center for Excellence in HIV/AIDS.

During the 1990s, disease and overdose rates skyrocketed. Out of the 16,000 population in Downtown East, approximately one-third of them were drug users (CNN International, 2013). In 1997, 19% of injection drug users were infected with HIV, the highest annual rate ever recorded in the developed world (National Geographic, 2010). Approximately, one overdose occurred daily in the region. The open-air drug market was coupled with increasing poverty, violence, homelessness, and crime. Doctors Julio Montaner and Thomas Kerr of the BC Centre for Excellence in HIV/AIDS organized the harm reduction program, INSITE, and pushed for changes in the impoverished community.

The concept behind harm reduction is to focus on the prevention of harm, rather than the prevention of drug use itself. According to Harm Reduction International, harm reduction refers to “policies, programs and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unable or unwilling to stop” These programs have been around for several decades, most notably as safe injection sites and needle exchange programs in Europe. The world’s first supervised injection site opened in 1986 in Switzerland; founder Jakob Huber states “this was at that time revolutionary for drug policy globally.” These programs operate largely in legal gray areas – funded by local health authorities and ignored by police. They have traditionally lacked outright legal approval. Starting in 2000, countries including Germany, Luxemburg, Switzerland, Norway, and Spain have granted full legal sanctions to safe injection sites. Today, there are roughly 90 such facilities in Europe and Australia (Holeywell, 2013). Harm reduction is grossly underfunded when ten of billions of dollars are spent on drug enforcement; harm reduction seeks to invest in health and human rights through alternative measures. For every dollar spent on drug enforcement, 10 cents would cover annual HIV and hepatitis C prevention for people who inject drugs globally (Harm Reduction International, 2015).

INSITE is the first drug harm reduction program in North America. The supervised injection site is exempt from Section 56 of the Controlled Drugs and Substances Act and allows drug users to safely shoot-up without fear of arrest or police harassment. It is funded by the British Columbia Ministry of Health and run by Vancouver Coastal Health (regional health authority) in conjunction with the Portland Hotel Society (nonprofit serving mental health and addiction issues). INSITE has 12 injection rooms with on-call nurses, clean needles, filters, clean water, and alcohol swabs. They only thing not provided are the drugs. Nearly 800 people use those booths every day. One INSITE client states “there’s typically a line to get in before the site opens its doors at 10 a.m.” The facility also connects users with professional healthcare services such as counseling, housing assistance, addiction services and mental health treatment. The three-story building is divided between INSITE located on the first floor, and ONSITE located on the two floors above. ONSITE is a detox and rehab facility where no drugs are allowed. When clients are ready to get clean they are referred upstairs where they are offered therapy, yoga, and housing services; the detox process is entirely up to the addict. It is estimated since INSITE started the number of users entering detox has increased by 30%, and 40% of people who enter ONSITE detox make it through the program, a relatively high number compared to other recovery programs (National Geographic, 2010). In addition to the supervised injection facility and detox center, INSITE also has a mobile needle exchange program. INSITE staff members drive around Vancouver in search of addicts to provide clean equipment and safe injection kits. These kits can include mouthpieces, glass pipe, alcohol swabs, band-aids, lighters, gauze, and clean needles. The van operates over 20 hours a day with INSITE staff having 150 to 200 contacts per day. “Giving out the tools of addiction is extreme but essential for staying safe and saving lives,” states an INSITE employee, especially when more than half of INSITE users are homeless, living in shelters, or have untreated mental issues. INSITE can help get addicts off the street, away from isolation, and in contact with treatment if desired (Figure 3 and 4).

Figure 3 Percentage of street-involved youth reporting homelessness in Vancouver, 2005-2011

Figure 4 Patterns of access to additions treatment among people who use illicit drugs in Vancouver, 1996-2011

INSITE connects addicts, who are sick human beings, with health care professionals. Much of society does not understand that addition is a complex, biological disease. According to the National Institute of Drug Abuse, “addiction is a chronic, often relapsing brain disease that causes compulsive drug seeking and use (2012).” The brain changes over time challenging an addict’s self-control and hampering his or her ability to resist intense impulses to take drugs. Nobody chooses to be an addict. Intravenous drug users, like users at INSITE, are the most reviled by society and other non-intravenous users. Isolation is a large factor of addition and illicit drug users tend to be isolated from their communities. Society needs to take the stigma out of addition and see addicts as human beings with enormous burdens. INSITE helps fight this stigma.

INSITE advocates also claim society benefits more than the addicted because HIV rates are a public health issue. Sharing needles and using dirty needs increases hepatitis and AIDS among the general population. INSITE clients are 70% less likely to share needles than other addicts in Vancouver. Advocates also argue the tangible financial benefits. With societies rising healthcare costs, rationing taxpayers’ dollars becomes more important. In the United States alone it is estimated the total overall costs of substance abuse – including productivity and health- and crime-related costs – exceeds $600 billion annually; approximately $193 billion goes toward illicit drugs. Addicts who become sick or infected require taxpayers’ dollars. HIV infections over a lifetime cost approximately $380,000 per person for treatment (National Institute of Drug Abuse, 2012). Emergency ambulances for overdoses cost 1,000 per trip on average, regardless if the overdosed person is uninsured. For every dollar spent at INSITE, the Canadian government saves the healthcare system four dollars. Critics argue that the three million dollars INSITE receives from taxpayers is far too much (CNN International, 2013). Addition counselor, David Berner states addicts in recovery save the community thousands because they don’t use INSITE, doctors, psychiatrists, ambulances, police, and courts. He poses the argument that taxpayers should not have to bear the costs of irresponsible people, or addicts. “Why should tax payers’ dollars pay for free needles when these addicts don’t care about the rest of the population?” he asks.

Regardless of the financial debate, INSITE has strong support from the local Vancouver community at 76% approval rating (National Geographic, 2010). Support is lowest among the regions conservatives, including Prime Minister Stephen Harper who outwardly criticizes the facility and has attempted to close INSITE on multiple occasions. INSITE’s legal battle to remain open has been long and bitter. After 10 years and finally appearing before the Supreme Court, INSITE received full approval in May 2011. The facility has been the focus of over 30 studies since opening. One four-year study on the effects of opening supervised injection sites in Toronto and Ontario had astounding results. The results showed over 9,000 people in Toronto use illicit drugs and more than 75% would use supervised injection sites (CNN International, 2013). This would change user needle habits with injection sites, and large number of hepatitis c infections could be avoided. The study also found public support for supervised injection sites is over 50%. Yet the 4-year study on facility expansion was shut down within an hour by all levels of municipal government. Experts say there is only one reason the INSITE model hasn’t been adopted anywhere else in North America – because it is politically controversial.

Critiques argue that INSITE is not a solution to this public health crisis. Most governments still have blanket bans on drugs and see harm reduction programs as condoning crime. Additionally, drug control issues and policies are taboo and politically unsexy; drug control policy does not win votes and is an ugly topic. Supervised injection sites transcend illegal drug use and give users a method to harm themselves. Counselor Berner argues INSITE “ignores completely the mechanics of addition.” Addicts want more and more of their chosen substance until they “keel over.” His answer to conquering addition is getting people into treatment and therapy. The “best harm reduction is abstinence” and getting users engaged with human contact. The “notion of INSITE is distinguishing,” declares Berner and “it is not even a band aid. It’s a totally waste of time.” Doctors Montaner and Kerr would counter-argue that INSITE’s model “works to decrease adverse health, social and economic consequences of drug use without requiring abstinence from drug use (2015).” This proves the best, current solution for society. This debate around INSITE can be examined from a benefactor’s perspective using consequentialism.

Consequentialism focuses on results or consequences of the decision or action. It is also referred to as teleological derived from the Greek telos; a telos is a goal or an end purpose. INSITE clearly serves its purpose of saving lives and lowering HIV rates. But what other consequences does INSITE generate? One of the major challenges of consequentialism is acquiring all of the facts to determine how all stakeholders will be affected. It is very difficult, and some would argue impossible, to determine all of the ripple-effect consequences INSITE creates. The Canadian government was making ethically controversial decisions in first allowing INSITE to open. There is limited evidence of harm reduction programs long-term effects, regardless of the positive short-term outcomes – which include practically, feasibility, effectiveness, safe and cost-effective. With social, economic, and political factors playing into the INSITE model, it was difficult to fully assess all the possible outcomes of INSITE. With vast studies having now been completed, the consequences of INSITE are more obvious, making the ethics behind INSITE easier to analyze.

The most commonly referred to consequential theory is utilitarianism. This approach identifies all possible actions in a situation, then the positive and negative consequences for all stakeholders. The best ethical decision is the one yielding the greatest net benefit for society. The worst ethical decision is the one yielding the most harm to society. The entire theory focuses on maximizing benefit while minimizing harm (O, L., & Nelson, K., 1995). INSITE has provided strong evidence of such outcomes. In applying utilitarianism, an important question to ask is who is society? Society could be INSITE clients, the Downtown East population, Vancouver, all Canadian citizens, the peoples of North America, or the entire human population. Defining whom society is changes the ethics behind the INSITE model. For the purpose of this analysis, society will be defined as Vancouver’s population as most of the scientific evidence revolves around the city. There is strong proof INSITE decreases Vancouver’s unfavorable health regardless of ideology, beliefs, or criticisms.

Another challenge of consequentialism is the assimilation of minorities into society as a whole. Minority groups can be left out or overlooked. INSITE clients and all Vancouver addicts are a minority population in Vancouver. In analyzing the INSITE model and when society is defined as the addict minority group, we must ask what is the best result for addicts. Harm reduction programs may be the most beneficial for reducing HIV infection and overdose rates but are they the most beneficial programs to addicts themselves? No. Critic Berner has emphasized treatment and therapy are the answers to addition. Berner believes the most beneficial solution for addicts is sobriety. The problem is not all addicts are willing to accept this solution or able to achieve the best result for themselves. Does this mean the best overall outcome for addicts refusing to get treatment is to shun and ignore them until they desire sobriety? Harm Reduction International vehemently states, “people who use drugs do not forfeit their human rights, including the right to the highest attainable standard of health, to social services, to work, and freedom from cruel inhuman and degrading treatment (2015).” This includes a lack of clean needles and medical supplies. INSITE operates under the lesser of two evils for drug addicts– choosing to save lives by allowing users to use instead of death. Since opening its doors, INSITE has had 1,000 overdoses but not a single death. In addition, the healthcare services and anti-stigma atmosphere INSITE provides directly benefit INSITE clients. From this aspect the supervised injection site upholds consequential by choosing the best possible outcome for addicts and society. One must also consider that not all addicts use INSITE. Yet, these non-INSITE clients still reap benefits in the addition community. Needle sharing and infection rates are lower within their community. It is evident that INSITE lowers Vancouver’s HIV societal rates as a whole, but debatable on the direct benefit to addicts as the action itself is question.

Haines definition of consequentialism includes both the action itself and the consequences of the action. “Consequentialism is the view that morality is all about producing the right kinds of overall consequences.” From this classification we must also acknowledge the action of giving users legal places to inject drugs or drug equipment. Is this the best way to help addicts? What type of message does this send to users? What type of message does this send to future generations? As mentioned above, treatment is the ideal solution in handling addiction. Yet, the reality of Vancouver’s drug situation is that addicts will continue to use. There has been no clear evidence on increasing drug usage in Downtown East surrounding INSITE. Most INSITE clients describe the facility as their safe haven and absolutely necessary to prevent overdose. There is also no substantial evidence that INSITE and harm reduction programs give the “green-light” on illicit drug use; some evidence suggests harm reduction practices actually reduce illicit drugs use.

It is difficult to determine if INSITE follows consequentialism without asking the key questions addressed above. By evaluating the history of harm reduction, the opening of INISTE and preceding scientific studies, one is able to appreciate the complicated situation. Both advocates and critics offer honest perspectives of the harsh reality of drug addiction and adverse health effects on society. INSITE is achieving its goal of reducing HIV and overdose rates in the Downtown East neighborhood. By the information presented and overall consequences found in Vancouver, INSITE does conform to consequentialism. INSITE yields the greatest net benefit for society, while minimizing harm to drug users. Though INSITE is controversial it has offered the best solution to Vancouver’s drug problem and the INSITE model should be considering for expansion in other regions.

Resources

Drug Facts: Understanding Drug Abuse and Addiction. (2012, November 1). National Institute of Drug Abuse.Retrieved March 29, 2015, from http://www.drugabuse.gov/publications/drugfacts/understanding-drug-abuse-addiction

Haines, W. (n.d.). Consequentialism. Retrieved March 29, 2015, from http://www.iep.utm.edu/conseque/

Harm Reduction International. What is harm reduction? (2015, January 1). Retrieved March 26, 2015, from http://www.ihra.net/what-is-harm-reduction

Holeywell, R. (2013, February 1). Vancouver Offers Drug Users a Safe Place to Shoot Up.

Retrieved March 26, 2015, from http://www.governing.com/topics/health-human-services/gov-vancouvers-safe-but controversial-haven-for-drug-users.html

Insite – Supervised Injection Site. (2015, January 1). Retrieved March 26, 2015, from http://supervisedinjection.vch.ca

National Geographic’s Taboo: Shooting heroin legally [Motion picture]. (2010). Canada: National Geographic.

O, L., & Nelson, K. (1995). Deciding What’s Right: A Prescriptive Approach. In Managing business ethics: Straight talk about how to do it right (Third ed., pp. 88-109). New York: J. Wiley & Sons.

Urban Health Research Initiative of the British Columbia Center for Excellence in HIV/AIDS. (2013, June 1).Drug Situation in Vancouver. Retrieved March 27, 2015, from http://www.cfenet.ubc.ca/sites/default/files/uploads/news/releases/war_on_drugs_failing_to_limit_drug_use.pdf

World’s Untold Stories: “Shooting Up Legally” [Motion picture]. (2013). Canada: CNN International.

Image: http://www.macleans.ca/wp-content/uploads/2011/09/Insite2_wide.jpg