Blackwell Science, LtdOxford, UKADDAddiction0965-2140© 2006 The Authors Journal compilation © 2006 Society for the Study of Addiction
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Editorial
Editorial
Editorial
EDITORIAL EDITORIAL
The place of supervised injecting facilities within harm
reduction: evidence, ethics and policy
INTRODUCTION
Supervised injecting facilities (SIFs) are commonly
defined as legal facilities that enable the consumption of
pre-obtained drugs in an anxiety- and stress-free atmo-
sphere 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 coun-
tries, 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, Aus-
tralia (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.
EVIDENCE
The need for realistic expectations about what SIF out-
comes are observable in light of the considerable practi-
cal 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. Fur-
ther, 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 prac-
tice 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 exper-
tise (in the context of ‘scientific trials’ and ‘medical super-
vision’), and focuses less explicitly on values and ethics,
and the political aspects of consultation and participa-
tion in policy development (Hathaway 2002; Fry et al.
2005).
ETHICS AND POLICY
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
© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction
doi:10.1111/j.1360-0443.2006.01386.x
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 environ-
ment, powerful groups can easily obtain or misrepresent
evidence for their arguments. Evidence therefore is nec-
essary, but not sufficient, as the differential policy out-
comes 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 impor-
tant 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 poten-
tially harmful drugs and the State’s and community’s
right to prevent or interfere in this. As some commenta-
tors 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, con-
sent in the case of intoxicated clients, staff role bound-
aries 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 opportu-
nities to enhance our current practices (Guilleman &
Gillam 2004). The teams involved in SIF operation and
evaluation are sure to have encountered a host of inter-
esting 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
Addiction, 101, 465–467
466 Editorial
ethical underpinnings of harm reduction can help
directly to confront this perspective (Fry et al. 2005).
POLICY DEVELOPMENT
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 autono-
mous individuals. In an important recent paper, Fischer
et al. (2004) suggest in relation to SIFs that ‘little atten-
tion 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 regu-
lated risk consumption and socio-spatial ordering under
the guises of public health’ (p. 357). The point is, this pol-
icy shift may not displace more punitive measures, but
incorporate these in the overall governance (i.e. regula-
tion 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.
CONCLUSIONS
Supervised injecting facilities occupy a potentially impor-
tant place in harm reduction policy and practice in those
jurisdictions that have secured community, legal and
political approvals for implementation. In addition to rep-
resenting an opportunity to gather data on operation and
outcome variables, with SIF trials also comes a responsi-
bility 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 inter-
ests as authority in relation to planning and implement-
ing 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.
© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction
Acknowledgements
We are grateful to Nick Crofts for comments on an earlier
draft, and Griffith Edwards for editorial input. The opin-
ions expressed by the authors are their own.
CRAIG L. FRY 1,2,3 , STEFAN CVETKOVSKI 1 & JACQUI
CAMERON 1
Turning Point Alcohol and Drug Centre, Melbourne1,
Department of Public Health, University of Melbourne2, and
Centre for Drug Policy Research, Melbourne, Australia3.
E-mail: craigf@turningpoint.org.au
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