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The Ideological Aversion to Harm Reduction

Ronald W. Dworkin
Ronald W. Dworkin
9 min read

Putting a patient under general anesthesia is a dangerous business. Waking a patient up from anesthesia is an ugly one. After I turn off the gas the patient typically thrashes and writhes like a sinner in Hell. Yet such resistance has never bothered me. I don’t want good and submissive patients. On the contrary, I want patients with the will to live. Passivity while waking up from anesthesia usually means a complication of some kind.

Anesthesiologists are unusual in this regard. Most physicians prefer patients who are submissive, pleasantly civil, and who do as they are told. This is probably why the medical profession has traditionally resisted a public health approach called “harm reduction.” Rather than try to end dangerous behaviors, harm reduction simply tries to mitigate the damage they cause. It accepts that many people will act against physician advice—thrash and writhe, so to speak, in their search for happiness—and irrationally court danger.

For example, rather than try to eliminate substance abuse, needle exchange programs recognize that some people will inevitably become addicted to drugs. These programs seek to lessen the spread of disease by giving users clean needles. Harm reduction accepts that some people will engage in ill-advised sex; rather than push abstinence, it promotes contraception to make ill-advised sex safer. Rather than ban cigarettes, harm reduction takes the desire for nicotine as a given and promotes vaping as the less dangerous alternative.

Many doctors find harm reduction strange. They instinctively view an act of opioid abuse, tobacco usage, or unsafe sex as an anarchistic phenomenon, a revolt against medicine’s ideals. Harm reduction, on the other hand, accepts that some people will live outside the law, medically speaking. Nevertheless, physician attitudes are changing. Emergency room doctors, for instance, have grown more comfortable with referring substance abusers to community treatment and needle exchange programs. As physician education improves, so likely will harm reduction’s status among doctors.

But that won’t be enough. Progress has stalled in two major areas of harm reduction—opioid abuse and smoking—not because of physician resistance but because of non-physicians drunk on ideology. For example, more than two-thirds of physicians now believe electronic cigarettes can help people stop smoking. Yet more than two-thirds of counselors at smoking quick-stop centers discourage callers from trying these products. Although the counselors lack a medical education, they do have an ideology that prejudices them against vaping. Anti-vaping ideology is more popular on the political Left than on the Right. Ideologues on the political Right discourage opioid harm reduction by demanding jail time, or at best treatment centers, for substance abusers.

Politicians with an agenda, health professionals with a one-sided passion, and front-line workers with little medical education embrace these ideologies with enough vehemence to bring progress on tobacco and opioid harm reduction to a halt. Simply teaching doctors about harm reduction won’t be enough. History shows that a popular ideology was typically needed to sweep away resistance to health reform. Doctors themselves could not do it. If anything, doctors were usually behind the curve.

For example, when the healthy lifestyle movement picked up steam in the mid-20th century, most doctors ignored it. As Jack Berryman found in his 1995 book, Out of Many, One: A History of the American College of Sports Medicine, even as late as 1984, only 15 percent of American doctors advised patients to exercise. The real push for the healthy lifestyle movement came from non-physicians, including gym owners like Jack LaLanne, and author Jim Fixx, who popularized running. By 1980, over 50 percent of Americans exercised daily, with professional medicine having little to do with the trend.

The push for change came not from doctors but from a popular ideology that captured people’s attention. The goal of an ideology is to improve the quality of people’s lives. A catchword or slogan usually sums it up. In the fitness and diet movement that word was “lifestyle.” When spoken, it meant living for personal happiness independent of what the world said or did. A new belief in personal happiness through healthy lifestyle resonated with people and sparked the fitness craze.

Chronic disease shows a similar pattern. In the mid-20th century, doctors focused primarily on acute disease, and the emerging private health insurance system awarded reimbursement on this basis. As people lived longer, chronic disease grew in importance. Yet, other than in special rehab centers geared toward stroke and polio victims or veterans with war wounds, the medical profession took little initiative. Most doctors then saw chronic diseases such as osteoporosis and joint problems as the natural consequence of aging, meriting little intervention. The drumbeat for reform came from public health activists and from businesspeople worried about chronic disease’s effects on worker productivity.

Once again, change required ideology. The operative buzzword this time was “wellness.” This term tapped into people’s desire to live longer, healthier, and better. Since all popular ideologies eventually rise to the level of government, “wellness” soon influenced policy at the federal level. In 1988, the Centers for Disease Control (CDC) established the National Center for Chronic Disease Prevention and Health Promotion. Today, chronic disease consumes 85 percent of the nation’s healthcare budget. Doctors eventually came around on the issue, but they did not lead.

Harm reduction follows the same pattern. In contraception, Margaret Sanger, the birth control activist, was a public health nurse, not a doctor. Even as late as 1959, after birth control pills had already been invented (with the help of Planned Parenthood, not the medical profession), the physician-dominated NIH refused to fund research in the area. It was an ideology—feminism—that advanced the cause, with the slogan: “My body, my choice.”

The same happened with the “designated driver” movement, which grew out of public health and celebrity activism rather than the medical profession. In the late 1980s, the Harvard Center for Health Communication worked with Hollywood to push the designated driver concept through entertainment programming. The slogan “designated driver” became so popular that, in 1991, Webster’s College Dictionary added the phrase to the American lexicon.

Ideologies mold people’s opinions into a fixed set of ideas, while also containing an element of hope and aspiration. Two ideologies work in this way to slow the cause of tobacco and opioid harm reduction.

Anti-vaping ideology’s embrace by the political Left, including the public health establishment, explains why some of the strongest anti-vaping laws exist in blue states such as Massachusetts, California, and New York. The anti-vaping crowd has some justification for its hostility toward vaping. The swelling numbers of teenagers using e-cigarettes toward the end of the last decade caused concern, although the numbers were not as high as advertised. Included were 18- and 19-year-olds, who were adults. Also included were teenagers already smoking cigarettes. Rather than an epidemic of three million new teenagers vaping in 2019, the number was probably less than 100,000. Still, the makers of electronic cigarettes did themselves no favors by appearing to ignore the problem.

What is the element of hope and aspiration in anti-vaping ideology? A perfection of the world at large, a better conduct of life, with “smoke-free” the operative slogan. Because the old victory over tobacco represents such an important public-health milestone, all nicotine products are viewed as a kind of retreat, especially e-cigarettes, which mimic the act of smoking. Anti-corporate beliefs that subordinate moneymaking to the greater good also pervade the ideology. The old slogan, “Big tobacco,” was easily re-directed toward e-cigarette makers like JUUL.

In the vaping debate, ideology often trumps science. For example, among counselors at smoking quick-stop centers, more than two-thirds believe exposure to second-hand e-cigarette vapor is harmful. This is incorrect. Second-hand vapor consists mostly of liquid droplets that fall to the ground in seconds. There is no side-stream smoke, as in regular cigarettes, but only whatever the person vaping has exhaled. What is exhaled has such a low concentration of toxins—indeed, such a low concentration of anything—with none of the dangerous tar and carbon monoxide present in tobacco smoke, that second-hand vapor likely poses no risk to bystanders. But while many doctors have modified their views toward vaping according to the science, many frontline counselors remain wedded to their belief.

Many conservatives, on the other hand, oppose needle exchange programs and overdose prevention centers, although there has been some movement on the former. When the first needle exchange program in the US was established in 1988, most Republicans viewed it as a moral hazard. More recently, some states with Republican-dominated legislatures have accepted the logic of these programs. Yet ideological resistance continues, and has led to the recent closure of needle exchange sites in some conservative counties. Although more than half the studies done on these programs show they help slow the spread of blood-transmitted diseases such as HIV and hepatitis, the ideology trumps the science.

In 2021, New York City opened the nation’s first overdose prevention center, where drug users can consume illegal drugs under supervision, have their drugs tested for impurities before injection, and receive the antidote naloxone if they overdose. Other regions are planning similar facilities. The principal goal is to reduce the 100,000 overdose fatalities that the US saw last year, a 30 percent increase on the year before.

Some resistance to the center comes from progressive community leaders who fear that opening a center only in their community will flood their neighborhoods with more substance abusers than they can handle. Their resistance is more practical than ideological; they want more centers opened up around the city to spread the population of substance abusers around. Ideological pushback comes mostly from conservatives, including US Rep. Nicole Malliotakis, a Republican, who introduced a bill that would prevent organizations operating these prevention centers from receiving federal funding.

Here the element of hope and aspiration is directed toward a utopia in which everyone behaves responsibly and rationally, and where people are law-abiding and search for happiness only within prescribed grooves. The ideology recoils from harm reduction’s counsel of skepticism. Harm reduction recognizes that some people will find their way to drug addiction by way of legitimate pain issues, or because there will always be people inclined to stupefy themselves to escape their problems. After all, even Maoist China failed to permanently stamp out opioid abuse, as heroin returned to China in the 1980s after the era of mass arrests and executions waned. Yet ideologues opposed to harm reduction view such doubts about humanity’s possible perfection not as wisdom but an obstacle. They persist in their illusion of a “drug-free society” and in their strategy of “zero tolerance” (more operative slogans).

Rep. Malliotakis contends that funding prevention centers will distract from attacking the opioid epidemic’s “root cause.” Her choice of words is interesting, as the phrase “root cause” is also a popular catchphrase on the ideological Left (as when attacking the “root cause” of poverty). In each case, the phrase symbolizes a complex political outlook grounded in the hope that someday a hidden reality behind a difficult social problem will be exposed and easily corrected, leading to a better life for all. Whenever the phrase “root cause” is spoken, it usually indicates the workings of a significant ideological current. Rarely, however, are “root causes” actually found. Life is simply too complicated to have a single root cause for anything.

As more of life is medicalized, medicine’s vision of a world made orderly, safe, and rational—in other words, “cured”—expands. A stable equilibrium once thought impossible in certain areas of life suddenly seems possible, and ideologues grow determined to achieve it. They dismiss as pessimistic harm reduction’s wisdom that some aspects of life cannot be stabilized.

Here ideologues and doctors share a common perspective. The believe they should always be trying to cure the incurable, as that’s where they show their mettle. To accept an outcome as incurable is to give up before the battle even begins. Worse, to admit people are incurable is to turn one’s back on them. To demonstrate their ingenuity and humanity, both ideologues and doctors want to tackle the unknown, the unknowable, and the incurable, which, to them, is only a relative, not an absolute, concept. Things are incurable only for the time being, within the compass of present knowledge. To say otherwise is to accept a restricted perspective.

Sadly, the history of health reform shows that an appeal to common sense rarely carries the day against such determined thinking. It takes another ideology to win—one with its own hopes, aspirations, and catchwords. Here, the cause of harm reduction has a weakness, for any harm reduction ideology must instinctively align itself with common sense, which is usually the antithesis of ideology. Sort of the anti-ideology ideology: not starry-eyed, but hardheaded about life’s limits; not conceived for the purpose of making every person virtuous, but, at best, somewhat stable, and for society to be nothing more than fairly stable, too. The catchword for this anti-ideology ideology might be “reality,” while the catchphrase might be “Let’s get real.”

So many ideologies try to remake human beings. So many ideologues imagine vistas of human perfection. In hope and aspiration, their minds soar like a flock of birds. It’s time to bring those minds back to earth. Less tobacco smoking and fewer drug overdose deaths is the hope and aspiration of harm reduction ideology.

Science / TechHealthMedicine

Ronald W. Dworkin

Ronald W. Dworkin is an anesthesiologist and political scientist. He has taught in the George Washington University Honors program, and is the author of four books and numerous magazine essays.