Andrew on needle exchange:

This restriction might make sense if needle-exchange programs increased the number of addicts. But they don't. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, has comprehensively reviewed the scientific studies on needle exchange. "It does not," he says, "result in an increase in drug abuse, and it does decrease the incidence of HIV. . . . The idea that kids are going to walk out of school and start using drugs because clean needles are available is ridiculous." My experience in Washington was consistent with Fauci's view. Addicts who came for needles were generally in their 40s and 50s. The availability of clean needles no more caused their addiction than the provision of clean shot glasses would cause alcoholism," - Michael Gerson,

I am sure this is correct, and I (of course!) favor needle exchange, insofar as I can be said to favor anything that makes me squeamishly clutch my arms to my chest.  But does anyone think this will change the minds of the opponents of needle exchange?  Their objection is not, at its heart, a practical one.  Rather, they don't want to implicitly ratify shooting up by providing higher quality materials with which to do so. 

I wonder if this isn't the same class of objection that many of my interlocutors have about paying for kidneys.  A lot of people framed the idea as "rich people buying the poor's kidneys", even though the actual proposal on the table is for the government to pay a bounty to kidney donors in the name of anyone who happens to need one.  (Since my impression is that kidney failure disproportionately strikes the poor, the net effects are, I think progressive.)  But it is true that probably more people who sell kidneys will be in the bottom half of the income distribution.

And yet when I look at what progressives would usually regard as the objective outcomes--certainly if they were assessing a needle exchange--the net goods obviously outweigh the net bads.  For most people, kidney donation is not very risky.  They lose some small utility from surgical recovery, the ability to drink a lot of alcohol at once, and have a risk of losing the other kidney so small that it doesn't register in the mortality statistics for kidney donors.  (This may be because outside of trauma, a disease that is going to kill one kidney will probably kill both).  And if the program results in a lot more kidney donors, the risks attendant upon losing your one remaining kidney presumably fall sharply.

On the plus side, every kidney donated takes one person off dialysis and lengthens both their life expectancy, and their Quality Adjusted Life Year expectancy.  This is such an unmitigated win that libertarians have a hard time seeing how you could possibly desire to see the state step in and stop this transaction.

Well, even I would like to see very careful screening in such a program--today's donors are probably more thoughtful and committed about, say, giving up drinking, than you might find if we paid for kidneys.  But assuming we can do that, why still object?

Because it feels like ratifying the fact that the poor in America need money more than the wealthy.  It feels like creating injustice.

Interestingly, I note that we only feel this way because we already banned the practices we're discussing.  If it were legal to purchase syringes (and I can't tell you the libertarian indignation that filled my heart as I typed the word "if"), then allowing the distribution of clean needles to addicts would have very little expressive value.  Because you need a government waiver to do this, allowing it seems to put our stamp of approval on it.  "Go shoot up!  Just be safe!"  Whereas, to use Gerson's metaphor, no one feels like the government has put its stamp of approval on binge drinking merely because the bartender gives you a fresh glass every time you order a new drink.

Similarly, if we didn't already have this ban on compensation for kidney donation, the poor probably would be more likely to sell theirs.  Yet I'm not sure that it would then be obvious to many progressives that we should ban the practice to stop this disparity. In that world, the action--banning--would do obvious harm to actual people, the kidney patients who were already benefitting from donated kidneys.  Banning compensated kidney donation would not be a cheap expressive good.

These framing effects seem pretty powerful to me.  And it's another reason to legislate carefully--to err on the side of doing too little rather than doing too much.  Once we've enacted a law, undoing it has powerful expressive connotations.    The resistance to actively participating in something that we might very well tolerate can lead to some very bad outcomes for the people we're all presumably trying to help.

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