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Safe Injection Sites: An Ethical Debate
Transcript of Safe Injection Sites: An Ethical Debate
An Ethical Debate
What is a Safe Injection Site?
Safe Injection Sites are legally sanctioned and medically supervised injection centers for intravenous drug users.
To date, there is one Safe Injection Site established in North America located in Vancouver, Canada.
There are an estimated 125 000 Canadians who are intravenous drug users. One method of aiding this population and reducing an influx in said population is the establishment of Safe Injection Sites.
Are safe injection sites unethically enabling and promoting drug use? Or is aiding this population one of our responsibilities in providing ethical nursing care?
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Changing the Culture of Drug Use
CNA Code of Ethics
The establishment of safe injection sites promotes safety to both the public and the "Injecting Drug User" (IDU) population.
Such facilities have be proven to reduce cases of:
Over Dose death
Injections performed in Public
Public syringe disposal
Risk of theft & violence associated with the culture of drug use (Jozaghi & Andresen, 2013, p. 7)
One of the primary focuses of safe injection sites is disease prevention. These facilities have been proved to reduce the spread of HIV and Hepatitis C. (Jozaghi & Andresen, 2013, p. 7)
Of the 1506 registered users of Insite, 87% are infected with Hepatits C and 17% with HIV (Kondro, 2010, p. 1)
"Just because of the programs at Insite my drug use is now a third of what it was. They gave me positive thinking and stuff and I realized I can do it" (Jozaghi & Andresen, 2013, p. 7)
Additional services provided by Safe injection facilities:
addiction services (Jozaghi & Andresen, 2013, p. 7)
provides access to various health care professions including counselors, physicians and primarily nurses (Jozaghi & Andresen, 2013, p. 6)
Safe injection sites inspire many intravenous drug users to become safety and educational ambassadors within their own community (Jozaghi & Andresen, 2013).
Junkies have become advocates of the safe injection sites, promoting its use to other IDU's (Jozaghi & Andresen, 2013, p. 9).
"I always carry extra rigs in my pocket to give out to other junkies. We try to promote InSite every chance we get... if we see somebody new in town we try to take them to InSite. We are tired of seeing people OD in allies, we are tired of seeing rigs on the ground" (Jozaghi & Andresen, 2013, p. 9).
These facilities have initiated a change in the drug use culture. IDU's are advocating not only for SIS but also for each other. The profound sense of belonging and self worth that nurse's promote has given the members of this marginalized population the initiative they need to improve their condition as a whole (Jozaghi & Andresen, 2013, p. 9).
"I call it the community centre for junkies 'cause we are welcomed there, we are not judged for who we are, or what we do. Staff gives us respect and they don't judge us" (Jozaghi & Andresen, 2013, p. 9).
Free and Informed Consent
Risks and Harms
CNA Code of Ethics
CARNA Nursing Practice Standards
"Harm reduction seeks to avoid or bypass the moral questions about drug use and drug users, and focuses instead on definitions of drug related harm, harm reduction, interventions and evidence of impact, and cost. As it has been said recently of harm reduction policies and practices, "anything goes", if it actually reduces harm" (Fry, Treloar, & Mehar, 2005, p. 450).
Harm reduction isn't paying enough attention to these ethical issues which can lead to ethical breaches. For harm reduction to be successful an accepted framework for ethical decision making needs to be established. Ethical principles and guidelines needs to be acknowledged and followed as well (Fry, Treloar, & Mehar, 2005, p. 451).
"Nurses provide care directed first and foremost toward the health and well-being of a person, family or community in their care" (CNA, 2008).
"Nurses collaborate with other health care providers to maximize health benefits to persons receiving care and those with health-care needs" (CNA, 2008).
"In all practice settings, nurses work to relieve pain and suffering, including appropriate and effective symptom and pain management, to allow persons to live with dignity" (CNA, 2008).
"Nurses make fair decisions about the allocation of resources under their control based on the needs of persons, groups or communities to whom they are providing care. They advocate for fair treatment and for fair distribution of resources for those in their care" (CNA, 2008).
A focal point of the Nursing profession in Canada is to promote and provide holistic health care focusing on both the individual and population. The nursing role in relation to Safe Injection Sites focuses primarily on the concept of harm reduction. CNA has highlighted that this ethical dilemma has become a value-based conflict rather than a public health decision (CNA, 2013, p. 49).
"Nurses questions and intervene to address unsafe, non- compassionate, unethical, or incompetent practice or conditions that interfere with their ability to provide safe, compassionate, competent and ethical care to those to whom the are providing care, and they support those who do the same" (CNA, 2008).
3.2 The nurse protects and promotes a client’s right to autonomy, respect, privacy, dignity and access to information (CARNA, 2013).
3.5 The nurse advocates for and contributes to establishing practice environments that have the organizational and human support systems, and the resource allocations necessary for safe, competent and ethical nursing care (CARNA, 2013).
Service to the Public:
4.1 The nurse coordinates client care activities to promote continuity of health services (CARNA, 2013).
4.5 The nurse articulates nursing’s contribution to the delivery of health care services (CARNA, 2013).
4.7 The nurse integrates infection prevention and control principles, standards and guidelines in providing care and service to protect the health and well-being of clients, staff and the public (CARNA, 2013).
The values of harm reduction are consistent with the values of professional nursing presented in the CNA Code of Ethics: the provision of safe, ethical, competent and compassionate care; the promotion of health and well being; the promotion of and respect for informed decision-making; the preservation of dignity, in which care is provided on the basis of need; and the promotion of justice (CNA, 2013, p. 48).
In all practice settings, nurses work to relieve pain and suffering, including appropriate and effective symptom and pain management, to allow persons to live with dignity (CNA, 2008).
Nurses identify and address conflicts of interest. They disclose actual or potential conflicts of interest that arise in their professional roles and relationships and resolve them in the interests of persons receiving care (CNA, 2008).
"When providing care, nurses do not discriminate on the basis of a person's social status, health status, lifestyle, mental ability, socio-economic status or any other attribute" (CNA, 2008).
The ethical commitments of RN's are outlined in the CNA's Code of Ethics which highlights important values that guide nursing practice and the delivery of care to ALL Canadians (CNA, 2013, p. 48).
Targets the causes of risks and harms, and takes into account factors which may render people who use drugs particularly vulnerable, such as age, gender and incarceration (International Harm Reduction Association, 2009).
“Addiction is not a life choice. Addiction is a health issue” (Jozaghi & Andresen, 2013).
The harm reduction approach to illicit drug use is based on a strong commitment to public health and human rights. It focuses on the prevention of harm rather than prevention of drug use (International Harm Reduction Association, 2009).
Knowledge Based Practice
The nurse exercises reasonable judgment and sets justifiable priorities in practice (CARNA, 2013).
The nurse advocates for and contributes to establishing practice environments that have the organizational and human support systems, and the resource allocations necessary for safe, competent and ethical nursing care (CARNA, 2013).
Service to the Public
The nurse effectively assigns care or nursing service and supervises others when appropriate or required to enhance client outcomes (CARNA, 2013).
The nurse articulates nursing's contributions to the delivery of health care services (CARNA, 2013).
The nurse participates in quality improvement activities (CARNA, 2013).
Opposes deliberate hurts and harms inflicted on people who use drugs, and promotes responses to drug use that respect and protect fundamental human rights (International Harm Reduction Association, 2009).
It is the RN's responsibility to provide care based on the best evidence available. The evidence provided indicates that the establishment of safe injection sites have numerous benefits including the provision of safety (disease prevention, immediate health care attention), services needed to better themselves (addictions counseling, housing etc), as well as changing the culture of drug use by enabling the IDU's to advocate for themselves and for the safe injection sites. Each of these concepts falls under the nurses ultimate goal of providing
hollistic care to all people focusing
primarily on harm reduction.
Figure 4. The Association of Faculties of Medicine of Canada, 2010.
Acknowledge the significance of any positive changes individuals make, and the interventions are facilitative rather than coercive (International Harm Reduction Association, 2009).
Accept people as they are, avoid being judgmental, and focus on peoples current state (International Harm Reduction Association, 2009).
Sarah Gordon, Emily Gould, Kaitlyn Grieman, Geena Felesky, Taryn Cook
A central ethical issue for harm reduction that is especially relevant in the case of safe injection sites is the tension between the notion of an individual right to use potentially harmful drugs and the community's right to prevent or interfere in this (Fry, Cvetkovski, & Cameron, 2006, p. 465).
- These needle exchange facilities are sending a mixed message to the community about using drugs by unconsciously suggesting that drug use is acceptable if it can be controlled.
- This slight acceptability of using may encourage an increase in the trend, rather than find a way to abolish it appropriately (Elliot, Malkin, & Gold, 2002, p. 9).
In other words, safe injection sites have potential to enable drug use -
while the programs do seek to prevent the negative consequences of using, they pose as a complication to a nurse's moral standpoint. They provoke an ethical dilemma and conflict, suggesting that it is okay to condone or promote drug use rather than eliminate it.
Programs like safe injection facilities and needle exchange are aimed at harm reduction but evidence provided shows that these programs may actually be encouraging drug use to the public. There is not enough emphasis on the ethical problems that arise from these programs (safety, confidentiality and free and informed consent) allowing there to be ethical breaches.
The ethical concerns identified are:
(Fry, Treloar, & Mehar, 2005, p. 451)