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Harmful Societies: The Importance of the Social Harm Approach

• By discoversociety
• October 04, 2016
• 2016 , Articles , DS37

Simon Pemberton

‘When one individual inflicts bodily injury upon another, such injury that death results, we call the deed manslaughter; when the assailant knew in advance that the injury would be fatal, we call this deed murder. But when society places hundreds of proletarians in such a position that they inevitably meet a too early and an unnatural death …when it deprives thousands of the necessaries of life, places them under conditions in which they cannot live … forces them, through the strong arm of the law, to remain in such conditions until that death ensues which is the inevitable consequence – knows that these thousands of victims must perish, to remain in such conditions, its deed is murder just as surely as the deed of the single individual … which seem what it is, because no man sees the murderer, because the death of the victim seems a natural one, since the offence is more one of omission than  of commission.’ (Engels,1845/1987: 127)

Students often ask me where they should find an example of a social harm study and they are often baffled when I reply ‘Engels’.  Of course there are more recent examples. But for me, the analysis presented by Engels in The Condition of the Working Class in England (1845/1987) is one of the original, if not the original, social harm analysis. Engels not only described in forensic detail the harms visited on the proletariat in the Great Towns as they underwent immense social and economic transformation during the Industrial Revolution, but crucially he understood these harms as entirely preventable, a product of social relations that could be organised very differently to meet the needs of the many and not just the few. Engels correctly identified the disease, squalor and deprivation endured at this point in time, not to be ‘natural’, but an ‘inevitable consequence’ of the laissez-faire mode of capitalism that dominated 19th-century England.  In many respects, these concerns draw a current generation of social scientists to the social harm approach, allied to a desire to develop analyses that more accurately document the ways that the organisation of our societies serve to injuriously interrupt human flourishing.

If we are to take anything from Engels, his analysis demands that we subject to critical scrutiny the presentation of habitual harm as ‘natural’.  Let us consider a couple of examples.  Last year in the UK, it is estimated that 40,000 deaths were ‘brought forward’ due to air pollution (Royal College of Physicians, 2016).  Moreover, the latest figures from the Office for National Statistics suggested that there were 43,900 ‘excess winter deaths’ in 2014/15 in England and Wales (ONS, 2015). In addition, it is estimated that 13,000 (Great Britain) lives are lost from lung disease or cancers contracted via the workplace (HSE,2014).  The scale and magnitude of this harm is extraordinary; but few column inches are spared over these widespread injuries or political careers forged from campaigning on these issues.  Why? The presentation of these injuries is critical and as Steve Tombs (2015:36) points out, language plays a significant role in the ‘naturalisation’ of these deaths:

‘Excess winter deaths’, ‘deaths brought forward’ and ‘fatal injuries’ each seem to combine the technical and the prosaic, but in neither respect does the language signify the extraordinary phenomena to which it refers. None conveys a source, nor any sense of agency or structure, nor responsibility regarding the deaths at issue.’

Tombs is correct; language has a beguiling effect.  It serves to decontextualize injury, denying the social contexts through which harms are produced thus reducing them to ‘chance’ events, with causation attributed to the biological ‘lottery of life’.  For example, ‘excess winter deaths’ are indeed attributable to underlying health conditions; however this is of course only part of the story.  Omitted from this story are the chronic levels of fuel poverty in the UK that force individuals to decide whether to ‘heat or eat’; fuel poverty rates that are being driven by escalating domestic fuel prices and the profits of private energy companies; allied to the chronic disinvestment in the UK’s social housing stock meaning that many homes are thermally deficient.  The point is that these deaths are not about the cold per se, rather a multiplicity of political and policy decisions as well as a whole set of economic interests that profit from the status quo.  A status quo that mean that some people in our societies lack the means to heat their homes to such an extent it irreparably damages their health.

In my recent book Harmful Societies (2015) I sought to contest the extent to which structural harms and injuries are viewed as intractable features of our societies.  Adopting a social harm perspective I sought to argue that many taken for granted injuries are in fact preventable or at the very least the rate of these injuries should be viewed as a ‘given’.  Even if we accept the argument that capitalism is an inherently harmful mode of organisation; we might also observe that similarly placed societies appear to produce different levels of harm and injury. If this is the case and harm varies dramatically between capitalist forms, the argument that: ‘…This is capitalism! We benefit greatly from it and any injuries that result are unfortunate unintended consequences of the social progress it brings’ – does not frankly hold water.

To explore these assertions comparative rates of homicide, suicide, infant mortality, obesity, road traffic injuries, obesity, poverty, financial insecurity, long working hours, youth unemployment and social isolation were examined across 31 OECD countries.  As part of this analysis the 31 nation states were grouped into Harm Reduction Regimes: Neo liberal, Liberal, Post Socialist Corporatist, Southern Corporatist, Meso Corporatist, Northern Corporatist and Social Democratic. Groupings were based on the harm reduction features of each nation state, contrasting forms of regulation; welfare systems; criminal justice systems and social solidarity. It might be unsurprising that considerable differences existed between states, as well as the regimes in relation to these harms.  A clear pattern emerged.  The neo liberal regime, the regime that is closest to delivering the ideological model of the ‘free market/minimal social state/strong state’ form, without exception appears to be the most harmful, whereas the social democratic regime were the least harmful forms. Why? The analyses presented in Harmful Societies appear to point to three facets of social democratic societies that significantly reduce the production of structural harms.

• i) Solidaristic Societies that exhibited high levels of trust and low levels of inequality appear to perform better in relation to many harms. Social solidarity plays an important role in protecting populations from harm for a number of reasons. First, on an interpersonal level, those societies that have higher levels of solidarity appear to demonstrate greater levels of respect for others. Conversely, societies that are dramatically unequal prove to be the generative contexts for interpersonal harms, such as homicide, where fragmented societies exhibit higher levels of harm. Second, solidarity ensures greater levels of empathy for others, and militates against producing ‘bystanders to harm’. Thus, solidaristic societies are likely to produce the support necessary to create and sustain harm reduction systems, more so than those that are heavily individualistic. Individualistic societies that reify competition and the unfettered enjoyment of freedom demonstrate greater levels of social disorganisation. Greater degrees of social chaos ensue when numerous individual atoms pursue their own interests with little regard to the unforeseen consequences of their (in)actions or decisions. Chaotic societies are harmful societies, as the relatively unfettered exercise of freedom not only granted through the market, but also in all aspects of social life, such as workplaces, healthcare, education and public spaces, can have a host of injurious consequences. Road traffic deaths are an example of this, insofar as motorised travel is often viewed in capitalist society as the ultimate expression of individual freedom, yet the unfettered exercise of this freedom is incredibly harmful. Therefore those societies that have sought to limit the speed of motorised vehicles through road design, law enforcement and education appear to be able to organise urban spaces in ways that reduce road traffic deaths.
• ii) Decommodified societies serve to recognise the worth of human beings as distinct from the contributions they make to wealth accumulation and consequently succeed in restricting the production of capitalist harm. In crude terms, those societies that appear to have developed more universal and generous welfare systems perform better in relation to a number of harms, not only militating against the production of injuries, such as poverty and financial insecurity as we might intuitively expect. However, these systems also appear to reduce the prevalence of a number of physical harms, such as infant mortality and homicide addressing the contexts that appear to produce these harms.

iii) Societies that place greater fetters on the extraction of surplus value tend to produce less exploitative and, therefore, less injurious modes of production. The impulses of capitalist logic to continually ‘sweat’ the labour relation to extract greater levels of surplus value, left unrestrained, provide the generative contexts that explain the variance of many harms. Fetters appeared to come in two principal forms. First, trade union representation in the workplace produces more humane working conditions. The impact of worker representation has a direct impact in relation to long working hours, so that those nation states that have longer working days tend to have low rates of worker representation. The impact of unionism appears to be broader; for example, poverty, higher rates of union membership appear to reduce these harms, as a result of the impact of collective bargaining on wages on the extent of ‘in-work’ poverty. Second, state intervention through regulatory law and agencies can also have the effect of fettering the exploitative function of capital. Unfortunately, it is difficult to assess the impact of state regulatory systems with little comparative data available in relation to regulatory activities. It is interesting to note, however, the harm reduction function of state regulatory activities in relation to the role of regulations that limit the length of the working day, or the impact of redundancy regulations that militate against the harms for young people resulting from the loss of a job.

Through documenting contrasting levels of harms between different capitalist societies, Harmful Societies sought to challenge the notion that social harms are unavoidable ‘accidents’, ‘facts of life’, or ‘quirks of fate’; rather, as we have seen, the forms that societies take have a significant impact on rates of harm. Those capitalist societies that are the least harmful are those that cling most dearly to the various constituent parts of the ‘social state’ in the face of the restructuring logics of neoliberalism. In an era of austerity, it is these harm reduction structures that are under attack. It is therefore imperative that the social harm approach articulates the defence and expansion of these structures; otherwise the scale of collateral harms that may result will be grave, a legacy that will extend well beyond the current generation.

References Engels, F. (1845/1987) The Condition of the Working Class in England , London: Penguin. HSE (Health and Safety Executive) (2014) Health and safety statistics for Great Britain 2013/2014 ONS (Office for National Statistics) (2015) Excess Winter Mortality in England and Wales: 2014/15 (Provisional) and 2013/14 (Final) . Pemberton, S (2015) Harmful Societies: Understanding Social Harm , Bristol: Policy Press Royal College of Physicians (2016) Every Breath We Take: The lifelong impact of air pollution. London: Royal College of Physicians/Royal College of Physicians of Child Health Tombs, S (2015) ‘Book Review: Harmful Societies’, Criminal Justice Matters , 101 (1) 36-37

Simon Pemberton is a Birmingham Fellow currently researching aspects of social harm caused by states and corporations, as well as social structures, in particular the harms caused by inequality. Simon is also Co-Head of the Department of Social Policy and Social Work at the University of Birmingham. He tweets @socialharm

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Social harm future(s): exploring the potential of the social harm approach

• Published: 07 November 2007
• Volume 48 , pages 27–41, ( 2007 )

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The notion of social harm has sporadically interested critical criminologists as an alternative to the concept of crime. In particular, it has been viewed as a means to widen the rather narrow approach to harm that criminology offers. More recently, the publication of Beyond Criminology: Taking Harm Seriously has renewed interest in the notion of social harm. The book asserted a number of very valid reasons for a social harm approach that provoked a number of interesting critical responses. The article seeks to respond to five recurring questions: Should the social harm perspective move beyond criminology? If so, where should the perspective locate itself? From this position, how will the perspective continue to engage within ‘law and order’ debates and address the concerns of those affected by crime? If the notion of crime is problematic, how will the perspective form an alternative definition of harm? Moreover, without a notion of crime and the accompanying concept of criminal intent, how would the perspective allocate responsibility for harm? The article is not offering definitive answers to these questions, but possible directions for the perspective’s future development.

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I would like to thank those who contributed to and attended the Social Harm stream at the ASC 2006 meetings which led to the development of this article. Also, I would like to the British Academy for the Overseas Conference Grant (OCG 44594), which enabled me to take part in the stream. Finally, I would like to extend my appreciation to Marty Schwartz and David Friedrichs for their patience and support.

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Pemberton, S. Social harm future(s): exploring the potential of the social harm approach. Crime Law Soc Change 48 , 27–41 (2007). https://doi.org/10.1007/s10611-007-9078-0

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Social harm and the structure of societies

Interviewer: Lucy Vernall (Interviewer, Ideas Lab) Guest: Dr Simon Pemberton Recorded: 08/02/2012 Broadcast: 04/04/2012

Intro VO: Welcome to the Ideas Lab Predictor Podcast from the University of Birmingham . In each edition we hear from an expert in a different field, who gives us insider information on key trends, upcoming events, and what they think the near future holds.

Lucy: Today I’m with Dr Simon Pemberton who is a Birmingham Fellow and he is in both the School of Social Policy and the School of Law . Simon, you’re split across two schools.

Simon: That’s correct.

Lucy: Tell us what you’re doing with your Fellowship.

Simon: My Fellowship is to essentially develop the concept of social harm, to develop a working definition and ensure that that definition will be used to measure social harm within society.

Lucy: So, social harm is a term within criminology?

Simon: Well that’s where it began. Social harm originates out of a series of debates within criminology about the narrowness of the definition of crime, that essentially, focuses on individual acts of harm, things like inter-personal violence, theft, so on and so forth. So the idea of social harm originally was to expand that notion of harm to encompass the harms that organisations cause that nation states cause. But latterly the idea of social harm really now transcends criminology so there are a group of writers who think that – and I would include myself there – that actually there's something to social harm that could be very useful in terms of trying to understand the harms that occur within society, to produce an objective and well-rounded analyses of harm. It’s to take all the harms that occur in society and to understand the sorts of harms that causes the greatest level of harm, the way that those harms are disproportionately located amongst different groups within society.

Lucy: So to give us an example?

Simon: If you go back to the idea of ‘yes, well will it escape criminology?’, then yes, we say OK, well there are, I don’t know, there are something like 600 murders a year in the UK and of course those cause immense suffering and devastation to not only the victim of course who loses their life, but to the families and other people connected to that individual. But also to think, you know, if you take that as a physical harm, the other forms of physical harm. So to use an example: of the deaths caused by air pollution, so deaths brought forward in the UK each year through air pollution are estimated at 20,000 deaths a year. There are something like 8,000 deaths that occur through contraction of cancer as a result of the work that people do.

Lucy: 20,000 people a year die prematurely due to air pollution in this country?

Simon: Yes, that’s correct.

Lucy: That seems like an incredible figure.

Simon: It is. It’s a figure -

Lucy: And we worry about being murdered.

Simon: There are different narratives that frame these events and the point is that social harm tries to escape those narratives to basically analyse in the round harms in society because there’s a great level of sort of morality that surrounds particular forms of death and the point of social harm is to take a step back and think about harm as being a preventable social phenomena.

Lucy: So it’s to think about how could we prevent some of these deaths from happening?

Simon: Yes, that’s right. Whereas obviously crime is concerned with issues around intent, less commonly criminal negligence, the point of social harm is to think about harm as a preventable incident. That means that we can have a far broader lens if you like, so we can take a whole host of different harms that otherwise would have been left out of the notion of crime and left out of the remit of other social sciences, to think about harm as a preventable event and to think about, well OK then, when we compare those harms, which ones are the most regular, which ones cause the most damage to our life? So that really is the kind of second strand to this idea of defining social harm.

Lucy: So it’s looking at perhaps a mission or indifference where companies are pursuing profit rather than looking after their workforce and then that ends up with workplace cancers or other injuries.

Simon: Yes, that’s right. So one of the strictures of criminal law is that criminal law has a fascination with intent. Well actually, the greatest level of harms that are probably caused in our society are caused by indifference. Whilst corporations do many things for us that are positive, they create jobs, they deliver services for us, you know, there are also a whole host of harms that are caused by corporations through indifference, as you quite rightly say. But also social harm allows us to look at the structures of our society. There are a lot of harms that are generated through the very way we organise our society in terms of inequality, in terms of harms associated to poverty, homelessness, you know, where not one organisation, not one individual, is necessarily to blame but actually the decisions that we make as a society, the way that we structure our social relationships, the way we structure our markets, produce a whole host of harms.

Lucy: On the face of it, saying how could we reduce say the 8,000 people that contract cancer as a result of what they’ve done in the workplace, sounds great. The other end of the stick is, is this the health and safety gone mad approach, you know, is that what you end up with when you try to reduce this?

Simon: There are a number of societies, capitalist societies that have greater levels of regulation. If you use the jargon of red tape then ‘burdens on business’, one could empirically, it would appear that their societies – so if you take Scandinavian countries – tend to have far greater levels of legal regulation around the workplace. It would appear that those societies perform as well, if not better, economically than societies who have less red tape, less regulation, less burdens on business. So I’m not convinced empirically that that is necessarily proven.

Lucy: And how does the UK square up when you compare us with say Scandinavian countries, in this area of social harm?

Simon: I mean on the face of it, with work that I’ve done previously, suggests that actually neo-liberal countries like the US, I would argue increasingly the UK has a neo-liberal thorn of governance and policy. But those countries demonstrate higher levels of harm on a range of different indicators in terms of inequality, in terms of economic insecurity, in terms of physical insecurity, in terms of workplace injuries and harm. When you look, on the face of it, social democratic countries they appear to have a number of facets to their organisation that protect people within those nation states from some of the harms that capitalism itself generates.

Lucy: And having done this research, what do you lie in bed at night worrying about?

Simon: I worry most about the forms of analysis of harm that persist at the moment. There's a very individualised analysis of harm that dominates a whole host of debates around responsibility for crime, around the current debates around welfare as well. So that in essence we’ve used society in a very atomised way and consequently we neglect the structural determining context in which harms take place. So you know, there's a beautiful line that’s used by two American criminologists – Tift and Sullivan – who talk about societies create conditions in which people find it difficult to be good and for me, we’re neglecting these analyses. Really, it means that we arrive at more sensible conclusions about levels of crime and the way that we then prevent crime, but also in terms of the way that we think about the harms of poverty where we try to explain them through the behaviours of individuals rather than actually the structural organisation of markets and labour markets. So, you know, there’s some very persuasive analysis produced by Danny Dorling of the crime rates of murder following the policies of economic deregulation, deindustrialisation in the 1980s which demonstrates a peak in production of a whole set of events and murders. Now of course individuals are obviously responsible for those murders but also we have to take a step back and consider the social conditions in which those murders take place. Harms just aren’t naturally occurring, they don’t just randomly occur. There are reasons why some capitalist countries seem to outperform others in terms of preventing harm to their populations and we need to understand that.

Lucy: You’re saying that actually if we take time to think about this and approach it in a different way, we could potentially make a change.

Simon: Indeed. Whilst harm is a gloomy topic in itself, there are alternative models to organising society. We can follow those models; it’s just a case of political will.

Lucy: Dr Simon Pemberton, thank you very much.

Simon: Thank you.

Outro VO: This podcast and others in the series are available on the Ideas Lab website: www.ideaslabuk.com . On the website, you can find out how to e-mail us with comments, questions or suggestions for future topics for the podcast. There's also information on the free support Ideas Lab has to offer to TV and radio producers, new media producers and journalists. The interviewer for the Ideas Lab Predictor Podcast was Lucy Vernall and the producer was Sam Walter.

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Social harm

Importantly, the concept of harm has made it possible to extend the criminological gaze beyond national borders to include illegal and harmful acts involving powerful elites, such as governments and political leaders. The problem of state crime and culpability is an area that has attracted much consideration from critical criminologists for many years. In 1970, Julia and Herman Schwendinger, influenced by US foreign policy failures and the Vietnam War, argued that state institutions that tolerated, perpetuated or failed to prevent human rights abuses such as racism, sexism, or poverty were not only negligent in their civic duty but co-conspirators in crimes against humanity. From these analyses discourses emerged that began to link criminology to the preservation of human and social life and to the enactment of human rights.

Key features of social harm

• Encompasses social, economic, psychological and environmental injury or damage inflicted on society either intentionally or unintentionally
• A concept that enables criminology to move beyond legal definitions of ‘crime’ to include immoral, wrongful and injurious acts that are not necessarily illegal
• Originates theoretically from Edwin Sutherland’s 1945 work ‘Is “White Collar Crime” Crime?’
• Paddy Hillyard
• Christina Pantazis
• Simon Pemberton
• Larry Tifft
• Steve Tombs.

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Science News

Social media harms teens’ mental health, mounting evidence shows. what now.

Understanding what is going on in teens’ minds is necessary for targeted policy suggestions

Most teens use social media, often for hours on end. Some social scientists are confident that such use is harming their mental health. Now they want to pinpoint what explains the link.

Carol Yepes/Getty Images

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By Sujata Gupta

February 20, 2024 at 7:30 am

In January, Mark Zuckerberg, CEO of Facebook’s parent company Meta, appeared at a congressional hearing to answer questions about how social media potentially harms children. Zuckerberg opened by saying: “The existing body of scientific work has not shown a causal link between using social media and young people having worse mental health.”

But many social scientists would disagree with that statement. In recent years, studies have started to show a causal link between teen social media use and reduced well-being or mood disorders, chiefly depression and anxiety.

Ironically, one of the most cited studies into this link focused on Facebook.

Researchers delved into whether the platform’s introduction across college campuses in the mid 2000s increased symptoms associated with depression and anxiety. The answer was a clear yes , says MIT economist Alexey Makarin, a coauthor of the study, which appeared in the November 2022 American Economic Review . “There is still a lot to be explored,” Makarin says, but “[to say] there is no causal evidence that social media causes mental health issues, to that I definitely object.”

The concern, and the studies, come from statistics showing that social media use in teens ages 13 to 17 is now almost ubiquitous. Two-thirds of teens report using TikTok, and some 60 percent of teens report using Instagram or Snapchat, a 2022 survey found. (Only 30 percent said they used Facebook.) Another survey showed that girls, on average, allot roughly 3.4 hours per day to TikTok, Instagram and Facebook, compared with roughly 2.1 hours among boys. At the same time, more teens are showing signs of depression than ever, especially girls ( SN: 6/30/23 ).

As more studies show a strong link between these phenomena, some researchers are starting to shift their attention to possible mechanisms. Why does social media use seem to trigger mental health problems? Why are those effects unevenly distributed among different groups, such as girls or young adults? And can the positives of social media be teased out from the negatives to provide more targeted guidance to teens, their caregivers and policymakers?

“You can’t design good public policy if you don’t know why things are happening,” says Scott Cunningham, an economist at Baylor University in Waco, Texas.

Increasing rigor

Concerns over the effects of social media use in children have been circulating for years, resulting in a massive body of scientific literature. But those mostly correlational studies could not show if teen social media use was harming mental health or if teens with mental health problems were using more social media.

Moreover, the findings from such studies were often inconclusive, or the effects on mental health so small as to be inconsequential. In one study that received considerable media attention, psychologists Amy Orben and Andrew Przybylski combined data from three surveys to see if they could find a link between technology use, including social media, and reduced well-being. The duo gauged the well-being of over 355,000 teenagers by focusing on questions around depression, suicidal thinking and self-esteem.

Digital technology use was associated with a slight decrease in adolescent well-being , Orben, now of the University of Cambridge, and Przybylski, of the University of Oxford, reported in 2019 in Nature Human Behaviour . But the duo downplayed that finding, noting that researchers have observed similar drops in adolescent well-being associated with drinking milk, going to the movies or eating potatoes.

Holes have begun to appear in that narrative thanks to newer, more rigorous studies.

In one longitudinal study, researchers — including Orben and Przybylski — used survey data on social media use and well-being from over 17,400 teens and young adults to look at how individuals’ responses to a question gauging life satisfaction changed between 2011 and 2018. And they dug into how the responses varied by gender, age and time spent on social media.

Social media use was associated with a drop in well-being among teens during certain developmental periods, chiefly puberty and young adulthood, the team reported in 2022 in Nature Communications . That translated to lower well-being scores around ages 11 to 13 for girls and ages 14 to 15 for boys. Both groups also reported a drop in well-being around age 19. Moreover, among the older teens, the team found evidence for the Goldilocks Hypothesis: the idea that both too much and too little time spent on social media can harm mental health.

“There’s hardly any effect if you look over everybody. But if you look at specific age groups, at particularly what [Orben] calls ‘windows of sensitivity’ … you see these clear effects,” says L.J. Shrum, a consumer psychologist at HEC Paris who was not involved with this research. His review of studies related to teen social media use and mental health is forthcoming in the Journal of the Association for Consumer Research.

Cause and effect

That longitudinal study hints at causation, researchers say. But one of the clearest ways to pin down cause and effect is through natural or quasi-experiments. For these in-the-wild experiments, researchers must identify situations where the rollout of a societal “treatment” is staggered across space and time. They can then compare outcomes among members of the group who received the treatment to those still in the queue — the control group.

That was the approach Makarin and his team used in their study of Facebook. The researchers homed in on the staggered rollout of Facebook across 775 college campuses from 2004 to 2006. They combined that rollout data with student responses to the National College Health Assessment, a widely used survey of college students’ mental and physical health.

The team then sought to understand if those survey questions captured diagnosable mental health problems. Specifically, they had roughly 500 undergraduate students respond to questions both in the National College Health Assessment and in validated screening tools for depression and anxiety. They found that mental health scores on the assessment predicted scores on the screenings. That suggested that a drop in well-being on the college survey was a good proxy for a corresponding increase in diagnosable mental health disorders. 

Compared with campuses that had not yet gained access to Facebook, college campuses with Facebook experienced a 2 percentage point increase in the number of students who met the diagnostic criteria for anxiety or depression, the team found.

When it comes to showing a causal link between social media use in teens and worse mental health, “that study really is the crown jewel right now,” says Cunningham, who was not involved in that research.

A need for nuance

The social media landscape today is vastly different than the landscape of 20 years ago. Facebook is now optimized for maximum addiction, Shrum says, and other newer platforms, such as Snapchat, Instagram and TikTok, have since copied and built on those features. Paired with the ubiquity of social media in general, the negative effects on mental health may well be larger now.

Moreover, social media research tends to focus on young adults — an easier cohort to study than minors. That needs to change, Cunningham says. “Most of us are worried about our high school kids and younger.” 

And so, researchers must pivot accordingly. Crucially, simple comparisons of social media users and nonusers no longer make sense. As Orben and Przybylski’s 2022 work suggested, a teen not on social media might well feel worse than one who briefly logs on. 

Researchers must also dig into why, and under what circumstances, social media use can harm mental health, Cunningham says. Explanations for this link abound. For instance, social media is thought to crowd out other activities or increase people’s likelihood of comparing themselves unfavorably with others. But big data studies, with their reliance on existing surveys and statistical analyses, cannot address those deeper questions. “These kinds of papers, there’s nothing you can really ask … to find these plausible mechanisms,” Cunningham says.

One ongoing effort to understand social media use from this more nuanced vantage point is the SMART Schools project out of the University of Birmingham in England. Pedagogical expert Victoria Goodyear and her team are comparing mental and physical health outcomes among children who attend schools that have restricted cell phone use to those attending schools without such a policy. The researchers described the protocol of that study of 30 schools and over 1,000 students in the July BMJ Open.

Goodyear and colleagues are also combining that natural experiment with qualitative research. They met with 36 five-person focus groups each consisting of all students, all parents or all educators at six of those schools. The team hopes to learn how students use their phones during the day, how usage practices make students feel, and what the various parties think of restrictions on cell phone use during the school day.

Talking to teens and those in their orbit is the best way to get at the mechanisms by which social media influences well-being — for better or worse, Goodyear says. Moving beyond big data to this more personal approach, however, takes considerable time and effort. “Social media has increased in pace and momentum very, very quickly,” she says. “And research takes a long time to catch up with that process.”

Until that catch-up occurs, though, researchers cannot dole out much advice. “What guidance could we provide to young people, parents and schools to help maintain the positives of social media use?” Goodyear asks. “There’s not concrete evidence yet.”

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Ten Poverty and social harm: challenging discourses of risk, resilience and choice

• Published: November 2017
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This chapter explores the injurious nature of poverty as a condition and a generative context which determines the experience of related injury. Drawing on the social harm approach we seek to contextualise these injuries and to provide a counterpoint to dominant narratives of risk, resilience and choice that serve to individualise the harms of poverty. Using both quantitative and qualitative data from the PSE-UK study, four key findings emerge. First, poverty increases the risk of injuries in the home and at work, as well as the likelihood of being the victim of violence. Second, powerlessness is a key injury of poverty; the loss of control over key aspects of individuals’ lives is anxiety provoking – the PSE poor were three times more likely to report suffering from a mental illness than the non-poor. Third, the injuries of stigma and disrespect are daily features of life on a low income – the PSE poor were nearly eight and six times more likely to report instances of misrecognition due to class and disability. Finally poverty injuriously impacts relationships and the ability to participate socially; under financial constraint, PSE survey participants are more likely to relinquish friendships

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Essay On Social Issues

500 words essay on social issues.

Social Issues is an undesirable state which opposes society or a certain part of society. It refers to an unwanted situation that frequently results in problems and continues to harm society . Social issues can cause a lot of problems that can be beyond the control of just one person. Through an essay on social issues, we will learn why they are harmful and what types of social issues we face.

Drawbacks of Social Issues

Social issues have a lot of drawbacks that harms our society. They are situations that have an adverse and damaging result on our society. They arise when the public leaves nature or society from an ideal situation.

If you look closely, you will realize that almost all types of social issues have common origins. In the sense that they all are interconnected somehow. Meaning to say, if one solves the other one is also most likely to resolve.

Social issues have a massive lousy effect on our society and ultimately, it affects all of us. In order to solve some social issues, we need a common approach. No society is free from social issues, almost every one of them has some social issue or the other.

For instance, in India, you will find a lot of social issues which the country is facing. It ranges from the caste system to child labour and gender inequality to religious conflicts. Thus, we are going through a critical time where we all must come together to free our society from undesirable social evils.

Get the huge list of more than 500 Essay Topics and Ideas

Major Social Issues

There are a lot of social issues we are facing right now, some more prominent than the others. First of all, poverty is a worldwide issue. It gives birth to a lot of other social issues which we must try to get away with at the earliest.

Further, countries like India, Nepal, Bangladesh, Sri Lanka, Pakistan and more are facing the issue of the caste system since times unknown. It results in a lot of caste violence and inequality which takes the lives of many on a daily basis.

Moreover, child labour is another major social issue that damages the lives of young children. Similarly, illiteracy also ruins the lives of many by destroying their chances of a bright future.

In developing countries mostly, child marriage still exists and is responsible for ruining many lives. Similarly, dowry is a very serious and common social issue that almost all classes of people partake in.

Another prominent social issue is gender inequality which takes away many opportunities from deserving people. Domestic violence especially against women is a serious social issue we must all fight against.

Other social issues include starvation, child sex abuse, religious conflicts, child trafficking, terrorism , overpopulation, untouchability, communalism and many more. It is high time we end these social issues.

Conclusion of the Essay on Social Issues

A society can successfully end social issues if they become adamant. These social issues act as a barrier to the progress of society. Thus, we must all come together to fight against them and put them to an end for the greater good.

FAQ on Essay on Social Issues

Question 1: What is the meaning of social problem?

Answer 1: A social problem refers to any condition or behaviour which has a negative impact on a large number of people. It is normally recognized as a condition or behaviour that needs to be addressed.

Question 2: What are the effects of social issues?

Answer 2: Social issues affect our society adversely. Most importantly, it disturbs the harmony of society and gives rise to hostility and suspicion. Moreover, it creates large-scale social dissatisfaction, suffering and misery.

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The Impact of Safe Consumption Sites: Physical and Social Harm Reduction and Economic Efficacy

By Mary Grace Lewis

Abstract 

In recent decades, communities across the world have been implementing radical new methods for combating death and disease from intravenous drug use. Syringe exchange programs (SEPs), which employ the harm reduction model to combat the risks associated with drug use by providing people who inject drugs (PWID) with sterile needles and supplies, have been successful and are becoming more widely utilized in the United States. Along with syringe exchange programs, recently bills allowing for states to implement safe consumption sites (SCSs) are being written and passed. SCSs employ the harm reduction model to combat the risks associated with drug use by providing PWID with a safe, monitored, and sterile environment to inject drugs. By reviewing existing literature, I will consider the efficacy of SCSs at completing the following three goals: 1) reducing the physical harms associated with drug use for the individual injecting drugs, including decreasing overall rates of death and injury from overdose, and infection and disease from unsafe needle sharing practices; 2) reducing the social harms associated with drug use, including decreasing rates of public drug use, volumes of publicly discarded syringes and injection related litter, and decreasing drug related crime; 3) creating a more cost-effective alternative to zero tolerance drug policies by focusing on harm reduction. 

Keywords: opioid abuse, risk behavior, risk reduction, HIV, Hepatitis, overdose, syringe exchange program, supervised consumption site, safe injection facility, PWID

Literature Review

This paper adds to the existing literature on the impact of safe consumption sites in communities affected by drug misuse and the opioid epidemic. I have reviewed the most prominent existing studies on safe consumption sites and compiled data from several pilot SCSs as well as studies attempting to predict the impact of SCSs on specific communities in the United States. The result is a holistic summary of three primary areas which SCSs have found to improve: reducing physical harms of injectable drug use, reducing social harms of injectable drug use, and doing so in a manner that is cost-effective as compared to other interventions against drug misuse. With this compilation and review of existing research I seek to provide communities considering implementing safe consumption sites with a comprehensive yet accessible guide to the benefits of such programs. Introduction Opioid use is on the rise in the United States, with more than 130 deaths every day contributed to opioid overdose (CDC/NCHS, 2018). While opioids have approved medical uses and are regularly prescribed to medical patients for the treatment of pain, approximately 21-29% of patients who are prescribed opioids for chronic pain eventually misuse them, and 8-12% eventually develop an opioid use disorder (Vowles et al., 2015). Overdoses from opioids are on the rise, having increased in large cities by 54% in 16 states from July 2016- September 2017 (Vivolo-Kantor et al., 2018). People who engage in drug use are at higher risk of contracting and transmitting certain viral infections, such as hepatitis, a viral infection that can cause liver inflammation and if untreated lead to liver damage, failure, and in some cases death, as well as human immunodeficiency virus (HIV), which can lead to acquired immune deficiency syndrome (AIDS) (National Institute on Drug Abuse, June 2019). Opioid abuse and misuse, as well as the risk of infection, disease, and overdose that comes with injecting drugs, have become a public health crisis, costing the United States an estimated $78.5 billion annually, including healthcare costs, lost productivity, addiction treatment, and criminal justice involvement (Florence et al., 2016). Communities are looking for solutions, and some are beginning to implement a variety of public health interventions to reduce opioid misuse and decrease the harms associated with drug use. The harm reduction model of intervention is rising in popularity as a way to mitigate the risks that come with illicit drug use without trying to stop drug use altogether (Harm Reduction Coalition).

The Harm Reduction Model of Intervention

Introduction to Syringe Exchange Programs

Syringe exchange programs (SEPs) help reduce the risk of preventable diseases by handing out sterile supplies to people who inject drugs (CDC, 2019). SEPs provide supplies such as sterile needles, syringes, and other “works” used to inject drugs, including but not limited to cotton balls, alcohol swabs, cookers, and tourniquets. Additionally, most SEPs can help link patients to other critical services if requested, including drug rehabilitation services and HIV care, pre-exposure prophylaxis and post-exposure prophylaxis (CDC, 2019). Different clinical studies of needle exchange programs have shown high success rates in preventing the spread of hepatitis and preventing and treating HIV and AIDS. A study on the effect of a harm reduction housing and syringe exchange program on the viral loads of homeless individuals living with HIV/AIDS showed that after the intervention, 95% of patients were prescribed antiretroviral therapy and 87% of patients were virally suppressed after treatment (Hawk, Davis, 2011). A comprehensive international review of syringe exchange programs done in 2005 found that SEPs provide a substantial benefit by reducing HIV transmission safely, effectively, and cost-effectively. The program was evaluated using the Bradford Hill criteria, a common and robust method of assessing public health interventions that analyzes the intervention on a set of nine criteria to provide epidemiologic evidence of a causal relationship between intervention (presumed cause) and observed effect. This particular program was found to fill six of the nine criteria, providing some evidence for a causal relationship between SEP initiation and observed reduction in harms. The study concluded that communities with high rates of drug injection should implement syringe exchange programs to combat the harms of the behaviors (Wodak, Cooney, 2005).

Introduction to Safe Consumption Sites

Safe Consumption Sites (SCS), otherwise known as supervised consumption facilities or safe injection facilities, help reduce the risk of preventable disease, infection, and overdose from injectable drug use by providing a medically supervised room for people to inject drugs hygienically and with care available in the case of overdose complications or risk of death (Drug Policy Alliance). A study done in Vancouver on the lessons learned after the initiation of their first syringe exchange program found that, after the introduction of the program, the prevalence of HIV, hepatitis C, and other risk behaviors were still high, concluding that a more comprehensive program was still necessary (Strathdee, 1997). One such program is the safe consumption site, which was later implemented in Vancouver. Since then, SCSs have become an increasingly popular intervention used by cities facing opioid epidemics for their success at reducing risks of disease, infection, overdose, and social harms from injectable drug use in a cost-effective manner.

Reducing Physical Harm

A review of the literature on structural interventions to reduce HIV transmission among people who inject drugs found that some policies that are designed to reduce drug use might actually increase rates of HIV transmission, but that SCSs (and SEPs) usually lead to large reductions in HIV risk-behavior (Jarlais, 2000). One major HIV risk-behavior is syringe sharing. One study on safer injection facility use and syringe sharing in injection drug users found that the use of safe consumption sites was independently associated with reductions in syringe sharing (Kerr et al., 2005). A study on the HIV infections prevented by Vancouver, Canada’s safe consumption site used mathematical modelling to estimate how many HIV infections were prevented by the introduction of the program. It found that 5-6 infections were prevented annually, give or take 2 (Pinkerton, 2011). The official report of the first safe consumption sites in Ottawa and Toronto, Canada estimated the number of HIV infections prevented in the two cities combined was about 8-13 per facility per year. The estimated number of hepatitis C virus infections prevented in the two cities combined was about 35-55 per facility per year (Bayoumi et al., 2012). A retrospective study analyzing the reduction in overdose mortality rates in Vancouver in areas around safe consumption sites found a decrease in mortality of 35% after opening. Mortality rates in the general city decreased as well, but the decrease in areas around SCSs were considerably higher. The study suggested other cities consider the implementation of an SCS in areas where injectable drug use is prevalent (Marshall et al., 2011). Another study on estimated drug overdose deaths averted by Vancouver’s first SCS found that 8-51 deaths were prevented from the implementation of the SCS by the most conservative estimates, and 6-37% of all fatal overdoses were prevented (Milloy et al., 2008). In addition to decreasing rates of infection and disease transmission, safe consumption sites have been shown to improve injecting practices in patients. A study on changes in injecting practicies associated with the use of an SCS randomly selected SCS users found that patients that more consistently visited a safe consumption site had more positive changes in their injecting practices, including decresed syringe borrowing, sex trade, public injecting, and daily injections, and increased use of sterile water for injections, swabbing injection sites, filtering drugs, less rushed injections, and more safe syringe disposal (Stoltz et al., 2007). Further, a study on the impact of safe consumption sites on community HIV levels reviewed the potential impact of SCSs on HIV transmission as compared to current HIV prevention initiatives. The study highlighted the harms of HIV infection from drug use, arguing that reducing HIV infections among PWID through initiatives like SCSs will reduce HIV in the community at large, particularly as transmitted through sex (Tyndall, 2003). Additionally, although the goal of SCSs is to reduce the risks of drug use, rather than to decrease drug use altogether, some research has found that SCSs can complete both goals. A study on North America’s first medically supervised safe consumption site found that SCSs reduce overall rates of drug use, and potentially promote an increase in addiction treatment and thus injection cessation, which improves individual health long term (Debeck et al., 2011). For their impact at reducing rates of infection and disease, as well as improving clients injecting practices long term and decreasing the risk of HIV spread in the community, safe consumption sites are recommended to decrease the physical risks of injecting drugs. Reducing Social Harm In addition to decreasing adverse health effects of drug use, such as infection, overdose, and disease, safe consumption sites have been shown to decrease many of the social harms of injectable drug use in communities as well. A study focussing on an urban district of Melbourne, Australia found that public areas with high rates of drug use carry risks for both the community at large and the individual using drugs, such as risks related to public injection, publicly discarded syringes and injection-related litter, and drug-related crime rates (Dovey et al. 2001). Thus, it is in everyone’s best interest to find an alternative to public drug use. A study summarizing the findings from the evaluation of the pilot supervised consumption site in Vancouver, Canada found that public order in the area surrounding the facility increased by several measures after the initiation of the facility. There was a decrease in publicly discarded syringes, public injection drug use, injection-related litter, and presence of suspected drug dealers after the initiation of SCSs (Wood et al. 2006). Another similar study on safe consumption sites in North America and their place in public policy and health initiatives outlined the possible benefit of implementing SCSs in North America using data from existing SCSs. This study concluded that safe consumption sites decreased rates of public drug use, which is both more safe for the person injecting, and can make community members feel more safe. Additionally, this study found that the volume of discarded litter pertaining to drug use decreased after the implementation of SCSs, as well as rates of public congregations of PWID, increasing the quality of public spaces and safety for individual users (Broadhead et al., 2002). A study on a pilot observation and treatment center in Boston, MA found that after the initiation of the clinic, the average number of over-sedated individuals in public decreased by a sizeable 28% (León et al., 2018). The decrease in social harms has been found to be particularly attractive to both PWID and SCS stakeholders, with the interest of increasing both public and individual safety. A series of semi-structured interviews with participants in Philadelphia found that PWID and healthcare providers expressed support for a potential SCS, suggesting that an SCS would improve the health of PWID while reducing the public disorder and crime that are often associated with public drug use. Many SCS participants seemed particularly interested in the creation of a safe, private place to inject drugs, motivated by a desire to not upset other community members and children (Harris et al., 2018). A similar study on perspectives on SCSs among service industry employees in New York City, sampled from 13 different businesses that do not hold a liquor license, found a similar positive attitude toward SCSs, particularly for their influence on reducing the social harms of public injection drug use (Wolfson-Stofko et al., 2018). A common argument against safe consumption sites is that the draw of PWID to SCSs will increase crime rates and unfavorable behaviors in the surrounding areas. This isn’t the case, as SCSs are most effective when implemented in areas with already high rates of injectable drug use. Thus, PWID aren’t displaced to areas where they didn’t already inhabit, but rather given a safer more concealed area to inject drugs within those neighborhoods. Additionally, safe consumption sites have a net positive result on the communities in which they reside. SCSs have been shown to decrease drug-related crime (Wood et al., 2006; Broadhead et al., 2002; Dovey et al. 2001), decrease the volume of publicly discarded syringes and injection-related litter (Wood et al., 2006; Broadhead et al., 2002; Dovey et al. 2001) decrease rates of public drug use (Wood et al., 2006; Broadhead et al., 2002; Dovey et al. 2001), and decrease the number of suspected drug dealers and over-sedated individuals in public (León et al., 2018). This increases health and safety for both the individuals injecting drugs as well as the surrounding community members, and increases the perceived safety and value of the area of the SCS. Cost-effectiveness Safe consumption sites have been shown to decrease both public order and personal health risks of drug use. In addition to being effective at completing these goals, SCSs have been shown to be an increasingly cost-effective intervention. A study comparing Vancouver’s safe consumption sites to other interventions for the prevention of HIV, such as syringe exchange programs and methadone maintenance treatment facilities, found that SCSs were highly cost effective in comparison to other interventions. The study concluded that SCSs would be cost effective even if they only prevented a modest number of HIV infections per year due to the high cost of lifetime medical treatment for an individual with HIV (Jarlais et al., 2008). The official report of the Toronto and Ottawa Supervised Consumption Assessment Study used mathematical modeling to determine the benefit of SCSs on reducing HIV and hepatitis C infection rates, and concluded that the intervention had high effectiveness and relatively low cost. It is estimated that the amount of money saved per each HIV infection averted with the first SCS was $323,496 in Toronto and $66,358 in Ottawa. The savings per hepatitis C infection prevention is estimated to be $47,489 in Toronto and $18,591 in Ottawa. The same study estimated the optimal cost-effectiveness as measured by the extra cost of intervention divided by the extra health gain, expressed as a ratio of dollars per quality adjusted life years (QALY). There is debate over whether the threshold for cost-effectiveness lies at $50,000/QALY or $100,000/QALY, but it was found that these thresholds would be met with 3-4 facilities in Toronto and 2-3 facilities in Ottawa. (Bayoumi et al., 2012) A third study on the cost-effectiveness of Vancouver’s SCS similarly found that the program was very cost-effective as an intervention to prevent HIV infection, with an incremental net savings of almost $14 million and 920 life-years gained for patients over 10 years (Bayoumi and Zaric, 2008). A study on the predicted cost and benefits of an SCS in San Francisco, California, used mathematical models to estimate potential savings from five different outcomes, including averted HIV and hepatitis C infections, reduced skin and tissue infections, averted death from overdose, and increased medication-assisted treatment. The authors estimated that each dollar spent on an SCS would generate $2.33 in savings for a net savings of $3.5 to $2.2 million annually for a single facility (Irwin et al., 2016). A similar study was done in Baltimore, MD, of a cost-benefit analysis of a hypothetical SCS. The study estimated the benefits of an SCS using local health data and existing data measuring the efficacy of SCSs on six different outcomes, similar to those explored in the previous study on San Francisco. The study predicted that for $1.8 million in spending, a single SCS would generate $7.8 million in savings and prevent large numbers of infections and 5.9 overdose deaths annually (Irwin et al. 2017). Another similar study predicted a cost-benefit analysis of an SCS in Seattle, WA using a mathematical model and estimated that a pilot SCS would generate $4.22 in savings for every dollar spent, for a total savings of $534,453 annually. Hypothetically, if overdose rates continued to rise in Seattle and more SCSs were implemented, the benefit and efficacy would be even greater (Hood et al. 2019). Safe consumption sites don’t only decrease government spending treating HIV infections, but have also been shown to decrease other public burdens and costs. A study done on the SCSs in Sydney, Australia found that the burden on ambulances of attending to opioid-related overdoses and emergencies declined significantly in the vicinity of the SCS after opening (Salmon et al., 2010). A study analyzing the potential impact of an SCS in Baltimore, MD, estimated that the introduction of a single facility would avert 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations (Irwin et al., 2017). A similar study on the potential impact of an SCS in Seattle, WA estimated that a facility would prevent 45 hospitalizations, 90 emergency room visits, and 92 emergency medical service deployments (Hood et al., 2019). SCSs can free ambulances and emergency medical facilities to attend to other emergencies in the community, and also decreased emergency medical costs for people injecting drugs.

Conclusion Harm reduction interventions, specifically syringe exchange programs and safe consumption sites, have been shown to greatly reduce the harms associated with injectable drug use. Researchers have studied safe consumption sites for efficacy in three primary areas; 1) reducing individuals’ physical harms associated with drug use, such as the spread of HIV and hepatitis C, infections, and overdose, 2) reducing social harms associated with drug use, such as publicly discarded syringes and injection related litter, public crime, public drug use, and public overdose, 3) cost-effectiveness as compared to other similarly effective interventions and the price of tertiary treatment and prevention. Nearly every study on supervised injection facilities recommends the intervention for areas where drug use is prevalent. From the body of evidence, the advantage of SCSs should be heavily considered when a community is trying to prevent the harms associated with drug use.

References Ball, A. L. (2007). HIV, injecting drug use and harm reduction: A public health response. Addiction, 102(5), 684-690. doi:10.1111/j.1360-0443.2007.01761.x Bayoumi, A. M., & Zaric, G. S. (2008). The cost-effectiveness of Vancouver's supervised injection facility. CMAJ. doi:https://doi.org/10.1503/cmaj.080808 Bayoumi, A. M., Strike, C., Degani, N., Fischer, B., Glazier, R., Hopkins, S., . . . Zaric, G. S. (2012). Report of the Toronto and Ottawa Supervised Consumption Assessment Study, 2012 (Rep.). TOSCA. Retrieved from https://www.catie.ca/sites/default/files/TOSCA%20report%202012.pdf Broadhead, R. S., Kerr, T. H., Grund, J. C., & Altice, F. L. (2002). Safer Injection Facilities in North America: Their Place in Public Policy and Health Initiatives. Journal of Drug Issues,32(1), 329-355. doi:10.1177/002204260203200113 CDC/NCHS, National Vital Statistics System, Mortality. CDC WONDER, Atlanta, GA: US Department of Health and Human Services, CDC; (2018). https://wonder.cdc.gov. 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Principles of Harm Reduction. (n.d.). Retrieved July 25, 2019, from https://harmreduction.org/about-us/principles-of-harm-reduction/ Harris, R. E., Richardson, J., Frasso, R., & Anderson, E. D. (2018). Perceptions about supervised injection facilities among people who inject drugs in Philadelphia. International Journal of Drug Policy, 52, 56-61. doi:10.1016/j.drugpo.2017.11.005 Hawk, M., & Davis, D. (2011). The effects of a harm reduction housing program on the viral loads of homeless individuals living with HIV/AIDS. AIDS Care, 24(5), 577-582. doi:10.1080/09540121.2011.630352 Hood, J., Behrends, C., Irwin, A., Schackman, B., Chan, D., Hartfield, K., . . . Duchin, J. (2019). The projected costs and benefits of a supervised injection facility in Seattle, WA, USA. International Journal of Drug Policy, 67, 9-18. doi:10.1016/j.drugpo.2018.12.015 Irwin, A., Jozaghi, E., Bluthenthal, R. N., & Kral, A. H. (2016). A Cost-Benefit Analysis of a Potential Supervised Injection Facility in San Francisco, California, USA. Journal of Drug Issues, 47(2), 164-184. doi:10.1177/0022042616679829 Irwin, A., Jozaghi, E., Weir, B. W., Allen, S. T., Lindsay, A., & Sherman, S. G. (2017). Mitigating the heroin crisis in Baltimore, MD, USA: A cost-benefit analysis of a hypothetical supervised injection facility. Harm Reduction Journal, 14(1). doi:10.1186/s12954-017-0153-2 Jarlais, D. C., Arasteh, K., & Hagan, H. (2008). Evaluating Vancouvers supervised injection facility: Data and dollars, symbols and ethics. Canadian Medical Association Journal, 179(11), 1105-1106. doi:10.1503/cmaj.081678 Jarlais, D. C. (2000). Structural interventions to reduce HIV transmission among injecting drug users. AIDS,14. doi:10.1097/00002030-200006001-00006 Kerr, T., Tyndall, M., Li, K., Montaner, J., & Wood, E. (2005). Safer injection facility use and syringe sharing in injection drug users. The Lancet, 366(9482), 316-318. doi:10.1016/s0140-6736(05)66475-6 León, C., Cardoso, L. J., Johnston, S., Mackin, S., Bock, B., & Gaeta, J. M. (2018). Changes in public order after the opening of an overdose monitoring facility for people who inject drugs. International Journal of Drug Policy, 53, 90-95. doi:10.1016/j.drugpo.2017.12.009 Marshall, B. D., Milloy, M., Wood, E., Montaner, J. S., & Kerr, T. (2011). Reduction in overdose mortality after the opening of North Americas first medically supervised safer injecting facility: A retrospective population-based study. The Lancet, 377(9775), 1429-1437. doi:10.1016/s0140-6736(10)62353-7 Milloy, M. S., Kerr, T., Tyndall, M., Montaner, J., & Wood, E. (2008). Estimated Drug Overdose Deaths Averted by North Americas First Medically-Supervised Safer Injection Facility. PLoS ONE, 3(10). doi:10.1371/journal.pone.0003351 National Institute on Drug Abuse. (2019, January 22). Opioid Overdose Crisis. Retrieved July 25, 2019, from https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis#six National Institute on Drug Abuse. (2019, June). Drug Use and Viral Infections (HIV, Hepatitis). Retrieved July 25, 2019, from https://www.drugabuse.gov/publications/drugfacts/drug-use-viral-infections-hiv-hepatitis Pinkerton, S. D. (2011). How many HIV infections are prevented by Vancouver Canadas supervised injection facility? International Journal of Drug Policy, 22(3), 179-183. doi:10.1016/j.drugpo.2011.03.003 Salmon, A. M., Beek, I. V., Amin, J., Kaldor, J., & Maher, L. (2010). The impact of a supervised injecting facility on ambulance call-outs in Sydney, Australia. Addiction, 105(4), 676-683. doi:10.1111/j.1360-0443.2009.02837.x Stoltz, J., Wood, E., Small, W., Li, K., Tyndall, M., Montaner, J., & Kerr, T. (2007). Changes in injecting practices associated with the use of a medically supervised safer injection facility. Journal of Public Health, 29(1), 35-39. doi:10.1093/pubmed/fdl090 Strathdee, S. A., Patrick, D. M., Currie, S. L., Cornelisse, P. G., Rekart, M. L., Montaner, J. S., . . . Oʼshaughnessy, M. V. (1997). Needle exchange is not enough. Aids, 11(8). doi:10.1097/00002030-199708000-00001 Tyndall, M. W. (2003). Impact of supervised injection facilities on community HIV levels: A public health perspective. Expert Review of Anti-infective Therapy, 1(4), 543-549. doi:10.1586/14787210.1.4.543 Vivolo-Kantor, A. M., Seth, P., Gladden, R. M., Mattson, C. L., Baldwin, G. T., Kite-Powell, A., & Coletta, M. A. (2018). Vital Signs: Trends in Emergency Department Visits for Suspected Opioid Overdoses — United States, July 2016–September 2017. MMWR. Morbidity and Mortality Weekly Report, 67(9), 279-285. doi:10.15585/mmwr.mm6709e1 Vowles, K. E., Mcentee, M. L., Julnes, P. S., Frohe, T., Ney, J. P., & Goes, D. N. (2015). Rates of opioid misuse, abuse, and addiction in chronic pain. 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• Volume 50, Issue 6
• Choosing death in unjust conditions: hope, autonomy and harm reduction
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• http://orcid.org/0000-0002-9034-8566 Kayla Wiebe ,
• http://orcid.org/0000-0002-9926-7826 Amy Mullin
• Philosophy , University of Toronto Faculty of Arts and Science , Toronto , Ontario , Canada
• Correspondence to Kayla Wiebe, Philosophy, University of Toronto Faculty of Arts and Science, Toronto, ON M5G 1X8, Canada; kayla.wiebe{at}mail.utoronto.ca

In this essay, we consider questions arising from cases in which people request medical assistance in dying (MAiD) in unjust social circumstances. We develop our argument by asking two questions. First, can decisions made in the context of unjust social circumstance be meaningfully autonomous? We understand ‘unjust social circumstances’ to be circumstances in which people do not have meaningful access to the range of options to which they are entitled and ‘autonomy’ as self-governance in the service of personally meaningful goals, values and commitments. People in these circumstances would choose otherwise, were conditions more just. We consider and reject arguments that the autonomy of people choosing death in the context of injustice is necessarily reduced, either by restricting their options for self-determination, through their internalisation of oppressive attitudes or by undermining their hope to the point that they despair.

Second, should MAiD be available to people in such circumstances, even when a sound argument can be made that the agents in question are autonomous? In response, we use a harm reduction approach, arguing that even though such decisions are tragic, MAiD should be available. Our argument engages with relational theories of autonomy as well as recent criticism raised against them and is intended to be general in application, although it emerges in response to the Canadian legal regimen around MAiD, with a focus on recent changes in Canada’s eligibility criteria to qualify for MAiD.

• Ethics- Medical
• Right to Die
• Legislation

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Data sharing not applicable as no datasets generated and/or analysed for this study. Not applicable.

https://doi.org/10.1136/jme-2022-108871

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Introduction

In this essay, we consider questions arising from cases in which people request medical assistance in dying (MAiD) in unjust social circumstances. We develop our argument by asking two questions. First, can decisions made in the context of unjust social circumstance be meaningfully autonomous? People in these circumstances would choose otherwise, were conditions more just. We consider and reject arguments that the autonomy of people choosing death in the context of injustice is necessarily reduced, either by more directly restricting their options for self-determination, through their internalisation of oppressive attitudes or by undermining their hope to the point that they despair, and that such decisions accordingly fall below the standard needed to be recognised as autonomous. Second, should MAiD be available to people in such circumstances, even when the agents in question are autonomous? In response, we use a harm reduction approach, arguing that though such decisions are tragic, MAiD should be available.

We understand autonomy as self-governance in the service of personally meaningful goals, values and commitments. Our understanding of autonomy is relational, where autonomy can be both enhanced and undermined by social context and relationships 1 2 and engages with recent criticism of some relational theories. 3 We understand ‘unjust social circumstances’ as circumstances in which people do not have meaningful access to a range of options to which they are entitled. 4–6 Our focus on these questions in the context of MAiD is prompted by recent legal changes in Canada which made people with chronic and non-terminal conditions eligible for it, but our argument has implications for any jurisdiction in which some form of MAiD can be legally requested or in which that legality is being explored. We exclude conditions which are solely psychiatric from consideration, another area of current controversy in Canada.

Motivating the problem

Changes to Canada’s legal regime governing MAiD were ushered in by Truchon V Canada in 2019 7 and later Bill C-7 in 2021. 8 This legislation removed the requirement legislated in Bill C-14 that a patient’s death be ‘reasonably foreseeable’ to be eligible for MAiD. 9 Although Bill C-7 marks an expansion in eligibility from Bill C-14, the criterion that one’s death be reasonably foreseeable was not included in the Supreme Court of Canada decision in Carter. 10 Of particular concern are persons with disabilities who choose MAiD, the worry being that such persons might choose MAiD for social, rather than strictly medical reasons, because they cannot access alternative means of reducing their suffering, such as housing compatible with their condition or sufficient hours of paid care.

In 2022, an individual in Canada, who had been diagnosed with multiple chemical sensitivities (MCS), received MAiD. However, by their own description, their decision to choose MAiD was driven primarily by the fact that they were unable to access affordable housing compatible with MCS. 11 While it was true that they suffered from an illness, disease or disability that caused ‘enduring physical or psychological suffering that is intolerable to them and cannot be relieved under conditions that they consider acceptable’ as specified under the eligibility criteria of Bill C-14, 9 the primary source of their suffering was an inability to find appropriate housing, not the condition itself. 11 Another person, also with MCS, writes: ‘I’ve applied for MAiD essentially because of abject poverty’. 12

A point of clarification regarding the target cases in this paper: we think it is reasonable to expect that the number of these kinds of cases will be few relative to the proportion of patients who can and will access MAiD due to Bill C-7. That is, they represent a kind of ‘worst case scenario,’ rather than representing the majority of cases that are now eligible. However, these types of cases are arguably the most salient ones—they dominate news reports, catch public attention and influence public opinion. They are also worthy of consideration in their own right, and highlight an important philosophical issue: what, if anything, does injustice and oppression do to the status of an agent’s choice, and what is the best path forward? In terms of scope, the topic of this paper is not the moral status of MAiD in general, or whether one’s death should be reasonably foreseeable to be eligible for MAiD, but rather: whether the fact that many people will now be making end of life choices in the context of injustice counts as a reason to restrict that option.

Many have the reasonable intuition that persons who are operating within a restricted set of options have been driven to choose MAiD, 13 effectively problematising the status of their choice. In what follows, we engage with several iterations of this kind of argument. First, we address three different arguments that stipulate that unjustly restricted options undermine an agent’s autonomy, and persons in such circumstances should not be allowed to access MAiD because their autonomy is in question. Finally, we consider the argument that even if persons in such circumstances are autonomous, they should not be allowed to access MAiD for reasons to do with injustice. Before we do so, several terms should be defined and explained.

We understand personal autonomy to be one’s ability to govern one’s conduct and choices in keeping with what matters to them. On this view, personal autonomy requires the ability to understand the options that are available and what their consequences are, the ability to appreciate what matters to oneself, not necessarily by articulating it, but by making choices that aim towards it, and powers of self-governance, such as the ability to focus and persist in a course of action. To be autonomous, one must also take what one cares about to provide reasons for action, have a basic form of self-trust and self-worth 14–16 as manifested in the fact that they pursue what matters to them.

Although this is rarely emphasised, acting autonomously also requires hope. 17 To hope, one must have goals that matter personally, as opposed to those one would merely concede as reasonable for others to pursue, one must be able to explore pathways to realise those goals and be motivated to take one of those pathways when the goal seems realisable. We term this ‘engaged hope’ to differentiate it from mere optimism, such as wishing for the best without taking any action oneself. 18 Engaged hope also differs from merely having a desire to act in a particular way as it is a sustained attitude involving a readiness to take action in circumstances in which it appears feasible to make progress towards one’s goals.

Autonomy-based arguments against MAiD in injustice

There are many arguments to support the claim that MAiD should not be accessible to persons who have chronic, but non-terminal conditions, when those persons are seeking MAiD because their options have been unjustly restricted. In this section, we consider three related but distinct arguments that centre around the impact of oppression on agents’ autonomy. We list them here and engage with each in depth below.

First, some theorists argue that unjustly restricted options necessarily undermine autonomy, the status of an agent’s internal capacities notwithstanding. On this kind of view, even if an agent has thoroughly developed autonomy capacities and attitudes—such as understanding, strong sense of what they care about, self-worth and self-trust—they are still less than fully autonomous in virtue of lacking access to the range of options they are entitled to as a matter of justice. Second, some theorists argue that persons who have unjustly restricted options are likely to have internalised the oppressive attitudes that they have been subjected to. Here, it is not just the brute fact of restricted options, it is the way oppression has undermined their internal autonomy capacities and attitudes. Finally, we consider a general argument about hopelessness and autonomy, one we think is implied in much of the media coverage of the kinds of cases with which this paper is concerned. As this argument might go, someone who has had their options restricted so unjustly is requesting MAiD from a place of hopelessness and despair, and they therefore, cannot be making an autonomous choice.

Restricted options necessarily undermine autonomy

The first type of argument against allowing MAiD for persons who are chronically but not terminally ill states that if oppression restricts one’s options, autonomy has necessarily been reduced, although it may not be entirely undermined. While each proponent of this view has a slightly different story to tell, they all make having full-fledged autonomy dependent on a socially ideal state of affairs, where the agent has meaningful access to a wide enough range of options. 19–23 For example, Mackenzie argues that self-determination is one of three dimensions of autonomy, and self-determination requires freedom from oppression and substantive social equality. 24 On this sort of view, any choice to have MAiD in unjust circumstances would not be substantially autonomous because the agent does not have substantive social equality. The prima facie consequence of this view is that if a person is not autonomous, then at most, respect for their decision is no longer warranted, and at the very least, the status of the person’s choice is called into question.

These types of views are criticised by Khader, who argues that feminist theories of relational autonomy that claim that autonomy is necessarily reduced by restricted opportunities for self-determination can be too easily taken to warrant reduced respect for the actions and choices of oppressed agents. 3 We agree with Khader that restricted opportunities will often be insufficient to reduce autonomy. Of course, oppression can sometimes reduce autonomy, for instance, by subjecting one to coercion, drastically reducing hope, substantially constricting what one can imagine as a possibility for action, or limiting one’s access to the information required to make an informed decision. When an agent’s options are restricted due to oppression, this should certainly be condemned. However, the fact that someone’s options have been restricted is insufficient to reduce autonomy, because oppressed persons can and often do retain capacities and self-regarding attitudes necessary for autonomy, such as the ability to understand, appreciate the consequences of their choice, the capacity to value, the ability to reflect on the values guiding their decision, as well as the attitudes of engaged hope, self-worth and self-trust.

We agree with Mackenzie that access to substantive equality is important but disagree that such conditions are or should be understood to be requirements for autonomy. One reason is that such views provide the conceptual framework to justify ‘promiscuous paternalism’. 3 This is true despite the fact that some individual proponents of these views hesitate to conclude that paternalistic intervention is the correct course of action, even though they maintain that autonomy has been compromised significantly.

Another problem with this view is that it would disqualify many ordinary choosers from the realm of autonomy. To this end, it is important that an approach to autonomy be practically applicable in bioethical contexts. It is not feasible to expect medical professionals to assess the extent to which the person in their care has had their options restricted because of oppression and neither is it directly relevant. Medical professionals are properly positioned to detect a reduction in the capacities and self-regarding attitudes that their patients need to make autonomous decisions. If they were to attempt to assess the impact of oppression on patients who maintain the relevant capacities and self-regarding attitudes, we think they are likely to overreach and behave paternalistically to people solely because they have experienced oppression. Mackenzie herself argues that, although she thinks that having one’s options for self-determination restricted due to oppression directly and necessarily reduces autonomy, in medical contexts patients’ decisions should not be overruled on this basis alone and the ‘most salient dimensions’ of autonomy should be competency and authenticity. 24

Decisions to request MAiD by people with chronic conditions will certainly be impacted by the opportunities available to them. In an ableist society which values and is clearly built for people who are physically and mentally healthy, independent and able-bodied, and who live generally pain-free, people with disabilities and those living in chronic pain and suffering are not sufficiently valued. Further, they often experience significant barriers in achieving effective access to long term care—from general support to safe pain management—that would improve the quality of their lives. We agree that these constitute serious injustices. However, to claim that access to ideal social conditions is a requirement for autonomy is to mistake conditions for substantive justice for the conditions required for autonomy. 25 Further argument is needed to relevantly connect injustice (in the form of restricted options) to one’s actual autonomy capacities. We consider two such arguments below.

Oppression undermines internal autonomy capacities

While we think it is theoretically unsound to make autonomy contingent on access to ideal social conditions, we recognise that oppressive circumstances can be severe enough that agents despair, and do not take any action in pursuit of their goals. In another piece, arguing that certain self-reflective attitudes like self-worth and self-trust are required for autonomy, Mackenzie presents an example of one such kind of case. Mrs. H has cancer, has had part of a leg amputated, and her husband has left her due to her disability and regards her as an embarrassment. 26 Mrs. H, as described by Mackenzie, has lost all sense of self-worth, does not trust herself, and does not want any of the treatment options her medical team proposes. She wants to die. We agree with Mackenzie’s suggestion that Mrs. H as so described is not fully autonomous. However, the judgement that she is not autonomous is grounded in the fact that in this particular case, we have an agent who lacks self-trust, has no self-worth and has evidently lost engaged hope. She is not declared non-autonomous simply because her values have been shaped by sexist norms of traditional femininity, and she has arguably existed with a restricted set of options for some time.

We would, therefore, recommend interventions aimed to increase her sense of hope, such as putting her in contact with people successfully coping with a diagnosis like her own rather than interventions aimed at transforming her values. While Mrs. H’s case is, we think, an excellent example of how oppressive socialisation can contribute to undermining capacities needed for autonomy, particularly insofar as her self-worth is significantly damaged by the combination of her illness and her husband’s attitudes and actions, her case is relevantly unlike patients who are the target of this paper: those who are choosing MAiD in part due to unjust social conditions. Whereas Mrs. H’s refusal of care comes from a radically undermined capacity for self-trust, low self-worth and lack of engaged hope due to neglectful close interpersonal relationships, these persons are choosing MAiD due to a lack of alternatives. In these cases, there is no evidence to suggest that they do not trust themselves, or that they despair completely. Unlike Mrs. H, they demonstrate a considerable level of engaged hope: they are taking an active role in responding to their situation and are motivated to realise a goal. The fact that this goal is arguably grim and reflects a severely unjust social landscape does not detract from the legitimacy of their agency. It is an indictment of the options available, not of the status of their autonomy, given the options they have to work with.

To explore this argument further, we turn to Ho’s argument that the presence of oppressive circumstances renders decision-making in the context of oppression non-autonomous, because of the impact of oppressive norms. 27 28 Like Mackenzie, who focuses on the impact of sexist norms on Mrs. H’s autonomy, Ho’s argument is that unjust social circumstances—in this case, ableism—undermine autonomy in end-of-life choices. However, unlike Mackenzie, the cases Ho considers are arguably analogous to those that come under consideration in light of the changes to MAiD brought on by Bill C-7.

Ho analyses several examples of people who chose to die via passive euthanasia, discussing Larry McAfee (1985), Kenneth Berghsted (1969), Dan Crews (2010) and Elizabeth Bouvia (1983–1986). McAfee and Berghsted became quadriplegic after accidents (1985 and 1969, respectively), and requested that they be removed from a respirator and allowed to die. Crews, who was disabled at the age of three, asked to be allowed to die in his early twenties. Bouvia had cerebral palsy, and in her mid-20s (1983), made a request to a hospital in Irvine, California, that she be allowed to die by starving to death. 27 We grant that a relevant dissimilarity between these cases and the ones that are the target of this paper is that the former are instances of passive euthanasia, while the latter involve active euthanasia. However, the topic of this analysis is not to debate the ethicality of euthanasia per se, and we do not argue that passive and active forms are equivalent. Instead our focus is on making a choice to die (passively or actively) in the context of injustice, due to a lack of alternatives; in both types of cases, we have just this.

There are several common threads running through the cases analysed by Ho. First, each of the people in these cases were eventually granted the legal right to die. The second similarity, as Ho points out, is that no one was in a state of physical deterioration because of their disability. In each case, what prompted the request to die was arguably non-medical: the inability to afford or access care that sustained the quality of life they had before. And here, we have a case very similar to the 2022 MAiD cases we started with: the request for death is due to one’s social circumstances—importantly, a lack of options—rather than ‘strictly’ medical, such as a change in one’s health state, or a deterioration in one’s executive functioning. A third commonality is that each of the people involved went to considerable lengths to advocate for a solution that they wanted to be able to access. Bouvia’s persistence is particularly notable: she petitioned the hospital in Irvine, California, to be allowed to die. She was admitted but treated against her will, she petitioned the hospital’s decision to a lower court judge, appealed the judge’s decision, and was placed in another care facility where she was force fed again. Her physicians stated that she was ‘clearly intending suicide,’ and that she could live an estimated 15–20 years with current treatment. She sued the hospital and went before the Superior Court of Los Angeles, only to be turned down again. She appealed again, and finally in 1986, the California Court of Appeal granted her the right to decide for herself to refuse treatment. 29

The ability of the people discussed by Ho to advocate for themselves and navigate the courts and medical bureaucracies is arguably evidence of engaged hope, self-worth and a stronger commitment to pursue what they want than many ‘ordinary’ choosers do, choosers that we have no problem evaluating as autonomous. There is no evidence of diminished decision-making capacity or autonomy in these cases.

What about the possibility that people with disabilities who are choosing death because of limited options may be doing so due to internalised ableism? That is, perhaps these cases do resemble cases like that of Mrs. H. Perhaps Crews, McAfee, Bergstedt, Bouvia, and those currently electing for MAiD in Canada, are in part doing so because they have internalised an incorrect belief that life with a disability is less worthy than life without one. First, operating on the default assumption that people with disabilities have internalised such a downgraded sense of self-worth such that their testimony regarding their own experience is doubted constitutes another kind of ableism in the form of epistemic injustice. Their testimony is discounted because of their group membership—they are identified as people with disabilities and the fact that they have likely encountered ableism is thought to make them unreliable when it comes to giving the reasons for their decisions. When people living with disabilities state that their quality of life is intolerable to them due to a lack of access to care they ought to have, the ethically sound response is to criticise the social conditions that have downgraded their quality of life, not question their self-reflexive attitudes or how authentic or legitimate their evaluation of their quality of life is. Second, it is just not clear without question begging that it is accurate that persons who grow up with disabilities have, in fact, internalised ableism to such a degree that their autonomy should be questioned or assessed as deficient.

What should we think about the fact, then, that in each case outlined above, and with the cases emerging in the wake of Bill C-7, decisions towards death are being prompted not by development of a clinical condition, but by problems in access to needed healthcare, and more fulsome social and financial support for dependency needs? Is it that they have internalised an ‘ableist ideology’, whereby certain impairments due to disability are ‘more legitimate than other reasons for one to desire death’ as Ho has interpreted these types of decisions? 27 This is an understandable conclusion to draw—after all, each of these agents is making decisions in an ableist environment, the lack of long-term, robust and holistic care for disabled people being just further evidence of this.

We propose a different understanding of these kinds of choices. Each of these persons had a disability and decided to pursue assisted death due to a social reason. Does this mean they think their own lives are not worth living because of their disability, while more abled lives are? We answer no. It is reasonable to think that each of these agents viewed their suffering as insurmountable, and unlikely to change. Rather than betraying an ‘ableist bias,’ their decisions can be more charitably and respectfully interpreted as an accurate assessment of their situation. It is one thing to identify an ableist bias in a person or a policy where there is no lived experience with a disability, and quite another to attribute ableism to a person who has intimate experience living with their disability, and to on this basis question the legitimacy of their decisions regarding their own care. Trusting a person with a disability’s subjective reports of their own quality of life is not mutually exclusive with also arguing in support of and advocating for a world where the structural barriers that undermine their quality of life do not exist.

Third, even if investigating the authenticity of their evaluation of their quality of life to detect whether an agent had internalised nefarious bias were an appropriate response, it would be practically impossible to assess this reliably. It is difficult enough for individuals to accurately assess the degree to which internalised oppression might operate in their motivational landscape, and medical teams are not well-positioned to detect the presence of internalised oppression within the values sets of those requesting MAiD. We agree with Khader that this seems like a recipe for unwarranted paternalistic interference. 3 While neither Mackenzie nor Ho argue that decisions made by oppressed people should be disregarded for that reason alone, their arguments provide support to those who would argue for that conclusion.

If there are reasonable doubts regarding the autonomy of persons seeking MAiD, assessors should, as with all patients requesting an end to their lives, look for signs of coercion, confusion, a lack of self-trust so severe that it undermines self-governance in the service of what they care about, or a state of despair that entirely erodes hope, such that they do not pursue a course of action at all. Given that MAiD is being requested, the latter seems unlikely.

Oppression leads to hopelessness, which undermines autonomy

Finally, what about the argument that persons choosing within restricted options are hopeless? Unjustly restricted options do not necessarily undermine hope to the point of despair, but of course, we certainly recognise the possibility that such oppressive circumstances could lead some to despair. The case of Mrs. H as articulated by Mackenzie is one such example. However, persons requesting MAiD are arguably acting with engaged hope in seeking what they consider to be the best option of the options available to them.

To act with engaged hope one must have goals and take an active role in responding to one’s situation. There are several things such hope does not require. It does not require the person to act on their own or to ignore the views of others. Most projects, including seeking medical aid in dying, involve support from others and this is no threat to autonomy so long as those others do not withhold crucial information or act coercively. What matters is that the autonomous person’s goals and what they hope for are uncoerced and reflect a basic sense of self-trust. For example, someone who requests MAiD in part to spare their family the experience of their suffering or to ensure they can leave behind resources to support social causes they care about is not lacking autonomy if they do not feel pressured to do so, and if they do not feel undeserving of having what they care about taken seriously.

Finally, and crucially for the purposes of our paper, having engaged hope does not require the person to think they can achieve an ideal outcome in their course of action. Acting with engaged hope only requires that some outcomes are better, and others worse, according to the person’s own lights. For instance, Sathya Darya Kovac would have preferred to continue to live for several more years with her ALS if she were provided with more hours of paid home care to enable her to live at home with a companion animal. However, she chose MAiD as an alternative to either living in a shared residence with round the clock care or living in her own home with insufficient home care. 30 Her choice was tragically shaped by social conditions, but there is no evidence that a lack of hope undermined her autonomy and her determined pursuit of access to MAiD is instead evidence that she had a goal that mattered deeply to her and persisted in pursuing it.

Each individual considered in this paper lacked access, not only to better options but also options that they should have had as a matter of justice. Individuals in unjust circumstances can have the capacities and attitudes they need for autonomy undermined by leading them to lose self-worth and hope, or by denying them access to information about their options. However, we think that any assessment of their autonomy should focus on whether there has been a loss of those capacities and attitudes, and not simply on evidence that their options have been restricted due to oppression, or that they live in a society that devalues them and so they might have internalised oppressive attitudes. The presumption that autonomy is necessarily undermined by oppression is problematic and produces a conception of autonomy that is impossible to assess in medical contexts. Moreover, the persons who are the subject of news and legal proceedings, those battling to be able to access an option they desire, are rarely the persons whose autonomy has been compromised in the first place.

Argument from injustice

A fourth iteration of the argument against providing MAiD in unjust circumstances does not rely on the state of one’s autonomy but asserts that unjust circumstances are causing people with such conditions to choose MAiD when they would not otherwise do so. So, the argument goes, MAiD should not be available until social circumstances have significantly improved to ensure that the choice to receive MAiD is not in any way caused by circumstances that are, in theory, contingent. We agree with one claim involved in this argument: some people requesting MAiD would choose to continue living if circumstances were just and fair; indeed, they have explicitly stated as much. 11 31 32

However, even a charitable interpretation of the remainder of the argument relies on empirically dubious claims. Specifically, we suspect that this argument involves the unproven empirical causal claim that making it easier for such people to end their lives with medical assistance will take pressure off legislators and decision-makers who would otherwise seek to improve social conditions and access to care for health conditions. This argument also seems to rest on the inverse empirical claim that withholding an option (MAiD) in these contexts will compel legislators and decision-makers to bolster social and community support, given how dire circumstances are. There is no empirical evidence to support the causal arguments in either direction, and without good reasons to think the situation will improve, withholding treatment options amounts to further restricting (at times, removing entirely) the limited range of choices that people in these circumstances have.

This type of argument appears to us to license paternalistically over-riding the decisions of competent people whose suffering has led them to choose to die with medical assistance in order to make instrumental use of their suffering. While this is purportedly to help other people living with similar chronic conditions who do not, or are not currently, choosing MAiD, it is insensitive to the occurrent and very real suffering of people requesting MAiD, and is therefore unsupportable, no matter how noble the cause. Not allowing people to access MAiD because their request is driven by unjust social circumstances, when those circumstances show no short-term chance of improving, succeeds only in causing further harm. To force people who are already in unjust social circumstances to have to wait until those social circumstances improve, or for the possibility of public charity that sometimes but unreliably occurs when particularly distressing cases become public, is unacceptable.

Our response: argument from harm reduction

We characterise ours as an argument from harm reduction. Harm reduction has typically been used as a type of policy recommendation in public health (often surrounding sex work and drug use). However, we agree with Dea and Weinstock that the insights from harm reduction can be applied in a much wider swath of seemingly intractable debates. 33 34 A harm reduction approach requires a shift to an empirical 33 perspective on difficult debates, and, we would argue, it requires an explicit recognition of the non-ideal circumstances in which these difficult choices are made. A harm reduction approach acknowledges that the recommended solution is necessarily an imperfect one: a ‘lesser evil’ between two or more less than ideal options. In the cases we have been considering in this paper—indeed all cases implicated by a legal shift like that found in Canada’s Bill C-7 in the context of a society that provides less than adequate or just support for its citizens—we ask: what is the least harmful way forward, given the sociopolitical reality as it stands?

While harm is a notoriously contentious concept, in the context of this debate, we define the relevant type of harm as the subjective experience of ‘having enduring and intolerable physical or psychological suffering’ due to an incurable illness, disease or disability. This conceptualisation of harm is based on the fact that both Canadian legislation, 9 and central philosophical arguments, 35 pick out one’s subjective well-being or lack thereof (severe suffering) in relation to an illness, disease, or disability, as one of the central justifications for MAiD (or euthanasia), and we have defined it using the language in that legislation.

In the case of the availability of MAiD in Canada to people who not only might but have explicitly said they would choose differently if they had access to the options they preferred, we argue that the least harmful way forward is to allow MAiD to be available. Access to healthcare across nearly all dimensions continues to deteriorate in the wake of the pandemic even outside of long-term and palliative care, from basic care, 36 to surgical backlogs, 37 to a general consensus that the system is in a state of collapse. 38 In this context, refusing options to people who autonomously pursue MAiD amounts to perpetuating their suffering, hoping that this will ultimately lead to a better, more ‘just’ world. This is a world that currently does not exist and is unlikely to emerge in the near future. Even if it did, it is unfortunately even more unlikely that the people whose current suffering has led them to request MAiD will realise its benefits.

We agree that people living with disabilities need and absolutely deserve better access to healthcare, as well as a society in which there are more opportunities to contribute to their communities and realise personal goals. The fact that better supports are not provided in cases like these is abhorrent and the lack of options constitutes a deep injustice.

However, we disagree with any claim that the unjust lack of choices available to people is alone sufficient to undermine their autonomy. Those who launch legal proceedings or request and receive MAiD are unlikely examples of people whose reduced opportunities have led them to lose all hope and motivation for pursuing personally meaningful courses of action. Moreover, neither a reduction of opportunities in itself, nor the existence of oppressive ableist norms, is sufficient to directly undermine autonomy. We further argue against the claim that MAiD should not be available to people in these circumstances even if their autonomy is stable. Restricting an autonomous choice to pursue MAiD due to the injustice of current non-ideal circumstances causes more harm than allowing the choice to pursue MAiD, even though that choice is deeply tragic.

Ethics statements

Patient consent for publication.

Not applicable.

• Stoljar N ,
• Mackenzie C
• Veltman A ,
• Buchanan AE
• Venkatapuram S
• ↵ Truchon V Canada [ Superior Court of Quebec ]. 2019 . Available : https://www.canlii.org/fr/qc/qccs/doc/2019/2019qccs3792/2019qccs3792.html
• ↵ Carter V. Canada [ Supreme Court of Canada ]. 2015 . Available : https://www.canlii.org/en/ca/scc/doc/2015/2015scc5/2015scc5.html
• Anderson J ,
• Oshana M , Department of Philosophy, Florida State University
• Mulligan C ,
• Weinstock D
• Canadian Medical Association

X @KaylaJWiebe

Contributors We jointly worked on the paper from the inception of the idea, through development, revision, and to completion. We both contributed equally to and are jointly responsible for the content in this paper.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Linked Articles

• Response Autonomy is not a sufficient basis for analysing the choice for medical assistance in dying in unjust conditions: in favour of a dignity-based approach Maria DiDanieli Journal of Medical Ethics 2023; 50 421-422 Published Online First: 06 Jul 2023. doi: 10.1136/jme-2023-109284
• Response Medically assisted dying in Canada and unjust social conditions: a response to Wiebe and Mullin Timothy Christie Madeline Li Journal of Medical Ethics 2023; 50 423-424 Published Online First: 14 Jul 2023. doi: 10.1136/jme-2023-109327

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• Organ donation after medical assistance in dying or cessation of life-sustaining treatment requested by conscious patients: the Canadian context Julie Allard et al., Journal of Medical Ethics, 2017
• Canadian French and English newspapers’ portrayals of physicians’ role and medical assistance in dying (MAiD) from 1972 to 2016: a qualitative textual analysis Ellen T Crumley et al., BMJ Open, 2019
• Exploring key stakeholders’ attitudes and opinions on medical assistance in dying and palliative care in Canada: a qualitative study protocol Gilla K Shapiro et al., BMJ Open, 2021
• Medical Assistance in Dying at a paediatric hospital Carey DeMichelis et al., Journal of Medical Ethics, 2018
• Medical assistance in dying in hospice: A qualitative study James Mellett et al., BMJ Supportive & Palliative Care, 2022
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• Medically assisted dying in Canada and unjust social conditions: a response to Wiebe and Mullin Timothy Christie et al., Journal of Medical Ethics, 2023

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Health Effects of Vaping

At a glance.

Learn more about the health effects of vaping.

• No tobacco products, including e-cigarettes, are safe.
• Most e-cigarettes contain nicotine, which is highly addictive and is a health danger for pregnant people, developing fetuses, and youth. 1
• Aerosol from e-cigarettes can also contain harmful and potentially harmful substances. These include cancer-causing chemicals and tiny particles that can be inhaled deep into lungs. 1
• E-cigarettes should not be used by youth, young adults, or people who are pregnant. E-cigarettes may have the potential to benefit adults who smoke and are not pregnant if used as a complete substitute for all smoked tobacco products. 2 3 4
• Scientists still have a lot to learn about the short- and long-term health effects of using e-cigarettes.

Most e-cigarettes, or vapes, contain nicotine, which has known adverse health effects. 1

• Nicotine is highly addictive. 1
• Nicotine is toxic to developing fetuses and is a health danger for pregnant people. 1
• Acute nicotine exposure can be toxic. Children and adults have been poisoned by swallowing, breathing, or absorbing vaping liquid through their skin or eyes. More than 80% of calls to U.S. poison control centers for e-cigarettes are for children less than 5 years old. 5

Nicotine poses unique dangers to youth because their brains are still developing.

• Nicotine can harm brain development which continues until about age 25. 1
• Youth can start showing signs of nicotine addiction quickly, sometimes before the start of regular or daily use. 1
• Using nicotine during adolescence can harm the parts of the brain that control attention, learning, mood, and impulse control. 1
• Adolescents who use nicotine may be at increased risk for future addiction to other drugs. 1 6
• Youth who vape may also be more likely to smoke cigarettes in the future. 7 8 9 10 11 12

Other potential harms of e-cigarettes

E-cigarette aerosol can contain substances that can be harmful or potentially harmful to the body. These include: 1

• Nicotine, a highly addictive chemical that can harm adolescent brain development
• Cancer-causing chemicals
• Heavy metals such as nickel, tin, and lead
• Tiny particles that can be inhaled deep into the lungs
• Volatile organic compounds
• Flavorings such as diacetyl, a chemical linked to a serious lung disease. Some flavorings used in e-cigarettes may be safe to eat but not to inhale because the lungs process substances differently than the gut.

E-cigarette aerosol generally contains fewer harmful chemicals than the deadly mix of 7,000 chemicals in smoke from cigarettes. 7 13 14 However, this does not make e-cigarettes safe. Scientists are still learning about the immediate and long-term health effects of using e-cigarettes.

Dual use refers to the use of both e-cigarettes and regular cigarettes. Dual use is not an effective way to safeguard health. It may result in greater exposure to toxins and worse respiratory health outcomes than using either product alone. 2 3 4 15

Some people who use e-cigarettes have experienced seizures. Most reports to the Food and Drug Administration (FDA ) have involved youth or young adults. 16 17

E-cigarettes can cause unintended injuries. Defective e-cigarette batteries have caused fires and explosions, some of which have resulted in serious injuries. Most explosions happened when the batteries were being charged.

Anyone can report health or safety issues with tobacco products, including e-cigarettes, through the FDA Safety Reporting Portal .

Health effects of vaping for pregnant people

The use of any tobacco product, including e-cigarettes, is not safe during pregnancy. 1 14 Scientists are still learning about the health effects of vaping on pregnancy and pregnancy outcomes. Here's what we know now:

• Most e-cigarettes, or vapes, contain nicotine—the addictive substance in cigarettes, cigars, and other tobacco products. 18
• Nicotine is a health danger for pregnant people and is toxic to developing fetuses. 1 14
• Nicotine can damage a fetus's developing brain and lungs. 13
• E-cigarette use during pregnancy has been associated with low birth weight and pre-term birth. 19 20

Nicotine addiction and withdrawal

Nicotine is the main addictive substance in tobacco products, including e-cigarettes. With repeated use, a person's brain gets used to having nicotine. This can make them think they need nicotine just to feel okay. This is part of nicotine addiction.

Signs of nicotine addiction include craving nicotine, being unable to stop using it, and developing a tolerance (needing to use more to feel the same). Nicotine addiction can also affect relationships with family and friends and performance in school, at work, or other activities.

When someone addicted to nicotine stops using it, their body and brain have to adjust. This can result in temporary symptoms of nicotine withdrawal which may include:

• Feeling irritable, jumpy, restless, or anxious
• Feeling sad or down
• Having trouble sleeping
• Having a hard time concentrating
• Feeling hungry
• Craving nicotine

Withdrawal symptoms fade over time as the brain gets used to not having nicotine.

Nicotine addiction and mental health

Nicotine addiction can harm mental health and be a source of stress. 21 22 23 24 More research is needed to understand the connection between vaping and mental health, but studies show people who quit smoking cigarettes experience: 25

• Lower levels of anxiety, depression, and stress
• Improved positive mood and quality of life

Mental health is a growing concern among youth. 26 27 Youth vaping and cigarette use are associated with mental health symptoms such as depression. 22 28

The most common reason middle and high school students give for currently using e-cigarettes is, "I am feeling anxious, stressed, or depressed." 29 Nicotine addiction or withdrawal can contribute to these feelings or make them worse. Youth may use tobacco products to relieve their symptoms, which can lead to a cycle of nicotine addiction.

• U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General . Centers for Disease Control and Prevention; 2016. Accessed Feb 14, 2024.
• Goniewicz ML, Smith DM, Edwards KC, et al. Comparison of nicotine and toxicant exposure in users of electronic cigarettes and combustible cigarettes . JAMA Netw Open. 2018;1(8):e185937.
• Reddy KP, Schwamm E, Kalkhoran S, et al. Respiratory symptom incidence among people using electronic cigarettes, combustible tobacco, or both . Am J Respir Crit Care Med. 2021;204(2):231–234.
• Smith DM, Christensen C, van Bemmel D, et al. Exposure to nicotine and toxicants among dual users of tobacco cigarettes and e-cigarettes: Population Assessment of Tobacco and Health (PATH) Study, 2013-2014 . Nicotine Tob Res. 2021;23(5):790–797.
• Tashakkori NA, Rostron BL, Christensen CH, Cullen KA. Notes from the field: e-cigarette–associated cases reported to poison centers — United States, April 1, 2022–March 31, 2023 . MMWR Morb Mortal Wkly Rep. 2023;72:694–695.
• Yuan M, Cross SJ, Loughlin SE, Leslie FM. Nicotine and the adolescent brain . J Physiol. 2015;593(16):3397–3412.
• National Academies of Sciences, Engineering, and Medicine. Public Health Consequences of E-Cigarettes . The National Academies Press; 2018.
• Barrington-Trimis JL, Kong G, Leventhal AM, et al. E-cigarette use and subsequent smoking frequency among adolescents . Pediatrics. 2018;142(6):e20180486.
• Barrington-Trimis JL, Urman R, Berhane K, et al. E-cigarettes and future cigarette use . Pediatrics. 2016;138(1):e20160379.
• Bunnell RE, Agaku IT, Arrazola RA, et al. Intentions to smoke cigarettes among never-smoking US middle and high school electronic cigarette users: National Youth Tobacco Survey, 2011-2013 . Nicotine Tob Res. 2015;17(2):228–235.
• Soneji S, Barrington-Trimis JL, Wills TA, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: a systematic review and meta-analysis . JAMA Pediatr. 2017;171(8):788–797.
• Sun R, Méndez D, Warner KE. Association of electronic cigarette use by U.S. adolescents with subsequent persistent cigarette smoking . JAMA Netw Open. 2023;6(3):e234885.
• U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease . Centers for Disease Control and Prevention; 2010. Accessed Feb 13, 2024.
• U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General . Centers for Disease Control and Prevention; 2014. Accessed Feb 12, 2024.
• Mukerjee R, Hirschtick JL, LZ Arciniega, et al. ENDS, cigarettes, and respiratory illness: longitudinal associations among U.S. youth . AJPM. Published online Dec 2023.
• Faulcon LM, Rudy S, Limpert J, Wang B, Murphy I. Adverse experience reports of seizures in youth and young adult electronic nicotine delivery systems users . J Adolesc Health . 2020;66(1):15–17.
• U.S. Food and Drug Administration. E-cigarette: Safety Communication - Related to Seizures Reported Following E-cigarette Use, Particularly in Youth and Young Adults . U.S. Department of Health and Human Services; 2019. Accessed Feb 14, 2024.
• Marynak KL, Gammon DG, Rogers T, et al. Sales of nicotine-containing electronic cigarette products: United States, 2015 . Am J Public Health . 2017;107(5):702-705.
• Regan AK, Bombard JM, O'Hegarty MM, Smith RA, Tong VT. Adverse birth outcomes associated with prepregnancy and prenatal electronic cigarette use . Obstet Gynecol. 2021;138(1):85–94.
• Regan AK, Pereira G. Patterns of combustible and electronic cigarette use during pregnancy and associated pregnancy outcomes . Sci Rep. 2021;11(1):13508.
• Kutlu MG, Parikh V, Gould TJ. Nicotine addiction and psychiatric disorders . Int Rev Neurobiol. 2015;124:171–208.
• Obisesan OH, Mirbolouk M, Osei AD, et al. Association between e-cigarette use and depression in the Behavioral Risk Factor Surveillance System, 2016-2017 . JAMA Netw Open. 2019;2(12):e1916800.
• Prochaska JJ, Das S, Young-Wolff KC. Smoking, mental illness, and public health . Annu Rev Public Health. 2017;38:165–185.
• Wootton RE, Richmond RC, Stuijfzand BG, et al. Evidence for causal effects of lifetime smoking on risk for depression and schizophrenia: a Mendelian randomisation study . Psychol Med. 2020;50(14):2435–2443.
• Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, Aveyard P. Change in mental health after smoking cessation: systematic review and meta-analysis . BMJ. 2014;348:g1151.
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Senator Stern’s Bills to Reduce Harm to Kids from Social Media Advance with Bipartisan Support

SACRAMENTO – Democrats and Republicans found common ground in the California State Senate this week on two measures authored by Senator Henry Stern (D-Los Angeles) aimed at reducing harm to children from social media and cyberbullying.

SB 1283 would make clear that school districts across California have the authority to restrict the use of social media on school campuses. While some schools and teachers have taken leadership by developing their own approaches, districts still have no rules of the road, and social media abuse and addiction continues to skyrocket. 

SB 1504 would require social media platforms to respond to reports of cyberbullying in a timely manner, and give victims and their parents and guardians more power to report and seek legal recourse if their pleas for help are ignored. 

Senator Stern, who witnessed Facebook’s inception firsthand as a sophomore at Harvard twenty years ago, warned that California must step in where Congress has not. “The anxious generation is suffering,” he stated, referencing Jonathan Haidt's book documenting the damage caused by social media addiction. “If we don’t step up and empower students, parents, and teachers to push back on Big Tech, the bullying, suicide, depression, and other harms befalling our kids are going to become a dangerous new normal.”

Social media use among young people is nearly universal, with up to 95% of those aged 13-17 using a platform daily, and more than a third reporting near-constant use in 2023. A University of Delaware study found that increased social media use correlates with decreased academic performance.

The LA County Office of Education supports SB 1283, aiming to create a safer learning environment. “By explicitly limiting or prohibiting the use of social media while on school grounds or under school supervision, SB 1283 will help prevent distractions, cyberbullying, and other forms of inappropriate behavior that can negatively impact students' academic performance and well-being.”

At James Lick High School in San Jose , teachers are working to eliminate cell phone distractions during class by encouraging students to store their phones during instructional time. Similarly, the San Ramon Valley Unified School District employs a combination of Social and Emotional Learning curriculum, counselor activities, and parent-student dialogues to teach the necessary social-emotional skills for navigating the digital world .

In their letter of support, the California Teachers Association stated, “CTA believes all LEAs should be allowed to adopt policies and regulations regarding the use and possession of electronic communication devices such as smartphones as well as social media. These policies and regulations must ensure that the use and possession of these devices and social media does not disrupt instructional time or other school programs.”

The US Surgeon General's 2023 Social Media Health Advisory highlights that children and adolescents spending more than three hours a day on social media are twice as likely to face mental health issues, including depression and anxiety. This is concerning given that a 2022 survey found teenagers average 3.5 hours per day on social media.

Despite existing California laws requiring social media companies to provide reporting mechanisms for cyberbullying, these tools are often difficult to access, and reports frequently go unanswered. In South L.A., public middle and high schools are plagued by fights, which are recorded and posted on social media, exacerbating the issue 

Amelie Serang, a freshman at Ruth Asawa High School in San Francisco, experienced harassment on the social gaming app Discord at age 11. “When I reported the users harassing me, I got no response or acknowledgement of my report and I still haven't,” she said. “The risk that not having an accessible, timely, and effective cyberbullying reporting process poses to minors is extreme. If I was in an even worse place than I was when I was told to kill myself, I may have listened to them and done it, and that scares me.”

These bills face significant opposition from the tech industry and social media platforms as they now head to the Assembly, where the first committees will decide their future in the coming weeks.

SB 1283: Senator Stern Speaks on SB 1283 (youtube.com)  

SB 1504: CA Senate Passes SB1504 Cyber Bullying (youtube.com)

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