Commentary
Public health or human rights: what comes first?

https://doi.org/10.1016/j.drugpo.2004.02.001Get rights and content

Abstract

Respect for human rights is a defining feature of harm reduction, which is commonly characterised as a public health-based movement. The importance it attaches to ‘user-friendliness’ and the view that drug users have a right to the same respect and dignity that other users of health and social care services receive is largely undisputed among harm reductionists. Within harm reduction there is also a developing discourse identifying drug use itself as a human right; nudging harm reduction towards being a rights based movement. This allows us to describe two philosophies of harm reduction: a ‘weak rights’ version, in which people are entitled to good treatment and a ‘strong rights’ version that additionally recognises a basic right to use drugs. Prioritising human rights or public health can lead to different concepts of harm reduction and different forms of ‘right action’. Privileging health may even, in some circumstances, be consistent with prohibitionary policies if these reduce harm. By contrast, the strong rights version of harm reduction subordinates public health considerations to the right to use drugs and implies support for policies that may sometimes increase harm. In the UK, the publication of ‘The Angel Declaration’, which recognises a right to use drugs and proposes a skeletal regulatory framework for a post-prohibition era, adds to the impetus for harm reductionists to clarify whether they fully embrace a right to use drugs within their understanding of harm reduction. This paper elaborates these issues in the context of the constraints upon the development of an evidence-based approach to controlling drug use that arise from the UN Conventions of 1961, 1971 and 1988.

Introduction

The debate concerning the place of ‘human rights’ within harm reduction has developed in recent years (Ezard, 2001, Hathaway, 2001, Miller, 2001). A fundamental human right to use drugs has been proposed as an adjunct to the Universal Declaration of Human Rights (van Ree, 1999). These developments occur alongside parallel demands that their right to use drugs should be recognised from among the growing number of people within the drug user movement who are also harm reductionists.

Within the UK, this debate has been further stimulated by the publication of The Angel Declaration, which results from a collaboration between a number of different drug reform activists and groups. It calls for an end to drug prohibition and recognises a right to use drugs, while promoting a system of regulated drug availability through licensed outlets alongside policies based on harm reduction. In effect, the Declaration generates a challenge to British harm reductionists to decide whether the right to use drugs is part of their definition of harm reduction: a debate that has resonance for harm reductionists elsewhere.

These debates have both theoretical and practical implications concerning what harm reduction is, what harm reductionists do in their practice, what sort of society—if any—harm reductionists are trying to generate and, concerning strategic questions of how best to get there.

Although harm reduction lacks a formal definition, different versions have been offered in the literature or are implied by more recent discussions about the right to use drugs. This paper contrasts two stylised versions of harm reduction: a ‘weak rights’ version prioritising health and a ‘strong rights’ version that fully recognises a right to use drugs. It is worth noting that these versions are exactly that—stylised. They are attempts to capture the essence of two possible, contrasting positions and are intended as an aid to analysis. In practice, many people may feel that their conception of harm reduction occupies some mid-ground between these two positions.

The choice of the terms ‘weak’ and ‘strong’ reflect the position of these two versions along a continuum of sovereignty over the body, in line with Mill’s original conception of liberty—the essence of which is captured in the following extract:

The object of this Essay is to assert one very simple principle, as entitled to govern absolutely the dealings of society with the individual in the way of compulsion and control, whether the means used be physical force in the form of legal penalties, or the moral coercion of public opinion. That principle is, that the sole end for which mankind are warranted, individually or collectively, in interfering with the liberty of action of any of their number, is self-protection. That the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinions of others, to do so would be wise, or even right. These are good reasons for remonstrating with him, or reasoning with him, or persuading him, or entreating him, but not for compelling him, or visiting him with any evil in case he do otherwise. To justify that, the conduct from which it is desired to deter him, must be calculated to produce evil to some one else. The only part of the conduct of any one, for which he is amenable to society, is that which concerns others. In the part which merely concerns himself, his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign.

–(John Stuart Mill, On Liberty, 1869)

The strong rights version embodies these principles of sovereignty over the body and limits the means by which we may promote health to those approaches that are essentially persuasive. In accordance with Mill, compulsion is not permitted other than when, by exercising one’s rights, they ‘produce evil to someone else’. This strong rights version is therefore rights-based: rights over the body are prioritised.

In the weak rights version sovereignty over the body is potentially more constrained. Although some formulations of public health attach paramount importance to human rights, in the stylised version described here, optimising the health of the population is prioritised above all other considerations. Within this conception, if evidence suggested that health would be enhanced by limiting the population’s dominion over their bodies, this constraint on liberty might be seen as an acceptable cost within a health-optimising project.

It is, of course, immediately important to acknowledge that definitions of public health are diverse and that some conceptions of public health are more rights-based, rejecting the more paternalistic approach considered here. For example, in a discussion of the ‘new public health’ Ashton and Seymour (1993, p. 108) refer to the links between empowerment, ‘citizen control’ and risk-taking behaviour in a way that is in sympathy with the strong rights model. Nevertheless, there is ambiguity within the public health literature about the degree of control that people may ultimately exercise over their bodies and this means that a public health approach seems potentially to accommodate both weak and strong rights versions.

Section snippets

The public health perspective

Although, for practical purposes, there is a good deal of consensus about what harm reduction is amongst its adherents, it has no formal, agreed definition. The International Harm Reduction Association—the official organisation of the harm reduction movement—does not currently offer one. A number of definitions of harm reduction have nevertheless been proposed (e.g., Hamilton et al., 1998, Lenton & Single, 1998, Newcombe, 1992). Within the definitions offered, harm reduction is commonly

A ‘strong rights’ version of harm reduction

In contrast to the health-optimising imperative, an alternative, under-pinning principle for harm reduction can be suggested, which is to regard people’s decision to ingest drugs of whatever sort by whatever means as an inalienable human right. van Ree (1999) has proposed exactly such a thing within the pages of this journal, in which he advocates the inclusion of a new ‘Article 31’ within the Universal Declaration of Human Rights “Everyone has the right to use psychotropic substances of one’s

The Angel Declaration

During 2001, a group of UK drug law reform groups and individual activists gathered together to attempt a process of harmonising their view of what system should replace drug prohibition, in order to campaign collectively on this platform rather than speaking from contradictory stances. The process largely look place within an Internet discussion list—the Blue Skies Group—and was moderated by a barrister and board member of the British civil rights organisation Liberty. Membership was

Discussion

The language of human rights provides a comfortable, verbal touchstone for harm reductionists. Yet, it can refer both to relatively uncontroversial rights—such as the right to treatment with respect and dignity by services, as well as more basic rights over the body—the right to use drugs of one’s choice. This suggests that individual harm reductionists should be clear about which rights they regard as inviolable, which are more qualified rights, and which are not necessarily rights at all.

This

Acknowledgements

I am grateful to the anonymous referees whose comments caused me to attempt a number of revisions and improvements.

References (23)

  • Fromberg, E. (1992). A harm reduction educational strategy towards ecstasy. In P. O’Hare, et al. (Eds.), The reduction...
  • Cited by (56)

    • Policy actor views on structural vulnerability in harm reduction and policymaking for illegal drugs: A qualitative study

      2022, International Journal of Drug Policy
      Citation Excerpt :

      Critics have questioned the extent to which contemporary harm reduction policies have balanced protecting the rights of PWUD and promoting population health. For example, some have argued that the institutionalization of harm reduction has over-emphasized individual risk reduction (e.g., behaviour change, personal responsibility), and masked social and structural injustices that drive harm for PWUD (Ezard, 2001; Fischer et al., 2004; Hathaway, 2001; Hunt, 2004; Keane, 2003; Pauly, 2008; Roe, 2005). These critiques support initiatives to re-center human rights in drug policy, and refocus harm reduction policy and practice towards addressing structural, rather than personal factors that contribute to harm at the population level (Albert, 2012; Campbell & Shaw, 2008).

    • “There are solutions and I think we're still working in the problem”: The limitations of decriminalization under the good Samaritan drug overdose act and lessons from an evaluation in British Columbia, Canada

      2022, International Journal of Drug Policy
      Citation Excerpt :

      However, studies show that policing in drug markets is associated with poor social and health outcomes for people who use illicit drugs (PWUD), including reduced access to health and social services, and unsafe drug use practices that contribute to infectious disease and overdose (Aitken et al., 2002; Beletsky et al., 2014; Hayashi et al., 2013; Small et al., 2006; The London School of Economics & Political Science, 2014; Volkmann et al., 2011; Werb et al., 2008). Moreover, punitive approaches to substance use and associated campaigns, such as the War on Drugs, perpetuate stigma and marginalize and impact PWUD participation in society (Hunt, 2004). The criminalization of drugs contributes to intersecting structural vulnerabilities based on drug use, racial identity, socioeconomic status, sexual orientation, and gender identity (Friedman et al., 2021; Gordon, 2006).

    • Reducing harms through interactions: Workers orienting to unpredictable frames in a low-threshold project for people injecting drugs

      2020, International Journal of Drug Policy
      Citation Excerpt :

      This changes the traditional institutional client-worker power dynamic (see Drew & Heritage, 1992; Juhila & Hall, 2017) and enables a particularly client-centred approach – one of the core aims of harm reduction. Compassionate and open approaches to interaction are important avenues through which to strive for harm reduction's aim of social equality (see Hunt, 2004; Hurme, 2004; Tammi, 2007) and increase socially excluded people's confidence towards society and social and healthcare services (see Krüsi et al., 2009; Perälä, 2012). The results should be interpreted through the study's institutional context; the existence of the analysed frames cannot be generalised to all harm reduction work.

    • Supervised consumption rooms: The French Paradox

      2013, International Journal of Drug Policy
      Citation Excerpt :

      A repressive context towards drug users contributes to creating an “environment of risk” which increases the marginalization and stigmatization of drug users as well as their exposure to infectious diseases (Bourgois, 1998; Rhodes et al., 2007). On the contrary, a “strong rights version” of risk reduction recognizes the right of individuals to consume drugs (Hunt, 2004) and by inference supports the implementation of supervised drug consumption rooms. France is a model state in the area of opioid substitution treatments (OST), with approximately 80% of the country's heroin-dependent drug users benefiting from OST.

    • Well-written but misplaced: A response to Barrett's comment

      2012, International Journal of Drug Policy
    View all citing articles on Scopus
    View full text