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The Pairodocs have been on a bit about euthanasia recently, but please indulge us. It’s a deep subject - literally life-and-death.
Since my first piece on euthanasia (“MAiD”), and then again since Julie’s more recent piece about extending it to the mentally ill, several interesting issues have bubbled up through comments and discussion. I thought these were worth fleshing out.
Did someone order MAiD service?
What’s in a name? A lot. MAiD used to be a name for someone who cleans your house. And in the same way that a maid can sanitize your bathroom, the term “MAiD” sanitizes suicide. By coining such a clean and optimistic term, euthanasia proponents seized the linguistic high ground. But despite the obfuscatory name, “MAiD” actually means a person committing suicide (or being suicided). This was until very recently considered an extreme act. Perhaps the single most extreme act there is. At worst, suicide is a mortal sin that prevents that individual from being buried on hallowed ground and leaves his soul in purgatory. Now it’s just a medical procedure.
Euthanasia is not assisted suicide
There is an important distinction between euthanasia and assisted suicide. These terms are often used interchangeably, but are in fact distinct. Euthanasia is passive on behalf of the party being euthanized (with the exception in humans of taking part in the decision to be put down). The hamster that was gasping and suffering was euthanized by a whack from my dad’s shovel before we buried it in our backyard. It wasn’t a case of assisted suicide.
Assisted suicide is a human-specific way to end a life, as lesser life forms can’t ask to be killed. Jack Kevorkian never “killed” anyone, he just set it up so the patient could easily kill himself. With assisted suicide, the doctor or nurse might put in an IV and get the meds ready, or provide the pills in a cup by the bedside, but in the end the patient has to push the plunger or swallow the tablets. Assisted suicide, unlike euthanasia, is an active act.
Far from being a distinction without a difference, assisted suicide is very different philosophically and practically from euthanasia. A very interesting natural experiment has been underway since California legalized assisted suicide at almost the same time that Canada legalized euthanasia. In California, the doctor puts the suicide meds out for you but you have to take them. In Canada, you just lie there and let the doctor perform a “medical procedure”.
The euthanasia slope is more slippery than assisted suicide
It’s hard to kill yourself. Atheists might recognize this difficulty as the strong evolutionary urge to live. The religious among us might see it more as a recognition that our life is a gift, and ending it by our own hand is a sin against God. Either way, I can’t tell you the number of people I’ve seen in the ER through the years who had stood on the edge of a cliff, stared down the barrel of a gun, tied a rope in a tree, or looked at the cup full of pills and then changed their mind. They deeply felt that suicide was the wrong choice. But when the patient is a passive recipient of “medical care” as with MAiD, this epiphany cannot happen. It’s easy for “MAiD recipients” to think of themselves as having a medical procedure, whereas it is more clear to the person who is required to swallow a lethal overdose – even if it was put on the nightstand by a doctor – that he is committing suicide.
Your right to die is not the same as the state’s obligation to kill you
Another distinction that is important, and that was a source of controversy and misunderstanding amongst commenters on various forums, is the difference between arguing to have the “right to die” versus the need to have a program run by the state and funded by the taxpayer that approves, facilitates, and even performs the killing. There is actually a wide difference between these two arguments. The libertarian dream is freedom of choice, not state-administered and funded programs to control and provide those choices.
You absolutely have the right to die. You can stop eating and drinking. You can jump off a cliff, shoot yourself in the head, hang yourself, or take pills. Even though I think it is a sin to commit suicide, I can’t stop you in the end even though as a physician - and a human being - I will certainly try to convince you not to. After 27 years in ER, one of “Milburn’s Laws” is “Patients who really want to kill themselves, kill themselves” despite our best efforts to prevent them from doing so. Despite (and some would argue perhaps because of) a proliferation of therapists and counsellors, self-esteem promotion, suicide prevention, “wellness” initiatives and more, suicide rates have increased.
In practice, choosing euthanasia is about hopelessness and not the medical condition
A number of commenters supported euthanasia in people with terrible physical diseases, but felt that we cross a line when we offer it to depressed patients. But in my experience, people who choose to be euthanized always do so because of hopelessness, whether or not we call that hopelessness “mental illness”. The vast majority of those with cancer, dementia or sore joints want to live their lives out to the fullest. They want to spend time with family and friends, see more sunsets and sunrises, play music, write their life story for their grandkids, clean the junk out of their house, finalize their finances, and more. The ones who want the express checkout lane are the ones who feel they have nothing left to live for. It has been said that “He who has a why to live for can bear almost any how.”
So although many commenters on our previous pieces see that euthanizing mentally ill patients has crossed a line, they don’t see that the distinction between hopelessness caused by mental illness and hopelessness caused by physical illness is actually artificial. In my experience, we are already euthanizing depressed people.
And, if one agrees that the criteria for “being approved for MAiD” should be that one’s suffering is intolerable, how can we deny euthanasia to those suffering from mental illness, which in my experience causes suffering at least as severe as those with physical diseases.
Furthermore, in a system where real care is routinely delayed or even unavailable, providing rapid access to suicide services seems doubly immoral. One of my patients with a neurodegenerative disorder faced an 18 month wait to be reassessed by a neurologist, but could talk to a MAiD assessor within 48 hours.
There is no such thing as “necessary suffering” if one believes in suicide
Several commenters said that they supported assisted suicide because it prevented “unnecessary suffering”. But “unnecessary” suffering is a tautology for people who believe in suicide. The Buddhists say it best. “Life is Suffering”. If one lives, one suffers. Life is a sexually transmitted disease with a 100% fatality rate. We all die. And we will all suffer before we do.
If we believe in preventing unnecessary suffering, the solution to any physical or emotional pain is always clear. Girlfriend breaks up with you? Kill yourself. Wife sleeps around and then leaves you? Kill yourself. Your knees ache every morning for hours? Kill yourself. Every patient I’ve seen choose to be euthanized chose it because of hopelessness, not because of the disease. Well-adjusted people with good relationships, even when they have terrible cancers, ALS or other conditions that cause suffering, want to squeeze every drop out of this precious, short existence that they can.
If you have a painful, progressive cancer but could live another 6 months or year with it, why put up with the pain? Why not end it now? That is what MAiD enthusiasts suggest is most rational. And in a strictly rational sense, it is true: why suffer? It is part of the same rationalism that led the Nazi regime to feel virtuous when euthanizing “useless eaters” such as the disabled. They only suffer anyway, and who would want to live like that, after all?
Overcoming challenge, pain, and grief makes us who we are
We can and do learn to deal with pain. Many people, for instance, will say that they would rather die than be paraplegic or quadriplegic. But it turns out that most paralyzed people learn to live with their injury and find joys in their new life. I have known many people who died of cancer who told me near the end of their life that their time of dying was incredibly meaningful and beautiful. Facing mortality and pain is frightening, but seems to bring appreciation for the beauty and joy in life.
How can we objectively regulate something that is inherently subjective?
The careful attempts to formulate logical and sensible MAiD regulations resulted in gobbledegook. The original legislation demanded that death be “reasonably foreseeable”, but of course death is not just “reasonably foreseeable”, but inevitable for us all – even a healthy newborn baby. The updated wording only demands that the person have a “grievous and irremediable” medical condition. But any medical condition could be considered “grievous and irremediable” as this is subjective.
Most diseases that I deal with in family practice are “irremediable” - Crohn’s disease, emphysema, and arthritis are just 3 examples. Nobody can cure them, so most people will die with them if not of them. “Grievous” is not an objective word, but rather depends on the person’s subjective view of the severity and tolerability of his symptoms. Uncle Joe might weep bitterly over his sore knees while Aunt Mary goes golfing with worse. One can’t make an objective standard for suffering and grief, which are inherently subjective and personal.
Once the obfuscatory language is boiled off, what our regulations actually say is: if you don’t want to live, we’ll help you die. When someone is “approved for MAiD”, it means that they did not want to live with their symptoms, not that they couldn’t.
Wanting to live forever is the flip side of euthanasia
“A man’s days are numbered. You know the number of his months. He cannot live longer than the time You have set.” (Job 14:5)
After writing my first article on euthanasia, an astute friend talked about the apparent contradiction between our zeal for euthanizing people in the same system that sees ancient demented people receiving aggressive medical interventions and even life support. As my dad said about a friend who lingered in a nursing home for 10 years with slowly progressive dementia, and finally bed sores and other horrors, “if he was a dog they would have put him down”. But instead he was tube fed, treated for every infection, and even had surgery for impacted gallstones that prolonged his life.
Just as we now see suffering as the result of a failure of the medical system (and something that we can “cure” with euthanasia), our medical system sees death not as a natural ending to every life, but as a failure. There is a joke amongst family doctors:
Q: Why do they nail coffins shut?
A: So that the oncologist can’t give any more chemo.
But it’s not fair to single out oncologists. ICU physicians keep people on life support in many cases where it seems like a cruelty. Family doctors treat nursing home patients (with life expectancies of a few months at most) with things like cholesterol-lowering drugs or bone-builders that are at best only useful in patients over several years. We don’t like to admit that someone’s time has come. Nobody dies of old age anymore. Instead, they die of a disease that – perhaps – the doctor didn’t treat aggressively enough.
Even more extreme and overt versions of wanting to cheat death have arrived. Biohacking or uploading your consciousness to the cloud. Maybe we can all live to 100, or 150, or forever? If only we can find the tech. If only we do enough research.
Mitch Albom in The Time Keeper wrote: “Soon man will count all his days, and then smaller segments of the day, and then smaller still—until the counting consumes him, and the wonder of the world he has been given is lost.“
In the end the desire to either live longer than was your fate or to end your life before your time are attempts to control life and death. We desire to become Gods, and be the unchallenged masters of our own destiny. But perhaps rather than spending so much time trying to control our lives, we should be living them to the fullest. That means taking what comes and making the most of it, rather than trying to control it.
Euthanasia and overly-aggressive treatment of clearly-dying patients are both about control. They are 2 sides of the same transhumanist coin.
Sunsets are beautiful
Some of the most beautiful and memorable times of our lives – the times that we will most cherish, and the times where our relationships are tested and deepened – happen around deathbeds.
Psalm 139:16 “All the days ordained for me were written in your book before one of them came to be”
For instance, one of my cancer patients died slowly. We kept him as comfortable as possible at home for months where he had a succession of visitors. He grew closer to his children and their families. He passed on stories, gave away precious keepsakes, answered questions about his parents and grandparents and family history. He brought to mind that saying “Whenever an old person dies, a library burns down”. My patient made sure to give away as many books as he could before the fire.
When he finally was too weak to manage at home, we brought him into hospital. His siblings were scattered around numerous provinces. They all came back home, together for the first time in many years. Two asked about euthanasia and I explained that it was not an option as he was now incompetent, and that it had not been his wish. I let them know that we could treat his pain and discomforts, and that this was their chance to say their good-byes.
They said their goodbyes and told him they loved him. They held his hand and moistened his lips. They told stories in his ear and for the first few days watched as he would break into a barely perceptible smile. Eventually he stopped eating and drinking altogether. Even when he didn’t react anymore they still talked to him. Only God knows how much he heard. They brought in photo albums and reminisced, told old stories and hugged and laughed and cried. They took turns going home and cooking group meals to bring to the hospital.
I thought he would last a handful of days at most. He set my record for such a patient by living for well over a week after his last drop of water. There were several times when he looked uncomfortable but they were rare and quickly cured with medication.
After he finally passed, one of his siblings said to me, even though she felt uncomfortable saying it, that the last week had been one of the most beautiful times of life for her and her siblings and family. It had brought them together and reconnected them. It made them realize how much they meant to each other. She said “I think he held on that long to keep us all here. He knew somehow.” God knows if she was right.
I have often thought about what would have been missed if that patient had chosen to be euthanized.
A sunset is often the most beautiful time of the day. My work has shown me that there is a beauty in dying just like there is a beauty in living. Euthanizing patients destroys that beauty.
Suicide is not the natural order of things
As Kevin Hines (see Julie’s Substack) discusses, suicide has “ripples”. It disturbs the natural order. Its consequences are like a shock wave that strikes wives, husbands, children, parents, friends, and the community. It is stigmatized for good reason: it is one of the worst things you could do to someone else. I’ve told patients considering suicide that it would be much less traumatic and destructive for their loved ones to hit them over the head with a baseball bat than to commit suicide.
Life is not easy and it shouldn’t be. And choosing death over life should be even harder. But since the advent of MAiD, more and more are doing so as state-sanctioned suicide has sanitized, legitimized, and facilitated the process. The rise of MAiD is not a “success”. It is a tragedy.
This is the podcast version of Julie’s recent Substack on the issue of euthanasia, or “MAiD”, and its pending extension to patients with mental diseases.
A number of readers have asked for a podcast version of our Substacks, and I felt it was worth re-issuing this 2022 article as a podcast. It meshes, with some significant overlap, with Julie’s recent Substack on the same topic, and an upcoming (and likely our last, at least for a while) follow up by me to address some bones of contention.
So if you like listening rather than reading, here you go. Remember that the written version contains useful links and a few spicy memes. Thanks for listening.
I’m a slow thinker. It’s why I don’t do Twitter. It takes me a long time to come up with an opinion. I have to keep turning over an issue and looking at it from different angles. I read both sides of an argument. I often find some book on philosophy, poli sci or history that is relevant. And finally after all of that I (might) have an opinion on the subject.
So it took me a while to write about the Canadian election, which happened 6 months ago.
It was obviously time for a change
There is a saying that government is like underwear. After a while it gets dirty and you have to change it. Over time the problems of the day rub off on the once fresh government until it accumulates a stink, and people eventually want something that smells better. The fact that the Liberal government under Trudeau the Younger was 10 years old in 2025 was a strong predictor that it was the Conservatives’ time for electoral success, even if the Libs had been doing a reasonable job.
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Are we being killed with kindness?
mercredi 10 septembre 2025 • Durée 34:36
I was honoured that Dr. JD Haltigan agreed to speak with us for the Free Speech in Medicine Podcast. Julie (the X/Twitter-literate half of the Pairodocs) loves his tweets so much that she feels that they “are sharing the same brain”. He is fearless in following the evidence on psychopathology in modern society, and speaking about what it says, even when it leads to politically incorrect places.
As you’ll hear, Dr. Haltigan is a developmental psychologist with an interest in psychopathology and how it develops. Why do more and more people identify as mentally unwell in modern society? What is the role of feminism and safety culture in this trend? Dr. Haltigan has some great insights into these questions.
If you don’t yet, you should follow his work. He writes here on Substack. You can find his work at jdhaltigan.com, and follow him on X/Twitter @jdhaltigan.
I hope you enjoy the conversation as much as I did.
When I started family practice in ‘99 I held flu shot clinics for several years for patients in the rural community of Lansdowne, Ontario, where I worked. I was taught that “Flu Shots Save Lives”. The government advertised them to my patients. Demand was high. The pay was good.
Over the years I became more skeptical about vaccines, including flu shots. What does the science say? We learned during COVID that public health messaging is often very disconnected from facts and reality.
When I wanted to know the truth behind flu shots, the first person I thought of was Dr. David Zitner. A retired family doctor and expert in medical data science, David is also the Senior Healthcare Policy Fellow at the MacDonald-Laurier institute. Even better, through his work with CURAC (the College and University Retirees Association of Canada) he has specifically dug into the question: should we be promoting flu shots. I’m glad he described himself as a gadfly, so I didn’t have to! But he’s just the kind of gadfly that we love at Free Speech in Medicine.
We cover many topics, and some may fly by fast for non-medical listeners. Some links of great interest:
* TheNNT.com is a website well worth bookmarking. “Number Needed to Treat” is essentially the odds that a drug will help you if you take it (typically calculated for a 5-year period). eg: if the NNT is 100, there is a 1 in 100 chance the drug will help you.
* For those of you too young to have grown up with friends with , you can . It was a disaster that should have made the medical profession more careful and humble.
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What's the D-eal on D
dimanche 7 avril 2024 • Durée 42:03
I was very honoured to speak with Dr. Kanji Nakatsu, a PhD in pharmacology and emeritus professor from Queen’s University, about the interesting and somewhat controversial subject of Vitamin D.
Is D a wonder drug? Or a fad? Should we be supplementing? If so, how much?
This discussion is a little technical, and perhaps not for everyone, but I hope many of you find it of interest.
This should be a scientific, not political, topic. But like everything that brushed up against COVID, it got gooey politics all over it. My hope is that we can return to objectivity and stay away from politically-fueled motivated reasoning regarding this and other nuanced topics. I think we have to be careful not to contract what I call FDS or “Fauci Derangement Syndrome”, where we start to automatically believe the opposite of everything he and The Experts™ said during the last few years - even though in most cases that will lead you to the right conclusion. Even a broken clock is right twice a day, so approaching each topic with a neutral view is the only way to return to real scientific thinking.
It remains a bit unclear to me if we can separate out whether Vitamin D is a risk FACTOR or a risk MARKER. I’m not sure if we have a definitive answer yet, but the bulk of the evidence seems to be that supplementing Vit D is at worst benign, and much more likely very good for your health.
Dr. Nakatsu is an impressive human - obviously brilliant, and at 78 years old about to bicycle across the country as you will hear. He is worth listening to very carefully. You can find info at his website https://areyougettingenough.info/ He is involved with the Canadian COVID Care Alliance (CCCA - which I gather is in the process of broadening its mandate and morphing into the Canadian Citizen’s Care Alliance).
Thanks to Dr. Nakatsu for an interesting discussion. You can find him , or at the websites above.
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Is there Harm in Harm Reduction - Part 4
samedi 10 février 2024 • Durée 19:29
Urban wastelands
One of my friends described our hometown of Sydney’s downtown as looking more and more like a zombie apocalypse.
Those who are addicted to the point of homelessness tend to migrate to larger centres. A rural community won’t put up with Joe Smith, Mike and Maggie’s son, pitching a tent in the field where the kids play baseball, leaving dirty needles around, and passing out on the grass. Cities are big and anonymous and such behaviour is tolerated. More than tolerated, some would say it is implicitly encouraged by the presence of harm reduction programs that make a lifestyle of homeless addiction more sustainable, as well as selective non-enforcement of loitering, panhandling, and other bylaws.
A recent media article I came across referred to ‘safe’ injection sites as “controversial”. This is an understatement. Although harm reduction is preached as gospel truth, one who speaks with a representative sampling of doctors, nurses, or thinking citizens will find mainly dissenting opinions.
Although one can selectively comb the literature to find small studies where harm reduction programs tout their local successes, a look at the big picture suggests a different conclusion. Even though our downtowns are more and more being turned over to addicts, Experts™ tell us to reject the evidence of our own eyes and ears. Harm reduction is working great, we just need to do more of it. Do The Experts™ know something that we don’t?
I recently attended an online education session on a pilot project designed to bring “harm reduction” into the ER. The presenter suggested that we should be screening patients for addiction (requiring another piece of paperwork and a longer triage process), providing naloxone kits, starting “opiate replacement” and “safe supply” immediately, and prioritizing people with addictions ahead of other ER patients (sorry little old lady with the broken hip, I’ll be another 25 minutes…).
At the end of the session I asked if there was actual evidence that this program was helping. I pointed out that although we have invested far more in harm reduction in the last generation, there are more addicts and more overdose deaths, not fewer. ER funding is a zero-sum game: when we do more of one thing we do less of another; when we prioritize one person we de-prioritize others. The answer I got was that indeed, there was no actual evidence that this pilot project was helping, but that we “have to do something”. And that “we think it might be worse if we weren’t doing this”. One presenter suggested that if we could find “the denominator” - ie: the total number of addicts - then we would see that even though there are more addicts, and even though there are more overdose deaths, that a smaller PERCENTAGE of addicts are dying of overdose. , that would prove that harm reduction helps. It felt like a stretch, to say the least. A moving of the goalposts. (Or for you math-y folks, this is called .)
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Is there Harm in Harm Reduction - Part 3
jeudi 8 février 2024 • Durée 15:12
The watering down of language
When I was a medical resident in Kingston Ontario in the late 90’s, we would sometimes receive patients from the Rideau Regional Centre. This was a residential facility or “Institution” between Kingston and Ottawa that at its peak in the mid-50’s housed over 2500 mentally handicapped people.
Back then in the 90’s, the government was in the last stages of phasing out these larger centres in favour of “small options homes” and “community care” for the handicapped. Whether this is an improvement is a debate I won’t step into here, except to say “it’s complicated”.Some of these residents had been admitted to the centre when they were very young, and many were old by the time I cared for them. They would arrive with their original paper charts, some of which had admission data from the 1940’s, 50’s or 60’s. Admission notes included diagnoses such as “Low-Grade Idiot”, or “High-Grade Imbecile”. Back then, these were technical terms. “Idiot” meant someone with an IQ of 0-25, an “Imbecile” between 25 and 50, and a “moron” between 50 and 70.
As I don’t have to point out to you, these terms were co-opted from being technical and medical to being terms of insult and derision. Their use in medicine was abandoned. Numerous iterations have followed. “Retarded”, which etymologically means “slow” followed, but also became a term of derision. So then we used the word “slow”. “Mentally handicapped” followed. “Delayed” or “developmentally-delayed”. “Differently-abled”. Or now I have heard the term “Multiple Learning Disabilities” to describe someone who in 1950 would have been a “High-Grade Moron”.
The peak of “euphemizing” about mental handicaps hit a few decades ago. I remember listening to the news and hearing about the “Association for Community Living”. What was this new organization? Did they help seniors remain in their homes? Or provide affordable housing? A church organization? Were they a swinger’s group? No, this was the new name for the Association for the Mentally Retarded (it is VERY hard to find traces on the internet, as record of its existence now seems to be memory holed). The Association for Community Living supports mentally handicapped people, but there is no longer any trace of that apparent in their name. It has been euphemized to the point of being completely devoid of meaning.
This process has been called the “euphemism treadmill”.
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Is there Harm in Harm Reduction? Part 2
samedi 3 février 2024 • Durée 19:50
Once again you have the option to listen or read. Either way, thanks for being here and I look forward to your comments and ideas.
The Solution to drug addiction is unlikely more drugs
Big Pharma was a Big Part of creating this crisis in the first place. At minimum it poured gasoline on a fire lit by the loss of religion, social and community connections. Yet of course Big Pharma has come up with "the solution", which is (surprise!) more drugs. Call me Mr. Suspicious-Pants, but I just don’t trust them. But, according to The Experts™, the best thing to do for narcotic addicts is to put them on Opioid Replacement Therapy (ORT) in Opioid Replacement Programs (ORP’s).
Methadone was the first drug used for ORT, and for many decades was the only show in town. Methadone is a once-a-day, slow-onset-slow-offset narcotic that does not give the “high” of other shorter-acting versions, and is thus felt to be less addictive. But like other narcotics, methadone still blunts emotion, saps energy, and likely causes increasing chronic pain over time through “receptor upregulation”. This phenomenon is known as narcotic-induced hyperalgesia.
As mentioned in part one, opioid replacement therapy is an odd name, as it implies that an addict’s problem is that he lacks opioids. But a few generations ago, the name made more sense. Those entering a methadone program would sign a contract. They agreed to stop using other drugs, and methadone replaced the drug they were giving up. Admission to the program, continued attendance, and continuing to receive methadone was contingent on adhering to the contract. If your urine spot-test was “dirty”, you were out. There were expectations and standards for those in the program. You weren’t free to use whatever drugs you wanted if you wanted to be in the program.
Freedom without responsibility = disaster
Circa 2012 I attended a large conference where a certified Harm Reduction Expert™ who ran a methadone clinic was asked what he did when a patient failed a spot test. His answer shocked me (and I should add - also those sitting around me). A dirty test was a failure of the program, not the individual, he explained. It was a sign that the dose was not high enough. If an addict was getting enough methadone, he wouldn’t be using other drugs in the first place. This was when it struck me that today’s ORP’s are not what I learned about in the 90’s, where contracts were strict, and tapering was de rigueur.
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In the run-up to the election there was a lot of fighting over which poll was more accurate. Conservatives disbelieved polls that pointed Liberal, and vice versa. What was initially a clear lead for the Conservatives shrank and then disappeared under the influence of a clever Liberal campaign which tapped into the most central part of Canadian identity: anti-Americanism. When the Liberals won, many of my conservative friends were surprised and disappointed. I was not surprised.
A long socialist slide
Western society’s slide towards socialism - including the 2025 Canadian election result - is a predictable outcome of a gradual but inexorable transformation of our collective vision of government’s role in society. Politics - and thus our choice of government - is downstream from culture.
Historically, a centralized authority was seen as being a necessary evil, there to prevent your neighbour from killing you and/or stealing your stuff. Food, clothing, and shelter were your own problem.
But over generations the Overton window through which we view government’s role has shifted inexorably leftward. As we expect more of government, it has grown to occupy a much larger place in our economy and our day-to-day lives, as I have previously written about:
This shift in politics has developed as the belief in positive “rights” has become entrenched in our collective psyche. (You can flip back to another previous Substack for more on positive versus negative rights.) If we have a “right” to an always expanding wish list of services, then government must necessarily take more from productive citizens to provide these things to citizens who are less productive and responsible.
A major leftward shift
A simple but controversial example. Is it the duty of the state (and therefore the taxpayer) to support a woman who gets pregnant and cannot support her baby? A hundred years ago, even the most extremely progressive politicians would not have thought so. Such a duty was thought to lie with the mother herself, the father, the families involved, and the local community and church. Benevolent societies might help, but were run by volunteers, and contributed to voluntarily. Generations ago, not even the most progressive politician would have suggested the government take on this moral and financial responsibility.
In 2025, even the most “far-right” politician would not DARE suggest that such support is not the duty of the government. That is how much the Overton window has shifted.
Similar changes have occurred in most realms - housing, education, addictions, healthcare, dental care, child care, and now school lunch programs. There are few areas where we do not now see the government as responsible for providing the needs (and sometimes the wants) of the populace.
The mindset that one is responsible for taking care of himself - let alone his family or community - is less and less common, even amongst the more conservative demographic.
“Free” stuff is not really free, but rather quite expensive
Even some of my conservative friends, after ~1/3 of their taxes went towards healthcare for several decades, were thankful that they “didn’t have to pay” for their healthcare when they finally access the system. Wow, what a bargain! Lucky!
The word “free”, when used in place of “taxpayer-funded” is a politician’s trick. When Big Government runs a service, we pay a huge administrative premium on top of the price of the service. Someone must collect taxes. Someone must dole them back to organizations and individuals. Someone needs to be in charge of gender and racial equity. Someone must do an environmental impact assessment. Someone must manage the service delivery. And of course someone still has to actually perform the service.
All the extra steps require bureaucrats and functionaries, who have well-paid positions with pensions and benefits. Would you rather pay someone to dig a hole for you, or pay a government administrator to arrange it for you? Does it become “free” if you pay taxes to have it dug?
I’ll vote for you if you give me stuff
Although politics has always attracted graft and corruption, I do think that we once expected our politicians to be wise. Perhaps I’m over-romanticizing the past (I certainly know that politics has always been dirty) but it seems that we have devolved into pure “pothole politics”: we simply vote for people who promise us the most stuff. “Stuff” paid for with productive citizens’ taxes.
Voters who expect the government to give them free stuff vote for politicians who promise free stuff. And this means voting for politicians who are considered good “constituency men”. If you haven’t heard the term, here is an AI summary:
My take on the term is less generous. To me, a constituency man is simply someone who people think will get them free stuff. In my former home in industrial Cape Breton - a hyper-unionized and hyper-entitled place with very high rates of “disability”, welfare, and seasonal EI - we constantly vote in good constituency men who will “do anything for ya”.
Just as one example: Want support in insisting that your sore back really means you are disabled? No problem! I can’t tell you how many times I have seen this done by “good constituency men”. A colleague’s patient who was later caught building decks under-the-table while collecting compensation for a back too sore to work at the local call centre got a very supportive letter from his MLA when fighting for compensation payments. The politician helped get his constituent free stuff, guaranteeing that vote next election, as well as more votes from family and friends of the happily disabled man who knew the constituency man was someone they could count on.
One of Cape Breton’s most prominent/notorious politicians - Dave Dingwall - was famous for stating that he was “entitled to his entitlements” even though it was clear he was pork-barrelling. Despite this he is still beloved, and prominent in our community. People love him not because he is honest or wise, but because he uses his connections to bring a lot of money into the community.
Vote for a winner! Or you won’t get free stuff
A side effect of the belief in government-as-provider is the impetus to vote for the winning team. If you feel Team Red is going to make the government, and your goal is to get more “stuff”, you really should vote for the Team Red rep even if you don’t like him or the party. Hold your nose and vote red, or risk the cold funding shoulder for the next 4 years. This phenomenon pushes partisan pollsters to perjure and pump up their party’s prospects, as they know voters want to “back a winner”. This is why there is a blackout in the west on results in the east before polls close - it is well known that voters will change their vote to the winning party if they know which it will be.
Et tu, Poilievre?
How popular is the politicians-should-give-me-free-stuff belief? In an attempt to discredit Pierre Poilievre, CTV news deceptively spliced 2 video clips together to make it sound like “alt-right” Pierre wanted to (gasp!!) take away our “free” dental care that the benevolent Liberals had so generously granted to us. This was obviously an attempt to hurt his election prospects.
To me, the important takeaway from this incident was not that mainstream media is corrupt, evil, and deceptive. People who don’t know that are not reading this Substack.
Instead, the part of this story relevant to this Substack is that even the “Conservatives'” rushed to quickly distance themselves from any suggestion that they didn’t support “free” dental care. The Overton window on “free stuff” is so narrow and rigid that even conservatives won’t dare question it. Poilievre’s reputation would have taken a massive hit if people got the impression that he wasn’t 100% on board with giving us free stuff.
Voting is a conflict of interest for many Canadians in 2025, yet still they vote
Many more work for the government indirectly, either for companies who support themselves mainly with government contracts, as government consultants or contractors, or for “QUANGO’s” (QUAsi-Non-Governmental Organizations: non-profits who, if you trace their funding, are indirectly government-funded). These folks are not explicitly “government employees”, but are still paid by your tax dollars. The DOGE initiative in the USA woke many people up to what a huge issue this is.
Nurses and doctors are just one good example of groups who often base their vote on who is promising to give them the most of their fellow citizens’ money. Healthcare is the largest single employer in some communities and sucks up 12.5 % of our GDP - a number which grows with each election. And healthcare workers will vote for whichever party promises them the biggest raise.
It is standard to recuse oneself from voting if one has a conflict of interest. A CEO leaves the room when the board votes for that CEO’s salary. If you sit on the board of a granting agency, you are expected to recuse yourself if that board is about to vote on a possible grant for your cousin’s (let alone your own) business.
How many government workers, government contractors, nurses, doctors, or QUANGO employees recused themselves in the last Canadian election? How many CBC employees voted Conservative when that party’s leader was threatening to cut off their gravy train, while the Liberals were promising to keep it running smoothly down the same track?
Are we past the tipping point?
Although it’s hard to calculate precisely, many estimates are that more than half of Canadians are now net tax beneficiaries. They can vote for a government that promises to give them more of their fellow citizens’ money. The productive class is now a minority and is subject to the tyranny of the majority.
Does this phenomenon of voting in one’s own self-interest explain why ridings with more seasonal workers (net tax beneficiaries) are more reliable Liberal/NDP (they are pretty much the same party now) strongholds, whereas ridings with more farmers and oil-workers (net contributors) are more reliably Conservative?
Bruce Pardy has done an excellent video on the “Bureaucratic Singularity” - the point where the government is so big that it becomes a black hole that swallows all of society. Is the event horizon the point where more people take from, rather than contribute to, the tax pie?
Most people I know have self-contradictory ideas about government. They complain about high taxation while at the same time expecting the government to provide them with everything they want. They just don’t seem to get it.
A generation or two ago we would definitely have kicked the scandal-ridden, stale, unpopular and unsuccessful Liberals to the curb. But they promised us more free stuff than did the Conservatives.
Was the election result a sign we have crossed a tipping point here in Canada? (and likely elsewhere too - I’d love to hear if readers have opinions or data from other countries) Is it still possible to change course before we reach Bureaucratic Singularity? Darned if I know. Like Yogi Berra said: “Prediction is hard, especially when it’s about the future.”
To summarize, we don’t know that “Flu Shots Save Lives!” Are certain patients (old and frail, on chemo, those affected by lung disease) more likely to see benefit than harm? Are certain patients (younger, healthier, fewer comorbidities) more likely to see harm than benefit? Before vaccinating everyone willy-nilly, we should know the answers.
Given that flu shots are of dubious benefit, it seems likely that the large amounts of government money going towards producing, buying, distributing, and administering these shots every year would do more good somewhere else in the healthcare system. (Or, God forbid, simply reducing government expenditure). I have come to the conclusion that whatever the nitty-gritty detail on what subgroup might benefit, I resent my tax dollars going to promoting an intervention of unproven benefit. And until someone from public health answers Dr. Zitner’s request to provide the proof behind the “Flu Shots Save Lives!” claim, I’ll be skipping mine.
Data that contradicts visible reality should be treated skeptically
The below article in the Journal of the American Medical Association concludes that “safe supply” (the new golden boy of harm reduction programs) was associated with INCREASED harms - in this case opioid-related hospitalizations - in the area of British Columbia where it was implemented. This data seems trustworthy, given that it matches, rather than contradicts, real life evidence.
There is a joke about academics, who are prone to believing very ridiculous things if they appear in a journal: “one would have to be highly educated to believe such nonsense”. Much of the “evidence” for harm reduction falls into this category. The average joe/josephine who walks downtown, or reads the obituaries, knows that whatever The Experts™ are doing just ain’t working.
Most citizens do not set up tents on the sidewalk and use drugs in public
It’s great to want to help those with addiction issues. But at the same time, what does non-enforcement of loitering, littering, public intoxication, and other bylaws do to the ability of an average citizen to enjoy his city? To play with his kid in the park? To walk down a street without getting constantly panhandled? To not have his car broken into again and again? To not be randomly assaulted?
How is it that we can speak incessantly about the needs, wants, and rights of one group - those who abuse drugs - while at the same time completely ignoring the needs, wants, and rights of the great majority of society who do not?
Consider a law-abiding tax-paying citizen who has no criminal record. He wants to build a garage on his own property, which he owns and pays taxes on. First he needs a permit which requires a trip to city hall housing/zoning department. He has to pay a fee and spend time spent filling forms. The garage is finally built. The inspector comes and finds out that an ‘i’ was not dotted and a ‘t’ not crossed properly on the form. The citizen is forced to either pay a fine, or to have expensive modifications done on the garage to correct the error. (This is a real story, by the way). All this even though his garage affects no one else, and is on his own property. If he does not comply immediately he could end up charged higher fines or interest, and eventually if he did not pay he could be in contempt of court and face jail time. The police would eventually be called to enforce the bylaw. As the saying goes, “All laws are ultimately enforced at the end of a gun.”
Meanwhile, a few hundred metres away, a large group of addicts has taken over a park. Land that belongs to, and is maintained by, taxpaying citizens. They erect tents and more “permanent” shelters of various kinds on land where people used to walk their dogs and kids used to play. No building permits are demanded. No inspections are done. No police are involved. No attempt is made to remove them. No one is threatened with jail. There are no consequences.
We seemingly have chosen to enforce unreasonable laws on reasonable people, while at the same time not enforcing reasonable laws on unreasonable people.
Are “safe injection sites” creating “safety”, or a Zombie Apocalypse?
The first safe injection site in Canada opened in Vancouver around 20 years ago, and since then “harm reduction” has grown massively. It now includes the distribution of seemingly limitless clean needles, free tents, free drug paraphernalia (to crush and melt pills), naloxone kits (an injection drug that can be given to reverse the effects of an overdose) and most recently “safe supply”. In fact, more than 1 million dollars PER DAY was being spent in downtown Vancouver on these programs, even before “Safe Supply” (more properly called PSAD – Public Supply of Addictive Drugs) was added to the tally. We have put a lot of tax money into making homeless drug addiction a practically sustainable way of living.
Many harm reduction advocates lament NIMBYism (Not In My BackYard): that nobody wants to have a safe injection site in his neighbourhood. But there are logical reasons for this. These facilities are bug-lights for criminal behaviour.
Just several years ago, downtown Sydney Nova Scotia was safe. Like many downtowns in North America, suburban malls and online shopping had meant there were lots of empty shops, but it was safe. Male or female, one could stagger home from a bar at 2AM unmolested. Then we went all in on "harm reduction".
The local (taxpayer-funded) addiction help centre has become a focal point of loitering, public intoxication, scuffles and fights, littering, and even middle-of-the-day public sex acts (presumably prostitution-related). Piles of garbage are strewn around. My friend was propositioned by a prostitute while running on lunch break. Another friend saw a "fine gentleman'" receiving sexual services on the stoop of the senior's club just across the street from the help centre, in broad daylight. Panhandlers have become more aggressive and even threatening - a friend of mine now won't use the bank machine in the area after a bad experience.
Police do not enforce vagrancy or loitering laws. I suspect if they did, they would be pilloried for picking on addicts, who have been afforded coveted victim status in our current victim society.
Meanwhile (unless it changed in the last 5 minutes) overdose deaths in Sydney remain at an all-time high, violent crime has increased, and rates of addiction have not dropped. What harms have been reduced?
I drove by the centre last fall. As usual, there was much garbage and debris around. There was a mass of humanity milling about in various states of consciousness. Some passed out, several obviously severely intoxicated. Two were “up in each other’s grille” having a major verbal altercation. Ironically, in the midst of the mayhem, many were sporting brand new T-shirts that said in large letters: "HARM REDUCTION SAVES LIVES!".
The harm reduction advocates I know have never volunteered that one of these centres be located next door to their own lovely home in the suburbs. Instead they criticize others for not wanting it near their neighbourhood.
Where’s the proof?
Even harm reduction advocates will admit it’s not a panacaea, but more of a band-aid. But does it really do any good at all overall?
The original version of “the proof is in the pudding” was: “The proof of a pudding is in the eating”. But either way you phrase it, this adage is apropos to harm reduction. If these programs worked, they should work. We should see fewer overdoses. Fewer deaths. But instead, as we have spent more and more on “harm reduction” we have just the opposite happening. The same BC government that is still pushing forward hard with even MORE harm reduction just reported their 2023 stats and set a(nother) new record for drug overdose deaths at over 2500. Drug overdose is now by FAR the leading cause of death in younger age groups in Canada.
In response to this clear data trend, the main argument of “harm-reduction” proponents is that “it would be even worse if we weren’t doing all of this”. This is not scientific, but rather a statement of belief. And there are logical reasons that harm reduction may be (probably is, in my reading) making things worse.
But it’s probably worse than unhelpful
OK, I’ve pounded home my point that there is, to say it politely, a lack of evidence for efficacy of harm reduction programs. But let me take this one step further and suggest that there are several ways in which harm reduction could be making things worse.
There is a concept in behavioural science called “risk compensation” or eponymously “The Peltzman Effect”. Put a helmet on a kid before he rides his bicycle and he takes more chances. Enforce a facemask-wearing-rule in a hockey league and players aren’t as careful to keep their sticks down. A humourous corollary is this: the best safety device for cars would be a 6-inch spike mounted in the steering wheel pointing at the driver. Suddenly, everyone would drive much more carefully. To summarize risk compensation: the safer something feels, the more chances we take.
I’ll tell 2 real stories (with enough details changed to avoid identifying a patient unintentionally).
Many years ago, working in a big city ER, a young man I’ll call Zach came in late at night. He was in withdrawal from injection narcotic use. He wanted help to get clean. His friend had just died of an overdose the day before and it had hit him hard. They had been using together, and tried a little extra for a higher high. They passed out. Zach woke up, his friend never did. Zach told me he knew the same was in store for him if he didn’t get off drugs. I asked if he had a naloxone kit. Yes, he and his friend both had them. I then asked if he thought they would have used as high a dose if he hadn’t have had the kit. Zach thought for a minute and answered no. The presence of the kit made chasing a higher high seem “safe” to him. Does having these kits kill more people than it saves? We have distributed many thousands of naloxone kits, and yet more people are dying of overdoses. It is easy to point to the lives they save, but are there many deaths to which they have contributed by giving a false sense of security - deaths that we have no way of counting?
Another night in a big ER and another addict wanting to quit – I’ll call him Jimmy. Jimmy’s (latest) girlfriend had just kicked him out. He had nowhere else to go, being estranged from family (having stolen from his parents then grandparents). He had hit rock bottom. He was suicidal. Jimmy was young, good-looking, articulate, and clearly intelligent. I asked him how a guy like him ever got started in the first place? It’s easy to understand how people KEEP using, but what about the first time you pick up a needle and shove it into your own arm? I asked him wasn’t he worried about OD’ing? He explained that he was at a party, drinking with friends. He went out back to the garage where some of the guys were hanging out. A friend of his was experienced with injecting narcotics and encouraged him to try it. The friend allayed any fears about overdose. “What about catching diseases?” I asked. “I’m not stupid enough to use a dirty needle” Jimmy said. There was a large container of clean needles there, supplied by the local harm reduction clinic. I asked if he would have used had there not been fresh needles. He was adamant that no, he never would have used a dirty needle, and that in his several years of using he never had used anything but a fresh needle – all provided free of charge via “harm reduction”. Have we made it easier and “safer” for people to develop a drug habit in the first place? Would Jimmy ever have taken the first step onto the path that wrecked his life (to that point – I hope he recovered) had we not made that step seem “safe”?
At the same time these aspects of harm reduction have made drug use appear “safer”, the destigmatization movement is likely having an effect in lowering or removing one of the barriers to starting a drug habit by making use appear more normal or socially acceptable.
And finally, diversion of “Safe Supply” drugs is extremely concerning. This is the phenomenon where taxpayer-funded opiates are provided to addicts, with the assumption that they will replace opiates like fentanyl that the addict had been buying on the street. But just giving someone a less potent drug doesn’t automatically make them stop wanting the more potent one. Instead, it appears that many addicts take the free opiates and sell them, using the money to buy their drugs of choice.
Although advocates tend to downplay this issue, evidence suggests that it may be extremely common. (I highly recommend reading this well done article by Adam Zivo.) Basic economics dictates that increasing the supply of a product lowers the price. If a bunch of “free” opiates are suddenly given to addicts in a community, and those opiates are diverted and end up on the street thus increasing supply, this lowers the black market cost of these drugs. In some communities, a huge drop in the price of opiates has now made them a cheaper option than beer or marijuana for youth who want to get a buzz on before the Friday evening high school dance. Some believe this mass prescription of “Safe Supply” is creating a whole new generation of addicts, just as the mass prescription of Oxycontin and other opiates may have triggered round one of the opioid crisis.
Harm Reduction had noble intentions. But by making drug use appear safer, appear more normal and socially acceptable, and most recently by releasing a deluge of cheap opiates onto the streets of our communities, it is very likely part of the reason we see an ongoing increase in addictions, homelessness, and addiction-related deaths.
Time to change course?
We can’t “harm-reduce” our way out of the addiction crisis. But “harm-reduction” may be part of what has gotten us here in the first place. In a recent media piece lauding a “safe supply” physician who had received an award for his work, he unknowingly gave support to those of us who think it may not be helping. In the concluding paragraph he is quoted as saying “I’ve been doing this for 20 years and there’s more demand now than when I started... it’s worse”.
Einstein is credited with having said “The definition of insanity is doing the same thing over and over and expecting a different result”. Just as there are those who still advocate for communism by saying that we haven’t tried REAL communism yet, continuing to think that harm reduction will work if we just do more of it is, by this definition, insane.
If you’re interested in more…
To those of you who took the time to read or listen to the Is there Harm in Harm Reduction series, thank you. I’m happy to hear your thoughts, positive or negative, either by private message or here in the comments. Whether I’m totally wrong, totally right, or most likely a bit of both, this is an issue that needs a fulsome discussion and debate.
For a more positive view on the potential of addicts than you’ll get from Bonnie Henry, The Pairodocs recommends this recent Free Press article on the success of Hazard, Kentucky which is rebuilding out of the ashes of addiction and despair called Recovering Addicts Save an Opioid Town.
For a thoughtful and deep perspective on how Harm Reduction became “The Science”, I recommend my colleague Dr. Rick Gibson’s Substack “Wishful thinking about addictions”
If you want to hear me try my best to explain how the through-line runs from The Enlightenment through Freidrich Nietzsche, Carl Jung, and eventually to modern 12-step programs, have a listen to my conversation with David Gardener on his new Freedom Convo Podcast
And finally, for a hard-hitting critique of our current lenient, harm-reduction-only approach to addictions and homelessness, I recommend watching “Canada is Dying” by Aaron Gunn.
We have followed a similar process with the word “addict”. Many euphemisms have been used. “Drug abuser”, “substance abuser”, “person living with addiction” (as Lionel Shriver says, a description which makes it sound like they took in a roommate), a “person who abuses substances”. We seem to have somewhat settled on “a person with an SUD” (substance use disorder).
Recently the term “a person who uses substances” has come into common usage. The problem with that is that we all “use substances”. I drink coffee most mornings. I bet many of you have taken Advil for a headache. Some might have a drink of wine on Saturday evenings. Cheerios are a “substance”.
The term “a person who uses substances” does not differentiate the average person from someone who has emptied his wife’s bank account to supply his drug habit, wrecked his marriage, impoverished his family, and is living under a bridge. (Could living under a bridge be called “Community Living”?)
It’s not what you say, it’s what you do that matters
Our society tends to develop euphemisms for issues which are uncomfortable or difficult to discuss. But it seems to me that the term you use to describe someone is not nearly as important as the respect and compassion that you actually show that person.
I’ll never forget when one of those handicapped patients from the Rideau Regional centre died, watching 2 of his caregivers completely overcome with tears. The fact that his record indicated that he was officially a “moron” hadn’t stopped them from loving and caring for him over several decades. They wept for him as if he were a brother. On the other hand (if you’ll recall back in part 2), Bonnie Henry is very careful to use the term “people who use substances” instead of “addicts”. But then she says they have a “brain disease” and that they can never get better. Is that respectful? Is it compassionate? We can run on the euphemism treadmill but go nowhere.
When we water down a word, we lose something. There is still some stigma about being an “addict”. It is normal to be a “person who uses substances”. Perhaps this is why I meet lots of people who self-describe as “addicts” or “alcoholics”, many of whom haven’t used or touch a drop in decades, whereas I’ve yet to have met someone who describes himself, or is described by his family, as “a person who uses substances” who has kicked his addiction.
The first step to a cure is a proper diagnosis
We need straight talk. Many media reports muddy the issue of addiction and homelessness, referring to them as “intertwined”. It is suggested - or sometimes said directly - that some people become addicted because they are homeless. Yet in all my years in medicine I have never once met someone with this story. In 2024 nearly every homeless person in Canada is addicted, which suggests the arrow points in one direction, from addiction to homelessness, but not in the other.
If your brother, cousin, or friend called you some frigid winter evening and said that he was down on his luck and needed a place to stay for a while, how many people would tell him to go fly a kite? Not many. I sure wouldn’t. Now picture if you knew that person was addicted, injecting drugs regularly, stealing to support his habit, and had stolen or got in fights at the last few places where he stayed? Would that change your answer? Non-addicts rarely end up homeless, or if they do it’s not for long.
Getting stigma right, not getting rid of it
Julie and I sometimes joke that we need to start a “Restigmatization” movement to counterbalance the destigmatization movement. Why?
Shame is normal and necessary. There are whole books written on this subject. Shaming those who engage in personally and/or societally destructive behaviour is not only reasonable, it’s necessary. Shame helps hold societies together. We could probably steal our neighbour’s bicycle and sell it for money and get away with it, but that would be shameful. We could knock down a little old lady and take her purse, but that would be shameful. The vast majority of us don’t do these things, not because the police are watching us every minute (at least not yet), but because we would bring shame on ourselves and our families. We know certain actions are wrong - there is stigma attached to them. The only way to never feel shame is to not have a conscience.
As we destigmatize drug use, we can unintentional cross a line into normalizing and condoning it. We need to remember that it SHOULD be shameful to be an addict. It is bad for your family, for your community, and for you personally. If there is no stigma, there is less impetus to change.
What is the right amount of stigma? If there is too much stigma and shame, a person can feel beyond redemption, and give up on himself. An addict should not be made out to be hopeless or evil. But they are not just fine like they are.
It’s important to stigmatize the BEHAVIOUR and not the PERSON. An addict is not worthless or irredeemable or forever lost, despite what Bonnie Henry says. But the behaviour is destructive, costly, and socially irresponsible. Hate the sin, love the sinner.
We need to get stigma right, not eliminate it. You can love someone who drank and drove, or love someone who is doing time for grand larceny. But the DUI or their felony is not what you love about them. It’s not what you’re proud of them for. It’s the part that you hope they will change. So it’s not what you put on a t-shirt.
Compassion versus empathy - when does empathy become toxic?
Whole books have been written about “toxic empathy”. “Against Empathy” by Paul Bloom should be required reading for all parents, healthcare professionals, and teachers in my opinion. Toxic empathy is the kindness of heart that makes us want to give every kid a trophy. To let the screaming toddler eat the chocolate bar an hour before supper. To shut down free speech because someone’s feelings might be hurt. To avoid enforcing educational standards because someone might actually fail and feel bad.
Toxic empathy is destructive in many realms, including with drug use. We need to draw lines. We need to say that some things are not acceptable. We need to avoid allowing our natural empathetic instincts to push us over the line from helping to enabling.
American historian and thinker Christopher Lasch said:
“…the ideology of compassion, however agreeable to our ears, is one of the principle influences in its own right, on the subversion of civic life, which depends not so much on compassion as on mutual respect. A misplaced compassion degrades both the victims, who are reduced to objects of pity, and their would-be benefactors, who find it easier to pity their fellow citizens than to hold them up to impersonal standards, attainment of which would entitle them to respect.”
Is the key to success lowering standards?
A number of years ago there was much hand-wringing around physical activity (PA) guidelines. There was debate over what the minimum standards should be. There had been a sharp dropoff in PA over the preceding years, and rising obesity rates. The “solution”? Lower the standards. Experts™ said that having a high standard would mean too many people would fail to meet it, and thus would feel bad about themselves. We needed more “realistic” goals. So your tubby kid could now feel happy if he was active for an hour a day, rather than the previously recommended 90 minutes.
The joke “if at first you don’t succeed, lower your standards” feels like it has actually been applied to drug addiction through changes in language and the move from abstinence promotion to harm reduction.
The healthy solution when someone we care about is not meeting a standard is not to lower it, but to help that person achieve it. The way we talk about and treat addicts in 2024 is a great demonstration of “the soft bigotry of low expectations”.
It seems that in general in modern society, and specifically around the issue of addiction, we have a hard time remembering there is a difference between BLAME and RESPONSIBILITY. But clearly defining this difference is crucial if we want to help those addicted to drugs, but not enable them.
Addiction as a disease
Is addiction a “disease”? To be generous, perhaps in some senses. There are genetic and lifestyle risk factors. There are measurable differences in someone’s brain chemistry over time. We can treat certain symptoms with drugs. Addiction, like many diseases, causes morbidity and mortality.
But with just a bit of thought we see the problem with this model. Breast cancer is certainly what I would call a disease. Yes, a woman’s choices - smoking, obesity, poor diet, and lack of exercise all increase risk, as does genetic susceptibility, but breast cancer itself is not A CHOICE.
In all my years as a doctor, I have never seen a woman cure herself of breast cancer by waking up in the morning, looking in the mirror, and saying to herself “that’s it, I’m sick and tired of breast cancer and I’m just not going to have it anymore”. That just doesn’t happen. But I know MANY recovered addicts who have cured themselves of their addiction in exactly that way. They are in my family, they are my friends, they are my co-workers, I play hockey with them. They are people I admire. If addiction is a “lifelong disease” then why are there so many more ex-addicts than current addicts?
Speaking about addiction as a disease is infantilizing and disempowering. It suggests to an addict that he is a victim. That he is helpless. That he has no choice but to go on suffering.
Addiction is a BEHAVIOUR, not a disease. It’s a behaviour that is hard to change (by definition), but one that is possible to change. People can, and do, change their lives. They can and do wake up one morning and say “I’m done with this. Enough.”
The Experts™ look down on the addicted
Does the view that addicts are helpless victims - a view that is at the base of our harm reduction strategies - rob addicted people of their own human agency?
We have essentially given up on abstinence. Which in my mind is the same as giving up on addicts. Most recovered addicts I have met talk about having hit “rock bottom” before quitting their habit. By cushioning their “rock bottom” with harm reduction, it seems to me we are in all likelihood preventing abstinence. We are trying to fill the god-shaped hole in addicts hearts with clean needles and now with free supply of government-provided drugs.
In Brave New World, Aldous Huxley suggests that a drugged populace does not question authority, but rather depends on it. From Valium to Prozac to Ritalin and Adderal, and now an implicit acceptance of opioid addiction as a life choice. Are we creating a dystopia?
Stay tuned for Part 4 of Is there Harm in Harm Reduction: Data, Dystopias, and Detrimental Effects
I’ve watched this idea that giving people drugs will somehow make them use less other drugs creep into medical practice. Circa 2021 I had an alcoholic patient come to ER in a very bad state. He had been to ER a couple of nights earlier and was given a prescription for a huge bottle of clonazepam. This is a benzodiazepine - a drug that some call “dehydrated booze”, which can be used to wean people off alcohol in inpatient settings. But because it’s effects overlap so much with alcohol, it is dangerous when used in combination. And that’s what this patient had done. Most of the bottle (enough for a big daily dose for a month or two) was already gone. The patient did survive. When I reviewed the previous notes, it was apparent that the patient hadn’t solicited the prescription. He hadn’t said anything about wanting to quit or taper. The physician thought that if the patient was taking clonazepam, he would drink less. Instead, he used both drugs, and nearly died.
As Dr. Julian Somers so eloquently talked about at FSIM 2023 (watch for an online Free Speech In Medcine event with him coming up soon), methadone programs used to be a PROGRAM with many facets - vocational training with a view to employment, counselling for mental health issues, reconnecting with family. The “active ingredients” were everything but the methadone. Now a methadone (or Suboxone) program is about getting a drug every day, and little or nothing else.
In a well written City Journal article , journalist Erica Sandberg describes her experience in San Francisco, posing as a drug addict who had just arrived from the midwest. Here is an excerpt:
In NS, as I’ll go into below, there are zero government-funded inpatient abstinence-based programs for narcotic abuse, and fewer inpatient options for alcoholics than in the past.
This time for SURE this is going to work
Recently methadone has mostly been replaced by Suboxone, which is a somewhat safer alternative that blocks opioid receptors in our brain and spinal cord, blunting withdrawal symptoms. And by happy coincidence it’s more expensive, generating a higher profit for Big Pharma. Experts™ explained to me that changing from methadone to Suboxone would cause overdose deaths to plummet. I think you can guess what has actually happened.
Although there is no doubt that both methadone and Suboxone can mitigate the cravings that withdrawal causes, they do nothing to address the root causes of addiction, and used alone they do nothing to help an individual move past addiction and into the sober, meaningful life that lies beyond.
The Abandonment of Abstinence as a North Star
Despite the failure of ORP’s, increasingly they are the only tool in the healthcare practitioner’s toolchest here in Canada (and elsewhere as I understand it).
Over the years, healthcare overlords have increasingly abandoned funding “abstinence-based” programs (ABP’s) - those that are focused on helping patients get off drugs rather than just replacing them with a (purportedly) less harmful alternative drug. Most ABP's also involve reintegrating into the community - be it through finding a job, having a sponsor in the community, reconnecting with family, finding a group home, a church, whatever. ABP’s are organized on the belief that sending a person directly back into the same environment and circumstances that stimulated him to be addicted in the first place will likely torpedo his chances of staying sober, even if we do give him methadone or Suboxone in an ORP.
Harm reduction including needle exchanges, supervised injection sites, shelters, ORP’s, and most recently “safe supply” - have replaced abstinence-based programs. These interventions are more left-brained and mechanistic, with no need to bring in all that controversial spirituality or (God forbid) religion which were the foundation of success in 12-Step programs. Governments appear to be “doing something” to fix addiction when they run harm reduction programs, while at the same time that the death toll increases.
These programs give hard data for proponents to use to argue that they are working. The number of needles you give out, or the number of people on methadone, the number of people “retained” in programs can easily be counted - very important for the bean counters that abound in our overly-bureaucratized healthcare system. But not everything that can be counted actually counts.
When travelling recently I picked up an old-fashioned local print newspaper. There was a front-page article announcing the fantastic successes and expansion of the local harm-reduction program. In the article, the director touted the number of patients on methadone and Suboxone, increased staffing at the centre, and the huge number of free needles they had given out in the prior year. More than the year before! Wow! The program was clearly a success!!
Not once in the article was there any mention of how many overdose deaths had occurred that year. I looked it up - it had increased greatly in that area. And not once was it mentioned how many (if any) of their clients had become abstinent, gotten off the street, or found jobs. Nowhere could I see evidence that this program had actually helped anyone in a meaningful way. And for anyone who walked around the city it was clear that the problems of homelessness and addiction had objectively worsened.
Thomas Sowell and others have talked about how government-funded programs, although often started with a noble goal in mind, quickly morph into entities that are mainly focused on their own survival, growth, and enrichment. Free needles and drug-free people are not the same target. Program directors and politicians patting themselves on the back for the former, while ignoring the latter as it worsens, is frustrating to watch, and a perfect demonstration of Goodhart’s Law.
Giving out drugs is lucrative
Doctors make BIG MONEY doling out daily doses of drugs such as methadone and Suboxone. This creates a perverse incentive where physicians want as many people on methadone and Suboxone as possible (cha-ching, cha-ching). I have had numerous addicts tell me that they asked to taper off their ORT, they have been directly told not to do so, because it would be “dangerous”.
I should mention that there are thousands of ex opioid addicts who strongly disagree with Dr. Henry’s view.
A doctor friend of mine took a methadone prescriber's course recently. Being logical, old-fashioned, and innocently naive to the new dogma in addiction medicine, she asked about tapering. The Expert™ running the program tut-tutted. You could never take an addict off methadone, she explained. "It would be like taking a diabetic off their insulin". She was told that addiction is a “lifelong disease” that can only be treated by "replacement" and “harm reduction”.
In many provinces, “addiction specialists” who run ORP’s are amongst the highest paid physicians. For instance, a CBC article from Newfoundland details how 2 of the highest 10 paid physicians in that province run methadone clinics. One bills 1.6 million dollars per year, the other “only” 1.2 million. This is many times more than a regular old family physician can manage to bill. It’s also far more than your neurosurgeon earns, and he trained for 8 extra years beyond med school and has to be prepared to get called in at 3AM to do a delicate emergency operation on your brain.
ABP’s are not a panacea, but they should be an option
Why were abstinence-based programs abandoned? Well, here’s my understanding. These programs are expensive. Many patients fail. Many relapse. Being sober is hard. Those who work in these programs are poorly paid for a difficult and emotionally taxing job. It’s much easier just to hand out ORT.
Currently if you are an addict in Nova Scotia and you want help, the only “help” I can get you is to refer you to start on ORP. And unlike something like cancer treatment or a referral to neurology, there is no wait to start on ORT.
On the other hand, if you want to get off drugs, there are currently no government-funded inpatient or residential programs. If you want one you’ll have to search around yourself for a handful of community-led residential ABP’s. The ones that I know are always begging and scraping to find enough money to keep the lights on. (If you want to donate, for just one example check out Talbot House in my home of Cape Breton.) There are some excellent and highly-regarded residential programs like Homewood, which you can access if you - or someone you know - has 10 or 20 large burning a hole in your pocket.
The spectre of withdrawal
This may seem like an aside, but I believe the exaggeration of the difficulty and danger of opiate withdrawal contributes to the move away from abstinence and is part of the push to go “all in” on harm reduction.
Nowadays we talk about withdrawal from opioids as something cruel, inhumane, dangerous, and possibly deadly. We keep people on narcotics or ORP’s for long periods of time (sometimes for life), and if we taper at all we do it extremely slowly. Opiate addicts are given the impression that they can’t stop on their own, and in fact to do so would be dangerous. They get tied into potentially counter-productive ORP’s that are expensive for the taxpayer and coincidentally highly profitable for the physicians who run them, and Big Pharma. Movies like Trainspotting and other pop-culture depictions of opiate withdrawal helped make it the bogeyman it has become.
The problem is this story is wrong. Opiate withdrawal is no doubt very difficult - gooseflesh, chills, sweats, diarrhea, vomiting. I’ve seen it many times and it ain’t no picnic. But PURE opiate withdrawal is not medically dangerous (unlike withdrawal from other substances such as valium or other benzos, barbiturates, or alcohol). People withdrawing from opiates sometimes feel like they WANT to die, but they won’t.
When tens of thousands of heroin-addicted soldiers arrived home from Vietnam at the end of the war, the vast majority simply stopped using. They had things to do, and drug addiction had not been “destigmatized” in their families and communities. When Chairman Mao took over and announced that all opiate addicts would be summarily executed, the vast majority simply stopped using. They preferred to stay alive. When the Beatles/Rolling Stones/every famous musician from the 60’s wanted to kick heroin, they sweated and shat and cursed for a weekend (often in the comfort of the Betty Ford clinic) and then moved on with life.
I still meet many recovered addicts who did the “Cold Turkey” method. One memorable patient had lived in Ontario for years. He got a call that his mom had fallen ill, and he had to come home to Cape Breton tout suite. He bought a plane ticket for Monday. His mom didn’t know he had developed an addiction and he didn’t want her to find out. He needed to be ready to look after her. He paid a friend to lock him up in his basement for the weekend with the instructions to “bring food to the basement window out back but don’t let me out no matter what I say”. He flew home Monday morning a little weak and unwell, but having kicked his opioid habit. When I met him, he hadn’t used in the 12 years since then.
Withdrawal is a speed bump, not a brick wall
My (somewhat belaboured) point is that people CAN and do quit drugs when they really want to. When they are motivated. When they have something meaningful to move on to. Withdrawal is not cruel and unusual. It’s a necessary hurdle that an addicted person must jump over to become drug-free.
Is it better to just rip the band-aid off quickly?
There was a very interesting study done on smoking cessation in Britain several years ago. It compared those who tapered smoking - ie: cut down over time, with the goal of getting to zero smoking - with those who simply quit immediately and dealt with the withdrawal.
The result was surprising to some but fit with my experience with patients. Those who just quit were more successful by a significant margin. Why? Likely because those who slowly taper are actually in a mild withdrawal as long as they are tapering. They are cranky, irritable, and hungry, but are still smoking. They put up with this for many months, instead of the relatively short few weeks of the same (but debatably more intense) withdrawal after just quitting. The chronic withdrawal is so difficult to deal with that many just say “the heck with it” and go back to their original pack-per-day or whatever.
Rip the band-aid off quickly, or peel it slowly and painfully. It seems like the former works better, at least for smoking. I have to wonder - do we make it harder for people to become narcotic abstinent by slow drug tapers? Are we prolonging their agony in a vain attempt to avoid ultimately unavoidable withdrawal and discomfort?
You become who you hang around with
Slow tapers (or no tapers) and ongoing attachment to ORP’s may also unintentionally make it harder for a person wanting to achieve a sober lifestyle to do so. Having spoken with hundreds of patients over the years who have overcome addictions, there is one common refrain: stay away from other users.
If you quit smoking last week, don’t go to a party and hang around with your 3 friends who all smoke. If you quit alcohol, don’t head to a party with your friends who like to drink. If you want to stay off drugs, don’t hang around other people who are using.
Help centres and shelter projects - like those planned for cities like Halifax, Sydney, and Moncton here in the Maritimes of Canada - by nature warehouse addicts. Interestingly, surveys have shown that addicts themselves do not want this either, as they recognize that finding a supportive environment away from other drug users is best for them personally. Integration into non-drug-using environments, not enforced cohabitation and constant contact with other drug users, is what a person needs to be sober and regain a meaningful and healthy life.
Do harm reduction programs really help? Or do they enable users to continue their habit, thus increasing risks overall? Stay tuned for part 3 of “Is there Harm in Harm Reduction”.
