Empirical Science Meets Moral Panic: An Analysis of the ... · health position, Senator Nancy Pelosi submitted the following testi- mony at federal hearings on needle exchange: "Mr

Empirical Science Meets Moral Panic: An Analysis of the Politics of Needle ExchangeAuthor(s): David Buchanan, Susan Shaw, Amy Ford, Merrill SingerReviewed work(s):Source: Journal of Public Health Policy, Vol. 24, No. 3/4 (2003), pp. 427-444Published by: Palgrave Macmillan JournalsStable URL: http://www.jstor.org/stable/3343386 .Accessed: 25/01/2012 13:30

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Empirical Science Meets Moral Panic: An Analysis of the Politics of Needle Exchange

DAVID BUCHANAN, SUSAN SHAW, AMY FORD, and MERRILL SINGER

INTRODUCTION

ra X ESPITE eight major national reports affirming the benefits of needle exchange programs (NEPs) in preventing the spread of HIV/AIDS (i-8), they remain controversial with legislators and the general public (9). In contrast, a wide swath of public health professionals maintains that conclusive scientific evidence

has proven that NEPs: i) prevent the transmission of HIV, and z) do not increase drug use. A recent statement by then-Surgeon General David Satcher captures the prevailing position among public health authorities: "After reviewing all of the research to date, the senior sci- entists of the Department and I have unanimously agreed that there is conclusive scientific evidence that syringe exchange programs, as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs" (io). With such appar- ently compelling scientific evidence, one wonders why NEPs have not gained greater public support. In this paper, we analyze the arguments of proponents and opponents of needle exchange and recommend an alternative framework for advancing the cause of HIV/AIDS prevention by means of NEPs.

We begin with a brief review of the status of needle exchange programs in Massachusetts where every popular referendum seeking public approval for the opening of new local NEPs in Massachusetts

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has been defeated. We then examine possible reasons for the failure of scientific evidence to sway public attitudes. The paper raises the question of whether exclusive reliance on empirical research repre- sents the most appropriate response to what we see as primarily normative, ethical concerns voiced by opponents to needle exchange. Our analysis is based on the policymaking framework developed by Stone (ii), who argues that the process of policymaking is rarely reducible to questions of empirical fact. Rather it inevitably entails struggle over the meaning and significance that various policy options hold for collective community life. Stone contends that disputes over the "enduring values of community life" drive controversies over public policies. This paper identifies four themes that frame the opposition's values and ensuing ethical concerns about needle exchange. We conclude with recommendations for future directions in this critical public health policy debate.

NEEDLE EXCHANGE IN MASSACHUSETTS

In a continually evolving environment, NEPs operated in an esti- mated 36 states at the end of zooz, although only iz state legisla- tures-including Massachusetts-had formally authorized their legal operation (12,13). Meanwhile, in Massachusetts, injection drug use is now the leading cause of HIV infection, accounting for 5z% of all new AIDS cases in 2Q0I (I4). Disrupting this mode of transmission is consequently a major public health priority here.

In I993, the Massachusetts legislature passed legislation authoriz- ing the first pilot needle exchange program in the Commonwealth, with the qualification that start-up was contingent upon local approval. In I994, the legislation was amended to allow a total of ten "pilot" needle exchange programs. The specific wording of Chapter I II, section z I5 of Massachusetts General Law holds that the state Department of Public Health is authorized to:

... promulgate rules and regulations for the implementation of a pilot program for the exchange of needles in cities and towns within the Commonwealth upon nomination by the Department. Local approval shall be obtained prior to the implementation of the pilot program in any city or town. (MGL I C. III, s. zi5)

Significantly, the legislature failed to define what "local approval" meant and localities have interpreted the term differently. Pilot pro-

BUCHANAN ET AL. * POLITICS OF NEEDLE EXCHANGE 429

grams were initiated in Boston and Cambridge in I995 with the approval of their City Councils. Northampton started a pilot program in I996 based solely on the approval of the mayor. Provincetown started a new program in 1997 with the endorsement of the local board of health and support of the Chief of Police. There have been no new programs initiated since 1997. There have been a number of popular referenda seeking "'local approval" over the ensuing years, in Worcester, Springfield, Holyoke, and New Bedford, but whenever needle exchange has been put to a popular vote in Massachusetts, it has been defeated. The question is why, and how public health advocates might make a better case for this method of preventing the spread of disease.

The case of Springfield is instructive. In zooo, Springfield had the i ith highest rate of new AIDS cases in the nation (I 5). In a city with a population of just over 150,000, approximately ioo people are newly diagnosed with AIDS each year, with more than half (54%) of the cases attributable to injection drug use (14). In response to these distressing figures, the mayor, the Director of Health and Human Ser- vices, the Chief of Police, and the Public Health Council (board of health) have all gone on record officially in favor of starting a NEP there. The Public Health Council even declared a public health emer- gency to expedite the initiative, but the city attorney rendered an opinion that "local approval" required a vote of the City Council. In I998, in a close 5-4 vote, the City Council initially voted to approve the start of a pilot NEP. However, in response to the City Council's vote, a group of neo-conservative residents banded together to form a new organization, Citizens Against Needle Exchange (CANE), which launched a petition drive to put a measure on the ballot to stop the opening of the NEP. In a twist of events, the Registrar of Voters determined that, although they had come close, CANE had not col- lected the required IO,OOO signatures needed to qualify for the ballot. CANE then lobbied their state representatives, who introduced legislation to exempt the petition from the required minimum number of signatures, and thus, qualify for the ballot. In a compromise effort, the state representatives urged the Registrar to put the question on the local ballot as a non-binding resolution. It was, and in November I998, the measure asking voters to reject the NEP passed on 55-45%. Subsequently, one City Council member changed his vote, placing the City Council on record against needle exchange. Local public

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health AIDS activists have since worked hard to get the City Council to re-consider, but all parties acknowledge that prospects for passage have worsened since that time.

Recognizing that the drive to open NEPs has stalled, the Massa- chusetts State Department of Public Health implemented a $IOO,OOO

media campaign, including billboards, bumper stickers, posters, and paid radio advertisements, in six targeted cities in April I999. Unfor- tunately, the campaign appears to have backfired, generating howls of protest from city councilors about interfering in local affairs and using taxpayer monies to support what they deem a partisan political cause. After the media campaign, a ballot measure in Holyoke (one of the six targeted cities, with the highest AIDS rates) was defeated by an even wider 60-40 margin. Frustrated at the local level, public health activists have introduced a bill in the state legislature to pre- empt the "local approval" clause and give decision-making authority to the state DPH. However, this measure has been stalled in committee for more than three years.

Beyond these local skirmishes, it is well known that the Congress does not support the distribution of sterile syringes (I6,I7), despite numerous reports from their own appointed scientific experts, pan- els, and commissions, attesting to the benefits. What are public health professionals to make of this situation and how might we proceed to build greater public support for the use of NEPs to prevent AIDS?

THE TWO SIDES OF THE DEBATE

Recent statements by the two sides of the debate illustrate how advocates of needle exchange tend to define the issue strictly as an empirical, scientific matter, whereas opponents define the question primarily as a normative, ethical one. Typical of the predominant public health position, Senator Nancy Pelosi submitted the following testi- mony at federal hearings on needle exchange: "Mr. Chairman, as you know, I serve on the Labor-HHS Appropriations Subcommittee where the issue of federal funding for needle exchange programs has surfaced as a controversy. Our subcommittee has a history of attempt- ing to let science, not politics, determine public health policy. The HIV epidemic remains an urgent public health problem. Our public policy on HIV prevention should be based on science, not politics" (I 8).

In contrast, then-Governor of New Jersey, Christine Whitman, provides a representative example of the opposing perspective: "I am

BUCHANAN ET AL. * POLITICS OF NEEDLE EXCHANGE 43I

familiar with the recent studies regarding needle exchange programs conducted by the National Academy of Science and the Centers for Disease Control and Prevention ... I, however, do not view this issue solely in terms of science, but also in legal, public policy, and philosophical terms ... The free distribution of hypodermic needles would send a mixed signal. It would tacitly encourage illegal drug use. Gov- ernment should not be in the business of facilitating illegal activity. Scientific theories about needle exchange do not outweigh the long- standing legal, public policy, and philosophical determinations that are embodied in current law" (I9).

Two further examples demonstrate how opponents frame the issue as fundamentally an ethical matter. The Reverend Michael Orsi writes, "Each society must determine what it considers detrimental to a healthy society. Over the years, the devastating effect of illegal drugs on individuals, families and our society and civil institutions has forced us to enact laws that prohibit drug use and the parapher- nalia that deliver drugs. It has been proven time and again that the first step in curtailing the growth of drug use is to send a clear and unambiguous message that it is wrong and will not be tolerated . Whenever we allow compromise of what is right, we diminish our ethical resolve and moral authority" (zo). Last but not least, Presi- dent George W. Bush has declared, "Drug use in America, especially among children, increased dramatically under the Clinton-Gore Administration, and needle exchange programs signal nothing but abdication, that these dangers are here to stay. Children deserve a clear, unmixed message that there are right choices in life and wrong choices in life, that we are responsible for our actions, and that using drugs will destroy your life" (zi).

While space constraints preclude a discussion of the quality of the scientific evidence put forward in support of needle exchange, it is worth pausing to consider the complexity of the questions about whether NEPs prevent the transmission of HIV or whether they encourage illegal drug use. Suffice to say, obtaining definitive, unambiguous answers to scientific questions is difficult even under the most highly controlled conditions and the circumstances surrounding the lives of injection drug users are anything but well controlled. Thus, it should not be surprising that the claim that studies have pro- vided "conclusive" evidence "proving" the efficacy of NEPs was the subject of a recent debate in an unprecedented set of six editorials in

432 JOURNAL OF PUBLIC HEALTH POLICY - VOL. 24, NOS. 3/4

the American Journal of Public Health. In the lead article, Moss ques- tioned the credibility of the scientific evidence making the following observation, which also introduces larger issues that we would like to explore here (z2):

The second reason for polarization is that the basic mobilizing strategy for health initiatives in our era is the moral crusade. Lib- erals are accustomed to thinking it is conservatives who employ moral crusades, particularly on issues involving drugs or sex, the classic examples being Prohibition in the I920s and the venereal disease control laws in the late igth century. But getting AIDS research and treatment funded in the US was also a moral crusade, driven by gay activism and powered by the idea that stigmatization should not prevail . . . "Harm reduction," the ide- ology of the needle exchange movement, is the child of AIDS activism and is probably the dominant idea in public health approaches to drug use at present. It is also a moral crusade.

Moss is dubious about the persuasiveness of the scientific evidence and thinks that proponents have distorted claims of "conclusive proof" in the zeal of their moral crusade. However, in contrast to Moss's tone (which hints at disdain), we argue that policy recommendations regarding AIDS prevention-what should we do in the face of this threat-are inextricably moral and political issues. Rather than deluding ourselves into thinking that scientific evidence alone should determine public policy, public health activists would do better if they acknowledged the moral values that underlie their advocacy efforts as a way to address the ethical concerns of opponents. However squeamish he may sound, Moss is right: it is-inescapably- a moral campaign.

The appeal of resorting to claims of scientific evidence by public health advocates is understandable (23). In the modern era, a great divide has been drawn between facts and values, where values are now considered unamenable to objective verification (24,25). Values have come to be regarded essentially as individual subjective prefer- ences-direct, unmediated, and incorrigible feelings-that are therefore not rationally defensible nor subject to reasoned refutation (z6, 27). We like something or we do not. It is just how one feels about a situation and one cannot be mistaken in their feelings. This perception is reflected in that most common conclusion to almost any dis-

BUCHANAN ET AL. * POLITICS OF NEEDLE EXCHANGE 43 3

cussion these days, the catch-all phrase, "Well, everyone is entitled to their own opinion." Many people feel that it is pointless even to try to discuss or debate the values underlying heated public controversies, since it seems little or no rational headway can be gained. Thus, there is an almost desperate sense that, if any progress is to be made, it can only be made by the appeal to "objective," "value-neutral" scientific empirical data. The apparent lack of grounds for determining the validity of different value positions is indeed a real problem that bedev- ils our times and we do not want to dismiss or minimize it. But nei- ther are we quite as despairing as some who are resigned to the view that public debate on the core values that define our society is futile.

FOUR THEMES IN THE NORMATIVE

ARGUMENTS OF OPPONENTS

In Policy Paradox: The Art of Political Decision Making, Stone (i i) frames this issue as follows:

The fields of political science, public administration, law, and policy analysis have a shared common mission of rescuing public policy from the irrationalities and indignities of politics, hoping instead to conduct it with rational, analytical, and scientific methods. This endeavor [is] what I call the "rationality project" ... The rationality project [however] fails to capture what I see as the essence of policy making in political communities, the struggle over ideas. Shared meanings motivate people to action and meld individual striving into collective action ... What communities decide about when they make policy is meaning, not matters of fact, and science cannot decide questions of meaning.

Stone identifies three components of debates about policy options: problems, goals, and solutions. She observes that values frame how we define the problem, determine the goals we set, and provide the measure of possible solutions. Thus, controversies are driven by debates about the significance of potential courses of action in light of the enduring values of community life. Stone argues that the most salient "enduring values" in policy debates are equity, efficiency, security, and liberty. She claims that disputes about whether policies such as needle exchange promote or impede liberty, advance or hinder equity, and so on, in the end turn on interpretations of these core values, and hence, are not reducible to questions of empirical scientific analysis.

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Drawing on Stone's framework, our analysis begins by describing two contrasting moral orientations that provide the foundations for current value disputes over needle exchange. We offer one additional distinction that maps onto these fundamental moral orientations, and then discuss two dynamics that heat up the current clash over NEPs. (These elements are summarized schematically in Table i.) In exam- ining these four synergistic themes, this analysis aims to broaden understanding of the underlying forces that drive debates on needle exchange today. There are, to be sure, many other factors that have contributed to the current impasse on NEPs, such as the "not in my back yard" factor and the insidious element of racism that pervades all politics in modern American society, but these elements are sufficiently well-recognized that we do not need to re-hash them here (z8-3 3).

The most fundamental factor to recognize in analyzing the needle exchange debate today is the cultural divide between divergent moral orientations. In Culture Wars, Hunter (34) refers to these respective ethical frameworks as "orthodox" versus "progressive" orientations.* Hunter characterizes the orthodox moral orientation by its commitment to an external, definable, and transcendent authority that provides a fixed, unswerving measure of value, purpose, good- ness, and identity. The allegiance to transcendent authority supplies "a dynamic reality that is independent of, prior to, and more powerful than human experience. It tells us what is good, what it true, how we should live, and who we are." As Hunter scans American society, he sees that this position tends to draw its major support from lower middle and working classes.

In contrast, the progressive moral orientation is defined by the spirit of the modern age, the spirit of rationalism, secularism, and subjectivism. Here, moral authority is seen to reside in personal experience and scientific rationality. "Its values (autonomy, freedom) could be described as 'humanistic'-an ethical orientation in which human well-being becomes the ultimate standard by which moral judgments and policy decisions are grounded." For Hunter, this position draws its support mainly from a highly educated, professional

* Highly similar analyses have been put forward by Himmelfarb (35), where she terms the respective camps, "conservative traditionalists" and "liberal progressivists," and by Shogan (36), who defines the different categories as "traditionalists, unrelenting defenders of social orthodoxy, against modernists, agitators for social change."

BUCHANAN ET AL. * POLITICS OF NEEDLE EXCHANGE 43 5

TABLE I

Schematic Diagram of Different Sides of NEP Debate

Proponents Opponents

Problem Narrowly-defined: Broadly-defined: HIV transmission Moral degeneration

Goal HIV prevention Human improvement Solution NEP Affirmation of the good/

proscription of the bad behavior

Moral orientation Progressive Orthodox Legitimate authority Science God Type of argument Empirical, scientific Normative, ethical Ethical priorities Rights The Good Ethical motivation Pragmatic Utopian Symbolic meaning of NEP Social Justice Moral degeneration

upper middle class. In terms of the needle exchange debate, Hunter's typology offers both potential insight into the tacit assumptions underlying proponents' support of needle exchange, and provides a better understanding of the foundations of the opposition's position, where there has been a tendency in some quarters to dismiss them as ignorant, irrational, benighted zealots.

Building on Hunter's typology, we would add another distinction, the perceived relationship between the right and the good by the respective parties to the debate (37,38). In ethics, the good is defined in terms of ideals of human well-being and how one should live to realize a life worth living. What is right is defined in terms of justice, or fairness, in the allocation of rewards and retributions-ensuring that people get their due-and protecting people from undeserved harm. In an earlier era, the good was seen to take precedence over the right; establishing just social conditions was viewed merely as the means to attaining the higher goal of human well-being. In the modern era, however, the classical hierarchy has been inverted and concerns about the right have become preeminent. With a growing appreciation of the plurality of conceptions of the good life, increas- ing attention has turned to protecting and expanding a sphere of individual autonomy, demarcated by human rights and free from the imposition of any particular vision of the good life. Many philoso-


phers today, however, have lamented the inversion of the traditional relationship between the right and the good, where they see that a certain fervor about rights today has displaced concerns about the good life in popular thought (z6,27,39,40). In terms of perceived priorities, progressives are wont to defend individual rights, including for some, the freedom to take drugs or not (as long as it does not harm others), whereas those with a more "orthodox" bent are more concerned about what it means to be a good person, a vision in which they see no place for drug use (4').

Turning to dynamics, one factor that heats this debate is what Bel- lah and, more recently, Morone have referred to as that peculiar, quintessential American spirit of "messianic idealism," the sense that Americans are God's Chosen People and hence must live up to higher moral standards as a beacon to the rest of the world (42,43). Herman Melville gave forceful expression to this sense of calling to higher standards (44):

We Americans are the peculiar, chosen people-the Israel of our time; we bear the ark of the liberties of the world. God had pre- destinated, mankind expects, great things from our race; and great things we feel in our souls. The rest of the nations must soon be in our rear. Long enough have we been skeptics with regards to ourselves, and doubted whether, indeed the political Messiah had come. But he has come in us.

Far from fading into some quaint, antiquated notion of distant times, this messianic theme continues to resonate to modern day-through Harriet Beecher Stowe's revelation, "Americans are a people com- missioned to bear the light of liberty and religion through all the earth and to bring in the great millennial day, when wars should cease and the whole world, released from the thralldom of evil, should rejoice in the light of the Lord," to Woodrow Wilson's, "We have come to redeem the world in giving it liberty and justice." In its most recent iterations, both Presidents Reagan and Bush publicly declare other nations an "evil empire5" or an "axis of evil," once again invoking this sense of a divinely-ordained mission that echoes across the pages of American history (43). With respect to needle exchange, advocates need to recognize and respond to this long-standing, deep, and powerful yearning in America's self-understanding, this perceived duty to erad- icate human failings from the face of the earth and live as God's per-


fected creatures. This extraordinarily idealistic impulse is the bedrock upon which the opposition's goal of eliminating drug use is founded. They bristle at pleas to be "practical" or "realistic" and acquiesce in accepting human weaknesses and minor vices like drug use.

Finally, there can be little question that, like the earlier campaigns for temperance and prohibition, needle exchange has become a symbolic crusade. According to Gusfield, symbolic crusades are one major way through which social groups act to preserve, defend, or enhance the dominance and prestige of their own style of living within society (45). In this jostling process, a given issue comes to take on greater meaning as a symbol of group loyalty and differentiation. At the turn of the last century, pledges of abstinence or the determination to go on drinking became symbols of social status, identity statements associated with distinct cultural lifestyles. Prohibition became a bat- tle between two different ways of life: self-mastery, industry, denial, restriction, self-control, and will, on the one side, versus freedom, self-gratification, impulse, play, liberation, on the other. In Gusfield's analysis, anything less than perfect regulation of behavior, anything less than command, was a concession to Nature in the eyes of the temperance movement, and therefore, a sin of great magnitude. Sobriety was the cornerstone of this ethic because it ensures the car- dinal quality of self-command. The i8th amendment thus repre- sented public affirmation and ratification of the abstemious, ascetic qualities of American Protestantism.

The battlegrounds may have shifted today, but the war rages on. If Stone is correct and the factors identified here play significant parts in propelling the current public debate, then we conclude that, to advance the cause of AIDS prevention, public health advocates need to move beyond the monotonous appeal to scientific fact and address the enduring values of community life for which we stand.

FUTURE DIRECTIONS FOR

PUBLIC HEALTH POLICY ADVOCACY

To re-cap, we find four major reasons why public health advocates have been reluctant to wade into this debate on explicitly moral grounds. First, a scientific outlook is consistent with a particular moral orientation, the progressive worldview. Second, following from this, progressives have tended to equate "moral" with "moralistic" and a blinkered, dogmatic close-mindedness that they associate with reli-

438 JOURNAL OF PUBLIC HEALTH POLICY VOL. 24, NOS. 3/4

gious fanatics. Third, advocates fear getting sucked into a quagmire of irresolvable questions about moral values. Finally, advocates are leery of confronting their ambivalence about the question of individual liberty and drug use per se.

Due to these reasons, public health advocates have, in the main, albeit by no means exclusively, preferred to define the HIV/NEP problem narrowly: as strictly a technical, instrumental, scientific question of disrupting viral pathways (4 I). It would, however, be disingenuous to deny that AIDS, in general, and NEPs, in particular, have larger meanings and significance for activists too. For all the pretext of dis- passionate, disinterested, objective value neutrality, activists are motivated by righteous anger. The inequitable burden of AIDS and addiction violates our sense of the most basic moral norms of a just society. It is a disservice to the cause to deny our moral indignation.

According to Selznick, "Social justice means, above all, unflagging concern for those who have gained least from modern prosperity, education, and democracy. Social justice takes seriously the rightful claims of all persons to life, health, dignity, and hope" (46). Advo- cates know that AIDS affects far disproportionately those who have gained least from modern prosperity. Activists know that the burden of disease is not equitably distributed. In daily work with the poor, oppressed, disenfranchised, and addicted, we feel an acutely palpable harm; it weighs deeply on our conscience. The staggering inequities of the intertwined epidemics of AIDS and substance abuse borne by poor people and people of color are the moral wrongs that we seek to redress.

Public health activists will have a harder time making clear their position on drug use. There is far less consensus among progressives, with opinions ranging from libertarian to rigid adherence to norms of socialist conformity (true revolutionaries have no time for self-indul- gent play). The most serious erosion of public support for a more progressive position on NEPs undoubtedly stems from this perception of ambivalence: the unwillingness to state unequivocally that drug use is wrong. On an individual level, many advocates think that individuals should have the right to decide for themselves whether or not they want to try drugs. On this point, there needs to be more frank, can- did, and soul-searching discussion. Our concern is that, when we defend the right for the individual's freedom to choose whether or not to try drugs, we give short shrift to the real toll that drug use takes on a


societal level, and hence, undermine a more widespread sense of social responsibility in the general public. If proponents are unwilling to change our behavior to help those most in need, why should opponents? Poor and minority communities, who do not have the cushion to absorb the heavy costs of addiction, have been much less enthusi- astic about NEPs because of this wavering on the part of largely white middle class activists about whether drug use is okay, or not. That said, there is widespread consensus that NEPs provide one of the more effective means of outreach to injection drug users. NEPs are nearly universally staffed by people in recovery who genuinely want to help others get off drugs and into treatment. Taking a stronger public position that NEPs are as much about getting people into drug treatment as about preventing AIDS would help to alleviate concerns about abetting drug use to a large degree.

We close with two thoughts. The Catholic Church endorses a teach- ing known as the principle of double effect; it distinguishes between the intended and unintended effects of policies and practices (47). According to this principle, acts may be morally justified when their primary intent is good, even if an unintended side effect might other- wise be considered evil. Thus, withholding medical treatment to avoid the mere prolongation of suffering is permissible even if it means a patient may die. Along this line of reasoning, NEPs may be morally acceptable because their primary intent is to prevent AIDS, even if an unintended effect may be protracted drug use. This is not yet the official position of the church, although it is being debated (48,49). Our point is that, if public health advocates could be more open to the idea that "morality" is not the enemy, then we might find some new allies in unexpected places. The idiom of the church might also provide a language to reach groups for whom the appeal to scientific dis- course is not as effective or meaningful (50). It is worth noting that the Catholic Church is more likely to support of NEPs than over-the- counter pharmacy sales of syringes because NEPs provide the personal contact that Christians believe essential in recovering and re-affirming the sense of human dignity.

Finally, we recommend a point-by-point rebuttal of the moral claims of NEP opponents. In terms of the enduring values of community life identified by Stone, we should be making the case that NEPs promote equity because they prevent the most disadvantaged segments of our society from suffering further preventable harm. We


should be talking about how NEPs increase social and fiscal efficiency by immediately interrupting viral transmission at low cost, rather than passively waiting for the day when an individual addict may decide to change his or her life by entering treatment. We need to tell people that NEPs promote efficiency by saving taxpayer dollars that will eventually have to be spent for treating someone with AIDS if left unabated. In public debates, we should be arguing that NEPs promote security because they protect the "innocent" (women and children) and reduce the likelihood of HIV entering the general population. Lastly, we need to be clear that NEPs promote liberty because they increase the possibility that IDUs will one day be able to quit drugs, rejoin society, and lead productive lives; thousands and thousands of addicts in recovery are now able to do good work because they are not dead or dying from AIDS.

Turning to the issues raised in our analysis, whenever opponents say that they are concerned about some sort of general moral degeneration, we need to be clear that we are too: the persistence of poverty and racism are our most serious moral failings as a society. Whenever they say that they are concerned about what it means to be a good decent human being, we need to be clear that we are too: good decent people do not ignore the pain suffered by our neighbors and fellow citizens. Whenever they say that we, as a society, need to be clear about what is right and what is wrong, we need to say that living righteously starts with assuring that every member of our society has hope and self-respect unfettered by inequality. Whenever they say that we should strive to live in the image of God, we need to remind them that the Bible (and the Torah, and the Koran) teach us to stand in solidarity with the poor. When others point to personal responsibility, we need to stress each individual's personal responsibility for ensuring the conditions for people to be healthy. In conclusion, while we must not abandon our scientific foundations, we need to be clear that science is not the highest value to which all other values must be subordinated. To build greater public support, it is not the policy measure itself that needs to change, but the interpretive framework within which it is presented.

Acknowledgments: The research described in this paper was supported by the National Institute on Drug Abuse, grant #Roi DAi 2569, Merrill Singer, Principal Investigator.

BUCHANAN ET AL. * POLITICS OF NEEDLE EXCHANGE 44I

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ABSTRACT

The paper presents an analysis of the policy advocacy strategies used by both proponents and opponents of needle exchange programs in the US, drawing on the analytic framework developed by Stone. Based on a case study of the politics of needle exchange in Massachusetts, we argue that proponents of needle exchange have relied almost exclusively on empirical scientific arguments to build their case, while opponents have generally resorted to normative ethical arguments. Since the frames of argument are unrelated, the two sides talk past one another, bypassing progress towards resolution or consensus. By failing to address the ethical concerns raised by opponents, public health advocates of needle exchange are losing the larger public debate. The paper concludes with specific recommendations for how public health advocates should respond to the normative dimensions of this public policy issue.

Documents

Empirical Science Meets Moral Panic: An Analysis of the ... · health position, Senator Nancy Pelosi submitted the following testi- mony at federal hearings on needle exchange: "Mr