I am a member of a city council. The head of the health department, Dr. Stevens, wants us to approve a program for supplying clean needles to people addicted to illegal drugs, as has been done in some other localities. The main objective of these programs is to slow the spread of AIDS and other diseases that, although less in the news, apparently cause even more damage. Stevens proposes to kill two birds with one stone, and also to keep the program’s cost minimal, by putting it in the hands of volunteers, who will be trained by a local drug rehabilitation center at no cost to the city. These volunteers will talk with the addicts when exchanging needles and try to get them into rehabilitation, pointing out that in the long run addiction is as deadly as AIDS.
Public opinion and the council are divided. I am not sure whether to vote for or against. On the one hand, if the program works it will do some good at an insignificant cost—the needles themselves. On the other hand, it will put the city in the position of helping addicts get their fix.
Which consideration do you think is more important from a moral point of view? I probably also should ask whether you think there are others I am missing.
This question concerns cooperation in wrongdoing. Supplying addicts with clean needles is not wrong in itself; it is material, rather than formal, cooperation with their abuse of drugs. The morality of this material cooperation depends on rectitude of intention and acceptability of side effects. The intention—to limit the spread of disease and encourage addicts to accept treatment—is good. However, the availability of clean needles will make both initial and ongoing drug abuse more tempting. Moreover, in conducting a needle exchange program, the city will undermine the witness of the law against drug abuse by becoming an accomplice. Long-term benefits to individual addicts are uncertain. Alternatives should be considered—particularly better, more available, and better publicized treatment for addicts. If the common good calls for this alternative, a needle exchange program would not be fair to addicts.
I have argued elsewhere (see LCL, 534–40) that using a psychoactive substance is morally wrong unless one is motivated, not by mere emotion, but by a reason grounded in an intelligible good, such as health. Plainly, addicts’ use of drugs never is motivated by such a reason. So, the proposed needle exchange program, in my judgment, would contribute to behavior that is not only unlawful but morally wrong, and, given its bad consequences, not least its harmfulness to addicts themselves, objectively gravely immoral—though the personal responsibility of addicts no doubt is limited by the compulsive character of their behavior.
While it does not follow that such drug use must be forbidden by law, existing laws forbidding it ought to be presumed just and binding. To be sure, arguments have been advanced for legalizing some or many currently illegal uses of drugs, but these arguments, at least with respect to drugs that are injected, have been answered cogently.423 Moreover, even supposing some plan of limited and strictly regulated legalization were conceded to be preferable to prohibition, it would not follow that violating existing laws is morally acceptable, since acts violating these laws would be immoral even if the laws had never been enacted. Consequently, if the city adopts the needle exchange program, it will be contributing to behavior that is both gravely wrong and in violation of laws that should be presumed just and binding.
The immediate intention of the program and of the volunteers participating in it—that is, the object of their act—would be to collect used needles and distribute sterile ones. Neither those who supported the program nor the volunteers would have to intend that anyone actually use illegal drugs, and it is hardly likely they would intend that. So, adopting the program and carrying it out would not be wrong in itself. The ends in view would be to forestall the transmission of AIDS and other diseases, and to encourage addicts to enter treatment. These ulterior intentions are good.
Someone might object that at least those who set up the program would intend the unlawful use of drugs, since they would intend the program to slow the spread of AIDS, and this benefit would not be realized if the addicts did not use the clean needles to inject drugs. However, those responsible for the program could avoid intending the ongoing abuse of drugs and only accept it as a given. The situation is like others in which one may persuade someone determined to do a grave evil, which one cannot prevent, to do instead a less grave evil—for example, having fruitlessly tried to dissuade a suicidal man from jumping out a window above a crowded sidewalk, one might call his attention to a window overlooking a deserted alley and urge him at least to spare others.
Even so, doing something that helps another do wrong often is wrong. In this case, it is not likely that those helping drug addicts will be tempted to intend their wrongdoing. Indeed, it might be argued that the volunteers will be morally benefited by developing social virtues, inasmuch as they will unselfishly serve both drug addicts and the wider community. But the moral permissibility of accepting the projected program’s side effects must be considered in reference to three things: scandal (leading others to do wrong), undercutting public witness to the truth about drug abuse, and fairness to the addicts and others. Moreover, the proposed program’s expected effects ought to be compared with the likely effects of available alternatives.
With clean needles easily available without cost, addicts can be generous in supplying them to people inexperienced in injecting drugs. So, some nonaddicts who otherwise would be unwilling to begin injecting drugs will be persuaded by a companion’s offer of a clean needle to take that step. Indeed, since addicts are not registered, the possibility of picking up a discarded needle and exchanging it for a clean one will open the way for some young people to try injecting drugs for the first time. Thus, the easy availability of clean needles would remove one motive for people not yet addicted to steer clear of illicit drugs. Removing any motive to resist a temptation makes it more likely that weak-willed individuals will give in. So, the program may be counterproductive for some individuals by leading them into drug abuse.424 Without morally compelling reasons for accepting this bad side effect, doing so will be scandal.
Besides, if members of the city council adopt the program Stevens proposes, they will be making the city an accomplice in the unlawful behavior of drug addicts. The volunteers, acting with the authorization of public officials, will be aware of the identity of illegal drug users, but rather than dealing with them as such, will help them in their ongoing unlawful behavior. This open cooperation of the city with the unlawful behavior of drug addicts will suggest that only the risks incidental to drug abuse are bad. Hence, the program will tend to undercut the law’s effectiveness in teaching people, especially young people not yet addicted but tempted to abuse drugs, to avoid such self-destructive and socially harmful behavior. Then too, official complicity in addicts’ law breaking will tend to make the law they violate seem arbitrary, and so will tend to undercut respect for that law and law in general. These bad effects are extremely serious, since law’s effectiveness depends far more on forming the majority’s practical reasoning and judgments than on forcing the unwilling minority to comply.425
Moreover, if the public authorities tolerate and even cooperate with drug abuse, in practice they will be legalizing it, at least under certain circumstances. But doing that would be an abuse of power by a city council, because the prohibitions of drug abuse were enacted by state and federal governments. Moreover, since the legalization will not be straightforward, it is likely to lead to confusion and uneven enforcement of relevant laws.
Whether exchanging needles would be fair to addicts themselves would depend on the program’s benefits and harms to them, in comparison with possible alternatives. This consideration of prospective consequences might be helpful if accurate information were available—not only about immediate and easily observable consequences but about possible long-term bad effects. But I know of no solid evidence about the long-term results of needle exchange programs, and in the nature of the case it may be impossible to obtain. It is true that studies show a gradually decreasing proportion of returned needles contaminated with HIV.426 Thus, the program Stevens proposes probably would reduce the rate at which addicts in the city are spreading AIDS, hepatitis, and other diseases, and perhaps would bring some addicts into treatment. However, it is unlikely that many drug addicts are so well organized and self-disciplined that they will regularly exchange dirty needles for clean ones or resist the urge to share a needle when they wish to inject drugs and happen to lack a clean one. Even the program’s proposed message, that in the long run addiction itself is as deadly as AIDS, implies that addicts would receive limited benefits by being helped to avoid AIDS and other diseases if they persist in feeding a habit that eventually will kill them. Thus, the net prospective benefits of the program to individual addicts seem questionable.
Perhaps Stevens, considering things from the perspective of public health, is more interested in limiting the transmission of AIDS and other diseases from drug addicts to the population at large. However, the program will do that in the long run only if supplying clean needles to addicts will lessen the number of nonaddicts who otherwise would become infected. I doubt that there is much solid evidence on these matters.427
Public authorities should not resign themselves to the inevitability of vices such as drug abuse, regard those enslaved by them as hopeless cases, and seek only to limit further bad consequences. Rather, they should regard such a vice as a challenge to their creativity and look for constructive alternatives likely to help people live decent lives. One such alternative to Stevens’s program might be to do what the city can to minimize the availability of drugs while training the city’s welfare workers to deliver the message Stevens would have the volunteers deliver. But the welfare workers would come into contact with suspected addicts by helping them obtain food, medical care, and other necessities of life rather than by supplying clean needles. Volunteers could be trained to report drug dealers and help addicts willing to enter treatment deal with obstacles they might encounter. Such a program probably would have many good effects and would be less likely to have bad ones.
Of course, this approach demands that good treatment for drug addiction be readily available, so that an addict can receive it without significant delay. Providing the needed treatment facilities may be very costly, but the common good seems to require this alternative, which would be beneficial in limiting the many bad social consequences of abuse. Then too, since addiction is as deadly as AIDS in the long run, a needle exchange program manifests little or no concern for addicts unless the city has good treatment available and promotes its use. Hence, offering clean needles instead of good treatment hardly would be fair to drug addicts.428
Since the likely consequences of the proposed program and a possible alternative do not provide a cogent reason to vote for the program, you should base your decision on the other moral considerations—the element of scandal and the undesirability of the city’s complicity in unlawful behavior.
However, it does not follow that such a proposal could not be acceptable under other circumstances. Supplying addicts with clean needles would not be intrinsically wrong. Suppose it eventually became clear that such programs are quite beneficial and not very harmful? Might not the city then have adequate reason to become a reluctant accomplice in drug abuse? Perhaps. But in that case the laws would have to be modified so that, while selling drugs or possessing them in significant amounts would remain illegal, it would be lawful to buy and possess small amounts, and to use drugs in those situations in which the public authorities are involved.
423. For a case against legalization based on an extensive historical study: Jill Jonnes, Hep-cats, Narcs, and Pipe Dreams: A History of America’s Romance with Illegal Drugs (New York: Scribner, 1996); summary of argument against legalization, 413–41.
424. Panel on Needle Exchange and Bleach Distribution Programs, Commission on Behavioral and Social Sciences and Education, National Research Council and Institute of Medicine, Preventing HIV Transmission: The Role of Sterile Needles and Bleach, ed. Jacques Normand, David Vlahov, and Lincoln E. Moses (Washington, D.C.: National Academy Press, 1995), 199–200, notes these concerns but, after reviewing available research on existing programs, dismisses them (252), because of lack of evidence that the programs lead to increased drug use (though admitting that long-term effects are not yet known) and because: “The available scientific literature provides evidence based on self-reports that needle exchange programs do not increase the frequency of injection among program participants and do not increase the number of new initiates to injection drug use” (italics added).
425. Ibid., 105, notes that some are concerned about these potential bad effects and says: “Ideological and moral concerns are not scientific, empirically based arguments; however, this in no way dilutes their importance.” But the Panel quickly dismisses these concerns (105–6) and ignores them in its conclusions and recommendations (251–55).
426. See ibid., 251.
427. Ibid., having stated on the basis of evidence that needle exchange programs lower the proportion of contaminated needles in circulation, asserts as a “logical consequence”: “The lower the fraction of needles in circulation that are contaminated, the lower the risk of new HIV infections.” However, the Panel ignores the distinction between reducing the risk of transmitting the disease on each occasion of drug use and during a user’s entire life, and so fails to consider the possibility that the programs may slow the rate of the epidemic while saving few if any lives in the long run.
428. Ibid., 107 and 116–19, notes that many African-American leaders take this position but points out (119–20) that some support needle exchange programs, and takes the opposition into account only by saying (252): “Needle exchange programs should be regarded as a public health promotion and disease prevention strategy that fits within the broader harm reduction approach to public health” (italics added). Thus, on this issue the Panel offers a moral norm rather than looking for relevant evidence.