Module 8: Harm Reduction – Topic A Describe how harm reduction fits with professional ethics and standards.

Learning Objectives

By the end of this topic, the student should be able to:

• Define harm reduction.
• Define ethics and morals.
• Discuss professional ethics (as it applied to opioid use and opioid use disorder).
• Describe how professional ethics and standards guide the roles of social workers, nurses, and pharmacists.

Key Concepts

• Foundational to harm reduction is that the health care professional or service provider has two goals: to help, and not to harm.
• Harm reduction approaches acknowledge that an activity is going to happen, that there are risks associated with that activity, and that those risks can be mitigated.
• The central feature that most distinguishes harm reduction from treatment in the area of substance use is that harm reduction is underpinned by the philosophy/value to set aside treatment and outcome goals, etc., from reducing the harms associated with substance use — fundamentally, it is a non-judgmental approach.
• Morals are derived from a community, group, religion, etc., but are also your own sense of right or wrong.
• Ethics are rules from an external source, adopted by the individuals. Professional ethics are adopted by the members of a profession and help to guide decision making in their work.
• Nursing, Social Work, and Pharmacy vary with respect to national vs. provincial codes of ethics and standards of practice. Most do not specifically address harm reduction related to substance use.

Harm Reduction

"…harm reduction as a philosophy shifts the moral context in health care away from the primary goal of fixing individuals towards one of reducing harm."

On a daily basis, efforts and interventions to reduce harm occur across health professions.

Harm reduction approaches acknowledge that:

• An activity is going to happen.
• There are risks associated with that activity.
• Those risks can be mitigated.

Many associate harm reduction with illicit drugs and drug use. However, “harm reduction focusses on introducing practices that mitigate harms, not only of substance use, but also of the historical, socio-cultural and political factors related to responses to substance use” (Pauly, 2008).

Harm Reduction and Substance Use

The legal status of certain drugs, stigma, and lack of understanding about substance use led to a historical focus on prevention and treatment for substance use and substance users.

By definition:

• Preventing substance use/abstaining avoids harms associated with drug use.
• For someone experiencing harms associated with substance use, treatment (and the subsequent goal of abstinence) also eliminates harms associated with substance use.

However, these approaches failed to recognize that prevention and treatment are often ineffective. In these situations, interventions are often necessary. Interventions to reduce harms associated with ongoing substance use include, but are not limited to:

• Needle distribution programs
• Naloxone distribution
• Supervised consumption sites

Certain interventions, such as opioid agonist therapy (OAT), can be labeled both harm reduction and/or treatment, depending on the individual.

Attitudes and access to harm reduction services change and evolve over time.

Ethics and Morals

Morals are derived from a community, group, religion etc. but are also one’s own sense of right or wrong (McKay & Whitehouse, 2015).

Ethics are rules from an external source, adopted by the individual. Professional ethics are adopted by the members of a profession and help to guide decision making in their work (Canadian Nurses Association, 2017).

• Members of a profession may need to deviate from their morals in order to adhere to professional ethics
• Members of a profession may decide to deviate from adhering to professional ethics to maintain their morals

Moral uncertainty occurs when someone suspects but is unsure whether they are facing a moral or ethical dilemma, and may not know what moral or ethical principles are being challenged.

A moral dilemma exists when there is a clear conflict between two or more moral or ethical principles — there is no fully satisfactory outcome, i.e., some compromise will occur.

Moral distress occurs when one feels that there is a right course of action, but due to professional, institutional, societal constraints, that action can not be taken.

• This can result in moral residue, which can accumulate over repeated incidents and can cause distress to the individual

For health and social service professionals the following can complicate professional decision making about harm reduction activities:

• gaps in education,
• rapid changes in drug regulation,
• policy, and
• shifting patient and public perceptions around harm reduction.

Most professional codes of ethics and standards do not address or provide guidance on “harm reduction” specifically, so ethics and standards must be applied to harm reduction.

Harm Reduction and Professional Ethics and Standards in Nursing

The Canadian Nurses Association publishes the “Code of Ethics for Registered Nurses” (last edition was 2017).

• Although preventing harms in a variety of contexts is discussed in this document, substance use is not one of these, and the term “harm reduction” is not mentioned
• Harm reduction and substance use are not specifically addressed in the Standards of Practice developed by the Canadian Council for Practical Nurse Regulator
• Provincial and territorial Colleges and regulators direct members to the national nursing ethics and standards documents
• Harm reduction has been added as one of 15 new competencies by Ontario’s nursing regulatory body, the College of Nurses of Ontario (CNO) (2018, p.5, entry; 1.16), effective September 2020

Harm Reduction and Professional Ethics and Standards in Social Work

The Canadian Association of Social Workers (CASW) publishes several policy and position statements on their website, including supporting harm reduction as a key part of federal drug policy.

• The CASW “Guidelines for Ethical Practice” does not specifically address harm reduction
• In addition to many provincial bodies adopting the national ethics document, they also publish their own standards of practice and/or additional materials related to ethics
• Most provincial bodies do not address harm reduction specifically, however the Alberta College of Social Workers published “Your professional Duties around Overdose Response Kits” on their standards and ethics resources page

Harm Reduction and Professional Ethics and Standards in Pharmacy

At the national level, the Canadian Pharmacists Association (CPhA) publishes a series of topics in their “Advocacy” section. With respect to the opioid crisis, CPhA outlines actions pharmacists can take to tackle the crisis, including decreasing inappropriate opioid use and opioid use monitoring.

• In addition, CPhA states that pharmacists should engage in “Supporting harm reduction strategies to assist those with addiction” as well as linking to information for pharmacists about naloxone and its administration

Like the other professions, most Provincial codes of ethics/standards do not specifically address harm reduction, however many provide resources to members about harm reduction, particularly naloxone, that became available for distribution from pharmacies in 2016.

Stop and Think

Now that you have reviewed this content, consider the following scenarios:

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References