What do we owe people? Ethics and the rollback of harm reduction programs in Canada
Canada is facing a drug policy contradiction. Governments continue to describe toxic drug deaths as a “serious public health crisis”, yet some are dismantling parts of the public health response designed to prevent overdoses, reduce infections and connect people to treatment and social supports. Public debate often asks whether programs such as supervised consumptions services (SCS) and safer supply should have been implemented in the first place. That question matters. But once these programs exist and you take them away, another ethics question arises: what do governments owe people who have come to depend on these programs for survival?
Ending harm reduction programs is not simply a policy reversal but has real-world health impacts. For people who use drugs, these programs can help prevent withdrawal, reduce exposure to an unpredictable street supply, provide sterile drug consumption equipment and keep people connected to health and social supports. Closing programs may be presented as a way to resolve political controversy, but it can also create new ethics problems: disrupted care, increased risk of overdose, abandonment, and failure to justify the decisions to the people most affected. An ethics analysis can help make these decisions visible. It reminds us that closing a program is not merely a technical or administrative decision, but that it is about values; which values matter and whose harms count.
The current rollback
In Ontario, nine SCS were required to close or transition to Homelessness and Addiction Recovery Treatment (HART) Hubs in 2025. These HART Hubs do not offer evidence-based harm reduction services such as supervised consumption, needle and syringe exchange or drug checking. Less than one year later, Ontario ended funding for several remaining SCS, with a wind-down period intended to transition service users to HART Hubs. Harm reduction workers and organizations nationally and internationally voiced strong concerns that these changes could lead to increased harm for the most marginalized members of the community.
Other provinces have moved in a different but related direction. British Columbia has expanded involuntary treatment capacity under its mental health law. Alberta passed the Compassionate Intervention Act, creating a legal framework for involuntary assessment and treatment. Saskatchewan recently passed their own legislation as well. At the same time, federal funding for safer supply programs expired or were not renewed, leaving programs and participants in a precarious position.
Governments justified these changes by stating worries about public disorder, diversion of safer supply medications, or the need to shift from harm reduction to treatment and recovery (with the assumption that these are mutually exclusive). These concerns deserve public discussion. But the debate often makes a basic mistake: it judges each harm reduction program as if it were supposed to solve the entire drug toxicity crisis on its own. No single intervention can do that. SCS, SOS, drug checking, needle and syringe distribution, housing, treatment and social supports are related, but each do different work. Evidence that one intervention is not sufficient by itself is not evidence that it is ineffective, harmful or ethically dispensable.
The ethics of starting versus stopping (and not starting)
As a bioethicist who cares about the health and well-being of people who use drugs, I turn to bioethics, the field that examines the ethical dimensions of health, medicine and public policy, for tools to help think about this problem. We often distinguish between deciding not to start a treatment and deciding to stop a treatment. The same distinction applies to programs. Once a service exists and people rely on it, the government’s responsibilities change.
The principle of nonmaleficence, often summarized as the duty to do no harm, does not apply only when a government creates programs – it also applies when they remove them. If people use a program to avoid withdrawal, avoid the toxic street supply, or maintain contact with integrated health and social service workers, closing that program without an adequate alternative creates foreseeable harm. It also breaks an implicit promise of continuity where people were encouraged to enter a system of care and then that system was withdrawn.
This matters especially because harm reduction programs often serve people who are already structurally disadvantaged through poverty, homelessness, criminalization, racism, disability, stigma, limited access to healthcare and other factors. Removing programs for such groups can entrench existing injustices. For these reasons, withdrawing an essential program raises different ethical concerns than never having offered it in the first place.
What adequate alternatives require
None of this means harm reduction programs are beyond critique. It also does not mean a program can never be changed or closed. But the ethical bar is high. Closing or rolling back a program without an adequate alternative can leave an already disadvantaged population worse off. We have wrestled with similar situations before. For example, participants in studies of heroin-assisted therapy were not provided access to the intervention after the trials ended, despite many reporting benefits, which they felt put them at increased risk. Similarly, responsible rollback of harm reduction programs requires strong evidence, transparent reasoning, meaningful consultation with affected populations, and clear exit strategies that protect people from preventable harm.
The exit strategy cannot simply point to treatment and recovery services as if they automatically replace harm reduction. Treatment, housing, counselling and primary care are essential, but they do not do the same work as supervised consumption services, safer supply, sterile consumption equipment, or drug checking. An intervention that does not offer overdose prevention or safer use supports can leave people at greater risk of harms, including death. As one safer supply participant reported, “I won’t make it without this program.” Even if policymakers disagree about the best long-term model, they still need to account for the immediate risks created by the withdrawal of services.
What do we owe harm reduction program participants?
A helpful ethics test is whether a decision can be justified to the people who bear its risks. The philosopher T.M. Scanlon argues that an action can only be justified if the affected people cannot “reasonably reject” or disagree with it. Applied here, the question is not only whether governments can defend closures to the public. It is whether they can defend closures to people whose health, stability and survival depend on these programs. This is critical for public trust and especially demonstrating trustworthiness to the populations most affected.
This approach requires asking different questions. Instead of asking only whether safer supply reduces drug use, we should ask whether it reduces exposure to a toxic supply and improves access to health and social services. Instead of asking only whether safer supply was clinically appropriate, we should ask what society owes people facing foreseeable, preventable death. Instead of asking only whether supervised consumption services cause public disorder, we should compare those concerns with the harms of closure, including more isolated use, more public consumption, more discarded drug debris and most importantly, more preventable deaths. Instead of considering treatment and harm reduction as opposites, we should ask how both can be part of a continuum of care.
The duty to avoid preventable harm
Canada’s rollback of harm reduction programs is not merely a disagreement about drug policy. It is a public health ethics problem. When governments close programs without adequate alternatives, they shift foreseeable risks onto people who are already structurally disadvantaged. Once people are invited into systems of care and have come to rely on them for survival, governments acquire new obligations. At minimum, they owe clear justification, meaningful consultation, careful transition planning and a serious effort to prevent avoidable harms. Political convenience does not erase these obligations.
The author would like to thank Dr. Adrian Guta and Kate Scott for their helpful comments on an earlier version of this post.
Daniel Buchman is senior scientist and director of the Everyday Ethics Lab at the Centre for Addiction and Mental Health, as well as an associate professor at the Dalla Lana School of Public Health and Department of Psychiatry at the University of Toronto.