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Preventing HIV Transmission: The Role of Sterile Needles and Bleach
The moral arguments that are a common theme of community groups concerned with needle exchange and bleach distribution programs also appear in federal policy statements. A critique of the New Haven needle exchange evaluation study by the Office of National Drug Control Policy illustrates this point (1992:1): "There is no getting around the fact that distributing needles facilitates drug use and undercuts the credibility of society's message that using drugs is illegal and morally wrong."
Ideological and moral concerns are not scientific, empirically based arguments; however, this in no way dilutes their importance. Needle exchange and bleach distribution programs can be established only within the context of communities, and their success or failure is highly dependent on the support and leadership of community members. The strength of the scientific arguments and their weight relative to the ethical case for or against these programs can be and have been debated at length by ethicists and other concerned individuals.
Although it is beyond the scope and expertise of the panel to fully examine the complex range of ethical issues that might be judged relevant to analyze the establishment of public health policies, we nonetheless present two fundamentally divergent views that may contribute to an understanding of the polarization encountered when the establishment of needle exchange and bleach distribution programs is considered.
Within the context of an ethical debate, whether needle exchange and bleach distribution programs contribute to increased drug use in society constitutes one of many harms and/or benefits that must be weighed relative to others (Pellegrino, 1990; O'Brien, 1989). Weighing the relative benefit and relative harm associated with an action before making a judgment about its ethical soundness has been called the proportionalist approach to ethical analysis (Fuller, 1993). Using this approach, one can argue that people are morally compelled to support a lesser harm (evil) in order to prevent a greater harm. From this perspective, the most convincing argument in favor of needle exchange programs lies in their claim as a significant strategy for reducing harm.
Two ethical traditions take the proportionalist approach. In Jewish medical ethics, the principle of pkuach nfesh mandates the protection of human life and holds that, when a life is at stake, all prohibitions contained in the Torah and the Talmud may be waived to save that life (Jakobovits, 1959). The other ethical tradition that supports the proportionalist position is the moral theology of Alphonsi Mariae de Ligorio (1907), which argues that it is ethical to support a less evil activity in order to prevent a more evil one. In the case of needle exchange and bleach distribution programs, according to this tradition, even if some empirically demonstrated harms