Traditionally, medical care has had two mutually exclusive goals: either to cure disease and to prolong life or to provide comfort care. Given this dichotomy, the decision to focus on reducing suffering is made usually only after life-prolonging treatment has been ineffectual and death is imminent, usually by days or hours. As a result, one of the best kept secrets in a hospital today in the United States is palliative care and hospice care. We estimate that of the 2.4 million Americans that die each year, about 80% end their lives in hospitals attached to the latest advances in technology; 300,000 die at home under hospice care. The reasons why more people do not receive palliative or hospice care range from the patient’s fear of abandonment and the unknown, the family’s denial of the inevitability of death of their loved one, and physician’s denial of medicine’s limitations. Unless the options of palliative or hospice care are given to patients the fears that people have of dying--fear of dying alone and fear of dying in pain--will continue to make the dying process one that lacks dignity and respect. In this review article we have reviewed the state of palliative and hospice care in the United States through a historical, ethical and legal perspective. We have discussed its scope in the developing world and the potential challenges.Journal of Advances in Internal Medicine 2017;06(02):38-44.

The death of (American) high school football players following an on-field collision during a game (according to media, eight in 2013, five in 2014, seven in 2015, and at least three in 2016) has alarmed us that we should make serious adjustments or improvements on the way the sport is currently practiced. Parents are increasingly worried whether they should allow their children to play football, some school districts have entirely shut down their football programs, and the number of male high school football players has continuously fallen to about 1.08 million in 2015, a 2.4% decline from 2010.[1] On the other hand, college and professional football leagues (NCAA Football and NFL) which are the preeminent games in the U.S, let alone the NFL the most watched sport followed by Major League Baseball (14 %). And youth and high school football programs are the gateways leading to as well as a nursery for the college and professional leagues. Thus, the warning signs are taken as great threats to hurt the football organizations’ lucrative business, so they have systematically downplayed and denied the seriousness of the players’ brain injuries and politically lobbied against the scientific research on the link between paying football and head injuries, though they recently admitted some truths about the danger of the sport. This paper, focusing on traumatic brain injury (TBI) and its degenerative kind, chronic traumatic encephalopathy (CTE), will survey the historical and medical narratives about head injury and contact sports, particularly American football; examine the current controversies and difficulties that occurred with research procedures and results of the scientific communities on head injury and football; investigate the currently proposed football practice-guidelines and game-rules by football organizations; lastly, propose recommendations which may serve as rather concrete and exhaustive guidelines for the elementary and secondary student football programs. [1] Ken Belson, “As Worries Rise and Players Flee, a Missouri School Board Buts Football,” The New York Times, Sep. 28, 2015, accessed Oct. 18, 2016, http://www.nytimes.com/2015/09/29/sports/football/As-Worries-Rise-and-Players-Flee-a-Missouri-School-Board-Cuts-Football.ht ml. INTRODUCTION American Football, a high contact sport, requires players to wear full protective padding, including helmets. Despite these precautions, players are repeatedly subject to intense blows to the head that can cause mild traumatic brain injury (MTBI), or concussions, which range in severity. A more severe concussion is classified as a traumatic brain injury (TBI), and many concussions can lead to the degenerative condition known as chronic traumatic encephalopathy (CTE). CTE was initially thought to have been a disease primarily associated with boxing, and was originally named “dementia pugilistica” or “punch-drunk syndrome.” This life-changing and currently untreatable disease can cause loss of memory, difficulty controlling impulsive or erratic behavior, aggression, depression, impaired judgment, and the gradual onset of dementia.[1] According to Brain Injury Research Institute (BIRI), approximately 1.6-3.8 million sports and recreation-related concussions are reported each year. About 60% of these are due to playing football.[2] As of 2015, the total of 87 out of 91 deceased NFL players has been tested positive for CTE according to new figures from the nation’s largest brain bank focused on the study of traumatic head injury[3] The CTE The Effect of Chronic Traumatic Encephalopathy (CTE) on Elementary and Secondary Student Football Players and Preventive Guidelines 2 of 19 must have begun at some point in a player’s career, but it is almost impossible to pinpoint when exactly it does. However, it is presumed that the CTE begins early on, as we observe the fact that a player such as Tyler Sash, a former NFL Giants safety, died at the young age of 27 years old. Tyler Sash played for 16 years when his brain exhibited the level of CTE comparable to that of the late Hall of Famer, Junior Seau, who committed suicide when his age was 43year-old. For a young player to display the symptom at such an advanced stage, he would have had to experience MTBI starting perhaps when he was in elementary school.[4] It is reported that the incidence of concussion in high school sports is .24 per 1000 between years 1997-2008.[5] Of all concussions here, more than half were reported in the sport of football (incidence .60), and girls soccer had the second highest rate (incidence .35). And most significantly, the concussion rate has increased 4.2-fold over the 11 years (15.5% annual increase). The top four sports with an increased incidence of concussion include football, soccer, lacrosse, and wrestling.[6] A recent report from a Canadian study shows a similar finding with top sports including rugby, hockey and American football (incidence 4.18, 1.2 and .53 respectively) and an overall incidence of concussion as .23 per 1000.[7] The BIRI also reported that a concussion suffered by a high school student has much more of an impact than one by a college student. Lack of proper diagnosis and management of a concussion may result in serious long-term consequences or risk of coma or death.[8] Boxing is banned in elementary and secondary schools and at most colleges because medical evidence is clear that chronic brain damage was prevalent among most fighters. Unless we do something drastically to protect our children who play the sport from getting concussions, the fear is that elementary schools and high schools will place a ban on football as well. This ban could be forced upon the schools by lawyers and even insurance companies. Or the cost of educating our children could become greatly expensive by the cost of insurance premiums for children who play football. In 2013, eight high school students die directly from on-field injuries in a game, five in 2014, seven in 2015, and at least three died in 2016.[9] These incidents lead a number of school districts to shut down their football programs because of safety concerns.[10] The number of male high school football players has fallen to about 1.08 million in 2015, a 2.4% decline from five years ago.[11] And the case reported about youth football or “pee-wee football” whose players are primary school students (the age of 5 to 15) is even worse. When Dr. Ann McKee, the neuropathologist and head of Chronic Traumatic Encephalopathy Center (CTE Center) at Boston University, testified before a House Judiciary committee on football brain injuries in 2009, she said that “because a young athlete’s brain is still developing, the effects of a concussion, or even many smaller hits over a season, can be far more detrimental, compared to the head injury in an older player.”[12] A recent statistical data, seen as confirming McKee’s view, indicate that the rate of concussions in elementary level football games has been much higher than both high school and college football. Youth football players (ages 8-12) were 26 times more likely to receive a concussion in a game than in practice.[13] There are numerous youth/pee-wee leagues among which the largest league is Pop Warner, which boasts over 400,000 boys and girls participating in its programs and over 5,000 football teams in the United States today.[14] And most high school football programs, whether the schools are public or private, are governed by the National Federation of State High School Associations (NFHS), as the NFHS writes rules for the football programs’ practices and games. It seems as if these organizations began to address the safety concerns and propose various programs and rules. However, it seems far from that their guidelines or protocols are concrete enough or effective to protect these young players from the known dangers of the sport, particularly from developing CTE. Thus, we propose our own rather concrete and exhaustive recommendations which can serve to be included as part of their guidelines or procotocols and to set some research directions for the scientific community dedicated to preventive pediatric sports health related to football. The methodological approach we take in proposing our recommendations is creative as well as eclectic, in the sense that we will investigate other organizations’ suggestions and, when evaluated as viable, include them as our own. To proceed now, this paper, focusing on TBI and CTE, will survey the historical and medical narratives about head injury and contact sports, particularly American football; examine the current controversies and difficulties that have occurred with research procedures and results of the scientific communities on head injury and football; investigate the currently proposed football practiceguidelines and game-rules by football organizations; lastly, propose recommendations. The Effect of Chronic Traumatic Encephalopathy (CTE) on Elementary and Secondary Student Football Players and Preventive Guidelines 3 of 19 [1] “What You Need to Know About Brain Injuries & Concussions,” Brain Injury Research Institute, accessed Oct. 18, 2016, http://www.protectthebrain.org/FAQs.aspx.

Tissue donation is a crucial element of cancer research and as a result of the lack of tissue samples, survival rates for brain cancer have not changed significantly in approximately fifteen years. Due to a particular shortage in brain tissue, children with central nervous system tumors do not have a favorable prognosis as compared to other types of cancers. With increased tissue donation, research in this field can function more efficiently to better understand pediatric tumor biology. This would almost certainly lead to the development of more effective therapies, and ideally, improvement in survival rates. Today, there is no standard method of approaching families of children with cancer for tissue donation. As a result, there are different levels of success for physicians. This paper will propose ways to encourage physicians to discuss the donation of biopsy and autopsy tissues with the families of children with cancer in the most effective, compassionate, and ethical manner. In order to reduce stress for families in such difficult decisions, it is important to outline the methods of approaching families. In addition, specific protocols for limited autopsy will be examined, as the samples recovered by these autopsies is the primary source of tissue used for research in this field. The ultimate goal of this paper is to increase the frequency of tissue donation in pediatric brain cancer through education of physicians, patients, and their families. A legal and ethical analysis of all potential solutions will be conducted, forming the basis of recommendations, and conclusions will be made.

Over the past two decades, roughly 20,000 people in Central America have died from chronic kidney disease of unknown origins (CKDu).[1] CKDu is growing into an unsolvable epidemic due to the mysterious cause of the disease and the little treatment available in the underdeveloped region. CKDu primarily affects sugarcane workers in Nicaragua and El Salvador, but it has also appeared in the rice paddy fields of Sri Lanka. Researchers from Sri Lanka, Boston University, and University of Colorado have proposed causes for the disease such as the pesticide glyphosate, occupational hazards like heat and dehydration, and sugar consumption, respectively; however disagreements still persist. The goal of this paper is to add to the claims already made so that a clearer hypothesis is formed. The paper will also focus on CKDu in Nicaragua to raise more awareness and to pressure the sugarcane companies into changing the country’s policy. Many aspects of CKDu will be analyzed including a history of sugarcane and pesticide usage, medical information about CKDu and Nicaragua’s treatment of the disease, ethics of the companies, and the environmental impact. The methods used in this research include observations and discussions with former sugarcane workers and their relatives during a two week trip to Nicaragua.

Dramatic advances in neonatal medical information and technology occur daily and these advances are being implemented almost immediately. Despite the dramatic technological advances, diagnostic and prognostic certainty for many neonatal conditions remains illusive. As a result, the appropriate decision-makers have to decide whether some handicapped newborns, such as those with congenital anomalies, low-birth-weights, and genetic defects, should be treated aggressively or not at all. This uncertainty has led to many handicapped newborns with serious congenital anomalies being treated aggressively. This treatment prolongs the lives of many newborns when in the past they would have been allowed to die. Such life-prolonging treatment decisions have far-reaching ramifications. One thing that is clear to serious observers in the field is that the implementation of medical advances and technology for some newborns is a mixed blessing at best. Despite proposed federal regulations (1984 Child Abuse Law)1 and medical guidelines (American Academy of Pediatrics) 2 that have helped to clarify treatment issues, there is still no consensus among responsible decision-makers on a moral criterion to assist parents and health care professionals on treatment decisions. There is general agreement within the medical, legal, and ethical professions that there are some handicapped newborns, in particular situations, whose lives need not be saved. Consensus ends, however, when an attempt is made to determine which specific newborns should receive or not receive medical treatment. This diversity of opinions has brought to the forefront the urgent need for a normative moral criterion to assist decision-makers in their discernment of treatment decisions for these never-competent patients.3

Heroin is a synthetic opioid drug that is becoming the drug of choice among many opioid drug abusers. The recreational use of heroin has become a problem resulting in nearly two thousands deaths a year and costing the United States about $22 billion each year due to medical costs, lost productivity, social welfare, and crime. This issue will only deteriorate further as the supply of heroin from south of the border continues to increase and as more individuals continue to become addicted to the drug. In an effort to address the problem, numerous overdose education and prevention programs have been launched around the country. Some of these nearly 200 programs also distribute a drug that can prevent heroin overdoses. This drug, naloxone, is an opioid antagonist that can reverse an opioid overdose by acting on the central nervous system and is used as a harm reduction agent. The U.S. Food and Drug Administration (FDA) approved a naloxone auto-injector, Evzio, to be available effective April 3, 2014 by prescription to those who may experience or witness an overdose. Opinion is divided, medically, legally, and ethically, as to whether this nationwide distribution of naloxone is providing a service or disservice to heroin users, as well as whether or not this distribution is a wise use of taxpayers’ money.

It is estimated that 2.1 million married couples or 5 million people in the United States are affected by infertility.[1] Infertility is defined as failure to get pregnant after one year of unprotected intercourse. About 40% of infertility cases are due to a female factor and 40% due to a male factor. The remaining 20% are the result of a combination of male and female factors, or are of unknown causes. [2] Issues of human infertility are extremely complex physiologi‐ cally, psychologically, financially, legally and ethically. It is estimated that 85-90% of infertile couples will receive conventional treatment and 10-15% may become candidates for various forms of Assisted Reproductive Technologies (ARTs) to assist them in having their own biological children. In-vitro fertilization (IVF) is one of the most utilized reproductive proce‐ dures that has allowed couples to have their own biological children. IVF accounts for 99% of ART. This procedure has been effective but it is still inefficient and expensive. One aspect of the inefficiency is that numerous embryos have been frozen through a process called cryopre‐ servation. It has been estimated that there are 400,000 embryos frozen and stored since the late 1970s. [3] In reality, the actual number of frozen embryos is probably closer to 500,000 with an additional 20,000 embryos added yearly. [4] Freezing these embryos has allowed for a limitation on the number of embryos transferred to a woman’s uterus which has decreased the number of multiple gestations. It also allows couples to use the frozen embryos in the future if the initial cycles are unsuccessful. This is not only more effective but also lowers the cost. The issue is now what to do with the 400,000 to 500,000 frozen embryos that remain as “spares.” Various alternatives have been suggested. The embryos could be thawed and then destroyed, continued to be cryopreserved indefinitely, used for research, or offered for donation/ adoption. All of these options present problems medically, legally and ethically.

Medical tourism is a vastly growing medical phenomenon in which patients from around the world travel internationally in search of inexpensive and quick, medical procedures. These economically driven treatments can be as different as plastic cosmetic surgery to fertility treatments. The one aspect that they have in common is the poor quality of treatment and care some hospitals and clinics offer to patients. Medical tourism is risky at best with many aspects of the process lacking monitoring or standardization. The surgical procedures are often medically unsafe, illegal and could be considered unethical. Without a doubt, medical tourism is a growing and very critical public health concern. Despite the many risks, however, medical tourism is a thriving industry: 6 million US citizens alone continue to travel globally into the medical tourism phenomenon. India has become the center for medical tourism over the last 5 years. India is specifically known in field for its specialties in cardiovascular, neurology/spine, orthopedic, oncology and weight loss surgeries. Due to the income it has accumulated from the paying tourists, India is not only expanding in medical tourism, but other countries are imitating their medical entrepreneurship, adding to the growing medical tourism business. Medical Tourism is being promoted as a viable solution to the financial dilemma regarding the costs of medical and surgical procedures that often result in a medical disaster for the patient. The guidelines being proposed in this paper seek to protect the health and life of patients by making sure they are fully informed of the medical and legal risks and benefits of any proposed treatments and procedures they may seek in a foreign country. The only hope is that with appropriate guidelines and standards, medical tourism can be rendered medically, legally and ethically more acceptable and be in the best interest of patients, physicians and society as a whole.

The foreign-born population in the United States, according to the "Current Populations Report" published in 2010, is estimated to exceed 39.9 million, or "12.9 percent of the U.S. population." The increase in foreign-born peoples and their need for health care is a complicated issue facing many cities, health systems and hospitals. Over the course of the past few years Mercy Hospital of Philadelphia has treated increasing numbers of foreign-born African patients. The majority have been presenting in the late stages of disease. The increase of foreign-born documented and undocumented African patients seen by Mercy Hospitals seems to reflect a foreign-born population "boom" in Philadelphia over the past decade. To meet the needs of this growing population, the Mercy Hospital Task Force on African Immigration and the Institute of Catholic Bioethics at Saint Joseph's University designed a program that centers on the third world concept of "Health Promoters." This program is intended to serve as one possible solution for hospitals to cost-effectively manage the care of this growing percentage of foreign-born individuals in the population. This notion of a "Health Promoter" program in Philadelphia is unique as one of those rare occasions when a third world concept is being utilized in a first world environment. It is also unique in that it can serve as a paradigm for other hospitals in the United States to meet the growing need of health care for the undocumented population. As of November 2012 the Mercy Hospital of Philadelphia clinic became operative for patients who were referred from the Health Promoter clinics. To date, a total of forty-two patients have actively participated in the screenings, sixteen of which have been referred to Mercy Hospital of Philadelphia clinic for further evaluation. More than 75% of patient referrals were a result of high blood pressure. According to the American Medical Association, readings of 140-159 mmHg and above are indicative of stage 1 hypertension. Among those who presented at the Health Promoter screenings the mean systolic pressure for males was 140 mmHg and for females was 140.48 mmHg.

AbstractMr. A's physician recommends immediate dialysis. However, Mr. A is in the United States illegally, has no family living in the area, and is unemployed. The Emergency Medical Treatment and Labor Act requires the hospital not only to examine Mr. A, but to provide him with any needed stabilizing treatment without considering his lack of insurance coverage or ability to pay. The needed treatment to stabilize Mr. A is dialysis. Therefore, the physician admits him and starts dialysis. But Mr. A will need to continue dialysis indefinitely. Because he has no insurance and is an illegal immigrant, he is not eligible for any outpatient dialysis units. He is also unable to afford any medical treatments. Once Mr. A is stabilized, should he be discharged? His physician and social worker turn to the hospital ethics committee for help. What should Mercy Hospital do?

The need for clean water has risen exponentially over the globe. Millions of people are affected daily by a lack of clean water, especially women and children, as much of their day is dedicated to collecting water. The global water crisis not only has severe medical implications, but social, political, and economic consequences as well. The Institute of Catholic Bioethics at Saint Joseph's University has recognized this, and has designed a slow-sand water filter that is accessible, cost-effective, and sustainable. Through the implementation of the Institute's slow-sand water filter and the utilization of microfinancing services, developing countries will not only have access to clean, drinkable water, but will also have the opportunity to break out of a devastating cycle of poverty.

Public health officials are grappling with a new wave of heroin abuse across the New York Region. “During the first six months of 2009, 25 people in Nassau County died of heroin overdoses—more than from homicide and drunk driving combined; in 2008, 46 people fatally overdosed on heroin, up from 27 in 2007, according to Nassau officials. In New York City, recent drug raids of so-called heroin mills yielded hundreds of thousands of bags of drugs at a time, up from several hundred bags a year.” One of the most alarming aspects of this increase in heroin use is that it is occurring among teens and people in their early 20s; and many come from upper or middle-class suburban families. Another alarming aspect is that the heroin that is available in the Northeast is purer and more lethal than the kind that ravaged New York City in the 1970s. Dealers often mark bags of heroin with words like “Red Bull,” “Lexus,” “Kiss of Death,” “R.I.P” or skull and crossbones. This spike in heroin use is attributed to its widespread availability and low cost. A bag of heroin can sell for $5 to $25 and induce a sixto -eight hour high. Cocaine, by comparison, can cost $40 to $60 for a 30-minute high while prescription pain killers like Vicodin or OxyContin sell more than $40 a pill on the street.[ii] New York Public Health officials have made the availability of heroin and heroin addiction a major focus, but a comprehensive strategy is lacking. BACKGROUND AND REVIEW Public health officials are grappling with a new wave of heroin abuse across the New York Region. “During the first six months of 2009, 25 people in Nassau County died of heroin overdoses—more than from homicide and drunk driving combined; in 2008, 46 people fatally overdosed on heroin, up from 27 in 2007, according to Nassau officials. In New York City, recent drug raids of so-called heroin mills yielded hundreds of thousands of bags of drugs at a time, up from several hundred bags a year.” 1 One of the most alarming aspects of this increase in heroin use is that it is occurring among teens and people in their early 20s; and many come from upper or middle-class suburban families. Another alarming aspect is that the heroin that is available in the Northeast is purer and more lethal than the kind that ravaged New York City in the 1970s. Dealers often mark bags of heroin with words like “Red Bull,” “Lexus,” “Kiss of Death,” “R.I.P” or skull and crossbones. This spike in heroin use is attributed to its widespread availability and low cost. A bag of heroin can sell for $5 to $25 and induce a sixto -eight hour high. Cocaine, by comparison, can cost $40 to $60 for a 30-minute high while prescription pain killers like Vicodin or OxyContin sell more than $40 a pill on the street. 2 New York Public Health officials have made the availability of heroin and heroin addiction a major focus, but a comprehensive strategy is lacking. Heroin, also known as diamophorine, is a semi-synthetic opioid drug of the opium poppy. Heroin usually appears as a brown or white powder or a black sticky substance known as “black tar heroin.” 3 As with other opioids, heroin is used as both a pain-killer and a recreational drug and has a high potential for abuse. Heroin can be injected, snorted/sniffed, or smoked, routes of administration that rapidly deliver the drug to the brain. “Heroin enters the brain, where it is converted to morphine and binds to receptors known as opioid receptors. These receptors are located in many areas of the brain (and in the body), especially those involved in perception of pain and in reward. Opioid receptors are also located in the brain stem—important for automatic processes critical for life, such as breathing (respiration), blood pressure, and arousal. Heroin overdoses frequently involve suppression of respiration.” 4 Heroin acts as a pro-drug that allows rapid and complete central nervous system absorption; this accounts for the drug’s euphoric and toxic effects. 5 Regular heroin users develop a tolerance in which the user’s physiological and psychological response to the Heroin Addiction: An Ethical Evaluation of New York City’s Heroin Manual 2 of 9 drug decreases, and additional heroin is needed to achieve the same intensity of effect. Heroin users are at a high risk for addiction. It is estimated that about 23% of individuals who use heroin become dependent on it. 6 A range of treatments exist for heroin addiction, including medications and behavioral therapies. Treatment usually begins with medically assisted detoxification to help patients withdraw from the drug safely. Medications such as clonidine and buprenorphine can be used to help minimize symptoms of withdrawal. The most effective treatment is behavioral treatment in combination with medication. These are usually delivered in residential or outpatient settings. 7 Heroin use and addition is a major problem both internationally and nationally. The United Nations estimates that there are more than 50 million users of heroin, cocaine and synthetic drugs. Global users of heroin are estimated at between 15.16 million and 21.13 million people ages 15-64. 8 According to the 2008 National Survey on Drug Use and Health (NSDUH), approximately 3.8 million Americans aged 12 or older reported trying heroin at least once representing 1.5% of the population aged 12 or older. Approximately 453,000 (0.2%) reported using heroin within the past year and 213,000 (0.1%) reported using it in the past month. The number of current (past month) heroin users aged 12 or older in the United States increased from 153,000 in 2007 to 213,000 in 2008. There were 114,000 first-time users of heroin aged 12 or older in 2008. 9 In New York City, accidental heroin overdoses is the fourth leading cause of early adult death, claiming more than 600 lives each year. 10 In addition, heroin use, particularly in those who inject the drug, is also responsible for spreading needle-related infectious diseases such as hepatitis and HIV/AIDS. To address the critical problem of heroin overdoses and the increased spread of hepatitis and HIV/AIDS, the New York City Department of Health and Mental Hygiene in 2007 prepared a 16-page guidebook called Take Charge, Take Care: Ten Tips For Safer Use (NYC.gov website). The purpose of this guidebook, according to representatives of the Department of Health and Mental Hygiene, is “to help people who are injecting drugs reduce the harm associated with this type of drug use until they are able to get into treatment and recovery.” 11 Approximately 70,000 copies of the pamphlet have been produced and distributed at a cost to New York City taxpayers of slightly more than $32,000. 12 Proponents argue that this guidebook can help heroin users avoid health issues and potential inflammation, infection and other problems. More importantly, it could possibly save lives and prevent the spread of needle-related infectious diseases. Opponents argue that the 10-step guidebook could encourage the use of heroin, could deceive users into believing there is a safe way to inject heroin, and could be considered a gross misuse of taxpayers’ money. The purpose of this article is threefold: first, to present the facts presented in Take Charge, Take Care; second, to examine the arguments for and against the guidebook; and third, to give an ethical analysis of this guidebook as a harmreduction approach to lessen the negative consequences of heroin use. TAKE CHARE, TAKE CARE The New York City Department of Health and Mental Hygiene produced and distributed Take Charge, Take Care as part of a long-term comprehensive strategy to prevent heroin overdoses and decrease the spread of infectious diseases like hepatitis and HIV/AIDS. In addition to this informational guidebook, the comprehensive plan includes face-to-face community outreach initiatives, expansion of drug abuse treatment facilities and 47 state-authorized needle exchange programs throughout New York City’s five boroughs. 13 The guidebook is part of a harm-reduction model that could lessen the negative consequences of illegal drug use. Harm reduction can be seen as a set of principles and strategies about human behavior, which, when incorporated into a prevention or treatment program, seek to reduce the negative consequences of high-risk behaviors such as alcohol and drug use and unprotected sex. This approach is also known as damage limitation, casualty reduction and harm minimization. 14 Harm reduction operates on a set of principles and assumptions about how individuals make changes. These principles include recognizing that the desire for change must reside within the individual that long-term change begins with small, realistic and attainable steps; that low-threshold strategies wherein the individual need not commit to abstinence can be effective in bringing about desired change. Harm reduction also affirms individuals as the primary agents in reducing the harm from their at-risk behavior and establishes the quality of individual and community life and well being, not simply cessation of all high-risk behavior, as a criterion for successful interventions. 15 The basic tenet of harm reduction is that there has never been, is not now, and never will be a drug-free society. The aim of the Take Charge, Take Care is to lessen the harm of heroin in New York City through education, prevention and treatment. It is a realistic policy that is based on the fact that a certain number of heroin users Heroin Addiction: An Ethical Evaluation of New York City’s Heroin Manual 3 of 9 will continue to use drugs and some action must be taken to help these individuals and those indirectly affected by their drug use. The goal of this policy is similar to many standard harm-reduction strategies. It is to “move the individual along the continuum toward abstinence, thereby reducing the harmful consequences of the behavior. The continuum model accepts abstinence as the ideal risk-reduction strategy; however, a