The Lancet and drug harms: missing the bigger picture – TBS

Values IcebergA Throw Back Sunday post from 2007 on values and evaluating drug harms.


The Transform Drug Policy Foundation offers a response to the recent Lancet article that ranked drugs by harm. The writer suggest that the article is flawed in two important ways. First he argues that it fails to consider harms caused by the illegal status of the drug. Second, he says that the nature of the paper lends itself to criminalization of the drugs judged to be more harmful.

I’ll use this as an opportunity share an opinion I didn’t share in my original post–it’s impossible to separate values from these kinds of decisions. Values influence which harms are identified, how those harms are ranked, who’s opinion is sought, the intended use influences the design, etc.

UPDATE: I received the following comment from a reader:

“Values influence which harms are identified”. Yes that is a description of what happens at present but is shouldn’t be a prescription for what should happen. If we are to base drug classification on scientific evidence then the aim should be to get as close to objectivity as possible.

Let me clarify. In an ideal world I’d agree with the comment, we could objectively quantify harms and know that there is one set of facts for us to operate from. My judgment is that this is fantasy. For example, purportedly objective American harm reduction discussions tend to very heavily emphasize HIV/AIDS. Why? Because the early American harm reduction advocates were HIV/AIDS advocates.

Other tough questions:

  • Should growing up with an addicted parent be considered a harm? Beyond child protective service cases? If yes, how should this be quantified? If not, why?
  • How about the emotional pain experienced by other family members? If the answer is yes, how should these be weighted relative to the harms caused to children?
  • Should the malaise cast over communities be considered a harm? If one looks at certain communities, American Indian reservations for example, the despair due to alcohol (a legal drug) goes well beyond unemployment. Should the pall addiction can cast over an affected community be considered?
  • Should harms to non-users be weighted more heavily? Based on the belief that the user is exercising personal liberty and assumes risks in doing so?
  • When it comes to making harm reduction policy decisions, one harm reduction strategy can reduce harm to one population and increase risk of harm for another.

Don’t get me wrong, I’m glad this study was done and I look forward to more studies like it. I’m just convinced that values can’t honestly be eliminated from the equation. It might be helpful to integrate scientific evidence and a discussion the values like liberty, safety, etc.

One thought on “The Lancet and drug harms: missing the bigger picture – TBS

  1. I have a huge amount of respect for Professor Nutt, especially after the way he and his colleagues at the ACMD were treated by the UK government. However, the method they use in this paper is incredibly unscientific and renders the results even more value-laden than you suggest. The Delphic method used in the paper is wide open to group polarisation bias, and existing individual value-judgements will inevitably affect the results.

    We need a good study of drug harms which includes the harms of criminalisation as a separate category to truly understand the difference between drug harms and prohibition harms. We also need to develop a more objective method for reaching conclusions on harm. It worries me to see the Lancet article referenced so often without people properly discussing the inherent methodological issue present.


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