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International Journal of Drug Policy 19 (2008) 486–491

Short report

Is groin injecting an ethical boundary for harm reduction?

Peter G. Miller a,∗, Nick Lintzeris a,b, Luciana Forzisi a,1

a National Addiction Centre, Institute of Psychiatry, King’s College London, SE5 8AF, UKb Drug Health Services, Sydney South West Area Health Service, c/o Royal Prince Alfred Hospital,

Page Building Level 5, Missenden Road, Camperdown, Sydney, NSW 2050, Australia

Received 3 July 2007; received in revised form 4 October 2007; accepted 4 October 2007

bstract

ackground: Femoral vein (or groin) injecting by street drug users is an emerging public health issue in the UK. It has been proposed thatroin injecting is becoming normalised among UK injecting drug users (IDUs), yet harm reduction strategies are currently piecemeal and someay be crossing the boundary of responsible provision of information. This paper discusses the interventions available to service providers

ealing with groin injecting and explores the utility of ethical frameworks for informing service provider decisions.ethods: Methods analysis of possible service provider responses using White and Popovits’ ethical decision-making framework.esults: The use of ethical frameworks suggest that different types of groin injectors should receive different interventions. Injectors forhom the groin is a site of ‘last resort’ should be given information about how to inject there less dangerously, whereas ‘convenience’ groin

njectors should be actively encouraged to inject elsewhere.

onclusion: Groin injecting is a behaviour which represents a boundary for some harm reduction practices (such as providing ‘how to’ooklets to all injectors) as well as being an argument for more complex and environmentally appropriate harm reduction responses such asrug consumption rooms and training IDUs to maintain healthier injecting sites.rown Copyright © 2007 Published by Elsevier B.V. All rights reserved.

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eywords: Femoral injecting; Groin injecting; Harm reduction; Ethics; Eth

ntroduction

Femoral (or groin) injecting is an often dangerous prac-ice reported by up to 50% of injecting drug users (IDUs) inhe UK (Maliphant & Scott, 2005; Rhodes et al., 2006). Its almost impossible to guarantee that groin injection can beafe (though a small minority never develop complications),specially given the small margin for error and the risk that itay be attempted whilst intoxicated. Deep venous thrombo-

is (DVT), accidental arterial injection, venous ulceration andocal infections can all complicate injection into the groin andave serious health consequences for the injector (Rhodes,

riggs, Kimber, Jones, & Holloway, 2007). The apparentormalisation of groin injecting within the UK IDU popu-ation is a major problem for which effective solutions are

∗ Corresponding author. Fax: +44 20 7701 8454.E-mail addresses: P.Miller@iop.kcl.ac.uk (P.G. Miller),

icholas.lintzeris@sswahs.nsw.gov.au (N. Lintzeris),uciana.Forzisi@iop.kcl.ac.uk (L. Forzisi).1 Fax: +44 20 7701 8454.

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955-3959/$ – see front matter. Crown Copyright © 2007 Published by Elsevier B.oi:10.1016/j.drugpo.2007.10.001

eworks; Injecting clinic

urrently lacking (Rhodes et al., 2006). At the moment, theost common response is the distribution of ‘how to’ book-

ets which may benefit some groin injectors whilst increasinghe risk in others such as those who have already experiencedarms such as DVTs or abscesses that change local anatomyZador, 2007). Though there is an absence of evidence, annquestioning distribution of such booklets and posters maye contributing to a greater uptake of groin injection, and inoing so, producing harm rather than reducing it. This paperill review the responses available to service providers using

n ethical framework to (i) explore the most ethically appro-riate responses to groin injection and (ii) discuss what toolsre available for making these decisions.

roin injection

The apparent increase in groin injecting is a major concernor services dealing with IDUs (Maliphant & Scott, 2005;hodes et al., 2006). Rhodes et al. (2006) reported that up

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o 45% of IDUs in English cities report groin injecting inhe last 4 weeks, rising to over 50% in some areas. Theyoncluded that groin injection is increasingly becoming aormative behaviour for IDUs, having moved from being arisk boundary’ to an ‘acceptable risk’. This conclusion isupported by research findings that novice and early careernjectors sometimes use the groin as their primary injectingite (Maliphant & Scott, 2005).

Recent work has suggested that groin injectors can beivided into two groups which reflect different aetiologiesRhodes et al., 2007): ‘last resort’ groin injectors, who havexhausted all viable peripheral veins (Darke, Ross, & Kaye,001) and ‘convenience’ groin injectors, who have only usedsmall number of previous injecting sites and the groin is a

ite of ‘utility and convenience’ (as described by Maliphant &cott, 2005). This distinction may prove useful when consid-ring the interventions which may be appropriate for reducinghe harm associated with groin injection.

There are few obvious benefits associated with groinnjecting outside the situated rationality described by Rhodest al. (2006). This situated rationality revolves primarilyround: speed of injection, surety of injection, the hiddenature of the site and a more ‘intense hit’. Groin injection haseen found to have particular benefits for homeless injectorsRhodes et al., 2006) and crack-heroin ‘speedball’ injectorsRhodes et al., 2007). However, such benefits are likely toiminish substantially within the treatment setting and groinnjection rapidly becomes unjustifiable in some risk environ-

ents such as medically supervised injecting centres (Zador,007).

arm reduction ethics

According to Rumbold and Hamilton harm minimisationttempts to “assess the actual harm associated with any par-icular drug and then asks how these harmful effects maye minimised. . . within an amoral framework” (1998:135).nsuring that harm reduction interventions are ethical helpschieve the main goals implicit within this definition becausethics are ultimately aimed at preventing harm. Ideals suchs beneficence and non-maleficence are tailored to this veryoal. Ethical considerations are particularly important inarm reduction theory and practice because so many of thenterventions included under the banner of harm reductionross traditional moral boundaries and utilise interventionshich have not been subject to substantial ethical debate

Strathdee & Pollini, 2007). This has significant implica-ions for service providers, the staff and, most importantly,he service users. Sadly, to date, there is often little dialoguen key ethical issues (White & Popovits, 2001: i) Conse-uently, many alcohol and other drug (AOD) workers are

eft struggling to define what ethical practice in some harmeduction programmes might look like (Solai, Dubois-Arber,enninghoff, & Benaroyo, 2006). This lack of open ethi-al debate has created areas that have “strong no-talk rules”,

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f Drug Policy 19 (2008) 486–491 487

ften prompted by confrontational relationships with par-ies outside the AOD sector that hold different values. As

hite and Popovits note “The silence is fuelled by fear thatpen discussion of such events and issues would harm therganisation and the professional field” (White & Popovits,001: i).

A key issue for harm reduction ethics is the conflictetween an individual’s right to use potentially harmfulrugs, and the State’s or community’s duty to determine howr if this is practised (Hathaway, 2001). This reflects widerebates about risk taking and whether society can legitimatelyraw boundaries around some forms of risk and not othersKeane, 2003; Miller, 2001). For instance, some argue that its an individual’s ‘human right’ to use drugs in a safe manners long as it does not harm others (Hathaway, 2001). It haslso been argued that the legal status of many drugs directlympinges on the dignity of already marginalised people andhat ethical responses to drug-related problems must include

easures which seek to maintain or enhance the dignityf individual drug users (Ashcroft, 2005). Situations wherehe values of autonomy and beneficence or non-maleficencere in competition go to the core of many moral argumentsurrounding risk behaviour and the ethics of treatment oregulation of the behaviour.

utonomy and rational choice

This is particularly difficult when considering the role ofaddiction’, not just drug use, and its impact upon auton-my (Hall, Carter, & Morely, 2003). While drug use can beutonomous, by definition addiction is a loss of autonomy andn Latin the word addict (‘addicere’) came to mean someoneho was a slave to anything. It may be that some peopleho engage in groin injection do so because of needs of their

ddiction, such as in the case of ‘situated rationality’ (Rhodest al., 2007), rather than making a rational choice based on thevailable information. However, traditional Liberal concep-ualisations of autonomy failed to describe the reality of theaddicts’, particularly within the context of deprivation andarginalisation seen in homeless and ‘speedball’ injectorsho are most likely to groin inject (Rhodes et al., 2007). Theotion of “relational” autonomy has gained prominence as aeaction against the failings of the more traditional, liberalnderstanding of autonomy. Relational autonomy focuses onhe importance of supportive social conditions for fosteringutonomous action and proposes that individual autonomys socially dependent (Sherwin, 1998). In other words, “theapacity and opportunity for autonomous action is depen-ent on our particular social relationships and the powertructures in which we are embedded Autonomy requiresore than freedom from interference: it requires that one’s

elationships with particular individuals and institutions be

onstituted in such a way as to give one genuine opportunitiesor choice” (MacDonald, 2002: 197). Thus, simply provid-ng information for people to make a ‘rational choice’ maye both logically and ethically flawed.

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thical decision-making frameworks

In trying to assess whether specific interventions meethe goals of harm reduction, ethical frameworks can proveseful heuristic frameworks from which to start. There iso consensus on a universal theory of ethics, nor possi-ly should there be (Fry, Treloar, & Maher, 2005; Keane,005). As ethical frameworks are ultimately embodimentsf philosophical thinking, moral positions and personal val-es, they are dependent on their historical and social contextCallahan, 2003). Ethical decision-making frameworks canake the job of coming to solutions to ethical dilemmas

asier, particularly for clinicians looking for guidelines andrameworks that can help them make quick, defensibleecisions.

Ethical decision-making frameworks have been proposedy a number of different authors, but two basic models haveeen previously proposed in the AOD sector (Solai et al.,006; White & Popovits, 2001). Both have been informed bythical debate and include elements of both principlism andommunitarian ethics.

Solai et al. (2006) report on the use of a framework basedn three levels of norms: institutional norms (embodied inhe objectives and philosophy of the institution), professionalorms (the deontology of the various professional groups),nd personal norms (the values and feelings prevailing in theonduct of one’s personal life) (Ricoeur, 1996, 2000). Thispproach is primarily an applied ethics process, the goal ofhich is to reach consensus decisions on ethical challenges.

t includes eight steps and facilitates the search for consen-us on the best decision to be made in a given situation: (i)o identify the practical ethical problem; (ii) to identify thelient’s individual context as known to the staff member; (iii)o identify the responsibilities of each staff member in the carerocess; (iv) to identify the diverse values considered by eachtaff member as essential to reaching a favourable outcome tohe problem; (v) to identify the conflicts of values occurringn this situation; (vi) to identify alternative solutions to thethical conflict identified; (vii) to choose the option whichllows best the realisation of the objectives of the institutionn a consensual way; and (viii) to give a justification for thishoice (Solai et al., 2006: 19).

White and Popovits propose a simple model of ethicalecision-making comprised of a series of related questions2001: 26). They also provide a basic checklist for ensuringthical issues are addressed adequately (White & Popovits,001: 7–9). Their model of ethical decision-making consistsf three related questions:

1) Whose interests are involved and who can be harmed?2) What universal or cultural specific values apply to this

situation and what course of action would be suggestedby these values? Which of these values are in conflict inthis situation?

3) What standards of law, professional propriety, organisa-tional policy or historical practice apply to this situation?

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f Drug Policy 19 (2008) 486–491

While this framework is by no means perfect, particularlyn its ethnocentric assumption of ‘universal’ values and itsack of consideration of power relationships, it does supply

useful starting point in the process of ethical decision-aking. Importantly, it explicitly includes the variables of

rganisational policy and historical practice, which often playmajor role in clinical practice. While either of the above

thical decision-making frameworks would suit the purposesf assessing the most appropriate responses to groin injec-ion and in this paper, we will use White and Popovitis’ramework to analyse service provider responses to groinnjection.

ervice provider responses

There are a very limited number of responses availableo service providers when dealing with service users whore currently or may potentially be groin inject. This listf responses is only a list of actions available to serviceroviders and represent the end of the process which should,s a model of best practice, incorporate the views of servicesers. These include:

1) Provision of harm reduction information about how togroin inject.

2) Training IDUs to find other injecting sites and goodinjecting techniques.

3) Permitting groin injectors to access treatment (such asdrug consumption rooms (DCRs) and injecting clinics(ICs)), but banning them from good injecting; withinsuch services.

4) Excluding groin injectors from accessing services.

Each of these options must include issues such as thenjecting history and status of the service user, their healthtatus and what services are available to them. In the fol-owing analysis we will explore issues such as the degreef service user input, the influence of staff bias and theay in which conflicting ethical considerations can be

ccommodated.

hose interests?

The first step in White and Popovits’ (2001) model ofthical decision-making is to determine whose interests arenvolved. Parties involved would include:

The individual injecting drug user and whether commenc-ing groin injection is within their best interest.Workers within the service bring with them personal, pro-fessional and social attitudes, including personal beliefsabout the acceptability of groin injection and the role of

treatment in drug use.Professional bodies, including nursing association, doc-tor’s bodies and drug worker unions, each of whom haveprofessional codes of conduct and standards of practice

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which influence the ways in which they interpret and dealwith groin injection:service commissioners such as government health depart-ments who focus on issues such as treatment effectivenessand cost.The local community who also have a substantial inter-est in what occurs within as they usually experience theconsequences of treatment success or failure, as do policymakers and the broader community.

hich values?

The second question asks which ‘universal or culturallypecific’ values apply to this situation. The major valuesnvolved with the issue of groin injection include: auton-my, beneficence and non-maleficence, though other valuesay occasionally apply. Looking at each of the available ser-

ice provider responses, it can be seen that different ethicalonsiderations apply for different interventions.

rovision of harm reduction information about howo groin inject

As previously mentioned, the provision of ‘how to’ book-ets currently constitutes the default response for most AODervices in the UK. At a simple level, supplying such informa-ion might be seen as supporting an individual’s autonomys it allows them to determine their own course of action.owever, using the insights from relational autonomy dis-

ussed earlier, it may be that IDUs might choose to groinnject because of the social pressures of the moment (Rhodest al., 2006). Similarly, the influence of ‘addiction’ on theirbility to make a rational choice should also be consideredCohen, 2002). Given that it is impossible to guarantee theafety of groin injection, simply supplying such informationo all IDUs may well have unintended consequences. On thether hand, not supplying harm reduction information to anndividual who is determined to start groin injection couldead them to make a serious mistake, thereby causing moreerious harm. The most appropriate response in this caseight be more graduated. For instance, using the distinc-

ion between ‘last resort’ and ‘convenience’ groin injectorsould allow for harm reduction information to be provided atmuch lower threshold for last resort injectors, whereas con-enience groin injectors would be more strongly encouragedo use other sites.

raining IDUs to find other injecting sites and goodnjecting techniques

Assisting groin injectors to find other viable injecting sitesithin an appropriate environmental context (such as DCRs

nd ICs) can be seen to fulfil the principal values of autonomy,eneficence and non-maleficence. The autonomy of the IDU

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s preserved because they make the ultimate decisions aroundhich sites they wish to inject in, within a safe environment.eneficence and non-maleficence are both served because the

DU is being asked to engage in achievable behaviour changeithin a safe context. These options are also more attractive

rom a public health perspective as they have the benefit oflearly taking a position that groin injection is not sociallycceptable. However, the most obvious problem with thisuggestion is that there are no DCRs in the UK and only a fewCs. Training IDUs in other harm reduction settings whicho not supply safe environments for injectors day in and dayut also addresses some of the ethical concerns about how toeal with groin injection, although these are ultimately onlyalf measures. Without addressing the many environmentalontributors to risk (Rhodes, 2002), these measures would bet least partially setting IDUs up to fail. As such interventionshich address environmental contributors to risk are ethicallyore acceptable than those that do not.

ermitting groin injectors to access treatment (suchs DCRs and ICs), but banning them from groinnjecting

Banning groin injection within facilities such as DCRsnd ICs would seem to satisfy most ethical concerns. While,ot allowing groin injection on site marginally contravenesheir autonomy, this would not be a major issue for manyDUs as they would still be able to use their drug of choicend they will have support on site to assist finding other veinsithout environmental pressures such as fear of arrest or rob-ery by peers. However, blanket bans within such facilitiesight contravene beneficence and non-maleficence, particu-

arly for those who no longer have other viable veins left.hese injectors would ultimately be prevented from ben-fiting and it would therefore be preferable if they coulde allowed within the service. Again, assessing whetherDUs are convenience all last resort groin injectors mightrovide an obvious solution. Allowing last resort IDUso groin inject only after assessment may be an ethicallycceptable solution, though implementation may presentroblems.

xcluding groin injectors from accessing services

Excluding groin injectors from accessing services contra-enes the autonomy of the IDU and may also cause furtherarm by denying the service user the benefits of treatment.t also breaks the principles of non-maleficence (by mostrobably sending them back onto the street to inject) andeneficence (because no real benefit is gained for this indi-idual by not allowing them to inject in the groin, aside from

he obvious health risks, which the individual IDU is choos-ng to disregard). On the other hand, a convenience groinnjector with viable alternative injecting sites presents a dif-erent ethical case. In this case, whilst not allowing groin

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njection does impact on the individual’s autonomy, it cane argued that the principle of beneficence would be bettererved by encouraging them to use an alternative injectingite.

xternal influences on the decision-making process

White and Popovits’ (2001) third question looks at theery important and often overlooked influence that standardsf law, professional propriety, etc., apply to the decision-aking process. For many ethical conundrums, it may be

hese considerations, rather than ethical values, which deter-ine a final course of action and it is important that when such

onsiderations are at play, they are identified. For instance,ust because an agency has always dealt with groin injec-ion by excluding service users, this does not make it ethical.his question also allows the important discussion about what

s achievable in the real world of clinical practice. Clinicsperate on protocols that are ‘best fit’ for the majority anddherence is usually imposed because of the belief that ifveryone does not conform the system collapses. In such envi-onments, ethically inspired calls for case-by-case responsesre unlikely to be implemented, possibly wasting everyone’sime. This reinforces the need for simplicity and transparencyn final guidelines, so that both staff and service users receivend acknowledge equitable treatment and that policies areorkable.In evaluating the suitability of ‘how to’ booklets from

his perspective it can easily be seen that blanket solutionsre easiest for some service providers and even policymak-rs. However, such a solution is ethically appropriate for theeasons highlighted earlier although the use of the ‘conve-ience’ and ‘last resort’ categories allow for more tailoredpproaches when providing information, without becominglinically impractical. Differentiating responses for these tworoups follows a logical and demonstrable criterion whichlearly provides a reason for delineating responses, such asllowing groin injection in DCRs for last resort groin injec-ors, but not for convenience groin injectors. It also allows forifferent clinical settings to have different policies, wherebyn IC (with onsite staff and pharmaceutical drugs) might beble to reasonably argue that there is no good reason forllowing groin injection (Zador, 2007).

onclusion

This paper has demonstrated how an ethical decision-aking framework is helpful in the absence of a large

vidence base for informing clinical decisions and direct-ng future research. It is clear that graduated, but realisticesponses, are the most desirable for this problem, but that

hey must be simple and transparent. Teaching non-groinnjecting practices within safe environments such as DCRsnd ICs is one of the most ethically acceptable interventionsor dealing with current groin injectors. The indiscriminate

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rovision of ‘how to’ booklets is ethically indefensible. How-ver, the dissemination of information using schemas suchs ‘convenience’ and ‘last resort’ to determine who shouldeceive such information is more ethically acceptable.

From this analysis, it appears that groin injection is aehaviour which represents a boundary for some harm reduc-ion practices (such as providing ‘how to’ booklets to allnjectors) as well as being an argument for more complex andnvironmentally appropriate harm reduction responses suchs DCRs and training IDUs to maintain healthier injectingites.

cknowledgement

We would like to thank Deborah Zador for comments onarlier drafts of this paper.

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