As mental health moves into the “reasons” that euthanasia will be approved, I have wondered how things like mandatory holds will be enforced. How will it be viewed as wrong and a person is a danger to themselves and forced into medical treatment if they are suicidal, but then suicidal it’s is actually assisted if approved?
For all the mental health awareness and supposed lack of stigma we claim to embrace as a society, it’s telling that the apparent moral position change that suicide becomes ok but only if approved by the government is actually a position that anyone views as defensible. I suppose it may reduce the inpatient population, but it’s a huge abandoning of care as society and a failure to clearly say life is worth living and we’ll support you until you feel better. (And people do come back from this. I know from personal experience and have a wonderful life now despite having many years of treatment resistant depression and multiple suicide attempts - it was right for the norms of society to force me to learn to live. I’m glad society hadn’t decided euthanasia was ok for people like me back then.)
This was obviously going to happen as a result of MAID. We were supposed to celebrate, or at least support, some suicides, while discouraging others. And, for yet others, I guess we would draw up a pro/con list to decide.
But all the structural incentives are pro-suicide. The most insidious is that, when a friend's loved one (eg aged parent) has done it, it becomes unkind to talk about the wrong of MAID in that friend's presence.
The idea that the state is somehow morally neutral and yet pursues a goal of "harm reduction" is incoherent. The state always pursues some good, and always privileges some kinds of behaviours over others.
That is why this isn't really about "harm reduction". It's actually about enabling vice. Because our rulers and the NGO swarm they support, are in fact vicious.
"But this overlap masks the fact that on the first “unenforceability” approach, there remains an official and public condemnation of the practice. In contrast, the “reasonable disagreement” model avoids making any official judgments, and doesn’t choose sides between competing visions of the good."
For me this is the key point. A good example is tobacco, the smoking of which has been legal forever but which began to attract a stigma in the 1980s that still survives to this day. That stigma is a large reason for the, yes, *reduction in harm* from tobacco.
A mentality which sees a harm reduction approach as mutually exclusive from attaching stigma to an activity brings us the worst of both worlds. We as a society do not have to validate the life choices of everyone who happens to be doing something that is (rightfully) not illegal. And we sure as hell don't have to go so far as to let those life choices detrimentally affect (in this case) the lives of other people who are in physical proximity to harm reduction centres.
Yes, the idea that it’s controversial to protect children over addicts if a choice had to be made is stunning. Nobody should ever think it’s ok to traumatized or put a child at risk to give an addict space to indulge in their vice. The concept is shocking.
Stigma is critical. It tends to stop or at least reduce behaviour that harms the individual and collective society. The reduction of clear moral outrage against clearly morally wrong actions is clearly morally harmful. We have ample evidence of exactly that. Particularly if such actions are not apparently actionable by law enforcement at this point.
I find the term destigmatization to have been terribly abused by the poverty industry (I live in Vancouver, it is a booming and rich industry) and is simply an excuse to abdicate personal responsibility for anything and everything. Its a great term for the mob to scream (YOU ARE STIGMATIZING US) if anyone tries to make things better in a particular area
What bothers me about the harm reduction approach to drug addiction is that the proponents have been chasing an idea that's conceptually flawed to the point where it results in a net increase in harm. The impulse is sound: stop people from dying of drug overdoses and reduce the spread of disease so they've got a chance to get into recovery. It's just that the proponents of harm reduction have never really made that next step work, so their net accomplishment is swapping a quick premature death from drug overdose for a longer, slower premature death due to all of the other negative effects of drug use. There's insufficient availability of drug treatment programs, and relapse rates for opioid addiction is something like 80-90% in the year following treatment. Meanwhile, drug addiction impacts communities with increased rates of crime, antisocial behavior, and public disorder. On a purely utilitarian basis, this approach is not working well and something different is required. Step 1 would be recognizing that drug use *is* the problem.
The societies and service providers work on overdrive to stop or at least slow down any attempt at expanded recovery programs and facilities. They routinely whip up anger in any neighbourhood where there may be an attempt to build some facilites (we see this in Vancouver regularly). The harm reduction approach is simply about keeping your heart beating while you rot in the streets so they can get their funding, jobs, offices, and director stipends. That may sound harsh, but I am around this in Vancouver and there are hundreds of these organizations and any talk of recovery systems is shot down hard time and time again. They want to keep the people there at all costs. Harm reduction strategies are utter failures and completely self serving for the industry who uses the drug addicts and mentally ill as the gasoline for their engine.
In the tale of Pandora, the gods gave humanity a gift wrapped in beauty but laced with danger. Once opened, the jar released plagues, grief, and chaos into the world—leaving only hope fluttering at the bottom. The Canadian shift toward harm reduction policy bears a faint echo of that myth. Like Pandora’s jar, the transition from moral condemnation to harm minimization has released powerful new freedoms and tools of compassion into public life. Yet, alongside these benefits, come complex and unintended consequences that are only now beginning to emerge with clarity. To confront them honestly requires the same moral seriousness once embedded in the prohibitions these policies replaced.
You rightly acknowledge the historical evolution of Canadian criminal law from a system rooted in moral judgment to one guided by harm reduction. Many will view this shift as progress; especially in areas where old laws enforced stigma and suffering. The decriminalization of same-sex relationships, the legalization of abortion, and the regulated sale of cannabis have expanded personal freedom and aligned policy with contemporary notions of justice and equality. It is not difficult to sympathize with a framework that seeks to reduce suffering rather than punish it. The early success of harm reduction, especially in the context of HIV prevention, offers a compelling case for pragmatism over moral absolutism.
Still, you raise a fair concern that this pragmatic approach may be drifting into a form of moral abdication. When policy no longer distinguishes between tolerating vice for practical reasons and treating all vice as morally neutral (or even socially acceptable) it risks eroding the public’s ability to make shared judgments about right and wrong. The example of supervised injection sites near schools, and the growing permissiveness surrounding euthanasia, reveal how a policy designed to minimize harm can begin to challenge other social goods, such as the safety of children or the affirmation of life. A reasonable counterargument is that these trade-offs are manageable through tighter regulation or better communication, not a reversal of policy. But what if the deeper issue is not administrative, but philosophical?
One might object that the state's refusal to impose a singular vision of the good life is precisely what makes liberal democracy worth preserving. In a pluralistic society, competing moral frameworks are inevitable, and the strength of the harm reduction model lies in its capacity to navigate disagreement without coercion. Yet, as you suggest, complete neutrality can become a kind of passivity. If no practice can be condemned (no matter how harmful or destabilizing) then governance itself begins to lose its moral compass. At some point, a society must ask not only whether harm is being reduced, but what kind of future is being constructed through such reductions. The tension between autonomy and collective well-being is not a problem to be solved once and for all, but a balance that must be vigilantly managed.
So, we are left in a space not unlike Pandora’s world after the jar was opened. We now inhabit a more free, more humane, but also more morally uncertain society. The shift toward harm reduction is not a mistake, but it may not be a panacea either. As we continue down this path, Canadians will need to recover a richer vocabulary for moral conversation—one that respects pluralism without surrendering judgment, and that can weigh both liberty and responsibility without defaulting to bureaucratic neutrality. The hope that fluttered from the bottom of Pandora’s jar still lingers. But like all hope, it will require care, wisdom, and courage to guide.
Is the argument for having a nicely mowed lawn and a trash-free property in suburbia relevant here? Maybe? I think it is interesting that municipal bylaws are pretty choosey and sometimes outdated, but they at least attempt to define and enforce what the community wants and expects. I would expect provincial and federal laws to do the same. I agree with the author: we’re losing sight of what’s important to our cohesion as a society.
“If you tell me that you’re suffering, who am I to question that?” An abrogation of the responsibility inherent in being a physician. Replace suffering with "a cat", or "trapped in the wrong body" and we are off on the race to the bottom.
MAiD is actually MAD. It is akin to capital punishment and, in fact, the drugs used and their administration are identical . It is not suicide as the active (swallowing) of medications is rarely chosen. So if not suicide, it is...?
There is a reason the Canadian medical colleges no longer use the Hyppocratic Oath; if there is money to be made, you can find a willing physician.
The Hippocratic Oath doesn’t include “primum non nocere”. (For one thing it was written in Greek, not Latin.) The Oath is more uncompromising than that. If you take first do no harm literally, then anything that reduces some harm is OK. If someone thinks he is being harmed by continuing to live, then killing him satisfies primum non nocere.
So no, the Hippocratic Oath in simple direct language prohibits killing one’s patients. It abuses society’s trust that doctors won’t kill people even if bribed to act as knowledgeable assassins. The larger context is that doctors are supposed to go into the houses of the sick with the goal of making people better, not worse, but the “no-killing” is non-negotiable.
True few med schools give a nod to old Hippocrates the oppressor anymore. Pity.
Edit: Euthanasia doesn’t pay well enough in Canada that doctors are going to get rich off of doing it. That was kind of a cheap shot. The fees the provincial health ministries pay to doctors for all medical services are public documents available on line. Doctors must accept the regulated fee and not charge one cent more.
I took the Hyppocratic Oath when licensed in PQ. The reference to Primum Non Nocere was deliberately separate (Greek is alive and well), and I do not share your interpretation that killing is harm reduction.
The suggestion that you can find physicians who will do anything for money is a malicious truth. In Quebec, a physician can charge well above the scheduled benefit as the rot of public health care is more advanced (though the discussion of salary has reappeared so don't stand in the way of the stampede).
Not sure about the medical establishment fee structure but big pharma does OK. So does big Government (which is proportionally huge in Canada) that saves oodles of $$$ on avoided pension payments and Medicare costs. Here’s an interesting song https://www.facebook.com/share/r/16g9sdMQvN/?mibextid=wwXIfr
Pharmaceutical companies *usually* prefer that their good customers — patients with chronic diseases that need fabulously expensive drugs for months to decades — stay alive as long as possible. It’s hardly good for Pharma’s business interest for such a good lifelong customer to be killed with drugs that cost $5 tops, with no chance for repeat sales.
Governments, pension funds, and disability insurance companies do benefit from euthanasia, sure, but step back and remember why we have euthanasia in the first place. The Supreme Court found that there was a right under the Charter to be killed. It struck down the law of murder but gave the Government time to amend the law to allow doctors to do it on patients’s request. So here we are. Canadians never said they wanted euthanasia. (I think it appeals to an atheist fringe of Godless Marxists. Kidding!). The Supreme Court said we have to accept it whether we want it or not. If the Government ever changed its mind and legislated that euthanasia was really murder again, no one could be convicted of murder. That’s why we have to have the euthanasia. If we don’t, the Supreme Court will vacate all murder convictions. That’s what you get when unelected Courts make law instead of just enforcing what Canadians want the law to be.
Thank you for adding the big pharma’s perspective I missed looking at that side of the coin. I let my working hypothesis of Canada as a totalitarian neocommunist state blind me to that aspect.
I see the trend to courts making law instead of interpreting it is as a direct result of legislators’ risk aversion (a polite Canadian term for cowardice). Instead of addressing and voting on issues and then facing the electorate it was easier to come up with vague solutions and passing the hard decisions over to the courts. This is not a Canadian invention I remember a US legislator (US senator from Utah?) complaining about this 10 15 years ago. Like most things Canadian the process was shamelessly copied (allowing for enough time for translation into French 🙄)
We need to ask better questions - like when you say 'reducing harm' that's not measurable to my mind. Which specific harm. Which specific kinds of harm. What is your definition of harm? etc
As a policy wonk I am struggling with the inclusion of abortion in your analysis. If you include it you are encompassing human rights - a woman’s right - in your harm reduction analysis. It seems you’ve included it because your argument is really about religious morals 50 years ago that would not have tolerated these shifts. I am religious and when I look at the complex social challenges you’re describing from the context of a human rights lens then I think your argument falls apart. Libertarians are keen supporters of having the right to make choices for oneself and not by the state. By extension this view assumes you don’t want help from state and while this may be true for you, of course there are other humans who will require it. Balancing policy development within these parameters where one over-privileges personal liberty at the cost of caring for those who are unable to do so is not balanced. And secondly, 50 years ago women did not play a significant role in the development of social policy but with job equity today they are its leaders. Women’s roles (excuse the gendering) have a long, long history as compared to men of caring for other humans. It’s the type of training that brings empathy and understanding to complex, complicated social issues. Prehaps there is a policy rebalancing required but the solution is not going to be an either this or that response. And morals (not criminal laws) are mortal judgements of the worthiness of other humans - if you’re religious your creator will judge you but in the meantime using the golden rule with regard to other humans should be mandatory. It can guide us in building a safe and good life within a society that also behaves with empathy and understanding for our fellow humans. These are not slippery slopes. They are issues that require complex critical thinking and creative solutions. With due respect I do not think your analysis offered much of a way forward, and your inference that harm reduction policy bears responsibility for complex social issues (and therefore should be brought to an end) ignores completely that our global society is so much more complex than it was 5 decades ago.
Harm reduction has undergone a transformation even more profound than Mr. Potter indicates. Back in the 1970s it meant reducing the harm a heroin addict did to society. The focus was on society, not the addict. In those days, it is said a heroin habit could cost $100 a day*, which the addict had to raise by constantly mugging, stealing, prostitution, and robbing cars and homes. The people suffering harm here were the victims the addict stole from, and from johns trolling for cheap sex. The solution proposed (and it was tried in Amsterdam) was to distribute free heroin, not to protect the addict from overdose and disease but to reduce his incentive to commit crimes in the neighbourhood. If the addict died or got sick, so what?
The solution didn't work because addicts given free heroin will sell some of it to raise money for future fixes from a dealer they prefer (as we see now with safe supply.) Since this was recognized as increasing the problem of drug addiction by recruiting new addicts -- a downside *not* acknowledged by safe(r) supply activists today -- the net harm unfortunately was not reduced by free heroin.
Today, as Mr. Potter points out, the focus of harm is entirely on the addict and the normal society being harmed by drug addiction and its detritus of discarded needles and social disorder can go fuck itself. It wasn't always thus. In Amsterdam the addict stoned on free heroin could fall into a canal and drown for all anyone cared.
Note that needle-exchange programs greatly increase the problem of discarded infected trash. The addict doesn't actually have to turn in a needle in order to get a new one. "I need a new needle/syringe because I, uh, lost my old one." He gets a free new one and then is "encouraged" to discard it in the safe-injection site's sharps container. But he can take it with him and discard it in a playground or on a transit vehicle if he feels like it. Previously, the addict had to hang onto his "works" for reuse in case he couldn't get a new one when he scored his fix. Another shift in the focus of harm reduction.
I grant there is no cure for drug addiction when drugs are cheap and plentiful and there is no longer social stigma that incentivizes getting clean, and EMS rescues most of the overdoses so they survive with brain damage instead of dying. Also important, unlike in the 1970s the chronically mentally ill were not mostly living on the streets, although they soon would be as the civil libertarians were just then closing all the mental hospitals. The "dual-diagnosis" mentally ill patients have always been a challenge for both mental health and addiction agencies to do much for. I suppose the only solution is to organize your life so you don't have to visit the drug corridors of places like Vancouver and Hamilton, which we pretty much do anyway, and leave them to it. The churches should stop feeding them, though.
* John Prine refers to "a hunnerd dollar habit" in his song, "Sam Stone." Fentanyl is so cheap that panhandling will cover it.
I don’t think the issue with safe injection sites is the drug use. If you’re talking straight drugs, alchohol presents almost as many challenges as most street drugs and often more. While we don’t really want bars next to schools either, most people are okay having a bar or pub in their neighborhood and might even welcome it. I’ve seen a lot of drug use in my time and a lot more public flashing has resulted from alchohol than any street drugs I can think of. The issue we seem to have is that a huge percentage of those attending these sites are mentally ill and we have no plan for that. You don’t masturbate in front of children because you’re on drugs or homeless. You masturbate in front of children because you have substantial mental health issues.
I’m not sure what the answer is here, because we seem to be extremely short of resources to deal with mental health issues properly and locking people up for mental issues who are more of a nuisance than an actual threat seems pretty problematic and creates a lot of situations that are ripe for abuse.
Most people tolerate the regulated sale and consumption of alcohol even though it does cause more problems in aggregate than drugs do, simply *because* alcohol is regulated. (And because we know what happened when we tried to ban it.) Bars can't legally serve intoxicated customers. Those that do, and promote the fights and brawls that result, are usually located in non-residential areas. (If they once were residential areas, they aren't anymore!) Bars can lose their liquor licences. Alcohol-intoxicated drivers are easier to prove the charge than drugs. Etc. Drug use is not regulated AT ALL. Dealers can pump people full of meth until they go into blind paranoid rages or with fentanyl until they drop dead in the street. Addicts shitting in the street and driving normal people out of the neighbourhood are a function of completely unregulated use of abundant cheap drugs, the very supply issues that regulation of alcohol tries to control and more or less succeeds at.
And when you come right down to it, normal people do use alcohol. Normal people don't use fentanyl or meth.
Excellent review of where Canada has gotten to. I was amazed at the depth of the insight in the article. Then I read at the end that the author lives in Montreal. This is like having a front row seat at the epicenter of an earthquake.
The next question is where does the slippery slope lead to?
Zivo deserves a lot of credit for having the tenacity to follow the safe supply story despite the obstacles that medical officials threw up along the way. Also, Zivo brought medical staff on the front lines in from the cold and earned their trust. Some of the candour from these people must certainly have come at personal cost and society owes them for sharing their experiences of public policy gone bad.
As mental health moves into the “reasons” that euthanasia will be approved, I have wondered how things like mandatory holds will be enforced. How will it be viewed as wrong and a person is a danger to themselves and forced into medical treatment if they are suicidal, but then suicidal it’s is actually assisted if approved?
For all the mental health awareness and supposed lack of stigma we claim to embrace as a society, it’s telling that the apparent moral position change that suicide becomes ok but only if approved by the government is actually a position that anyone views as defensible. I suppose it may reduce the inpatient population, but it’s a huge abandoning of care as society and a failure to clearly say life is worth living and we’ll support you until you feel better. (And people do come back from this. I know from personal experience and have a wonderful life now despite having many years of treatment resistant depression and multiple suicide attempts - it was right for the norms of society to force me to learn to live. I’m glad society hadn’t decided euthanasia was ok for people like me back then.)
This was obviously going to happen as a result of MAID. We were supposed to celebrate, or at least support, some suicides, while discouraging others. And, for yet others, I guess we would draw up a pro/con list to decide.
But all the structural incentives are pro-suicide. The most insidious is that, when a friend's loved one (eg aged parent) has done it, it becomes unkind to talk about the wrong of MAID in that friend's presence.
Spot on!
Articulating suicidal intent was once grounds for admission and treatment, even against one's will. Now you can be referred for the "final solution".
The idea that we should condone government sanctioned "offing" of people with mental health problems is abhorrent.
The idea that the state is somehow morally neutral and yet pursues a goal of "harm reduction" is incoherent. The state always pursues some good, and always privileges some kinds of behaviours over others.
That is why this isn't really about "harm reduction". It's actually about enabling vice. Because our rulers and the NGO swarm they support, are in fact vicious.
Great piece.
"But this overlap masks the fact that on the first “unenforceability” approach, there remains an official and public condemnation of the practice. In contrast, the “reasonable disagreement” model avoids making any official judgments, and doesn’t choose sides between competing visions of the good."
For me this is the key point. A good example is tobacco, the smoking of which has been legal forever but which began to attract a stigma in the 1980s that still survives to this day. That stigma is a large reason for the, yes, *reduction in harm* from tobacco.
A mentality which sees a harm reduction approach as mutually exclusive from attaching stigma to an activity brings us the worst of both worlds. We as a society do not have to validate the life choices of everyone who happens to be doing something that is (rightfully) not illegal. And we sure as hell don't have to go so far as to let those life choices detrimentally affect (in this case) the lives of other people who are in physical proximity to harm reduction centres.
Yes, the idea that it’s controversial to protect children over addicts if a choice had to be made is stunning. Nobody should ever think it’s ok to traumatized or put a child at risk to give an addict space to indulge in their vice. The concept is shocking.
Stigma is critical. It tends to stop or at least reduce behaviour that harms the individual and collective society. The reduction of clear moral outrage against clearly morally wrong actions is clearly morally harmful. We have ample evidence of exactly that. Particularly if such actions are not apparently actionable by law enforcement at this point.
I find the term destigmatization to have been terribly abused by the poverty industry (I live in Vancouver, it is a booming and rich industry) and is simply an excuse to abdicate personal responsibility for anything and everything. Its a great term for the mob to scream (YOU ARE STIGMATIZING US) if anyone tries to make things better in a particular area
What bothers me about the harm reduction approach to drug addiction is that the proponents have been chasing an idea that's conceptually flawed to the point where it results in a net increase in harm. The impulse is sound: stop people from dying of drug overdoses and reduce the spread of disease so they've got a chance to get into recovery. It's just that the proponents of harm reduction have never really made that next step work, so their net accomplishment is swapping a quick premature death from drug overdose for a longer, slower premature death due to all of the other negative effects of drug use. There's insufficient availability of drug treatment programs, and relapse rates for opioid addiction is something like 80-90% in the year following treatment. Meanwhile, drug addiction impacts communities with increased rates of crime, antisocial behavior, and public disorder. On a purely utilitarian basis, this approach is not working well and something different is required. Step 1 would be recognizing that drug use *is* the problem.
The societies and service providers work on overdrive to stop or at least slow down any attempt at expanded recovery programs and facilities. They routinely whip up anger in any neighbourhood where there may be an attempt to build some facilites (we see this in Vancouver regularly). The harm reduction approach is simply about keeping your heart beating while you rot in the streets so they can get their funding, jobs, offices, and director stipends. That may sound harsh, but I am around this in Vancouver and there are hundreds of these organizations and any talk of recovery systems is shot down hard time and time again. They want to keep the people there at all costs. Harm reduction strategies are utter failures and completely self serving for the industry who uses the drug addicts and mentally ill as the gasoline for their engine.
In the tale of Pandora, the gods gave humanity a gift wrapped in beauty but laced with danger. Once opened, the jar released plagues, grief, and chaos into the world—leaving only hope fluttering at the bottom. The Canadian shift toward harm reduction policy bears a faint echo of that myth. Like Pandora’s jar, the transition from moral condemnation to harm minimization has released powerful new freedoms and tools of compassion into public life. Yet, alongside these benefits, come complex and unintended consequences that are only now beginning to emerge with clarity. To confront them honestly requires the same moral seriousness once embedded in the prohibitions these policies replaced.
You rightly acknowledge the historical evolution of Canadian criminal law from a system rooted in moral judgment to one guided by harm reduction. Many will view this shift as progress; especially in areas where old laws enforced stigma and suffering. The decriminalization of same-sex relationships, the legalization of abortion, and the regulated sale of cannabis have expanded personal freedom and aligned policy with contemporary notions of justice and equality. It is not difficult to sympathize with a framework that seeks to reduce suffering rather than punish it. The early success of harm reduction, especially in the context of HIV prevention, offers a compelling case for pragmatism over moral absolutism.
Still, you raise a fair concern that this pragmatic approach may be drifting into a form of moral abdication. When policy no longer distinguishes between tolerating vice for practical reasons and treating all vice as morally neutral (or even socially acceptable) it risks eroding the public’s ability to make shared judgments about right and wrong. The example of supervised injection sites near schools, and the growing permissiveness surrounding euthanasia, reveal how a policy designed to minimize harm can begin to challenge other social goods, such as the safety of children or the affirmation of life. A reasonable counterargument is that these trade-offs are manageable through tighter regulation or better communication, not a reversal of policy. But what if the deeper issue is not administrative, but philosophical?
One might object that the state's refusal to impose a singular vision of the good life is precisely what makes liberal democracy worth preserving. In a pluralistic society, competing moral frameworks are inevitable, and the strength of the harm reduction model lies in its capacity to navigate disagreement without coercion. Yet, as you suggest, complete neutrality can become a kind of passivity. If no practice can be condemned (no matter how harmful or destabilizing) then governance itself begins to lose its moral compass. At some point, a society must ask not only whether harm is being reduced, but what kind of future is being constructed through such reductions. The tension between autonomy and collective well-being is not a problem to be solved once and for all, but a balance that must be vigilantly managed.
So, we are left in a space not unlike Pandora’s world after the jar was opened. We now inhabit a more free, more humane, but also more morally uncertain society. The shift toward harm reduction is not a mistake, but it may not be a panacea either. As we continue down this path, Canadians will need to recover a richer vocabulary for moral conversation—one that respects pluralism without surrendering judgment, and that can weigh both liberty and responsibility without defaulting to bureaucratic neutrality. The hope that fluttered from the bottom of Pandora’s jar still lingers. But like all hope, it will require care, wisdom, and courage to guide.
Is the argument for having a nicely mowed lawn and a trash-free property in suburbia relevant here? Maybe? I think it is interesting that municipal bylaws are pretty choosey and sometimes outdated, but they at least attempt to define and enforce what the community wants and expects. I would expect provincial and federal laws to do the same. I agree with the author: we’re losing sight of what’s important to our cohesion as a society.
What a thoughtful, measured piece. Thanks.
“If you tell me that you’re suffering, who am I to question that?” An abrogation of the responsibility inherent in being a physician. Replace suffering with "a cat", or "trapped in the wrong body" and we are off on the race to the bottom.
MAiD is actually MAD. It is akin to capital punishment and, in fact, the drugs used and their administration are identical . It is not suicide as the active (swallowing) of medications is rarely chosen. So if not suicide, it is...?
There is a reason the Canadian medical colleges no longer use the Hyppocratic Oath; if there is money to be made, you can find a willing physician.
Like Latin, Primum Non Nocere, is dead.
The Hippocratic Oath doesn’t include “primum non nocere”. (For one thing it was written in Greek, not Latin.) The Oath is more uncompromising than that. If you take first do no harm literally, then anything that reduces some harm is OK. If someone thinks he is being harmed by continuing to live, then killing him satisfies primum non nocere.
So no, the Hippocratic Oath in simple direct language prohibits killing one’s patients. It abuses society’s trust that doctors won’t kill people even if bribed to act as knowledgeable assassins. The larger context is that doctors are supposed to go into the houses of the sick with the goal of making people better, not worse, but the “no-killing” is non-negotiable.
True few med schools give a nod to old Hippocrates the oppressor anymore. Pity.
Edit: Euthanasia doesn’t pay well enough in Canada that doctors are going to get rich off of doing it. That was kind of a cheap shot. The fees the provincial health ministries pay to doctors for all medical services are public documents available on line. Doctors must accept the regulated fee and not charge one cent more.
I took the Hyppocratic Oath when licensed in PQ. The reference to Primum Non Nocere was deliberately separate (Greek is alive and well), and I do not share your interpretation that killing is harm reduction.
The suggestion that you can find physicians who will do anything for money is a malicious truth. In Quebec, a physician can charge well above the scheduled benefit as the rot of public health care is more advanced (though the discussion of salary has reappeared so don't stand in the way of the stampede).
Not sure about the medical establishment fee structure but big pharma does OK. So does big Government (which is proportionally huge in Canada) that saves oodles of $$$ on avoided pension payments and Medicare costs. Here’s an interesting song https://www.facebook.com/share/r/16g9sdMQvN/?mibextid=wwXIfr
Pharmaceutical companies *usually* prefer that their good customers — patients with chronic diseases that need fabulously expensive drugs for months to decades — stay alive as long as possible. It’s hardly good for Pharma’s business interest for such a good lifelong customer to be killed with drugs that cost $5 tops, with no chance for repeat sales.
Governments, pension funds, and disability insurance companies do benefit from euthanasia, sure, but step back and remember why we have euthanasia in the first place. The Supreme Court found that there was a right under the Charter to be killed. It struck down the law of murder but gave the Government time to amend the law to allow doctors to do it on patients’s request. So here we are. Canadians never said they wanted euthanasia. (I think it appeals to an atheist fringe of Godless Marxists. Kidding!). The Supreme Court said we have to accept it whether we want it or not. If the Government ever changed its mind and legislated that euthanasia was really murder again, no one could be convicted of murder. That’s why we have to have the euthanasia. If we don’t, the Supreme Court will vacate all murder convictions. That’s what you get when unelected Courts make law instead of just enforcing what Canadians want the law to be.
Thank you for adding the big pharma’s perspective I missed looking at that side of the coin. I let my working hypothesis of Canada as a totalitarian neocommunist state blind me to that aspect.
I see the trend to courts making law instead of interpreting it is as a direct result of legislators’ risk aversion (a polite Canadian term for cowardice). Instead of addressing and voting on issues and then facing the electorate it was easier to come up with vague solutions and passing the hard decisions over to the courts. This is not a Canadian invention I remember a US legislator (US senator from Utah?) complaining about this 10 15 years ago. Like most things Canadian the process was shamelessly copied (allowing for enough time for translation into French 🙄)
We need to ask better questions - like when you say 'reducing harm' that's not measurable to my mind. Which specific harm. Which specific kinds of harm. What is your definition of harm? etc
Excellent piece. Thx for the thorough explanations!
As a policy wonk I am struggling with the inclusion of abortion in your analysis. If you include it you are encompassing human rights - a woman’s right - in your harm reduction analysis. It seems you’ve included it because your argument is really about religious morals 50 years ago that would not have tolerated these shifts. I am religious and when I look at the complex social challenges you’re describing from the context of a human rights lens then I think your argument falls apart. Libertarians are keen supporters of having the right to make choices for oneself and not by the state. By extension this view assumes you don’t want help from state and while this may be true for you, of course there are other humans who will require it. Balancing policy development within these parameters where one over-privileges personal liberty at the cost of caring for those who are unable to do so is not balanced. And secondly, 50 years ago women did not play a significant role in the development of social policy but with job equity today they are its leaders. Women’s roles (excuse the gendering) have a long, long history as compared to men of caring for other humans. It’s the type of training that brings empathy and understanding to complex, complicated social issues. Prehaps there is a policy rebalancing required but the solution is not going to be an either this or that response. And morals (not criminal laws) are mortal judgements of the worthiness of other humans - if you’re religious your creator will judge you but in the meantime using the golden rule with regard to other humans should be mandatory. It can guide us in building a safe and good life within a society that also behaves with empathy and understanding for our fellow humans. These are not slippery slopes. They are issues that require complex critical thinking and creative solutions. With due respect I do not think your analysis offered much of a way forward, and your inference that harm reduction policy bears responsibility for complex social issues (and therefore should be brought to an end) ignores completely that our global society is so much more complex than it was 5 decades ago.
Excellent response! Complex critical thinking is absolutely required.
Harm reduction has undergone a transformation even more profound than Mr. Potter indicates. Back in the 1970s it meant reducing the harm a heroin addict did to society. The focus was on society, not the addict. In those days, it is said a heroin habit could cost $100 a day*, which the addict had to raise by constantly mugging, stealing, prostitution, and robbing cars and homes. The people suffering harm here were the victims the addict stole from, and from johns trolling for cheap sex. The solution proposed (and it was tried in Amsterdam) was to distribute free heroin, not to protect the addict from overdose and disease but to reduce his incentive to commit crimes in the neighbourhood. If the addict died or got sick, so what?
The solution didn't work because addicts given free heroin will sell some of it to raise money for future fixes from a dealer they prefer (as we see now with safe supply.) Since this was recognized as increasing the problem of drug addiction by recruiting new addicts -- a downside *not* acknowledged by safe(r) supply activists today -- the net harm unfortunately was not reduced by free heroin.
Today, as Mr. Potter points out, the focus of harm is entirely on the addict and the normal society being harmed by drug addiction and its detritus of discarded needles and social disorder can go fuck itself. It wasn't always thus. In Amsterdam the addict stoned on free heroin could fall into a canal and drown for all anyone cared.
Note that needle-exchange programs greatly increase the problem of discarded infected trash. The addict doesn't actually have to turn in a needle in order to get a new one. "I need a new needle/syringe because I, uh, lost my old one." He gets a free new one and then is "encouraged" to discard it in the safe-injection site's sharps container. But he can take it with him and discard it in a playground or on a transit vehicle if he feels like it. Previously, the addict had to hang onto his "works" for reuse in case he couldn't get a new one when he scored his fix. Another shift in the focus of harm reduction.
I grant there is no cure for drug addiction when drugs are cheap and plentiful and there is no longer social stigma that incentivizes getting clean, and EMS rescues most of the overdoses so they survive with brain damage instead of dying. Also important, unlike in the 1970s the chronically mentally ill were not mostly living on the streets, although they soon would be as the civil libertarians were just then closing all the mental hospitals. The "dual-diagnosis" mentally ill patients have always been a challenge for both mental health and addiction agencies to do much for. I suppose the only solution is to organize your life so you don't have to visit the drug corridors of places like Vancouver and Hamilton, which we pretty much do anyway, and leave them to it. The churches should stop feeding them, though.
* John Prine refers to "a hunnerd dollar habit" in his song, "Sam Stone." Fentanyl is so cheap that panhandling will cover it.
I don’t think the issue with safe injection sites is the drug use. If you’re talking straight drugs, alchohol presents almost as many challenges as most street drugs and often more. While we don’t really want bars next to schools either, most people are okay having a bar or pub in their neighborhood and might even welcome it. I’ve seen a lot of drug use in my time and a lot more public flashing has resulted from alchohol than any street drugs I can think of. The issue we seem to have is that a huge percentage of those attending these sites are mentally ill and we have no plan for that. You don’t masturbate in front of children because you’re on drugs or homeless. You masturbate in front of children because you have substantial mental health issues.
I’m not sure what the answer is here, because we seem to be extremely short of resources to deal with mental health issues properly and locking people up for mental issues who are more of a nuisance than an actual threat seems pretty problematic and creates a lot of situations that are ripe for abuse.
Most people tolerate the regulated sale and consumption of alcohol even though it does cause more problems in aggregate than drugs do, simply *because* alcohol is regulated. (And because we know what happened when we tried to ban it.) Bars can't legally serve intoxicated customers. Those that do, and promote the fights and brawls that result, are usually located in non-residential areas. (If they once were residential areas, they aren't anymore!) Bars can lose their liquor licences. Alcohol-intoxicated drivers are easier to prove the charge than drugs. Etc. Drug use is not regulated AT ALL. Dealers can pump people full of meth until they go into blind paranoid rages or with fentanyl until they drop dead in the street. Addicts shitting in the street and driving normal people out of the neighbourhood are a function of completely unregulated use of abundant cheap drugs, the very supply issues that regulation of alcohol tries to control and more or less succeeds at.
And when you come right down to it, normal people do use alcohol. Normal people don't use fentanyl or meth.
Excellent review of where Canada has gotten to. I was amazed at the depth of the insight in the article. Then I read at the end that the author lives in Montreal. This is like having a front row seat at the epicenter of an earthquake.
The next question is where does the slippery slope lead to?
Appreciate the balanced and nuanced description of the problems created by the moves to harm reduction Andrew.
I would be interested on your thoughts as to where "safe supply" of narcotics programs fit into these approaches?
These, much like the second MAID stream, seem fraught with potential concerns and no objective guardrails?
I think Adam Zivo's work on this is pretty bang on.
Zivo deserves a lot of credit for having the tenacity to follow the safe supply story despite the obstacles that medical officials threw up along the way. Also, Zivo brought medical staff on the front lines in from the cold and earned their trust. Some of the candour from these people must certainly have come at personal cost and society owes them for sharing their experiences of public policy gone bad.