were associated with program implementation, it would still not necessarily be ruled out on ethical grounds.

A fundamentally different approach to ethical analysis is the deontologist approach. In this approach, actions are taken because they are right within themselves, not necessarily because some good will ensue. Accordingly, if one has concluded that injection drug use is immoral, then one may not ethically cooperate in any way with this behavior. Needle exchange programs would be viewed as immoral because they provide the material means for an immoral activity and therefore share in the evil of that activity.

Given these examples of two fundamentally divergent views of what is ethically acceptable, it is not surprising that there has been and continues to be substantial public discourse about the distribution of needles, syringes, and bleach. Nonetheless, both the public health and community well-being are at stake until we find common ground on which to clarify objectives and establish appropriate ways to reduce the spread of HIV, which may include the establishment of needle exchange and bleach distribution programs. As noted by O'Brien (1989), there is value in developing common definitions and mutually agreed-on ethical standards of analysis. Until such standards are set forth, it will be difficult to engage in a constructive ethical debate.

PUBLIC OPINION POLLS

A thorough review of public opinion polls conducted between 1985 and 1991 indicates that half of the general public supports harm reduction efforts that include needle cleaning, legalizing needle sales, needle exchange, and needle distribution (Lurie et al., 1993). Approval has tended to be higher for programs that combine bleach distribution and needle exchange than for programs that focus on needle distribution (Table 4.1). More important, the available evidence indicates that this support has tended to increase over time, as the issues have been publicly debated and more programs have been implemented.

For example, the Gilmore study (Table 4.1, Panel A) showed an increase in approval between 1988 and 1991 for teaching people to use bleach. In the same interval, that study showed an increase in support for legalizing the sale of needles and syringes to drug users (Panel B), and a similar rise in approval for needle exchange (Panel C). The studies in these three panels show substantial, sometimes majority support for measures that make sterile needles more available to injection drug users. With regard to the distribution of free sterile needles to injection drug users in order to retard the spread of AIDS (Panel D), again, between 1985 and 1991 across various locations, substantial support was found, although less than a majority in each opinion study.

As another illustration, the results of a 1994 household survey showed a



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