Andrew Potter: The end of harm reduction in Canada

Social policy in Canada has moved from being aimed at controlling vice to reducing harm. But where is it taking us?

By: Andrew Potter

Here’s a list of a few things that were illegal in Canada in my lifetime, and which are now legal: Homosexual behaviour; same sex marriage; abortion; the use of contraception; gambling on sports; growing, buying, selling, and consuming cannabis; euthanasia.

There’s an obvious consistency in the themes here. For a long time, the criminal law in Canada was used to sanction a fairly specific set of values, mostly around sexual behaviour, reproduction, and a belief in the dignity and sanctity of life itself. That is, the state was built upon a moral foundation that in turn rested on a particular vision of the good life that was implemented through the criminal code and enforced by policing units commonly referred to as vice squads.

This is no longer the case. A lot of what used to be banned as a form of vice is now legal, and has been moved from the criminal code to the regulatory state. In a few cases, as with of same-sex marriage or homosexual behaviour, this happened because people eventually realized that this was the sort of thing that is simply not the legitimate business of a liberal society — the state famously having no business in the nation’s bedrooms and so on.

But there are a host of other activities, including abortion, euthanasia (which we’ve agreed to refer to through the somewhat obscene acronym “MAiD”), and the use of narcotics, where there is no clear-cut “liberal” position. That is, they are subjects over which citizens holding legitimate but diverging visions of the good life might reasonably disagree. And in many of these areas, we have ceased to talk in terms of right and wrong, or virtue and vice, but instead speak about reducing harm.

And so, over the past few decades, the language of “harm reduction” has replaced morality as the dominant framework through which we make social policy in this country. This has had an enormous impact on Canada at every level, from our international treaties to the functioning of the smallest of urban neighbourhoods. Yet it has happened without much in the way of explicit public debate. How did we get here? And what is harm reduction anyway?

Harm reduction began in the 1980s as a very practical frontline response to widespread HIV infection amongst intravenous drug users. There was little in the way of theory or ideology behind it; it was, more than anything, a panicked reaction to the failure of prohibition-based approaches, whose goal was to get users to stop using. In contrast, the “harm reduction” model of needle exchange programs just tried to limit the hugely disproportionate harms that were coming from drug use (namely, HIV infection, which was at the time pretty much a death sentence).

Because this approach was quite successful in that context — drug users stopped being infected with HIV and hepatitis — social workers looked around to see where else it might be used. A natural extension of the needle exchange program was the supervised injection site, aimed at reducing deaths from overdoses.

Today, “harm reduction” has become a catch-all term for a broad range of approaches to social and public-health services, where the underlying goal is not to eliminate, but to simply reduce the harmful effects of, a wide range of stigmatized behaviours. The harm reduction model has been applied in recent years to practices that include sex work, abortion, euthanasia, female genital cutting, and even racism and free speech.

How harm reduction went from a very frontline tactical response to a specific harm to a more comprehensive strategy for managing social policy outcomes is a complicated question. One difficulty with harm reduction as an approach is that even as it has grown in popularity and in scope, its conceptual underpinnings have remained pretty opaque. There are in fact two competing views on what harm reduction actually is, and what has driven its proliferation in Canada is an unstated preference for one specific normative justification for the practice.

The first approach to harm reduction stems from the belief that while a given behaviour might be offensive, a nuisance, or morally objectionable to a great many people, we can’t stop it in any reasonably cost-effective way. On this view, a harm reduction approach is a purely pragmatic response that does not deny the inherent wrongness of the act, it just accepts that a purely prohibitionist approach is doomed to fail. Needle exchange programs were one example here; ending the prohibition-based war on drugs and moving toward a more regulatory and decriminalized approach is another.

But there is a second approach to harm reduction, which begins with the recognition that reasonable people can disagree about the moral valence of a range of controversial behaviours. This can include attitudes toward sex work, which depends on how one weighs values such as autonomy versus dignity; the morality of abortion, which depends on your views on individual autonomy and security versus the rights of the fetus; and euthanasia (or physician-assisted suicide), which balances individual autonomy and comfort against broader views on the sanctity of life.

According to this approach, there simply is no right answer to whether a given practice is moral or not. So where we have landed from a policy perspective is to permit these practices on broadly libertarian grounds, while embedding them in a regulatory and frequently medicalized framework that seeks to minimize the various harms that inevitably accrue.

Again, it is important to note here that there is a significant normative difference between these two approaches to harm reduction. But what confuses things is that in some cases, there is substantial overlap where both approaches support the same policy — abortion is a good example here. But this overlap masks the fact that on the first “unenforceability” approach, there remains an official and public condemnation of the practice. In contrast, the “reasonable disagreement” model avoids making any official judgments, and doesn’t choose sides between competing visions of the good.*

And here is the important thing to understand about how harm reduction became so widespread in Canada: It is motivated almost exclusively by a reliance on the second approach; that is, by a reluctance or even outright refusal to officially condemn as immoral the practice at issue.

This might seem like the right way to go. After all, isn’t the essence of the liberal state that it is neutral with respect to the good? That it makes no judgments on people's deepest moral convictions? Isn’t reducing harm the principled essence of policy-making in a properly liberal society marked by deep disagreement?

To some degree, yes. But there is an obvious downside when the state takes no official position on the good life, which is that it can leave us without the moral resources we need to avoid stepping onto some extremely slippery slopes. Two examples can help illustrate this. One has to do with growing debates over where to situate supervised injection sites. Another has to do with the extension of the provision of assisted suicide.

For the past few years, the Montreal neighbourhood of St. Henri has been at the centre of a fight over Maison Benoît Labre, a supervised drug consumption and transitional housing centre that opened in 2024 just steps away from an elementary school. The centre opened in the face of strong objections from the community, in particular from the parents of students at the school, and there has been ongoing conflict between residents and users of the centre. Shortly after it opened there was a raft of incidents like children being exposed to people masturbating and defecating in public, and the centre briefly closed over a lack of qualified personnel to run it.

Earlier this spring, largely in response to blowback over the Maison Benoît Labre case, the Quebec government introduced a bill that would ban safe consumption sites within 150 metres of schools and daycares. The response from social services organizations was not, as one might expect, relief that children would now be somewhat more safe, but rather alarm that the bill “could hinder access to essential services” for those who consume drugs or are homeless.

Characteristic of these responses was Montreal’s public-health director Mylène Drouin, who expressed deep unhappiness over the bill, and asked the province’s social services minister to consider grandfathering Maison Benoît Labre. When the minister asked Drouin what he should tell the parents in the community who were worried about their kids’ safety, her response was that public-health officials should “continue to involve them and raise awareness” and try to build empathy for the centre’s clients.

The difficulties with complete official even-handedness with respect to lifestyle choices become even starker when you look at the evolution of the debate over euthanasia in Canada. Canada has a two-track system for eligibility for MAiD: track 1 applies to those whose death from injury or illness is reasonably foreseeable, while track 2 covers a serious illness or disability causing “intractable suffering” regardless of whether death is foreseeable.

While Canadian law doesn’t currently allow MAiD for mental illness alone, there are growing signs that lines are being blurred. In June, New York Times Magazine published a piece by the Canadian writer Katie Engelhart that uses the story of an Ontario woman named Paula Ritchie, who sought and received MAiD, to explore the medical, legal, and ethical contours of Canada’s assisted-dying regime. Ritchie was ostensibly granted MAiD as a track 2 candidate, though there is little evidence that there was anything physically wrong with her. In fact, the doctor who approved Ritchie’s application was pretty clear where his sympathies lie. As he told Engelhart “If you tell me that you’re suffering, who am I to question that?”

Who indeed? In a newsletter dispatch responding to Engelhart’s article, National Post columnist Colby Cosh noted that there is no evidence yet “of any case where a doctor gave MAiD to anybody who didn’t have a clear, emphatically expressed desire to die.”

But that’s basically the whole problem, isn’t it? When Canada first established its MAiD regime, the initial concerns were whether or not people would feel pressured into seeking assisted death, either by family, by doctors, or by the general failure of the medical system to help them in any other way.

But what if the bigger problem is with people who have nothing clearly wrong with them, they just wish to die and would like the state to help them? What moral hill do we stand on from which we would deny them their application? When the state no longer takes a stand on what sort of life is worth living, what gives it the right to take a stand on whether life is worth living at all?

The past half century has seen a significant shift in how we make social policy in Canada, and the policy adventure with harm reduction is far from over. There is no question that the turn away from a values-based regime and the enforcement of morality through the criminal law has resulted in massive welfare and equality gains for many citizens. Canada is a more just society today than it was when I was born.

But the growing reliance on harm reduction as a substitute for the condemnation of vice for all manner of social ills has come at the cost of leaving us without much in the way of a public vocabulary in which to express any sort of moral judgements. It should not surprise us then that a society that has difficulty prioritizing the safety and security of school children over the needs of drug users is also one that looks increasingly unable to say no to helping its citizens die on demand. **

In both public policy and moral reasoning, not every slope is slippery. But when you step out onto the ones that are, you cease to have much control over where you end up.

* The key text here is the paper “Disagreement, Unenforceability, and Harm Reduction” by the McGill philosopher Daniel Weinstock.

** I made a small edit here because the way I originally phrased the last sentence was unclear — ap

Andrew Potter writes nevermind, a newsletter about the forgotten history of Generation X. He lives in Montreal.

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