This post is forthcoming on the Impact Ethics blog, but given the topical nature of the issue addressed in the piece, I am posting this preview here for comment and debate.
There has been much discussion lately in the news and public spaces regarding the resurgence of vaccine-preventable childhood infectious diseases and the problem of anti-vaccination and its milder cousin, vaccine hesitancy. These discussions were triggered, I suspect, by an outbreak of measles, a highly infectious vaccine-preventable disease that is the leading killer of young children worldwide, at Disneyland, that most magical of places. Or perhaps by the human interest element in Roald Dahl’s heartrending essay recalling the loss of his seven-year old daughter Olivia to measles, and in which he urged parents to get their wards immunized. Or perhaps due to the wildly irresponsible comments of US politicians like Rand Paul, who think that a public health measure that safely and effectively protects vulnerable children from a dangerous infectious disease should be resisted based on conspiracy theories and appeals to an absolute form of individualism. Maybe some combination of these things.
In the much bifurcated debate, vaccine proponents like me have pitched our tents squarely with norms founded on community welfare or social good, and with scientific evidence, which indisputably shows that recommended childhood vaccines are generally safe and effective, and that we need epidemiology-validated rates of coverage to achieve herd immunity. To borrow a maxim from a colleague, those of us in this camp believe “the devil is in the defaults”, and so have urged the establishment of default rules that express social good or community welfare principles, chiefly in the form of a robust and routine program of mandatory vaccinations sans religious or personal exemptions. Opponents have countered by questioning the science behind childhood vaccines or by referencing a parental right to be exempted from forced medical intervention that interferes with personal beliefs and preferences. In the background, there is a much less vocal or visible category of persons and groups who urge understanding of the values, beliefs, cultures, psychologies, valences, concerns and patterns of behaviour that lead to vaccine hesitancy, and adoption of strategies that emphasize engagement, shared and participatory decision-making and education (a safer bet in theory, but much less compelling in terms of actually changing attitudes to vaccination).
A missing perspective, or at least one that has not received much attention or discussion, relates to how we frame parental decision-making in relation to childhood vaccines. There is an implicit assumption, at least from the perspective of individualist or libertarian arguments (and to some extent, in the call for integration of parental views in shared or participatory decision-making), that parents have an automatic and unassailable right to make decisions regarding vaccination on behalf of their children. It follows therefore that taking away that right is seen as a violation or dilution of the parent’s liberty or participatory interests. This assumption is ethically and legally unfounded.
Decisions regarding whether a child should or should not be vaccinated reside with the child, but only if capable of making the decision. Since most young children will not have the capacity to make such a decision, especially during the crucial early years when most childhood vaccines are administered, the decision becomes a substitute or surrogate decision that must be rendered by a legal appointee (typically but not necessarily parents), but only to advance the best interests of the child. While Canadian courts and statutory instruments have awarded parents a privileged position in making substitute or surrogate decisions on behalf of their children, it is also the case that parental decisions must be made to promote or advance what is objectively deemed to be the child’s best interests in the specific context of the decision in question. The question therefore is not whether or not parental rights in this context can be suppressed for the sake of community welfare but rather, whether parental decision-making that denies a child an opportunity to receive potentially life-saving vaccines can ever be considered a best interest decision. I think not, and here’s why.
Objectively speaking, ensuring that vulnerable children get immunized against vaccine-preventable childhood diseases is as much in their best interest as making sure they receive necessaries of life such as food and shelter, or that a child wears a seat belt while travelling in a motor vehicle. In Canada and most other jurisdictions, vaccines that protect against childhood diseases are available, at no cost, starting from infancy. A few doses – in many cases not exceeding a couple – are all that is required to provide effective life-long immunity to dangerous and sometimes deadly infectious diseases. Side effects are generally rare and mostly minor – an immunized child can shake off most side effects in a matter of hours and at most, a day or two. Much like not wearing seat belts, failing to immunize a child exposes him or her to a preventable danger that could have devastating effects, including disability and death.
Putting aside arguments about social good, herd immunity, discouraging free loading and preventing harm to others, vaccinating a child for the child’s sake is not just the right thing to do, but also the only thing to do. There are no other measures that would objectively better protect a child from infectious disease – not sanitation, not prayer, not eating natural and healthy, not cutting ties with the outside world, not homeopathic nosodes, and certainly not parental objections, however honestly held. And because we cannot rely on objecting parents to reach this objective and somewhat evident conclusion, society ought to step in and do what promotes the unimmunized child’s best interests. At a minimum, society must insist that this idea is the default norm. Once that is done, we can then focus on helping parents understand the norm and on encouraging their participation in operationalizing it.
I usually do my best work at night. I always wondered if that was me or me? In other words, is it natural for me to feel groggy in the morning and energetic in the evening? It turns out the answer is yes!
It seems that phobias can be passed down by genes. I wonder which of my ancestors encountered an evil clown or mime? That being said, would this genetic base for phobias create a protected class of phobias for the purposes of human rights laws? Too bad I don't teach in a clown or mime school otherwise, I would have the perfect claim for disability leave.
An editorial just out in the British Medical Journal points out, correctly, that airport screening for Ebola is nothing but a "false sense of reassurance" and that a "[b]etter use of...resources [from countries able to help] would be to immediately scale-up..presence in West Africa" by, for example, building and staffing treatment centres. It is stunning that this rather obvious point would be missed by governments in countries like Canada and the U.S., where airport screening has been implemented, and by many news media outlets, who seem obsessed with discussing everything (Ebola in the West!; airport screening; experimental drugs, vaccines) but a concerted "boots on the ground" approach to helping affected countries in West Africa. As the article points out, Canada seems to have learned nothing from SARS screening - our government spent $17million to screen for SARS at entry points into Canada, but not one case was found. Seems like "Nothing works like failed policies" should be new our public/global health slogan.
Meanwhile, the graphic below shows that Canada's financial contribution to the Ebola problem is much less than Mark Zuckerberg's. Perhaps we can use some of the screening money to boost our presence on the ground?
One of the problem of corrupt governments is that the people don't trust the state no matter who is speaking, including healthcare workers (who may or may not be affiliated with the state). The continued attacks on Ebola healthcare workers is just a sad manifestation of this confluence of ignorance and mistrust.
Last week I delivered a seminar at the University of Toronto Faculty of Law where I argued that governments accross Canada should enact and implement mandatory immunization for all childhood infectious diseases where there is overwhelming evidence of positive immunization outcomes. This position reflects my thinking on the best option for dealing with recurring outbreaks of measles and other previously eradicated or near-eradicated childhood infectious diseases in Canada.
I offered the following five reasons in support of this position:
1. Mandatory immunization, whether in the form of compulsory infantile vaccination or (as is currently the norm), requiring school pupils to provide proof of immunization prior to school enrollment, has been shown to be the most effective means of achieving widespread coverage of the population.
2. Pre- and post-Charter jurisprudence, and decisions by courts in other jurisdictions such as the U.K. and U.S. indicate that mandatory immunization strategies are a legally valid impairment of individual rights for the sake of protecting public health. Read this, this and this for more on this point.
3. The rate of adverse events arising from immunization for most childhood infectious diseases is very low or non-existent, and most cases involve minor side-effects.
4. Provinces without mandatory policies jeopardize gains in provinces with mandatory policies (presently Ontario and New Brunswick).
5. Enacting mandatory policies creates a positive obligation (on the part of the provincial governments) to address vaccine injuries. Except for Quebec, Canada and Russia are the only two G8 countries without a vaccine injury compensation scheme.
I will expand on these points in a forthcoming paper. Meanwhile, thoughts, comments, criticisms and objections are welcomed.
Let me just start out by stating it plainly: the marijuana prohibition is bad law. Any criminal prohibition requires huge amounts of resources and restricts citizens' civil liberties; if there’s a risk of imprisonment it even engages s 7 of the Charter of Rights and Freedoms. So criminally prohibiting something that isn’t actually harmful (or otherwise unacceptable to society), is bad law. It’s a waste of resources and it’s a strain on the integrity of the legal system. Marijuana is not even close to harmful or intolerable enough to warrant criminal prohibition.
That’s not to say that marijuana doesn’t have any negative side-effects. Smoking it can cause respiratory problems because the smoke irritates the throat and lungs (although, marijuana can be eaten, vaporized, turned into pills, etc. instead, which would avoid this). While marijuana does not cause mental illnesses like schizophrenia, it can worsen symptoms of some disorders. Chronic use may also have a negative affect on brain development, meaning that marijuana use could negatively affect youth and unborn children. There is no conclusive evidence of any other negative long term effects of the drug. In the short term, marijuana causes impairment, can elevate heart rates and can be mildly hallucinogenic. There may be other long or short term side effects but, due to the obstacles present when researching an illegal substance, the empirical knowledge we have about the substance is relatively sparse. There is also no conclusive evidence supporting a claim that marijuana use is any way related to the use of harder drugs (contrary to the popular “Gateway Drug” argument). It does seem fair to say that marijuana use has harmful effects if used by specific groups, but generally is not particularly harmful for adult use. Just look at long-time marijuana user and comedian, Doug Benson. In the documentary Super High Me, he spent every conscious moment for 30 days high without any significant harm to his health or quality of life (certainly much less harm than was suffered in its inspiration, Super Size Me). He said it was actually pretty fun.
The fact that marijuana has very few negative side effects is a compelling reason to believe that having a criminal prohibition against it is a bad idea. Perhaps even more compelling are the negative side effects marijuana doesn’t have as compared to legal substances. Marijuana has been found to be less harmful than alcohol and cigarettes and may even be less harmful than caffeine and sugar. Most notably, marijuana has killed a whopping zero people ever, as opposed to alcohol, cigarettes and other drugs (including common pain killers and other medicines) that can cause fatal overdoses.
So, a quick recap to illustrate why the marijuana prohibition is bad law, period. Criminalizing something requires a lot of resources, limits citizen’s agency and potentially infringes Charter rights. Such a serious investment of resources and such serious criminal sanctions should be reserved for harmful or intolerable actions. As we’ve outlined marijuana is not particularly harmful and it’s certainly not intolerable. Especially when you take into account that the majority of Canadians support at least decriminalization if not legalization of marijuana.
Until now activism on this subject was seen as firmly outside the mainstream and supporters were assumed to be just a bunch of potheads. However, since then, Justin Trudeau has been outspokenly against the marijuana prohibition and the issue has become an important aspect of the Liberal’s policy platform. Trudeau’s stance has “evolved”, as he puts it, to promote legalization, as opposed to leaving the laws as-is or merely decriminalizing (marijuana would still be illegal but the sanctions associated would be less harsh). This is the first time a major Canadian political party has supported this position. It would mean that the substance could be legally produced, consumed and possessed, subject to regulations imposed by the government (for example, it would still be illegal for minors, sales would be taxed, etc). Trudeau’s position is based around the economic benefits and protection of youth that could be made possible if the substance were legalized (and these benefits would not be realized by decriminalization alone). Trudeau also asserts that valuable lessons will be learned by following the effects of legalization in American states.
So why do the Conservatives so steadfastly defend the marijuana prohibition? They claim it is illegal because of its harmful effects, but this claim is pretty clearly erroneous. They seem relatively concerned with marijuana use by youth, which is valid. However, it certainly seems that getting marijuana regulated and off the streets would limit children’s access compared to the status quo. Do they agree with Pope Francis that marijuana is literally evil? Are they looking to appeal to a paternalistic moral majority (who, by the way, isn’t the majority)? Are they simply ignorant? It’s hard to see how any of these would be reason enough to support a criminal prohibition. Some other things to consider though: there is little to no information available as to why the substance was prohibited in the first place, although it was likely heavily influenced by early 20th century racism. Harry Aslinger, the era's 1st commissioner of the United State’s Federal Bureau of Narcotics famously campaigned for the marijuana prohibition on the merits of quotes like “Reefer makes darkies think they’re as good as white men” and “this marijuana causes white women to seek sexual relations with Negroes, entertainers and any others.” Perhaps more influential on Canadian law was Emily Murphy’s white supremacist work “The Black Candle”. The book was published only a year before Canada’s marijuana prohibition and painted marijuana as a “new menace”. However, there is no proof beyond coincidence that this work influence the government’s decision regarding the prohibition. We may never know why the government chose to prohibit the substance but we do know that at the time it was motivated by white supremacy, and marketed with fear-mongering and sexist undertones - "It'll make women have sex!" I mean, look, a picture is worth a thousand words:
Click on the picture for more examples of marijuana propaganda.
Today, marijuana remains by far the most commonly prosecuted drug offence. It has been shown that minorities are much more likely to be prosecuted, despite roughly equal use across races. With all of the mystery around why the prohibition began and the lack of clarity as to why the Conservatives don’t want it to end, a seriously disturbing picture starts to form. I don’t mean to say that all conservative people (or anyone else who supports the prohibition) defend the status quo to further a white supremacist agenda. Maybe, by and large, their reluctance to decriminalize or legalize the substance is motivated by your everyday, no-name brand, ignorant, right wing, self-righteousness. But when the status quo is a bad law that promotes racial inequality, defending it out of ignorance is simply not good enough for Canadians. The Conservatives are quite simply going to have to do better than that and hopefully the Liberal party will see to that.
My colleague has been speaking about vaccinations and debunking the anti-vaccine crowd's attacks on vaccines. While I have no issue with his narrow focus on vaccines, I am troubled by the sometimes blind adherence many give to doctors when making the case for vaccinations or any other medically related issues.
It seems the doctors must have noticed a growing sense of skepticism, in general, and towards doctors. I say 'it seems' because now the psychiatrists have decided to label free thinking and non-conformity as a mental disease. Indeed, in many authoritatrian regimes, dissidents were usually labelled as mentally ill. It seems that such tactics are now catching up with us.
Here are a couple more videos from Global Edmonton exploring the legal and practical dimensions of requiring mandatory vaccinations to stem the measles outbreak in Alberta. It appears the Alberta government is not considering any mandatory measures, but would rather go the education route (Liberal Education Critic Kent Hehr disagrees). There are also some interesting comments from the Vaccine Risk Awareness Network that are worth checking out. I certainly think mandatory measures with no exemptions are defensible on Charter grounds, but would be interested in hearing more on the issue from constitutional law experts.