ARTICLE DOI: 10.1057/s41599-018-0119-3 OPEN Evidence and morality in harm-reduction debates: can we use value-neutral arguments to achieve value-driven goals? Giulia Federica Zampini ABSTRACT It is common to argue that politicians make selective use of evidence to tacitly reinforce their moral positions, but all stakeholders combine facts and values to produce and use research for policy. The drug policy debate has largely been characterised in terms of an opposition between evidence and politics. Focusing on harm reduction provides useful ground to discuss a further opposition proposed by evidence advocates, that between evidence and morality. Can evidence sway individuals from their existing moral positions, so as to “neu- tralise” morality? And if not, then should evidence advocates change the way in which they frame their arguments? To address these questions, analysis of N = 27 interviews with stakeholders actively involved in drug policy and harm reduction debates in England, UK and New South Wales, Australia, was conducted. Participants’ accounts suggest that although evidence can help focus discussions away from values and principles, exposure to evidence does not necessarily change deeply held views. Whether stakeholders decide to go with the evidence or not seems contingent on whether they embrace a view of evidence as secular faith; a view that is shaped by experience, politics, training, and role. And yet, morality, values, and emotions underpin all stakeholders’ views, motivating their commitment to drug policy and harm reduction. Evidence advocates might thus beneﬁt from devising strategies to morally and emotionally engage audiences. This paper aims to develop better tools for analysing the role of morality in decision-making. Using tools from disciplines such as moral psychology is relevant to the study of the politics of evidence-based policymaking. The School of Law and the Centre for Criminology, University of Greenwich, Queen Mary Building room 217 Old Royal Naval College Park Row, London SE10 9LS, UK. Correspondence and requests for materials should be addressed to G.F.Z. (email: G.F.Zampini@greenwich.ac.uk) PALGRAVE COMMUNICATIONS (2018) 4:62 DOI: 10.1057/s41599-018-0119-3 www.nature.com/palcomms 1 | | | 1234567890():,; ARTICLE PALGRAVE COMMUNICATIONS | DOI: 10.1057/s41599-018-0119-3 Introduction oo often, support for evidence-based drug policy has been discussed, exploring to what degree this was instrumental or framed in terms of opposites. In this characterisation, value-based (or both). Literature on the use of evidence in policy Tevidence is portrayed as the clean, scientiﬁc, neutral and has largely focused on instrumental selection of evidence to value-free solution to a dirty, partisan, ideological, and value- support a political or strategic aim, but less on how this relates laden politics. This article transcends this dualistic view by with stakeholders’ value-based, moral positions. Instances where introducing another element–that of morality. The concept of exposure to evidence enabled individuals to change their views on morality is deployed as a framing device for understanding harm drug policy issues deserve some attention, because, on the surface, reduction debates in drug policy. Throughout the paper, the term this fulﬁls the wishes of evidence advocates to overcome politics evidence refers to scientiﬁc evidence, or evidence which has been and morality as barriers to evidence-based policymaking. How- produced by deploying established scientiﬁc methods in a given ever, the conﬂation of morality and moralism by stakeholders ﬁeld. Evidence is organised hierarchically (Petticrew and Roberts, leads to a widespread supposition that morality only exists on the 2003), and although there are some differences across ﬁelds of side of the argument that is opposed to that backed by evidence. inquiry, evidence hierarchies tend to culminate with systematic This is both problematic and limiting. Liberal moral principles. reviews of Randomised Controlled Trials. Evans (2003) suggests alongside values, emotions, and experiences, underpin stake- that evidence hierarchies have mostly been constructed through holders’ commitment to harm reduction. Whilst policy analysis an exclusive focus on effectiveness of an intervention. A more would beneﬁt from further engaging with morality, evidence nuanced discussion is in order, but for the sake of brevity, the advocates need to reﬂect on their own morality, for the purposes focus will remain on evidence of effectiveness of given interven- of framing arguments and for engaging audiences. tions as a matter of political priority. Findings suggest that selection of evidence is not merely The concept of harm reduction, and particularly its proclaimed motivated by instrumental objectives, but rather underpinned by moral ambiguity, is reﬂected upon. A rhetorical shift away from a stakeholders’ values and existing moral positions. While evidence formal commitment to harm reduction–which entails reducing might affect people’s understandings of drug policy issues, it does drug-related harm to users–and towards promoting abstinence not necessarily change their deeply held views. People’s values and recovery–which entail abstaining from drugs and reaching and morals shape perceptions, thus making fundamental shifts in sobriety–has reinserted elements of morality that had remained policy much more difﬁcult to achieve despite available evidence. latent in UK and Australian drug policy (Home Ofﬁce, 2010; Stakeholders’ commitment to drug policy and harm reduction Berridge, 2012; Lancaster et al., 2015). Although harm reduction seems to be motivated by direct experience or emotional exposure began as a moral and political crusade to advocate for the rights to issues drug users face. Interestingly, some participants sug- and health of drug users, it was later incorporated into a much gested that if scientiﬁc evidence is accompanied by exposure to less openly moral model that emphasised economic arguments personal stories or direct experiences, stakeholders are more likely for drug treatment in order to justify them publicly and politically to engage by way of empathy. This is discussed with reference to (Roe, 2005). Scientists, advocates, and practitioners deployed a moral psychology literature, and particularly moral foundations value-free rhetoric to justify their endorsement of harm reduc- theory, which offers some insight into how morality operates and tion, shunning values in favour of cost-beneﬁt-driven, evidence- how it can be mobilised, potentially providing advocates with based rigour. Some commentators have argued that defending an ideas about how to engage their audiences. amoral position is preferable because it tacitly allows for a diversity of moral positions, whilst winning political backing (Keane, 2003; Beirness et al., 2008). Others disagree based on Morality, policy and harm reduction. Morality is an instrument limited achievements and loss of political control, arguing instead that individuals use to order practices and activities into cate- for an openly moral and humanist stance (Hathaway, 2001; gories of ﬁrst principles, or right and wrong (Fischer, 2004). Ezard, 2001; Hunt, 2004; Pauly, 2008). Morality is made up of values, beliefs, emotions, experience, In this context, evidence is relied upon as a tool to de-politicise principles and deliberations. It is constructed in dialogue between and de-moralise harm reduction debates. Yet the potential of the individual and the multiple environments the individual evidence to affect deeply held views is called into question: can experiences. In debates about evidence-based policymaking, evidence sway individuals from their existing moral positions, so morality is often mistaken with moralism; hence, it is con- as to “neutralise” morality? And if not, then should evidence ceptualised as subjective, reactionary, and inimical to progressive, advocates change the way in which they frame their arguments? sound, objective reasoning. Yet, morality underpins all reasoning To address these questions, I analysed data from 27 interviews and has no single political or ideological valence (Haidt, 2013; with stakeholders involved in drug policy advocacy, research, Hunt, 1999). Studies in moral psychology (Lakoff, 1996; Haidt, lobbying and decision-making in England, UK and New South 2013) and sociological studies of morality (Hunt, 1999) are useful Wales, Australia. Both countries, along with all Anglophone reminders that morality is multiple. Haidt (2013) posits that what countries, feature as ‘liberal’ in welfare regime typology categor- is regarded as moral by a liberal might be viewed as immoral by a isation (Esping-Andersen, 1990). Approaches to welfare deﬁne conservative because liberal and conservative moralities are fun- the relationship between state and citizen. In liberal states, there is damentally different; that is, different moral foundations under- a clear tendency to place the burden of responsibility on the pin political positions. Such foundations are primary in shaping individual, which is visible in established welfare policies such as people’s views and feelings about particular subjects. Some of the means-testing, workfare models, and punitive sanctions against perspectives reviewed in this article originate in the US and are the unemployed (MacGregor, 1999; Dee, 2013; Eriksson and grounded in moral psychology. This can be perplexing at the level Pratt, 2014). These shifts have become even more pronounced of terminology. In US moral psychology literature (Graham, since UK Conservatives and Australian Liberals have been in Haidt, and Nosek, 2009; Haidt, 2013; Lakoff, 1996), ‘liberal’ and government (Taylor‐Gooby, 2016; Deeming, 2017). Analysis of ‘conservative’ are used as shorthand ideal-types to denote a these two cases can give way to theoretical contributions that may propensity toward certain moral positions. In other literature, be relevant in the context of other Anglophone countries. these may sometimes be referred to through the authoritarianism/ In the following article, instances where evidence was used libertarianism dichotomy (Evans, Heath, and Lalljee, 1996; Fla- selectively to support stakeholders’ deeply held views will be nagan and Lee, 2003; Ray, 1982; Tilley, 2005). We know that 2 PALGRAVE COMMUNICATIONS (2018) 4:62 DOI: 10.1057/s41599-018-0119-3 www.nature.com/palcomms | | | PALGRAVE COMMUNICATIONS | DOI: 10.1057/s41599-018-0119-3 ARTICLE political and moral positions are not two-dimensional; we may ‘harm reduction style rhetoric, with its illusion of neutral thus observe an individual endorsing conservative economic standing in the name of empirical reason, is strategically policy whilst being socially libertarian. Conversely, another ﬂawed insofar as it disavows the moral footing needed to individual may endorse socialist economic policies whilst being address prohibitionism as both an immoral and irrational socially conservative. For this discussion, liberal and conservative approach to drug policy’ (Hathaway, 2001, p 135). positions are not intended as straightforward political afﬁliations, In response to Hathaway’s challenge, Keane takes a rather nor as political philosophies, but as moral positions associated opposing stance. She argues that ‘one of the distinguishing with particular moral foundations. elements of harm reduction has been its commitment to an In the United States, there is a literature on morality policy that amoral approach to drug use. This may not be achievable in surfaced in the mid-to-late 1990s (Haider-Markel and Meier, practice, but it is a powerful rhetorical intervention in the highly 1996; Meier, 1999; Mooney, 1999). This literature was overlooked moralised landscape of drug debate’ (Keane, 2003, p 227). until recently, when a number of scholars began applying the Following this logic, it seems clear that harm reduction is concept in the European context (Engeli, Green-Pedersen, and assumed to be stronger when value-neutral in appearance because Larsen, 2013; Heichel, Knill, and Schmitt, 2013; Knill, 2013). it can rest on the higher grounds of evidence rather than having Morality policy is here deﬁned as a ﬁeld where decisions are more to descend into messy politics and morality. This amoral and often based on ﬁrst principles (right and wrong). In such ﬁelds, evidence-based take on harm reduction becomes an effective signiﬁcant policy change is regarded as harder to achieve because advocacy strategy ‘by framing drug use as a technical and public contrasting positions are underpinned by conﬂicting, deeply held health problem rather than a moral issue’ (Keane, 2003, p 229). views (Knill, 2013; Meier, 1999; Mooney, 1999). Morality policy is Although public health problems can be framed as technical thus characterised by ‘clashes of ﬁrst principles’ and ‘not […] rather than value-oriented, they ultimately require normative technical debate about whether the policy will “work” or not’ engagement with values and principles. According to Roe, the rift (Mooney, p 676). in harm reduction reﬂects a historic tension within the move- Drug policy scholars and evidence advocates have long ment, between a moderate and medically dominated politics of popularised the concept of ‘what works’, derived from health promotion among marginalised individuals on one hand, evidence-based policy precepts, in order to move the debate and an activist, transformative politics pursuing deeper structural away from ﬁrst principles and towards pragmatic solutions and changes on the other (Roe, 2005, p 244). This tension will become compromise (i.e., Monaghan, 2010; Stevens, 2007; Strang et al., apparent in what follows, as advocating for drug users’ health, not 2012). Knill (2013) argues that drug policy debates happen on their rights (Hunt, 2004), ﬁgures as a morally and politically two levels: a deeper level of ﬁrst-principled positions, as well as a palatable stance for stakeholders. surface level concerned with practical implications, impact and “what works”. Policymakers in drug policy debates are often accused of selecting evidence in a political-tactical manner Methods (Stevens, 2007; Naughton, 2005). In the literature on models of For this paper, I analysed data from 27 interviews conducted in evidence utilisation, a political-tactical model features selection of England, UK, and New South Wales, Australia. Interviews were evidence that is motivated by a combination of strategic, political carried out as part of a PhD project focusing on understandings and interest-driven concerns. In this view, evidence is used as and uses of evidence in drug and prostitution policy (Zampini, ammunition to justify action or inaction on a given issue, in an 2016). There is a shared political and cultural heritage between instrumentally rational manner (Monaghan, 2011). This creates the UK and Australia, including the key elements of language and antagonism between evidence advocates and policymakers. the similarities in their legal system, which work well to underpin Knill (2013) proposes a different reading. He categorises drug a most similar comparative design. However, potential contrasts policy as a latent morality policy, where ﬁrst-principled positions emerge from the diversity in the structure of their respective can be strategically disguised or couched in debates about impact political systems. Australian federalism is well rooted in the and pragmatic solutions to problems, thus hiding morality country’s political structure. Similarly, the centralism of UK through evidence. This can be usefully applied to harm reduction. politics, despite more recent steps toward devolution and local- Whilst harm reduction is driven by liberal moral values such as ism, is still predominant (Zampini, 2014). With the UK under- tolerance, belief in universal health, individual and human rights going structural changes, devolving powers to its constituent and promotion of civil liberties (Hathaway, 2001; Marlatt, 1996), parts, this discussion becomes even more relevant in drug policy these values are underplayed in public health and in policy (Duke and Thom, 2014; Haydock, 2015). This process entails the debates. In this context, evidence is called upon to promote harm possibility of assessing propositions around the relative inde- reduction policies in an amoral, value-free manner (Strang et al., pendence of localities to pursue policies which deviate from 2012). Some believe that opting for value-neutral arguments by national and international directives or for the possibility of framing them as evidence-based wins them political backing, “bottom-up” initiatives to become established, which has been increased respect, and credibility (Beirness et al., 2008). By done elsewhere (Zampini, 2016). This, alongside logistical and standing on the shoulders of evidence, ‘harm reduction avoids practical ease, is the main reason smaller political units of ana- moral challenges to prohibition in favour of cost–beneﬁt analyses’ lysis, namely England and New South Wales, were selected. (Hathaway, 2001, p125), eschewing criticism and bypassing the Participants were chosen due to their direct involvement in moral and the political. policy-making, policy-relevant or policy-related research. Ethical The discussion between Hathaway (2001) and Keane (2003) approval for carrying out interviews was given by the University exposes problems that have remained latent in harm reduction as of Kent ethics committee. At ﬁrst, participants were identiﬁed a movement and as a practice since its inception. Hathaway calls through documents including academic and grey literature, eva- for the need to discard value-neutrality in favour of a value-laden, luations and reviews of relevant interventions. Participants were moral commitment to harm reduction principles. He argues that purposively identiﬁed and recruited through chain-referral. Dis- although there appear to be clear advantages to framing harm cussions verged on prominent issues in drug policy, including reduction in value-free terms, its pursuit is ultimately weakened harm reduction interventions, and particularly drug consumption by the lack of recognition of the shared values and principles that rooms. The analysis was an iterative process, allowing for the inform it. Hathaway’s conclusion rests on the premise that principle of emergence (Archer et al., 2013) to guide PALGRAVE COMMUNICATIONS (2018) 4:62 DOI: 10.1057/s41599-018-0119-3 www.nature.com/palcomms 3 | | | ARTICLE PALGRAVE COMMUNICATIONS | DOI: 10.1057/s41599-018-0119-3 investigation, whilst utilising existing models of the use of evi- and their moral stance, without needing to make their moral dence in policy as starting points, through the logic of adaptive stance manifest, by claiming that their position is evidence-based. coding (Layder, 1998). Few stakeholders are comfortable with overtly stating their Participants ranged from serving parliamentarians to moral position in the drug policy debate. Thus, they keep the grassroots-level advocates. This not only implies diversity in the focus on evidence, while engaging in debates about instrumental sample, it also signiﬁes differences of status, degree of involve- objectives. This is a typical trait of latent morality policy (Knill, ment in individual issues, and understandings and deployment of 2013), where selective use of evidence allows stakeholders to stick evidence. Participants’ varied professional backgrounds were with their pre-held view whilst justifying it through scientiﬁc grouped into three overarching categories: researchers (includes authoritativeness, or lack thereof. Thus, evidence is not simply medical/practitioners), politicians (includes political advisors, selected instrumentally, which would be political-tactical in aim: civil servants and bureaucrats) and advocates (includes knowl- Where evidence supports a particular policy, great. When it edge brokers). However, categories often intertwined, with some contradicts it, then people would be less interested. […] participants belonging to two or more. Quotes have been assigned Some degree of selective attention to what supports our using numbers preceded by the identiﬁers AU for Australia and world view (UK Researcher/Knowledge Broker 25) UK for Britain, and clearly stating the participants’ professional background(s). Identifying participants’ multiple professional The idea of selective attention is useful because it suggests that background is regarded as relevant because it contributes to individuals order and weigh evidence differently, not necessarily understanding their position vis-a-vis their experience and according to the evidence quality per se, but according to their training. deeply held views based on their principled positions (Zampini, Whereas the uses and understandings of evidence were set 2016). themes in the interviews, which led to establishing codes derived Still, the production and presentation of evidence was regarded from existing models of evidence utilisation (linear; enlight- as strategically and politically necessary, and beyond that, enment; political-tactical; interactive; evolutionary; dialogical and evidence was believed to have neutralising properties. Based on processual models as discussed by Weiss, 1979 and Monaghan, participants’ responses, the targeted production of evidence was 2011), values, emotions, experience, and beliefs were emergent useful in the debates surrounding the establishment and themes in participants’ accounts. These themes were con- continuation of a Medically Supervised Injecting Centre in ceptualised as belonging in the realm of morality. Participants Sydney: variously referred to morality, moral positions, and value-based, it was the neutralising factor of having […] that evaluation emotional or cognitive biases as barriers to the proper use of […] going on, it was producing reports all the time… it was evidence in policy. This warranted reﬂection and analysis of the just forming that wall around the centre that shielded it. proposed dichotomy between evidence and morality. (AU Political Advisor 8) In this case, evidence was useful to “neutralise” a politically Selective use of evidence: no mere instrumental cherry-picking. heated debate surrounding a controversial intervention. In other Participants saw the production and presentation of evidence as words, the framing of this debate in terms of evidence of strategically and politically necessary. Beyond that, evidence was effectiveness, rather than values such as human rights, was purported to have neutralising properties in what was regarded as politically useful. The reliance on evidence to shelter interven- a highly polarised domain. However, most participants argued tions which are politically difﬁcult to justify was noted by that stakeholders treat evidence selectively. Yet their selective participants in relation to other harm reduction policies including attention is not simply instrumental, but shaped by their moral needle and syringe exchange and opiate substitution treatment. values, politics, experience, professional training, and occupation. Exposure to evidence appeared, in some cases, to render people Participants mostly agreed that evidence could only go so far in less entrenched and more willing to engage in debates. In one case informing people’s views, because: where the participant had led a DELPHI exercise with a diverse range of stakeholders, they noted that: people will latch on to policy recommendations and conclusions that ﬁt with […] their view of the world […]. some people in this world […] are just so entrenched, but People have an underlying ethos of values and they frame the majority of people who did come from a range of their interpretation of the evidence around that. (UK different perspectives were able to move forward and Researcher/ Knowledge Broker 23) engage sensibly. (UK Researcher/Civil Servant 26) Here, the participant stresses interpretation and framing of Sensible engagement in debates might refer to people’s ability evidence as ﬁltered through one’s ethos of values. In the case of to shift their focus away from their deeply held views and towards the UK Home Affairs Select Committee on drugs (2012), the instrumental discussion about interventions (Knill, 2013), Home Secretary had a clear agenda to criticise Portuguese drug potentially fostering understanding and compromise. The same policy, which was identiﬁed as: participant inferred this when stating: selective use of evidence in order to support a prior if people could actually discuss the evidence and their position, rather than seeking to look at the evidence […] different views on it and have […] a discussion that doesn’t with a purported objectivity. (UK Politician 19) necessarily attack people’s perspectives then […] you can make progress. (UK Researcher/Civil Servant 26). In this instance, the Home Secretary framed her claims as based on evidence, or lack of evidence, as a justiﬁcation for Here, the participant makes a distinction between discussing dismissal of the Portuguese approach. Can a political-tactical aim the evidence and discussing people’s perspectives, which would be easily distinguished from a moral, value-based opposition? The imply directly engaging with their values and moral positions. Home Secretary’s position might have been political-tactical in In contrast with the idea that actors, and particularly those aim (Weiss, 1979), though at the same time it may have been whose political stakes are higher, use evidence selectively to make founded upon disagreement on ﬁrst principles (Mooney, 1999). It political gains while supporting their pre-held views, there are appears that stakeholders can satisfy both their strategic interest instances of powerful actors in both countries who took the 4 PALGRAVE COMMUNICATIONS (2018) 4:62 DOI: 10.1057/s41599-018-0119-3 www.nature.com/palcomms | | | PALGRAVE COMMUNICATIONS | DOI: 10.1057/s41599-018-0119-3 ARTICLE evidence on board even when it contradicted their existing In some cases, robust evidence of effectiveness of an position. Below is one example: intervention is not accumulated until that intervention is already in place on a reasonably wide scale. Early Needle and Syringe one Drug Minister said to me ‘look, I went into this Programmes were rolled out before robust evidence of their thinking one thing, but when the ACMD came back to me effectiveness was accumulated. Today, with their facts and their explanations, I took that on board, acted on their conclusions, on their recommendations’,so even without a randomised controlled trial for needle even though they had […] different values going into it, syringe programmes, we still can draw a conclusion that they didn’t impose that. (UK Knowledge Broker 23) needle syringe programmes do reduce HIV infection […] and we can say that with a very high degree of certainty in This suggests that some stakeholders place evidence above an area which is a mineﬁeld of emotional antagonism (AU values because they believe that evidence is value-free, or at least Medical Researcher 2) less value-laden than their own moral position. In such cases, upholding a fact/value distinction offers clear political gains for Here, the participant exposes how the evidence trumps evidence advocates. emotional antagonism around the issue of needle and syringe Participants believed that evidence-based policy was the only distribution; in other words, how evidence wins over emotion and rational and just principle on which to base drug policy, and as values. However, this bypasses the values and emotions which such they were all nominally committed to it. As Boswell (2018) would have motivated harm reduction activists to start needle argued, evidence-based policy is the ‘secular faith’ that binds exchange as an informal practice based on epidemiological stakeholders together, and a very useful myth to uphold and evidence alone, and prior to systematic accumulation of evidence frame to deploy. However, participants’ accounts suggest a of its effectiveness and cost-effectiveness. In Amsterdam, where propensity for some stakeholders to associate moralism with the ﬁrst needle and syringe programme was established in 1984, it views which are opposed to those they themselves hold. There are was the local ‘Junky Union’ that began to informally distribute many examples of this in the public domain. The Global Drug clean needles before the scheme was formally introduced by the Policy Commission published its latest report, introducing it with municipal government (Coutinho, 2000, p 1387). In this instance, the following paragraph: needle exchange appears to be motivated by a moral imperative to protect people from disease and death. It was a political initiative ‘Drug policy reforms have been difﬁcult to design, legislate of civil disobedience led by those activists which Roe (2005) or implement because current policies and responses are identiﬁed as pivotal to the creation of the movement. often based on perceptions and passionate beliefs, and what The establishment of the Medically Supervised Injecting Centre should be factual discussions leading to effective policies are in Sydney followed a similar pattern: local medical practitioners frequently treated as moral debates. The present report and activists started a medically supervised injecting centre aims to analyse the most common perceptions and fears, illegally, partly as a strategy to gain political attention, but also contrast them with available evidence on drugs and the because they believed that, morally, it was the right thing to do people who use them, and provides recommendations on (Wodak et al., 2003; Zampini, 2014). Indeed, they could rely on changes that must be enacted to support reforms toward evidence from other countries where the intervention was already more effective drug policies.’ (Global Commission on Drug in place, but was evidence primary in motivating their actions? Policy, 2017) Evidence alone is not sufﬁcient to motivate an intervention. There is a tendency to view, or at least present, the other’s Moral and political convictions need to precede, or at least position as moral, and one’s own position as evidence-based. accompany, evidence of effectiveness. Participants would thus place evidence on one side of the spectrum, and morality and politics on the opposite side, reinforcing the antagonism between evidence advocates and Liberal morality and harm reduction. The perception that policymakers: political support for harm reduction comes from economic and scientiﬁc, rather than moral grounds, was shared among parti- there is so much around the drugs debate that is morally cipants. Harm reduction interventions appeared easier to justify, and ideologically driven, that often I feel that politicians both publicly and politically, on the basis of value-for-money. An actually don’t care what the evidence base is (UK Knowl- economic principle thus overrides moral concerns for the health edge Broker 25). and rights of drug users. The case of expert opposition to the Medically Supervised I used to think that people would make decisions based on Injecting Centre in Sydney provides an example. In the quote things like human rights, or just people’s health, but below, the participant doubts the credibility of those experts who actually to make a decision […] these days unless you’ve opposed the intervention, suggesting that, had they been “true” got an economic argument that also justiﬁes it, you’ll ﬁnd it experts, they could not possibly have opposed it, so they must be that much harder to get support for it. (UK Researcher/ using their scientiﬁc expertise to disguise their moral opposition: Advocate 21) we also had so-called experts who opposed the injecting In line with a managerialist culture dominating the UK and centre […] I say so-called because I would doubt the Australian public health sectors (Germov, 2005; Pollitt, 2016), a validity of some of the experts that criticised the injecting value-free approach to harm prevails, whereby the rational centre (AU Political Advisor 8). calculation of harms is carried out in economic terms (Lenton Often, evidence advocates portray themselves as amoral, and and Single, 1998, p 219). When discussing the possibility of contrast morality with evidence, and beliefs and perceptions with establishing a drug consumption room in the UK, one participant factual discussions centred on effectiveness. This strategy is stated: 'my issue with this [...] it's never been a moral one. It's a perceived as successful because morality is conceptualised as cost-effectiveness issue' (UK Civil Servant/Advocate 22). In this moralism, and therefore seen as reactionary, emotional and case, a concern for cost-effectiveness prevails over a moral subjective, whereas evidence is conceptualised as progressive, concern for the health and rights of drug users as a matter of rational and objective. political strategy. Drug users occupy a low place in the hierarchy PALGRAVE COMMUNICATIONS (2018) 4:62 DOI: 10.1057/s41599-018-0119-3 www.nature.com/palcomms 5 | | | ARTICLE PALGRAVE COMMUNICATIONS | DOI: 10.1057/s41599-018-0119-3 of deservingness in society (a position that is value-based, Skinner The economic argument against prohibition, which would et al., 2007). This, coupled with the relatively widespread emphasise states’ ability to raise tax revenue from regulating perception that drug use is immoral, renders them both drugs, has not often translated into a signiﬁcant policy change in structurally constrained and immoral agents, in the eyes of some a different direction, perhaps with the exception of certain US (Stevens, 2011). states (Room, 2014). When referring to the money spent on the According to Pauly (2008), harm reduction principles address Medically Supervised Injecting Centre in Sydney, which has been issues of social justice by understanding access to health as the subject of multiple evaluations, one participant asked: structurally inequitable. A liberal morality implies an acceptance Why are we making such song and dance about this three that people should not be judged for their choices and behaviours. million dollars when there are zillions of dollars spent Whilst maintaining a strong normative position on the right to across the sector and across other sectors and none of that health, in moral terms, harm reduction remains a liberal stance gets evaluated? Why do we never evaluate the money that given the absence of judgement toward the individual and respect gets spent on prohibition, for example? (AU Medical toward their choice. Thus, harm reduction rests on ideas and Researcher 7) principles rooted in universal health alongside a liberal moral attitude towards the individual. For Stevens, ‘the answer to the The participant’s frustration is motivated by the perceived question of whether there is a right to drug use appears to be yes. hypocrisy arising from the lack of investment in the production of But it is a rather small yes’ (2011, p 236). Judgements among targeted evidence evaluating law enforcement expenditure vis-à- harm reduction stakeholders are split, with many supporting vis successful interventions. This might indicate that value-for- medicalised, dependent drug use whilst denying recreational use, money, an overriding principle in the multiple evaluations of the which is considered more morally ambiguous (McKeganey, Medically Supervised Injecting Centre (MSIC Evaluation Com- 2011). Given the clout of science and medicine in shaping both mittee, 2003), is not necessarily the main value which pushes drug the understanding and enabling of drug use within a public health policy in one direction or another. frame, an individualistic, rights-based approach to drugs is harder In the context of a paradigm shift toward conservatism in UK to justify politically (Hunt, 2004). politics, participants noted how drug use and addiction were Despite an overwhelming commitment to evidence as a just reframed to ﬁt the ideology of austerity. basis for decision-making in drug policy and harm reduction, Drug addiction is [depicted as] the cause of poverty. So when referring to certain aspects of drug policy such as the poverty ceases to be about not having enough money, and consequences of prohibition, some evidence advocates, who becomes the failings of the poor and the individual. So it ﬁts deﬁned themselves as supporting evidence-based policy ‘to a with an individualist political strand of thought and with a fanatical degree’ (AU Medical Researcher 2), express a sense of moral strand of thought (UK Civil Servant/Advocate 22) injustice on moral grounds. In such conservative times of austerity, the abstinence and Is it fair and just that the majority who prefer, say, alcohol recovery arguments were mounted on moral grounds (Stevens or tobacco, […] wants to punish people who have a and Zampini, 2018). different drug preference? (AU Medical Researcher 2) By critiquing maintenance prescribing, [the Conservatives] A preference entails a degree of choice, and thus expands tick moral boxes for the authoritarian and religious right beyond the medical to encompass rights, and even pleasure. The (UK Civil Servant/Advocate 22) above statement also appeals to a fairness principle, which is a moral foundation typically mobilised by liberals (Graham, Haidt In this context, can advocates who subscribe to harm and Nosek, 2009). Prior to the establishment of the Medically reduction–and its liberal moral underpinnings - challenge Supervised Injecting Centre in Sydney, participants acknowledged value-laden, moral arguments with evidence-based, value neutral that those who began running an injecting centre illegally, did so: ones? On the basis of an ethical belief […] it was a competing principle which was given much higher weight than Commitment to harm reduction: the power of emotional somebody else’s set of principles about some universal idea engagement. When reﬂecting on the inﬂuence of professional […] the good thing about harm reduction as a principle is it background and experience on individuals’ values and attitudes, does allow those negotiated responses. (AU Medical and speciﬁcally the differences between advocates and policy- Researcher 4) makers, one participant noted that: This statement implies that there is a moral basis for people’s Most of the people in NGOs are there because of some decision to support harm reduction interventions, even if they do belief system they have, […] and they are committed to it, so illegally. Yet it also implies that harm reduction as a principle […] whereas conversely most people in governmental can accommodate moral diversity. Some participants appeared to structures are by their nature not particularly driven by the support Keane’s(2003) view that the strength of harm reduction subject they are dealing with. (UK Advocate/Knowledge is its apparent value-neutrality and moral ambiguity. However, as Broker/Civil Servant 20) Roe (2005) noted, although harm reduction presupposes a lack of value judgement towards individuals’ choices, it does still rest on This reveals the common-held assumption that advocates are the values of universal welfare and universal healthcare. As one subject and value-driven, whereas politicians and bureaucrats are participant put it: not. However, interview data suggests that the degree of individuals’ engagement with drug policy and harm reduction Philosophically we work from a position of health for all will depend on the extent and nature of their experience and and a belief that our target populations have traditionally exposure to issues drug users face. If that individual is a Minister, had poor access […] to healthcare and that healthcare a Premier or a Prime Minister, the likelihood that drug policy and needs to be equitable. (AU Medical practitioner 12) harm reduction will ﬁgure highly on the political agenda appears Participants have emphasised the increased difﬁculty of to increase proportionately. For example, in New South Wales, gathering political support to fund treatment in times of austerity. the fact that Premier Bob Carr’s brother died of a drug overdose 6 PALGRAVE COMMUNICATIONS (2018) 4:62 DOI: 10.1057/s41599-018-0119-3 www.nature.com/palcomms | | | PALGRAVE COMMUNICATIONS | DOI: 10.1057/s41599-018-0119-3 ARTICLE apparently pushed drug policy higher on the political agenda, This is not only the product of politics or ideology, but also the which favoured the 1999 Drug Summit initiative, as well as the result of emotional and cognitive biases (Parkhurst, 2016), which, establishment of a ground-breaking harm reduction intervention despite being recognised, continue to be portrayed as negative as the Medically Supervised Injecting Centre (Zampini, 2014): because irrational. The Premier, who had lost a brother to drug overdose, who The human mind is perhaps not as rational as we might was quite ambivalent, he is quite a conservative person Bob wish and is subject to various biases and preconceptions Carr, but […] he put aside his own feelings, and […] he let and different ways of being inﬂuenced by data and linking it go through. […] If he had said no, that was it. Game over, those to consistency with an existing view of the world (UK right from the start. (AU Political Advisor 8) Politician 19) In this quote, the participant suggests that the premier’s Positivist notions, such as the reason/emotion dualism, limit feelings, underpinned by his conservative stance, would have the possibility of using emotional engagement both as a legitimate acted as a barrier to the implementation of the intervention. The ground for reasoning (Sayer, 2011) and as a subject of analysis. question remains, if the Premier’s brother had not died of an The role of values and emotions for the purposes of mobilisation overdose, would he have been able to empathise, to relate with the and underpinning change has been rescued and discussed in reality of a person who uses drugs, and consequently dedicate philosophical, sociological and political science literatures (Sayer, time and resources to drug policy reform? 2011; Nussbaum, 2003; Pedwell, 2014; Clarke, Hoggett and In a similar vein, Australian Prime Minister Bob Hawke Thompson, 2006). However, despite some notable exceptions (1983–1991) had instigated commitment to drug policy reform (i.e., Valentine, 2009), and albeit the literature on the use of and harm reduction at the federal level, bumping it up the evidence in policy acknowledges moral values, their sources and political agenda, because of his personal story: impacts are under-theorised, and explanations tend to emphasise interests, rather than values. His daughter had a heroin addiction, and he broke down on Evidence continues to be seen by many as a useful tool which TV and cried, and that was the start of a national campaign enables people to focus their thoughts away from their values and against drug abuse, based on the personal situation of the principles. Doing so might provide a middle ground for practical Prime Minister at the time, the one he was facing at home reasoning: with one of his kids, so that was enough to drive change… That was the start of the national strategy, it was driven out You to some extent separate out those beliefs that are the PM’sofﬁce. (AU Knowledge Broker 3) probably not subject to change because they are very integral to your […] world view […] and so how you For an individual to dedicate attention to this area, it appears interpret the evidence can be […] worked on […] without that a moral and emotional commitment is somewhat necessary. having to require people to change their fundamental […] This is also true for scientists, who might choose to engage in a underpinning world view. (UK Researcher/Civil Servant 26) form of research activism underpinned by a moral commitment to research for social change and justice, because: The drug policy debate is an emotional realm, with polarised views associated with cognitive and emotional biases, morality It’s not […]a “nice” area to do research, […] I mean these and politics. In this context, some participants emphasised that are people’s lives! (AU Medical Researcher 5) anecdotes in the form of personal stories, due to their accessible, Beneath the commitment to a rigorous, medical model to run emotions-ridden nature, go further than scientiﬁc evidence in services focusing on drug-using clients, there is a shared belief their ability to foster people’s understanding of drug policy issues. that the health needs and rights of these populations are generally Below, one participant claims that his story was a powerful driver not well catered for and that a principle of harm reduction should in shifting audiences’ attitudes towards drugs and drug use. underpin these services: They say how much their attitude changed about drugs and It all came together to give me an incredible interest in sex, drug use just by listening to my story and my presentation drugs and the public health issues around those […] our […] I can speak to a group of people and I can actually system didn’t cater well to those populations […] I was change their minds about drug policy […] I use the quite inspired by the model that was recommended […] emotion, yeah, and it is effective (AU Advocate 10) which would be non-judgemental, respectful, harm reduc- With a direct reference to using emotions, the participant tion in its focus (AU Medical Researcher 7) exposes the potential of fostering emotional engagement for In this instance, harm reduction is understood as a manner to underpinning attitude change. Other participants who did not tackle structural inequities and pursue change. This is consistent come from a scientiﬁc background and who more often dealt with with other participants’ accounts of their initial involvement in lay audiences, told of how stories and personiﬁed accounts could this area. Participants seem to pick their subject not only out of move people more than numbers, even though, they said, one training or necessity, but out of a value commitment. Although needs to use both. It is noteworthy that knowledge-brokers, stakeholders with a political or public service background are by advocates and activists, more so than researchers, are purpose- their nature generalists, and do not get to pick their subject, they fully engaging audiences emotionally through the use of personal will choose to be more or less invested in particular issues stories, aiming at empathic understanding of the issues drug users depending on their values and experience. face. Participants broadly recognise that human beings, including researchers, are subject to the limitations brought about by their beliefs and morals: Discussion: moral foundations, framing, and mobilising empathy. Among other outcomes, the rise of scientiﬁc over There are some things that you won’t necessarily change religious organisation of beliefs (Gieryn, 1983) contributed to which may be your […] personal beliefs and morals and shifting the moral domain away from the community and toward they do inﬂuence how you perceive evidence or react to it. the individual in the west. Within this process, which affected (UK Researcher/Civil Servant 26) both western liberals and conservatives (Haidt, 2013), liberals are PALGRAVE COMMUNICATIONS (2018) 4:62 DOI: 10.1057/s41599-018-0119-3 www.nature.com/palcomms 7 | | | ARTICLE PALGRAVE COMMUNICATIONS | DOI: 10.1057/s41599-018-0119-3 certainly further attached to science as ‘secular faith’ (Boswell, anxiety, whereas the latter is mobilised by empathy. Interestingly, 2018; Zampini, 2016), and to individual freedom as foundational a conservative morality as conceptualised by Lakoff is founded in their value system (Haidt, 2013). The liberal to conservative upon the mechanism of reward and punishment. He argues that spectrum is complex, and is characterised by varied, internally ‘rewards for obedience and punishments for disobedience are contradictory, and periodically changing positions, which do not crucial to maintaining moral authority; as such, they lie at the easily align with either individualised or community-based loci of heart of this moral system and are thus moral.’ (1996, p 164). moral values (expressed as the individualising-binding dichotomy Drug policy is manifestly based on mechanisms of reward (for [Graham, Haidt and Nosek, 2009]). those who abstain) and punishment (for those who use). Although the moral spectrum is not two-dimensional, and Conversely, Lakoff argues that, for liberals, ‘the primacy of moral foundations theory was put forth in order to express moral morality as empathy makes empathy a priority’ (1996, p 166). complexity, it has been observed that the importance of certain Empathy is seen as a fundamental element of liberal morality. moral foundations is greater for liberals than it is for Lakoff follows on to argue that conservatives. Speciﬁcally, liberals are more concerned with care, ‘morality as fairness is a consequence; if you empathise with harm and fairness, whereas conservatives are more concerned others, you will want them to be treated fairly. This makes with issues related with in-group protection (i.e., family or empathetic actions and actions promoting fairness into community), authority, loyalty and sanctity (Graham, Haidt and moral actions. Consequently, a lack of empathetic beha- Nosek, 2009). According to Haidt (2013, p 181), not only can viour, or actions going against fairness, are immoral’ for conservatives appeal to care and fairness, they also have ‘a near liberals (ibid). monopoly’ over authority, sanctity and loyalty; he calls this the ‘conservative advantage’. Although conservatives may have been Empathy, fairness and care are characteristics of a liberal pioneers in investing in harm reduction (i.e., in the UK under morality and can be associated with harm reduction, expressed as Thatcher), this has been regarded as primarily motivated by a concern for people’s health and rights. need to protect the in-group (i.e., the healthy, law-abiding As we have observed, some participants owed their commit- population) from the threat of drugs and drug users (i.e., the ment to harm reduction speciﬁcally to their experiential exposure, infected/criminal population) (MacGregor, 2017). Conservatives which enabled empathy and mobilised foundations of care and would thus primarily rely on authority, sanctity, and loyalty as fairness. Advocates and knowledge brokers who more often dealt foundations to justify commitment to harm reduction. Though with lay audiences including politicians and the public, conservatives are indeed motivated by moral foundations of care emphasised that evidence should not remain abstract (i.e., and fairness, these are less primary because they exist in presented through “impersonal” data and statistics) but should conjunction with other foundations, rather than reigning supreme, be personiﬁed through life narratives to allow for emotions and and as such they are interpreted and acted upon differently. empathy to play a role and “bring it home to people” (AU Liberals are comparatively unconcerned and even rejecting of Knowledge Broker 3). By way of example, stakeholders have loyalty, authority and sanctity as foundational to morality (Haidt, reported that drug-related deaths increased drastically in the past 2013). Liberals’ positions in drug policy can be conceptualised as few years in the UK. However, there has been no further resting on two axes: a rights-based axis, framing arguments investment in harm reduction services despite the tireless work of around the human rights of drug users, and a public health/ advocates who are exposing the magnitude of the problem universal health axis, framing arguments around drug users’ through numbers and headlines (ACMD, 2016; Dearden, 2017; inequitable access to health. In moral foundations terms, the care BBC, 2017; EMCDDA, 2017). and fairness foundations underpin these positions and are An alternative strategy would be to frame this issue in terms of primary in shaping liberals’ demands. Interestingly in harm individual experiences, presenting case studies in the form of live reduction debates, the ‘weak’ right to health is advocated much documents, stories and life narratives of people living with, and more openly and widely than the ‘strong’ right to use drugs dying from, addiction, alongside those numbers. In this way, (Hunt, 2004). Other than the ability to justify the former through whilst registering the scale of the problem through statistics, an an evidence-based framing, this might also be tied to the emotional connection might be enabled, encouraging moral individualistic nature of a rights-based argument, versus a public responses underpinned by empathy. If stakeholders’ moral health frame’s more universalist concern. It seems clear that foundations are already skewed towards care and fairness, and openly advocating for the right to use drugs is perceived as a if empathy is primary in the way that they operate, then advocates politically risky strategy. may have a good chance to garner support. If stakeholders’ moral According to Haidt (2013), liberal morality is problematic in foundations are skewed towards authority, loyalty and sanctity, termsofframing.Liberalsmay ﬁnd it harder than conservatives to advocates may well have a more difﬁcult task at hand. Yet, as make explicitly moral arguments because of their contemporaneous moral foundation theorists posit, alternate foundations, albeit not commitment to the individual (and her/his freedom), as well as primary, are still present and can be mobilised. This requires universalism, versus conservatives’ commitment to community and developing strategies around different moral framings that may in-group protection. As such, a public health framing may generally appeal to different stakeholders in the debate. be perceived as more successful, and less morally controversial, than a rights-based framing. Conservatives, who can appeal to the full spectrum of moral foundations and are comparatively less Conclusion concerned with individual freedom (Graham, Haidt and Nosek, In this article, I have argued that analysis of harm reduction in 2009), may ﬁnd it easier to explicitly frame their arguments in terms of morality provides an interesting angle to transcend the moral terms. Indeed, conservative arguments for recovery and evidence/politics dualism that brought evidence-based policy- abstinence are well supported by the moral foundations of sanctity, making to its impasse. Despite initial gains through the promo- loyalty and authority (Stevens and Zampini, 2018). tion of an amoral, economically driven harm reduction, political A parallel view focusing on the relationship between morality backing in both the UK and Australia is now waning in favour of and emotions is that of Lakoff (1996). He distinguishes a ‘strict less tolerant stances toward drug use, with much greater emphasis father’ from a ‘nurturant parent’ morality. The former, associated on recovery and abstinence, mounted on moral grounds (Ber- with conservatives, is one that responds more strongly to fear and ridge, 2012; Duke, 2013; Lancaster et al., 2015). Although ﬁghting 8 PALGRAVE COMMUNICATIONS (2018) 4:62 DOI: 10.1057/s41599-018-0119-3 www.nature.com/palcomms | | | PALGRAVE COMMUNICATIONS | DOI: 10.1057/s41599-018-0119-3 ARTICLE politics and morals with evidence might be perceived as advan- Received: 26 July 2017 Accepted: 1 May 2018 tageous on the surface, the extent to which value-neutral argu- ments manage to achieve value-driven goals is called into question. Partly through a process of de-moralisation, harm reduction lost its original objective–to ensure the health and rights of drug users – whilst becoming a compromised, money- Notes saving, crime-reducing set of measures deployed to fulﬁl interests 1 Advisory Council on the Misuse of Drugs, is a UK statutory body that provides outside those of drug users themselves (Hunt and Stevens, 2004). scientiﬁc advice on matters pertaining illicit drugs and their misuse. 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Social Policy Soc 9(1):1 Hubbard, Ben Hunter, and Deanna Dadusc for reading previous incarnations of this Monaghan M (2011) Evidence Versus Politics: Exploiting Research in UK Drug article. Policy Making? Policy Press, Bristol; Portland, Ore Mooney CZ (1999) The Politics of Morality Policy: Symposium Editor’s Intro- duction. Policy Stud J 27(4):675–680 Additional information Naughton M (2005) “Evidence-based policy” and the government of the criminal Competing interests: The author declares no competing interests. justice system - only if the evidence ﬁts! Crit Social Policy 25(1):47–69 Nussbaum MC (2003) Upheavals of thought: the intelligence of emotions. Cam- Reprints and permission information is available online at http://www.nature.com/ bridge University Press, Cambridge reprints Parkhurst J (2016) The Politics of Evidence: From Evidence-Based Policy to the Good Governance of Evidence Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in Pauly B (2008) Harm reduction through a social justice lens. Int J Drug Policy 19 published maps and institutional afﬁliations. (1):4–10 Pedwell C (2014) Affective relations: the transnational politics of empathy. Palgrave Macmillan, UK Petticrew M, Roberts H (2003) Evidence, hierarchies, and typologies: horses for Open Access This article is licensed under a Creative Commons courses. J Epidemiol Community Health 57(7):527–529 Attribution 4.0 International License, which permits use, sharing, Pollitt C (2016) Managerialism redux? Financ Account Manag 32(4):429–447 adaptation, distribution and reproduction in any medium or format, as long as you give Ray JJ (1982) Authoritarianism/Libertarianism as the Second Dimension of Social appropriate credit to the original author(s) and the source, provide a link to the Creative Attitudes. J Social Psychol 117(1):33–44 Commons license, and indicate if changes were made. The images or other third party Roe G (2005) Harm reduction as paradigm: Is better than bad good enough? The material in this article are included in the article’s Creative Commons license, unless origins of harm reduction. Crit Public Health 15(3):243–250 indicated otherwise in a credit line to the material. If material is not included in the Room R (2014) Legalizing a market for cannabis for pleasure: Colorado, article’s Creative Commons license and your intended use is not permitted by statutory Washington, Uruguay and beyond. Addiction 109(3):345–351 regulation or exceeds the permitted use, you will need to obtain permission directly from Roxburgh A, Burns L (2012) Accidental opioid-induced deaths in Australia 2008. the copyright holder. To view a copy of this license, visit http://creativecommons.org/ National Drug and Alcohol Research Centre, Sydney licenses/by/4.0/. Roxburgh A, Burns L, Drummer OH, Pilgrim J, Farrell M, Degenhardt L (2013) Trends in fentanyl prescriptions and fentanyl‐related mortality in Australia. Drug Alcohol Rev 32(3):269–275 © The Author(s) 2018 10 PALGRAVE COMMUNICATIONS (2018) 4:62 DOI: 10.1057/s41599-018-0119-3 www.nature.com/palcomms | | |
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