1. Running head: ETHICAL DILEMMA 1
Ethical Dilemma: The Needle Exchange Program
Tiffany Becerra
California Baptist University
Author Note
This paper is presented to Doctor Bradley and Professor Anacker in partial fulfillment for
the requirements of Ethics and Issues in Healthcare, NUR460A on March 31, 2017.

2. ETHICAL DILEMMA 2
The Needle Exchange Program
Drug use is a major problem throughout the world. More specifically, intravenous drug
use, or people who inject drugs (PWID), and the rates of hepatitis B (HBV), hepatitis C (HCV)
and human immunodeficiency virus (HIV) are on the rise. In 2012, almost three million people
were infected with one of these viruses, which was discovered upon hospital admission (Center
for Disease Control, 2015). The needle exchange program (NEP) grants PWID with access to
sterile syringes without cost to the user and disposes safely of used syringes (Center for Disease
Control, 2015). This paper will discuss the advantages and disadvantages of the NEP based on a
strictly ethical approach.
The Dilemma
An ethical dilemma happens when there are moral claims that conflict with one another
(Burkhardt & Nathaniel, 2014, p. 527). A major ethical dilemma that society, both local and
abroad, is faced with today is whether the NEP benefits those who utilize the program by
decreasing disease or whether it actually increases disease by promoting drug use. By
implementing the needle exchange program the expectations are that there will be a significant
reduction in the instances of needle sharing, and therefore a decrease in blood borne viruses in
this population.
By allowing access to clean needles without repercussion, it discouraged PWID from
sharing potentially contaminated needles while promoting a no charge testing of HIV, along with
access to a drug rehabilitation program (Abdul-Quader et al., 2013, p. 2886). Those that oppose
this argument protest that the number of allotted syringes per person, per year is not sufficient for
PWID. The number of syringes allotted per person, per year is 90, meaning that the average
PWID receives less than two needles per week throughout the year. This is assuming the PWID

3. ETHICAL DILEMMA 3
are only using once a week, which is highly unlikely (Abdul-Quader et al., 2013, p. 2879).
These same critics also argue that because the locations of NEP are so greatly disbursed
throughout the United States they make little impact and are under utilized for those living
outside of larger cities, mainly because of the stigma and negative attitudes that society has on
PWID (Parker, Jackson, Dykeman, Gahagan, & Karabanow, 2012, p. 156).
Additionally, critics argue that such programs actually promote injection drug use, which
in turn increases disease and has little impact on reducing blood borne viruses by giving away
sterile needles to intravenous drug users. This argument is backed by the increase in the number
of hepatitis infections in PWID, especially in the state of Tennessee, as numbers increased an
average of one percent per year in just six years (Center for Disease Control, 2015). As of 2017,
Tennessee has only one needle exchange location. In comparison, and despite the fact that it is a
much larger state, California has 41 locations, with most of them located in Southern California.
(North American Syringe Exchange Network, 2017). Arguments for why the NEP increases
disease also include the position that it is promoting drug use by giving away syringes at no cost,
that intravenous injection is the most efficient mode of transmission of HCV and HIV and that
promotion leads to more disease (Kerr et al., 2013, p. 1228).
The first NEP was implemented in the early 1980s in the United States and was funded
by the federal government after the launch of the war on drugs (Bramson et al., 2015, p. 217).
Today, NEPs are funded both federally and locally through the Centers for Disease Control and
Substance and Mental Health Services Administration. Potential arguments against federal
funding include that the money spent funding NEP can be better utilized on stricter laws
regarding drug enforcement. However, there is no federal money set aside specifically for NEPs
and because of the growing number of other federally funded programs, a decrease in federal

4. ETHICAL DILEMMA 4
funds would in turn lead to less funding locally for these programs (Green, Martin, Bowman,
Mann, & Beletsky, 2012, p. 14). In 2009 and 2010, the cost of the NEP program averaged
$188.80 annually (Islam et al., 2013, p. 314), whereas the average cost of a twelve-week course
of a three-drug combination for HCV runs between $232 and $454 (Sulkowski, 2014, p. 23).
With this information about cost effectiveness, the program has potential to be cost effective
with less money going for treatment and more money going towards the prevention of such
diseases. With the argument of federal money going to these programs and how it could/should
be better allocated, many also argue that federal funds should be cut to NEP all together because
the good that the program is attempting to promote depends strictly on the participation of PWID
and those who choose not to participate (Coutinho, 2015, p. 1491). At the same time many argue
about allocation of funds, others argue that NEP are unethical and that there are over 20,000 new
cases of HIV detected annually despite implementation of these NEP (Leary, 2012).
Decision-making and Moral Reasoning
The decision making process incorporates virtue ethics, which is built on the idea that an
individual’s actions are based upon their innate moral character (Burkhardt & Nathaniel, 2014, p.
531). One virtue that is associated with the NEP is nonmaleficence, or the avoidance to inflict
harm on another person during the performance of beneficial acts (Burkhardt & Nathaniel, 2014,
p. 529). These NEPs were implemented to help the population decrease disease and offer a safer
alternative to sharing needles. Another virtue associated with the NEP is that of trustworthiness
and being consistent and predictable (Burkhardt & Nathaniel, 2014, p. 531). For a PWID, they
know that they can come to a needle exchange center and be given a clean needle without being
judged or turned over to the authorities for their illegal activity. One can see how important the
virtue of trust can be and how it is imperative in the nurse to client relationship, or in any

5. ETHICAL DILEMMA 5
relationship. Additionally, compassion is one more virtue that is used while discussing the
virtues that the NEP contains. Compassion is shown in the regard for an individual’s welfare,
while at the same time being tender and sympathetic to that individual’s unique situation
(Burkhardt & Nathaniel, 2014, p. 526). Those who work facilitating clean needles to PWID in
the NEP do so because they have this consideration for others, which is a reason why many get
involved in such programs to begin with. A vice is an immoral behavior or habit that makes the
individual worse ("Dictionary.com | Meanings and Definitions of Words at Dictionary.com,"
2016). A vice that fits this dilemma is simply that of intravenous drug use and abuse. This vice
is the foundation upon which the NEP was created.
The first step in applying the ethical decision-making process is identification of the
dilemma itself. In this case, it is the dilemma of the effectiveness of the NEP. The desired goal
is the reduction of blood borne viruses. Next, one must gather data both for and against the
dilemma to gain more information and attempt to locate non-bias research, which is at many
times difficult. While gathering data, one must keep in mind the risks and benefits of the NEP
and who is involved in this dilemma. In this case, it is not only PWID but also the surrounding
communities and how this population impacts the community on a whole. The community and
legislators are empowered to make decisions on whether or not a city will house a NEP. There is
no other strategy as of now to discourage needle sharing, other than the NEP, with the exception
of educating PWID about the high risk associated with needle sharing. Upon implementing the
NEP, developers must be aware of the emotional impact drug use has on the population it serves,
which is why the values associated with the NEP are so important. The ethical dilemma of the
effectiveness of the NEP is far from being solved. As with many new programs, the public may
be resistant at first until they see results come full circle and know that the NEP is truly helping

6. ETHICAL DILEMMA 6
their community and not doing more harm. After the implementation of the NEP in New York
City, there was a significant decrease in the number of cases of HIV, from 50% down to 17% in
only twelve years (Abdul-Quader et al., 2013, p. 2886). Further action is required in order to
resolve this dilemma. Such actions include providing more access to NEP in non-urban areas, as
they are a greatly underserved population with a high rate of drug use (Parker, Jackson,
Dykeman, Gahagan, & Karabanow, 2012, p. 153).
Moral Reasoning
Nurses commit to deliver care based on a code of ethics before they even begin to
practice. These ethics give nurses principles to follow in order to deliver safe care and follow
professional standards. The American Nurses Association provides nurses with nine provisions,
along with explanatory statements; it is with these provisions or principles that nurses deliver
said care to their patients or clients. Beginning with Provision One: the nurse will practice with
respect and compassion in regards to the nurse relationship with the patient. This provision is
critical in that nurses need not agree with every decision their patient makes, including poor
decisions that lead to poor health outcomes, but instead address this behavior, educate and offer
proper resources to decrease such behavior (American Nurses Association, 2015, p.1).
Furthermore, Provision Three states that the nurse will advocate for their patient and
protect their rights and safety (American Nurses Association, 2015, p.9). This is especially true
when dealing with individuals who have made or continue to make poor choices that lead them
to seek out the NEP. The nurse must ensure trust with the client and protect their right to come
to a NEP without risk of being exposed or prosecuted. Nurses have the unique opportunity to
experience certain rhythms that evolve as new meanings, which develop to illuminate shifting
patterns that an individual shares with their community (Parse, 2014). This means that as the

7. ETHICAL DILEMMA 7
individual, the nurse has a unique history that is co-created with their own experiences, which
they share with the community and smaller populations they serve. This is important because
nurses are able to share their own experiences with their clients to facilitate conversation, which
may aid in the holistic approach of healing and promote trust.
Analysis.
When considering the ethical dilemma of whether or not the NEP is successful or not, the
decision is that it is in fact successful in reducing HIV and HCV rates locally. One study
conducted in the United States gathered information on roughly 7,000 participants who admitted
to intravenous drug use and needle sharing behavior. Of this group selected, about half had
access to a pharmacy based NEP, while the other participants did not. Upon further testing of
both groups, the group who did not have access to a NEP had higher rates of both HCV and HIV
(Sawangjit, Khan, & Chaiyakunapruk, 2016, p. 240). Furthermore, of the PWID who
participated in the NEP, only 1 out of approximately 1,000 reported that they used the NEP to
access a clean syringe for their first time injecting drugs (Kerr et al., 2017, p. 1228). This further
endorses the argument that NEPs do not promote intravenous drug use and that NEP are mainly
utilized by those who already have a history of injection drug use. Of the 1,000 participants,
nearly 800 of them reported being injected by someone else the first time they used intravenous
drugs (Kerr et al., 2017, p. 1229).
Humanbecoming and Personal Values
The theory fits the dilemma as the theory of humanbecoming incorporates a co-creating
truth as a seamless relationship of becoming that saturates the principles of the humanbecoming
theory (Parse, 2014, p. 27). This means that nurses must be mindful that each client they
encounter is part of a larger picture; the larger picture is not the individual, but the entire

8. ETHICAL DILEMMA 8
population of PWID and the safety the program is attempting to implement. This is especially
true for PWID as they may require mental treatment for addiction as well as for the physiological
effects. Focus should be placed on an understanding of the behavior that prompts the drug use
and a communal responsibility as nurses to offer assistance to this group.
My personal value system was applied to the decision making in that I also serve with
nonmaleficence. My values include: compassion, dependability and self-control. Of these
values, all three can be applied to the ethical dilemma of whether the NEP is doing harm or good.
I have compassion for those who suffer from addiction, as it is an illness they have no control
over. I express self-control when dealing with those who have beliefs and values that differ from
my own, even if they are harmful to the client. Dependability influenced my decision in that I
am dependable when dealing with clients and I believe that those working with the NEP should
also show dependability because this fosters trust with the population they serve.

9. ETHICAL DILEMMA 9
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