The value of harm reduction for injection drug use: A clinical and public health ethics analysis

Dis Mon. 2019 May;65(5):119-141. doi: 10.1016/j.disamonth.2018.12.002. Epub 2018 Dec 29.


The US is facing dual public health crises related to opioid overdose deaths and HIV. Injection drug use is fueling both of these epidemics. The War on Drugs has failed to stem injection drug use and has contributed to mass incarceration, poverty, and racial disparities. Harm reduction is an alternative approach that seeks to decrease direct and indirect harms associated with drug use without necessarily decreasing drug consumption. Although overwhelming evidence demonstrates that harm reduction is effective in mitigating harms associated with drug use and is cost-effective in providing these benefits, harm reduction remains controversial and the ethical implications of harm reduction modalities have not been well explored. This paper analyzes harm reduction for injection drug use using the core principles of autonomy, nonmaleficence, beneficence, and justice from both clinical ethics and public health ethics perspectives. This framework is applied to harm reduction modalities currently in use in the US, including opioid maintenance therapy, needle and syringe exchange programs, and opioid overdose education and naloxone distribution. Harm reduction interventions employed outside of the US, including safer injection facilities, heroin-assisted treatment, and decriminalization/legalization are then discussed. This analysis concludes that harm reduction is ethically sound and should be an integral aspect of our nation's healthcare system for combating the opioid crisis. From a clinical ethics perspective, harm reduction promotes the autonomy of, prevents harms to, advances the well-being of, and upholds justice for persons who use drugs. From a public health ethics perspective, harm reduction advances health equity, addresses racial disparities, and serves vulnerable, disadvantaged populations in a cost-effective manner.

Keywords: Bioethics; Clinical; Drug overdose; Ethical analysis; Ethics; HIV infections; Harm reduction; Health equity; Health policy; Heroin; Heroin dependence; Intravenous; Naloxone; Needle-exchange programs; Opiate substitution treatment; Public health; Social justice; Substance abuse; Supervised injecting facilities.

MeSH terms

  • Beneficence
  • Crime / prevention & control
  • Ethics, Clinical
  • Harm Reduction*
  • Health Policy
  • Humans
  • Illicit Drugs / legislation & jurisprudence
  • Needle-Exchange Programs
  • Personal Autonomy
  • Public Health* / ethics
  • Substance Abuse, Intravenous*
  • United States
  • Violence / prevention & control


  • Illicit Drugs