Careful Practices: Ethics and the Anethical in Canadian Addiction Trajectories.

A drug overdose epidemic in North America has sped the expansion of harm reduction services. Drawing on fieldwork in Ottawa, Ontario, we examine forms of care among people offering and accessing these resources. Notably, our interlocutors do not always characterize harm reduction as caring for oneself. Thus, we differentiate between the ethics of care through which one enters desired subject positions, and anethical careful practices. Harm reduction is sometimes anethical, enacted through minor gestures that do not constitute ethical work but allow for its future realization.

Rescuing Vapers Versus Rescuing Smokers: The Ethics.

Suppose for the sake of argument that wide access to electronic cigarettes would help a great many smokers quit and others avoid smoking, with a dramatic cumulative effect on population health. But suppose also that nowadays, teenagers rarely benefit from that effect, because most do not smoke and are not expected to smoke as adults. Many teenagers do vape. When the net effect of vaping on general public health is expected to remain very positive, should we nevertheless fight vaping, so as to protect teenagers from the direct risks of vaping? For example, what to do if and when certain targeted regulations that would protect teenagers would also, by making it harder to vape, substantially increase smoking in the general population? This situation may be common, and, by pitting the health interests of the general population against those of teenagers, poses an ethical dilemma. This article argues philosophically that if such tradeoffs between the health interests of adolescents and those of the general population exist, morally it is both permissible and preferable to promote the health of the general population. IMPLICATIONS: In the debate about electronic-cigarette based tobacco harm reduction, some disagreements are factual, for example, disagreements about how harmful vaping is to human lungs, and how much the option of vaping helps smokers quit. However, there is also an ethical debate: if tradeoffs between the health interests of adolescents at risk of vaping and those of the general population (driven by those of smokers) exist, who should be prioritized? This article argues that morally it is sometimes, at least, both permissible and preferable to promote the health of the general population over those of adolescents at risk of vaping.

Vaping Restrictions: Is Priority to the Young Justified?

The vast majority of smokers become dependent on nicotine in youth. Preventing dependence has therefore been crucial to the recent decline in youth smoking. The advent of vaping creates an opportunity for harm reduction to existing smokers (mostly adults) but simultaneously also undermines prevention efforts by becoming a new vehicle for young people to become dependent on nicotine, creating an ethical dilemma. Restrictions to access to some vaping products enacted in response to the increase in vaping among youth observed in the United States since 2018 have arguably prioritized prevention of new cases of dependence-protecting the young-over harm reduction to already dependent adults. Can this prioritization of the young be justified? This article surveys the main bioethical arguments for prioritizing giving health benefits to the young and finds that none can justify prioritizing dependence prevention over harm reduction: any reasons for prioritizing the current cohort of young people at risk from vaping will equally apply to current adult smokers, who are overwhelmingly likely to have become nicotine-dependent in their own youth. Public health authorities' current tendency to prioritize the young, therefore, does not seem to be ethically justified. IMPLICATIONS: This article argues that commonsense reasons for prioritizing the young do not apply to the ethical dilemma surrounding restricting access to vaping products.

The Ethics of Tobacco Harm Reduction: An Analysis of E-Cigarette Availability From the Perspectives of Utilitarianism, Bioethics, and Public Health Ethics.

Much evidence suggests e-cigarettes are substantially less harmful than combustible cigarettes. Assuming this is true, we analyze the ethical case for a policy of e-cigarette availability (ECA) as a tobacco harm reduction strategy. ECA involves making e-cigarettes available to allow smokers to switch to them, and informing smokers of the lower risks of e-cigarettes vis-à-vis smoking. After suggesting that utilitarian/consequentialist considerations do not provide an adequate ethical analysis, we analyze ECA using two other ethical frameworks. First, ECA is supported by a public health ethics framework. ECA is a population-level intervention consistent with respecting individual autonomy by using the least restrictive means to accomplish public health goals, and it supports equity and justice. Second, ECA is supported by four principles that form a biomedical ethics framework. By reducing smokers' health risks and not harming them, ECA fulfills principles of beneficence and non-maleficence. Because ECA allows smokers to make informed health decisions for themselves, it fulfills the principle requiring respect for persons and their autonomy. Here, we consider whether nicotine addiction and thus ECA undermine autonomy, and also discuss the ethical warrant for special protections for youth. Finally, ECA can also advance justice by providing a harm reduction alternative for disadvantaged groups that disproportionately bear the devastating consequences of smoking. Policies of differential taxation of cigarettes and e-cigarettes can facilitate adoption of less harmful alternatives by those economically disadvantaged. We conclude that public health and biomedical ethics frameworks are mutually reinforcing and supportive of ECA as a tobacco harm reduction strategy. Implications: Making e-cigarettes and information about them available is supported as ethical from multiple ethical perspectives.

Atenção à saúde no território como prática democrática: ações em cenas de uso de drogas como analisadores da democracia brasileira / Health care as a democratic practice: actions in drug use settings to analyze democracy in Brazil / Atención de la salud en el territorio como práctica democrática: acciones en escenas de uso de drogas como analizadores de la democracia brasileña

Propomos articular democracia, produção de saúde e cuidado com grupos vulnerabilizados. Utilizamos como analisadores ações estatais em cenas de uso de drogas ilícitas em São Paulo e no Rio de Janeiro, que coadunam com estratégias de intervenções sobre regiões tornadas negócios e sobre grupos que habitam tais regiões e, por isso, precisam ser removidos, que podem ser consideradas intervenções próprias ao neoliberalismo e seu correlato jurídico, o Estado de Exceção permanente. Entendemos que políticas de governo que pautam suas ações pela abstinência e internação dos usuários classificados como dependentes químicos estão em sinergia com a chamada guerra às drogas. Nosso objetivo é sinalizar que a atenção ao uso de substâncias psicoativas como preconizado pela estratégia da redução de danos tem potencial para capilarizar as diretrizes do Sistema Único de Saúde (SUS), da Reforma Psiquiátrica Brasileira e, desse modo, do escopo democrático nos territórios de maior vulnerabilidade social. (AU)

This article articulates democracy, health and health care among vulnerable groups. We use state actions in drug use settings in São Paulo and Rio de Janeiro carried out in conjunction with interventions to evict drug users living in districts that have become commercial areas to analyze democracy in Brazil; typical interventions associated with neoliberalism and its legal counterpart, the State of Permanent exception. We understand that government policies based on abstinence and internment of drug addicts are in tune with the so-called war on drugs. We highlight that the approach to the use of psychoactive substances embodied in harm reduction strategies has the potential to increase the capillarity of the guiding principles of the Brazilian National Health System (SUS), Mental Health Reform and, therefore, democracy in socially vulnerable areas. (AU)

Proponemos articular democracia, producción de salud y cuidado con grupos en situación de vulnerabilidad. Como analizadores utilizamos acciones estatales en escenas de uso de drogas ilícitas en São Paulo y Río de Janeiro, juntamente con intervenciones estratégicas sobre regiones convertidas en negocios y grupos que habitan tales regiones y que por eso tienen que ser retirados. Intervenciones propias del neoliberalismo y su correlación jurídica, el Estado de Excepción Permanente. Entendemos que políticas de gobierno que rigen sus acciones por la abstinencia e internación de los usuarios clasificados como dependientes químicos están en sinergia con la denominada guerra a las drogas. Nuestro objetivo es señalizar que la atención al uso de substancias psicoactivas conforme determinado por la estrategia de la reducción de daños tiene potencial para capilarizar las directrices del Sistema Brasileño de Salud (SUS), de la Reforma Psiquiátrica Brasileña y, de ese modo, del alcance democrático en los territorios de mayor vulnerabilidad social. (AU)

The Compromising Interpretive Model as a Harm Reduction Strategy for Families that Have Chosen High School Football.

In a reply to Ross, I argue that, as head injuries often lack external indicators, it is imperative that youth-patient-athletes themselves be convinced to report these injuries. Parents, although part of the pediatric triad, will be no help if the adolescent chooses to conceal the information from them as well. Further, I explain why a more deliberate focus on the role of parents in this relationship does not alter my support of the compromising interpretive model as a harm reduction strategy.

Re-assessing the Triadic Model of Care for Trans Patients Using a Harm-Reduction Approach.

The World Professional Association for Transgender Health's Standards of Care (WPATH SOC), now in its seventh edition, is a frequently cited, internationally recognized, evidence-based document that details a comprehensive framework for gender-related care of trans people. However, the WPATH SOC still relies heavily in some cases on gatekeeping practices, dubbed "triadic therapy," or a process where a trans patient is encouraged to seek out psychotherapy, and hormone therapy, and only then be able to engage in surgical options for transitioning. I use G. Alan Marlatt's harm reduction framework to argue that the triadic process creates its own set of harms that trans people have to contend with, especially insofar as it focuses on resolving gender dysphoria in a demanding, moralizing, and top-down way as opposed to enriching trans lives by reducing harms that prevent us from flourishing. Using Marlatt's criterion that harm reduction ought to be bottom-up, low threshold, and not moralizing, I develop a list of suggestions for what ought to be centrally considered in treating trans patients.

How Should Physicians in Low- and Middle-Income Countries Regard Electronic Nicotine Delivery Systems to Facilitate Smoking Cessation?

Electronic nicotine delivery systems (ENDS) have been widely referred to as "safer," "healthier," and more "effective" smoking cessation aids, but little evidence supports such claims. New concerns about pulmonary injuries associated with ENDS suggest reasons for concern about these products' health risks and potential for nicotine addiction. Nevertheless, multinational tobacco companies heavily market ENDS to retain customers with nicotine addiction, and global progress against tobacco use might slow as a result. The tobacco industry has managed to divide the tobacco control community by offering hope of harm reduction without actual evidence of ENDS' effectiveness or long-term safety. Low- and middle-income countries need this evidence to assess ENDS' value in mitigating tobacco use.

Drawing the line on in vitro gametogenesis.

In vitro gametogenesis (IVG) might offer numerous research and clinical benefits. Some potential clinical applications of IVG, such as allowing opposite-sex couples experiencing infertility to have genetically related children, have attracted support. Others, such as enabling same-sex reproduction and solo reproduction, have attracted significantly more criticism. In this paper, we examine how different ethical principles might help us to draw lines and distinguish between ethically desirable and undesirable uses of IVG. We discuss the alleged distinction between therapeutic and non-therapeutic uses of assisted reproduction in the context of IVG, and show how it is both problematic to apply in practice and theoretically dubious. We then discuss how the ethical principles of reproductive justice and beneficence apply to IVG for opposite-sex reproduction, same-sex reproduction, and solo reproduction. We suggest that these principles generate strong reasons for the use of IVG for opposite-sex and same-sex reproduction, but not for solo reproduction.

Research 101: A process for developing local guidelines for ethical research in heavily researched communities.

BACKGROUND: Marginalized communities often attract more than their share of research. Too often, this research benefits researchers disproportionately and leaves such communities feeling exploited, misrepresented, and exhausted. The Downtown Eastside (DTES) neighborhood of Vancouver, Canada, has been the site of multiple public health epidemics related to injection drug use as well as the site of much community-led resistance and struggle that has led to the development of cutting-edge harm reduction interventions (e.g., North America's first supervised injection facility, Insite) and a strong sense of community organization. This background has made the DTES one of the most heavily researched communities in the world. Amidst ongoing experiences of unethical or disrespectful research engagement in the neighborhood, a collaboration between local academic researchers and community representatives developed to explore how we could work together to encourage more respectful, community-responsive research and discourage exploitative or disrespectful research. METHODS: We developed a series of six weekly workshops called "Research 101." These workshops brought together approximately 13 representatives from peer-based organizations in the DTES with a variety of experiences with research. Research 101 created space for community members themselves to discuss the pitfalls and potential of research in their neighborhood and to express community expectations for more ethical and respectful research. RESULTS: We summarized workshop discussions in a co-authored "Manifesto for Ethical Research in the Downtown Eastside." This document serves as a resource to empower community organizations to develop more equitable partnerships with researchers and help researchers ground their work in the principles of locally developed "community ethics." Manifesto guidelines include increased researcher transparency, community-based ethical review of projects, empowering peer researchers in meaningful roles within a research project, and taking seriously the need for reciprocity in the research exchange. CONCLUSIONS: Research 101 was a process for eliciting and presenting a local vision of "community ethics" in a heavily researched neighborhood to guide researchers and empower community organizations. Our ongoing work involves building consensus for these guidelines within the community and communicating these expectations to researchers and ethics offices at local universities. We also describe how our Research 101 process could be replicated in other heavily researched communities.

Does a Patient's Trauma History Ethically Justify a Discriminatory Clinical Referral?

This article analyzes a child psychiatrist's referral approach when the patient's care must be transferred to an adult psychiatrist and the otherwise best adult psychiatrist has "accented" language, which is associated with the patient's prior trauma. The analysis considers the value of simplicity and a related "simplicity strategy," revealing that many ethical factors lay behind the simplicity approach. The inquiry then addresses simplicity regarding practical wisdom and context. The paper argues that simplicity should mean considering just what's relevant and no more. Applied to the case, simplicity includes respect for persons, openness, honesty, trustworthiness, beneficence, nonmaleficence, ethics of care, professional empathy, group inquiry, epistemic humility, and justice. An objection regarding undue complexity is noted and refuted.

Smoking and hospitalisation: harnessing medical ethics and harm reduction.

As resident physicians practicing Internal Medicine in hospitals within the USA, we are confronted on a daily basis with patients who wish to leave the hospital floor to smoke a cigarette. While many physicians argue that hospitals should do everything in their power to prevent patients from smoking, we argue that a more comprehensive and nuanced approach is needed. In part 1 of this perspective piece, we outline the various forms of smoking bans in hospital settings, applauding the development of indoor smoking bans while questioning the move towards stricter, campus-wide smoking bans. In part 2, we turn to traditional biomedical ethics to guide our approach to the hospitalised patient who smokes. This approach, which is informed by our backgrounds in harm reduction and medical anthropology, takes into account the lived realities of patients and acknowledges the complicated sociohistorical contexts of tobacco use.

Harm reduction: Philosophical drivers of conceptual tensions and ways forward.

Of the various debates surrounding harm reduction, a conceptual tension that perhaps has the most relevance for the provision of services is that of harm reduction as a technical solution versus a contextualized social practice. The aim of this paper was to examine this conceptual tension. First, the two perspectives will be presented through the use of examples. Second, philosophical drivers that serve to underpin and justify each perspective will be explicated at the level of the knowledge that we privilege; the ideologies that we subscribe to; and the interests that we stand to serve. In this paper, I argue that the existing tension between technical and social approaches to harm reduction is embedded within discord pertaining to ways of knowing, paradigms of inquiry, prevailing ideologies, and notions of harm and risk. Building on these sources of tension, I suggest a means of philosophical reconciliation between the two approaches and ways forward, namely through acknowledging multiple sources of knowledge, through embracing paradigmatic incommensurability, through considering alternative conceptions of people who use drugs as political subjects, through involving service providers and end-users in shared decision-making, and lastly through reaffirming people who use drugs as the intended beneficiaries of services.

Should we talk about the 'benefits' of breastfeeding? The significance of the default in representations of infant feeding.

Breastfeeding advocates have criticised the phrase 'breast is best' as mistakenly representing breastfeeding as a departure from the norm rather than the default for infant feeding. Breastfeeding mothers have an interest in representing breastfeeding as the default, for example, to counteract criticism of breastfeeding outside the home. This connects to an increasing trend to frame feeding babies formula as harmful, which can be seen in research papers, public policy and information presented to parents and prospective parents. (1) Whether we frame infant-feeding decisions in terms of harming or benefit, protection or risk matters because these distinctions are generally morally significant and thus (2) holding that those who decide to use formula 'harm', 'risk harm' to their babies or describing formula feeding as 'dangerous' is likely to contribute to guilt associated with formula feeding and thus to undermine the well-being of vulnerable women. It may undermine attempts to improve breastfeeding rates by leading women to reject information about health outcomes surrounding infant-feeding decisions. However, (3) these distinctions do not apply easily to infant-feeding decisions, in part because of difficulties in determining whether we should treat breastfeeding as the normative baseline for infant feeding. I show that neither the descriptive 'facts of the matter' nor moral or pragmatic considerations provide an easy answer before discussing how to respond to these considerations.

Patient safety ward round checklist via an electronic app: implications for harm prevention.

INTRODUCTION: Patient safety is a value at the core of modern healthcare. Though awareness in the medical community is growing, implementing systematic approaches similar to those used in other high reliability industries is proving difficult. The aim of this research was twofold, to establish a baseline for patient safety practices on routine ward rounds and to test the feasibility of implementing an electronic patient safety checklist application. METHODS: Two research teams were formed; one auditing a medical team to establish a procedural baseline of "usual care" practice and an intervention team concurrently was enforcing the implementation of the checklist. The checklist was comprised of eight standard clinical practice items. The program was conducted over a 2-week period and 1 month later, a retrospective analysis of patient charts was conducted using a global trigger tool to determine variance between the experimental groups. Finally, feedback from the physician participants was considered. RESULTS: The results demonstrated a statistically significant difference on five variables of a total of 16. The auditing team observed low adherence to patient identification (0.0%), hand decontamination (5.5%), and presence of nurse on ward rounds (6.8%). Physician feedback was generally positive. CONCLUSIONS: The baseline audit demonstrated significant practice bias on daily ward rounds which tended to omit several key-proven patient safety practices such as prompting hand decontamination and obtaining up to date reports from nursing staff. Results of the intervention arm demonstrate the feasibility of using the Checklist App on daily ward rounds.