This struck a chord for me, although I don’t think that he dove deeply enough into the whys, wherefores and consequences.

Before I explore this more deeply, I’ll quote him verbatim. Note that I find his distinction between questions and problems to be a bit confusing, when quoted outside the context of his book, so I’ve chosen to capitalize PROBLEMS, to emphasize that they are larger scale.

“Much public talk, at the CBC as elsewhere, turns on the existence of PROBLEMS and solutions, with the PROBLEMS often described as crises, as well. These PROBLEMS are not ordinary troubles or concrete difficulties that need to be faced and overcome or avoided. They are gigantic agglomerations that function in public talk as something like staple commodities - the vicissitudes of the economy, let’s say, or the PROBLEM of homelessness, reconciliation, or climate change. These are, first of all, stupefying abstractions, gathering together and consolidating an unthinkable variety of disparate stories and circumstances. They are, beyond that, resources - the property of the agencies that, in effect, extract the resource and depend on the periodic discovery of new deposits to stay in business. And, finally, PROBLEMS are syndromes that are defined, and confined, by the available solutions. Just as illness, in medicine, is often constructed to specifications derived from the available cures, so PROBLEMS in journalistic discourse take shape in relation to preformed solutions - the economy is defined by its imagined policy levers, the drug emergency is constructed in terms of the available treatment options, the health care crisis is seen to vary with the amount of money poured into it, and so on. In all cases, a mould or pattern is created - which then begins to overshadow and retrain individual instances of the supposed PROBLEM. One can’t avoid naming things, of course, or recognizing similarities between them, but I’m talking here about something more extreme: the transformation of predicaments - which individuals or communities might address - into industrial-strength PROBLEMS which are projected at a scale at which they can scarcely be conceived, let alone remedied. A PROBLEM of this kind allows no question. It gathers overhead like a dark cloud, presenting no precise definition or imaginable way out. It can move money, provoke political passion, mobilize opinion, and create jobs, but only in the interest of its continuation as a PROBLEM.

A real question - a question possessing sense and direction - presumes that there is something to be understood and something, moreover, that can be understood. PROBLEMS inhibit understanding. They are inert and senseless. Talk of the homeless crisis, the climate emergency, or systemic racism invites a response on the same level of generality on which the PROBLEM is formulated. “Systems” must be “put in place.” Personal actions that are within reach seem paltry by comparison. One becomes, willy-nilly, a citizen of utopia. Questioning, as I have been emphasizing, opens a path. PROBLEMS are a pathless maze - a game played by those whose livelihood and self-respect are tied up with their continuance. Only by putting the language of PROBLEMS and solutions into question will a livable world begin to appear and show its unthought possibilities.”

In a nutshell: Questions are practical, PROBLEMS are abstractions

Imagine you’re faced with a situation. Practically speaking, you need to know “what is to be done?”, bearing in mind that sometimes the best answer is to do nothing.

Making sense of the situation and deciding how to proceed (or not) presumes that there is something to be understood about the problem, and that doing something will make a difference. You’re looking for a sense-making path to a workable and effective solution that’s within your control.

The wind blows and the tree in your front yard topples over. At the end of the day, you’ll need to have it chopped up and carted away, without spending a lot of time trying to figure out whether the wind was too strong (due to climate change, perhaps, which is well beyond your control) or the tree was too weak (having been stressed by climate change…).

Similarly, your car won’t start because the battery is dead, so you get out the jumper cables. Your tap drips, so you find someone to replace the washer.

In simple and relatively uncomplicated systems, there’s generally a limited range of possible causes for any given situation, the linkage between cause and effect is pretty clear, and it’s usually obvious who has the knowledge and power to fix things. The car battery might be dead because you left the inside light on, it’s exceptionally cold out, the battery is old, or your alternator is no longer working. Jump-starting the car and remembering to turn off the inside light might be enough, or it might only be a temporary fix, if the battery is wearing out.2

In short, many situations simply trigger a quick fix, while others benefit from deeper analysis, looking for the “root cause”. It makes sense to dig deeper when the cause isn’t immediately obvious, the same issue keeps recurring, and/or when it affects multiple people. However, this still requires being able to draw clear linkages between causes and effects, which can be possible even in highly complicated systems. For example, the Space Shuttle “Challenger” exploded shortly after liftoff in 1986, and it was eventually determined that the fundamental cause was cold-induced stiffening of the O-ring seals in one of solid-fuel rocket boosters. Secondarily, it was noted that this problem had been previously identified but ignored for years, due to NASA’s organizational culture and decision-making processes. The solutions involved a redesign of the O-rings, avoiding launches in cold weather, and changes in the decision-making structure.

Some things are inexplicable and/or unpredictable

David Cayley is basically saying that we’re spending too much effort these days looking for root causes, without dealing with what’s right in front of us.

I agree, and I think the issue is that we’re looking for root causes in systems that are complex or chaotic, where it’s rare for there to be just one causal factor, events usually result from of a combination of factors, and the chain of events from cause to effect is not always linear. Implying that a single (or even a small number of) factors can completely explain a complex situation promotes a flawed, overly reductionist view — it creates the illusion of certainty in situations which are (and always will be) inherently uncertain. We talk about “following the science” when in fact there is no science and all we have are guesses.

In a complex situation, the cause of any given event may seem obvious in retrospect, but the presence of that cause won’t predict similar events in the future. The most visible, attractive, or politically expedient causal factor gets more than its share of the blame. A psychopathic murderer might attribute his psychopathy to growing up in a broken home, but most people growing up in broken homes don’t up as psychopathic murderers. These days, climate change gets the blame for every “weather” event, including the forest fires caused by arson.

In other cases, the search for root causes is carried to the opposite extreme, with every imaginable root cause identified and listed, even those which are non-specific, unfixable, and beyond anyone’s control. As David Cayley says, these situations become “gigantic agglomerations and stupefying abstractions, gathering together and consolidating an unthinkable variety of disparate stories and circumstances.”

Consider, for example, homelessness. There have always been homeless people, in this and every other country, rich and poor, capitalist and socialist.3 Back in the mid-1900’s (yes, more than half a century ago!), a Canadian government report concluded:

“ ‘… that [homelessness] was the result of systemic or societal barriers, a lack of affordable and appropriate housing, the individual/household’s financial, mental, cognitive, behavioural, or physical challenges, and/or racism and discrimination. It was acknowledged that most people do not choose to be homeless, and the experience is generally negative, unpleasant, stressful, and distressing.’

This definition provided us with four types of homelessness: unsheltered, emergency sheltered, provisionally accommodated, and at risk of homelessness. Back then, it was argued that the report’s definition of homelessness painted an overly broad picture, including those who were currently having a hard time financially.”

The Issue of Homelessness Has Evolved Over the Years, by the History Hound

Of note, nothing I’ve read about homelessness in the last couple of decades sounds much different, nor have we yet solved the homelessness PROBLEM! Why not?

Well, in that one paragraph, the authors listed eleven root causes for homelessness, many of which themselves have multiple root causes, including:

• systemic barriers (whatever those might be),

• societal barriers (whatever those might be),

• a lack of affordable housing (presumably reflecting an imbalance between low incomes and high housing costs)

• inappropriate housing (however that might be defined)

• individual or household

  • financial challenges (inadequate income, excessive or inappropriate expenditures, or both),

  • mental challenges (multiple possible diagnoses and degrees of severity),

  • cognitive challenges (again, multiple causes, some congenital, others acquired)

  • behavioural issues (whether due to disease or not),

  • physical health challenges (multiple possible diagnoses and degrees of severity),

• racism, and/or

• discrimination (which can be due to multiple factors).

Obviously, taking into account all those individual causes and their possible permutations and combinations, there are dozens of ways in which a person might theoretically end up homeless.

The theory of public policy making suggests a rigorous approach in which extensive data is gathered, the root causes of any PROBLEMS are enumerated and understood, the policy objectives are clearly defined, the full range of policy options are considered, and the “best” policy is chosen based on its being the most appropriate means to address the causes and achieve the desired ends. That “perfect” approach requires a lot of time, energy, resources, money, and intellectual capacity. Failing to do so leaves policymakers open to criticism for failing to address the challenge properly.

And yet, despite “knowing” the many root causes, we conveniently forget that there’s no predictable cause and effect relationship — many (if not most) people with some or even all of those challenges don’t end up homeless. That’s because the housing system is complex, and complex systems don’t lend themselves to simple cause and effect explanations. Even if they did, deciding what’s best is never simple, because personal and societal values enter into the analysis. There will always be tradeoffs, and there will never be 100% agreement. Is it better to ensure that everyone is housed, regardless of the cost, or is it better to do the best we can within a specified budget? Do we give the homeless a wide range of options, so that they have some autonomy, or do we limit their options, for the sake of efficiency? Can we do good without being perfect?

People and PROBLEMS are complex, in part because personal choices matter

The authors of that government report (and many since) were adamant that the homeless, by and large, do not choose homelessness, but rather are “forced” into their situation by external factors beyond their control.

This reflects a common oversimplification known as the “moral dyad”, which holds that

“… there are two clusters of beliefs that we hold about other humans. One cluster concerns agency. We think of other humans as having the ability to make choices, form plans, and work toward goals.

The other cluster concerns feelings. We think of other humans as having the capacity to experience sensations. We are especially inclined to notice when other humans feel pain.

The Moral Dyad model says that in any moral situation we are inclined to view one human or group of humans as having all of the agency, while the other individual or group feels all of the pain. That is, instead of recognizing that both sides have agency and feelings, we gravitate toward taking an either-or view of the situation.”

The Moral Dyad, by Arnold Kling

In other words, while we see ourselves as having both agency and feelings, we see other people as having either the responsibility for and ability to affect the situation or suffering the emotional consequences of the situation they find themselves in, but not both. We therefore see those who take action as oppressors (when their actions harm others) or saviors (when their actions benefit others). The powerless become victims. The homeless, in this framework, are the victims of barriers, discrimination, high housing costs, low incomes, etc., etc. They need rescuing (by activists, advocates, charities, agencies, etc., etc.).

However, philosophers have long debated the contributions of the homeless individual’s actions and choices.4 They do have agency. Their choices can be seen as “rational” (i.e. a conscious decision to live a “free” life5) or “deviant” (i.e. deciding not to comply with society’s expected norms regarding self-discipline and engagement with banks, government, law enforcement, etc.). Sometimes, rational choices are made on the basis of short-term gain, ignoring the long-term risks. It might be rational to try that first glass of wine because it pairs well with the main course, but there’s a risk, for some, that one glass of wine leads to another, and another, then to alcoholism, and then to homelessness.

As a concept, therefore, the concept of homelessness is now and always has been a “gigantic agglomeration” or “stupefying abstraction”, lumping together “an unthinkable variety of disparate stories and circumstances”. Every homeless person is unique. To declare that “personal choice” is NEVER among the causes of homelessness implies that the homeless cannot make personal choices to end their homelessness. That’s obviously untrue, insofar as the path out of homelessness involves many choices, including whether or not to engage with social services; to pursue, accept, and adhere to treatment for their predisposing illness(es); to accept housing and the associated rules that may not be everything they desire; and so on.6

Why does this matter? Questions are manageable, PROBLEMS are intractable

We’ve fallen prey to the assumption that “fixing” all of the external causes will be necessary to eliminate the entire homeless PROBLEM and, conversely, that there’s no hope of fixing the PROBLEM without addressing each and every causal factor for each and every victim. No single solution will meet every challenge. Any solution focused on one root cause will be open to challenge for ignoring another root cause. We have to go big or go home! Good isn’t good enough, we need nothing less than perfection!

Homelessness, in short, has become a PROBLEM. Here in Halifax, for example, we have literally beaten the bushes in search of homeless people, and then we’ve surveyed them to determine the history of their plight. It doesn’t improve when you over-simplify by sorting them into four basic groupings: unsheltered, emergency sheltered, provisionally accommodated, and “at risk of homelessness”.7 Whatever you do, you’re lumping disparate individuals together into groupings which aren’t helpful, in any practical sense.

This infatuation with PROBLEMS and the pursuit of comprehensive solutions has consequences.

First, in applying root cause analysis to complex systems, we transform predicaments into industrial-strength abstractions. PROBLEMS become so big, with so many causes (and, therefore, so many possible solutions) that individuals and communities cannot hope to deal with them without political support, dedicated organizations and facilities, knowledgeable staff, and, above all else, money. It takes a lot to get that going! While we’re waiting, the PROBLEM continues.

In the end, entire industries are dedicated to climate change, homelessness, addictions, etc. Once those are in place, they have momentum. Jobs are created, spaces rented, agencies formed, policies and procedures written and implemented, government funding is layered on, all with the associated government bureaucracy to keep everything aligned. Livelihoods and self-respect come to depend on the PROBLEM continuing to exist. It’s rare for advocacy organizations and activists to work themselves out of a job. Any reductions in government funding are seen as discriminatory. Individual victims come and go, but the PROBLEM is never solved.

By way of proof, consider Ending Rough Sleeping: What Works? An International Evidence Review. It’s a 76-page report purporting to “explore what works to end homelessness”, published in 2017 in association with the 50th anniversary of Crisis, an ironically named British charitable organization committed to ending homelessness. Crisis purports to know that “…the problem can be solved”, because homelessness “...is the result of a societal and policy failure”. Clearly, hundreds of things might help, in the right circumstances, but identifying the ultimate root cause as societal and policy failure hasn’t fixed things. Crisis might claim to know what it takes to end the homeless crisis, but they hadn’t succeeded in their first 50 years.8 In fact, they confidently predicted in 2017 that “If nothing is done to address the issue, rough sleeping is predicted to rise by a further 75 per cent within 10 years.” They’ve become one of those agencies that David Cayley describes as extracting the resource and depending on the periodic discovery of new deposits to stay in business. I suspect they’ll be around to celebrate their 60th anniversary next year, bigger and better than ever!

Another problem, as David Cayley pointed out, is that any purported solutions are often determined by what’s available (or, dare I say, profitable for someone?), rather than what’s best or what works. Post hoc evaluation is fairly rare. Aid workers rarely admit that their well-meaning efforts are at best useless or at worst harmful. They’ll quote carefully curated anecdotal examples of success (without totaling up the numbers so helped), while arguing (as Crisis does) that they still need more resources, because the PROBLEM is worse than ever.

Where to from here?

Given the size of the PROBLEM-solving apparatus, it’s never nimble. We pretend that dysfunctional social systems are like machines in need of new, better, or additional parts. However, complexity science tells us that the preferred approach to problem solving in complex systems is to avoid detailed planning and large-scale implementations.

We need to stop looking for the root causes and the big “Hail Mary” fixes. We should accept that we don’t know everything, and we can’t fix everything.

David Cayley suggests that we simply ask questions and respectfully talk about the issues of the day, exploring different points of view and all possible remedies, looking for a path through the maze. He suggests avoiding the abstractions and the tendency to make everything too big. He also warns against closed minds.

That doesn’t mean we do nothing. It’s far better (and safer) to try smaller things, fail fast (some of the time), and learn fast, changing direction quickly based on what helps and what doesn’t. Bearing in mind that we all have different knowledge, skills, beliefs, and values, all suggestions should be open for consideration, rather than shutting down discussion by labelling diverse opinions as misinformation or “wrong think”. Sometimes the “craziest” ideas turn out to be correct!

Some experts humbly call this “muddling through”. It’s actually a sophisticated method for problem solving in complex situations. You identify some measurable aspect of the situation, set a realistic short-range target for improvement (accepting that you won’t fully eliminate the situation), and then try out a few things that seem like they might help (like some of those ideas in that 76-age Crisis report).

This kind of approach isn’t new (or crazy). Consider the following, written in 1959:

“Policy is not made once and for all; it is made and re-made endlessly. Policymaking is a process of successive approximation to some desired objectives in which what is desired itself continues to change under reconsideration. Making policy is at best a very rough process. Neither social scientists, nor politicians, nor public administrators yet know enough about the social world to avoid repeated error in predicting the consequences of policy moves. A wise policymaker consequently expects that his policies will achieve only part of what he hopes and at the same time will produce unanticipated consequences he would have preferred to avoid. If he proceeds through a succession of incremental changes, he avoids serious lasting mistakes in several ways.”

The Science of “Muddling Through”, by Charles Lindblom, 1959

So, we can make headway by doing small, perhaps imperfect, things locally, working with the “victims” rather than trying to solve their problems for them. We can help the local guy who needs a square meal without solving world hunger first. We can get him indoors (if that’s his choice) without redesigning the national housing market.

When it comes to homelessness, then, we should be mindful of Occam’s Razor, which tells us that, all other things being equal, the simplest explanation is usually the best one. The commonest immediate causes of homelessness are substance use, domestic violence, and mental illness. When half of the homeless population suffers from addiction, they need addiction rehabilitation facilities, rather than safe injection sites and safer supply. Victims of domestic abuse need protective shelters, not encampments. We do the mentally ill no favors by assuming they can make their own rational housing decisions, when what they really need is treatment. None of these groups will benefit from some abstract government program to improve housing affordability, or by the UN declaring housing to be a right.

Another simple thing to remember is that the homeless come and go, which is to say that only about 10% are “chronically homeless”, and most of those are chronic addicts.9 Yes, a “point-in-time” survey, such as those done in Halifax, will turn up a lot of people who are unhoused, but for most of them it’s a temporary situation.10 The very fact that homelessness can be temporary and, in many cases, quite short-lived, tells us that (a) the events triggering homelessness sometimes resolve themselves, and/or (b) people can and do find their own solutions, and/or (c) the help available is effective, at least some of the time. Yes, it would be nice to eliminate homelessness altogether, but that may not be possible. Just as seatbelts and airbags reduce injuries without preventing car accidents, perhaps our existing homeless programs, while not preventing homelessness, are helping more than we realize. Have we surveyed those who were temporarily homeless to see what “worked? Which interventions are both simple and effective? Do we lose sight of all the good we are doing when we focus too much on the unchanging total and learn nothing from those who are no longer homeless?11

We do need to remember that solutions that work for one person or group in one location may not work for everyone everywhere, for any of a number of reasons. Local conditions matter, which is another reason to avoid big, standardized approaches. The solution that helps in our community, using our resources, is the best for us, for whatever reason. Another community may need a totally different approach.

What matters is that making things better, in any way, is progress, and should be celebrated. Yes, progress is likely to be incremental, and sometimes there will be slippage. Expecting the complete elimination of any given societal challenge is a recipe for failure and disenchantment. Looking for the big fix is more likely than not to lead to paralysis of thought and deed.

Whatever we do, we need to encourage individual agency. When those affected are labelled as victims, personal action seems useless.12 When homeless people see themselves as the hapless victims of something much bigger than they are, they give up, looking to others to fix their predicament, rather than believing that they can do anything for themselves. Addicts no longer pursue abstinence but throw themselves on the mercy of systems designed to keep them using addictive drugs (safer supply and opioid-agonist therapy, for example). Abused women and children trade abusive homes for abusive camps, accepting abuse as the way of the world. The mentally ill go untreated, and their mental health deteriorates with their surroundings.

What’s more, the victim label leads us to infantilize the afflicted. We let them get away with behaviours that we wouldn’t accept otherwise. Homeless addicts are excused from obeying the standards of society. They build camps in public spaces, hoard trash, cook indoors over open fires, use drugs in public spaces, and panhandle at every intersection, as though there are no social programs and they’ve lost the ability to follow any societal rules, no matter how fundamental. In some cases, we actually incentivize the very behaviours we want to eliminate. Additional resources are deployed to support people living in encampments or temporary shelters, when, in many cases, it would be far better and more economical to address their immediate challenges and support them with existing social programs and treatment services in proper housing.13

Above all, we need to remember that all of our human systems are value laden. The “facts” and the “science” are never neutral; success means different things for different people. There are few values upon which 100% of the population can agree. Some might argue that housing is a right, and that everyone deserves a guaranteed basic income, while others might feel that individuals should be incentivized to earn their own money and put a roof over their own head.

Sure, all social systems evolve, as do the values upon which they are founded. None are completely problem free. Utopia doesn’t exist. There will never be a clear-cut “right” answer for every problem.

In the final analysis, as David Cayley suggests, it’s better to avoid over-thinking and over-complicating everything. No more PROBLEMS! Focus on solutions.

Briefly, those groups all play by some version of “the rules”. To a greater or lesser extent, all three groups share the beliefs that there is knowledge (which can be discovered, shared, and utilized), that society has governing institutions (which have rightful authority and can be influenced), and that collective decisions may be imperfect but strive for the “greater good”.

Experts have credentials, backing up their opinions with “evidence”. Advocates seek to bring about change, often at the government level, through debate, argument, lobbying, advertising, etc. Activists are more disruptive, trying to effect change by interference, including protests, blockades, etc.

And then there are Anarchists.

It may seem odd to think that Anarchists exist in this day and age, given the association of the term with the communist (Marxist-Leninist) revolutions of the late 1800’s and early 1900’s. However,

“Anarchist ideas and movement tactics have gained wider influence on a growing variety of other social movements since the last decades of the 20th century. Anarchist movements have themselves grown during this same time period and have arguably become more prevalent than they were during the mid‐20th century.”

Contemporary anarchist and anarchistic movements, by Dana M. Williams

“… a large part of the anarchist movement today is submerged rather than overt. While there do exist self-defined formal anarchist organizations (such as the British and French Anarchist Federations), the bulk of the movement operates through informal and ad-hoc political formations, often without an explicit anarchist label, and obscured by the broader alternative globalization, environmental and antiwar movements in which it is embedded.”

“The architecture of today’s anarchist movement can thus be described as a decentralized network of communication, coordination and mutual support among autonomous nodes of social struggle, overwhelmingly lacking formal membership or fixed boundaries.”

Anarchism reloaded, by Uri Gordon

So, there’s no single Anarchist movement, but Anarchist ideas and tactics live on in various smaller scale “antiauthoritarian,” “autonomist,” or “libertarian‐socialist” movements.1

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What are Anarchists aiming for?

Briefly, Anarchists oppose many of the ways in which our society is currently structured, including capitalism. They envision something completely different.

“Anarchist identity is diverse, although anchored around an opposition to dominant culture, institutions, and hierarchical norms. The values and goals pursued revolve around a principled adoption of horizontalism, direct action, antiauthoritarianism, decentralization, anticapitalism, and mutual aid.”

Contemporary anarchist and anarchistic movements, by Dana M. Williams

At the same time, Anarchists aren’t well-organized or understood.

“… anarchism hasn’t been the most well-defined of ideologies, and …. anarchist movements tend to appear disjointed and hodge-podge, a haphazard gathering of motley students and dispossessed workers, who may not always be on the same page.”

A Brief Explanation of Anarchism, by Nick Gutierrez

The upshot is that any interaction with Anarchists won’t follow “the rules” as most of us understand them. Anarchists contest the means by which knowledge is discovered, shared, and utilized. They don’t automatically recognize institutional authority. They question top-down decision-making.

In some cases, they even rewrite the dictionary, redefining commonly used words. If you’re starting to feel like Alice in Wonderland, you may be talking to an Anarchist.

“When I use a word,’ Humpty Dumpty said in rather a scornful tone, ‘it means just what I choose it to mean — neither more nor less.’

‘The question is,’ said Alice, ‘whether you can make words mean so many different things.’

’The question is,’ said Humpty Dumpty, ‘which is to be master — that’s all.”

Through the Looking Glass, by Lewis Carroll

How will you know an Anarchist when you see one?

First, there’s the organizational structure, which is horizontalist and decentralized.

Anarchists oppose the “domination” of one group by another. Historically, they opposed the exploitation of the working classes by those who owned the means of production. Now, they oppose any form of “oppression”.

Horizontalist organizations aim to be popular, autonomous from centers of powers, collectivist, and directly democratic. These orientations are at odds with hierarchical decision making and top‐down leadership…. Relatively small organizations, impermanent or limited leadership, inclusive communication styles, and consensus decision‐making strategies are manifestations of these directly democracy [sic] anarchist values within organizations. Such values are ideals and thus are never fully realized in practice.”

Contemporary anarchist and anarchistic movements, by Dana M. Williams

“… the rejection of ‘all forms of domination’—a term encapsulating the manifold social institutions and dynamics (most aspects of modern society, in fact) which anarchists seek to challenge, erode and ultimately overthrow. It is this generalization of the target of revolutionary struggle from ‘state and capital’ to ‘domination’ that most distinctly draws contemporary anarchism apart from its earlier generations.”

Anarchism reloaded, by Uri Gordon

The Anarchist goal, therefore, is to be democratic, inclusive, and consensus-driven. However, as anybody who has ever been part of any decision-making group will know, it’s very difficult and time-consuming to involve everyone equally and then to achieve consensus. The difficulty increases exponentially as the number of group members increases, particularly when being antiauthoritarian means there’s limited leadership. It’s no wonder that these ideals are “never fully realized in practice”. It’s also not surprising that Anarchist groups tend to be small and impermanent. Functional examples are hard to come by!

Then again, some claim this to be a strength of Anarchism, in that it has no fixed target but rather aspires to be a form of “continuous quality improvement”.

“… anarchists’ discourse strongly expresses an open-ended tendency, eschewing both the notion of revolutionary closure and unitary blueprints for an ‘anarchist society’, in favour of a project based on diversity and perpetual experimentation.”

Anarchism reloaded, by Uri Gordon

Next, there’s the tactics. Anarchists take it on themselves to solve problems “directly”, in contrast to Experts, Advocates, and Activists, who seek to convince others in authority to take action (thereby solving the problem “indirectly”).

“Direct action is a key anarchist value, which aims to achieve ends immediately without appeal to intermediaries - especially politicians, elites, or other state actors…. Direct action includes a variety of approaches, from confrontational street tactics to the creation of counterinstitutions…. More broadly, direct action works with the goal of antiauthoritarianism, opposing not only the power of hierarchical institutions to dominate but also the ‘rights’ upon which they exist and purport to exercise such power. This antiauthoritarianism extends to a wide array of institutions, such as capitalism, patriarchy, White supremacy, colonialism, militarism, and the state.”

Contemporary anarchist and anarchistic movements, by Dana M. Williams

“Direct action… refers to any immediate attempt to self-manage one’s own affairs. Instead of asking other people to act on one’s behalf, the philosophy of direct action encourages people themselves to act. Thus, people do the things that are needed, acting either individually or collectively.”

Tactics: Conceptions of Social Change, Revolution, and Anarchist Organisation, by Dana M. Williams

Of note, direct action can be destructive (as in destroying the equipment used to harvest an old growth forest, or sabotaging a fossil fuel pipeline) or constructive (as in setting up a commune to model an alternative political and economic structure, or demanding that everyone else use language as defined by the Anarchists).

In taking direct action, Anarchists don’t simply bypass those in authority; they question the fundamental right of anyone to claim and exert any authority. Given the wide array of stablished “institutions” and hierarchical structures in our society, real and imagined, it’s no surprise that Anarchists find a lot of domination to oppose, and that groups opposed to one form of domination (or oppression) align themselves with groups opposed to another.

“The term domination thus remains inclusive of the myriad articulations of forms of oppression, exclusion and control by those subject to them, at countless individual and collective sites of resistance. This does not, of course, imply that the same mechanisms feature in all of these relations, nor that they operate in identical ways.”

“While what is resisted is, at the bottom of things, domination as a basic social dynamic, the resistance is seen to proceed through confrontation with the institutions through which this domination is administered. On such a reading, institutions such as the state, the capitalist system of ownership and labour—and also institutions such as the family, the school and many forms of organized religion—are where the authoritarian, indoctrinary and disciplinary mechanisms which perpetuate domination-regimes are concretely located.”

Anarchism reloaded, by Uri Gordon

Anyone who opposes domination finds a home in Anarchist ways of thinking. Intersectionality and Anarchism fit well together!

Finally, Anarchists seek to model the world they want to see, and so their organizational values, structure and tactics are intertwined.

“Anti-authoritarianism is a value that emphasises how tactics cannot be owned or restricted—thus, no one person or small group can dictate the selection or execution of a tactic. Horizontalism requires that everyone have equal control over a tactic (insofar as people consent to participation); anarchist tactics aim to level the playing field for everyone, including those not participating in the tactic. Self-management implies that people who are acting ought to be able to determine for themselves how they reach their goals, especially in terms of short-term decisions. Thus, anarchist tactics are not only crafted with such anarchist values in mind but are also created and decided upon via these values, with the ultimate goal of extending such values to the rest of society, in a virus-like fashion where people are inspired to adopt anarchist tactics for themselves.”

Tactics: Conceptions of Social Change, Revolution, and Anarchist Organisation, by Dana M. Williams

Yes, that sounds like a recipe for chaos (or, dare I say it, “anarchy”)! Nobody is in charge, everybody has equal control, and everyone makes decisions based on what’s best for them. Furthermore, Anarchists don’t waste time talking, they get out there and “do” things, the goal being to set a shining example for the rest of society to follow.2

“Anarchist tactics aim to accomplish two things simultaneously. First, they oppose things that anarchists considered to be bad, such as hierarchy, repression, and inequality. In this respect, tactics serve a diagnostic function that negatively frames societal characteristics with an anarchist analysis. Second, anarchist tactics promote things that anarchists consider to be good, like horizontal relationships, liberation, and egalitarianism. Thus, tactics are also prognostic frames that suggest better, more positive forms of social organisation.”

Tactics: Conceptions of Social Change, Revolution, and Anarchist Organisation, by Dana M. Williams

What are Anarchist tactics?

Anarchist tactics are quite diverse. Sometimes, when it suits their purpose, Anarchists align themselves with nonanarchists.3

“Mass organizing involves anarchists working alongside nonanarchists to build social movements capable of challenging capital, state, and other adversaries. Insurrectionism includes efforts to directly and violently attack those adversaries, typically through assassination attempts and bomb-throwing upon the rich and powerful. Finally, prefiguration incorporates anarchist values into practical actions, such as the creation of alternatives to mainstream social organization, lifestyles, and counterinstitutions (e.g., communes and cooperatives)….

The strategies pursued and tactics employed by anarchists are not exclusively anarchist in origin, nor do the people who use them necessarily self‐identify as anarchists. Most prominently, anarchists use a variety of street‐based tactics that attempt to control the streets, demonstrate the practicality of anarchist values and ideas, and achieve short‐term tactical goals.”

Contemporary anarchist and anarchistic movements, by Dana M. Williams

So, Anarchists don’t always brand themselves as such, and not everyone using Anarchist tactics is necessarily an Anarchist. By definition, given their opposition to hierarchy and centralization, they won’t have an organizational website outlining their membership structure, policies and procedures, leadership, and tactics. All of those will shift, according to the issue at hand.

“The defining characteristics that place an individual or organization into an antiauthoritarian camp, such as anarchism, are professed values, preferred movement structures, and chosen actions. An established anarchist identity is what separates explicit anarchists from implicit anarchists. Thus, antiauthoritarians fall into two categories: anarchist‐in‐name or anarchistic‐in‐style. Explicit anarchists—also called “capital‐A anarchists”—are most apt to form consciously anarchist collectives, create federation structures among multiple organizations, and identify strongly with past anarchist movement waves.”

Contemporary anarchist and anarchistic movements, by Dana M. Williams

In the end, you’ll know you’re probably dealing with Anarchists (in style, if not in name) when they aren’t following any sort of rules, they actively question whatever rules you thought were in place, you can’t tell who’s in charge, they refuse to accept that you or anyone else has any authority, you can’t tell what they really want, and what they want changes from one participant to the next. You may also find that they refuse to accept any basic “facts” upon which to base their discussions with you.

In practice…

That may all sound a bit theoretical. It helps to look at specific examples in which Anarchist values and tactics are apparent.

First, I’ll discuss an article entitled An Anarchist Approach to Addressing Housing Precarity: Implementing Anarchist Strategies to Program Efforts for Housing Justice, by Jayne Malenfant and Hannah Brais of the Department of Integrated Studies in Education at McGill University, Montreal. This article has the advantage of being specifically about Anarchist strategies, and it highlights the challenges inherent in translating those strategies to practical action.4

First, there’s the questioning of capitalist beliefs, including home ownership or rental and, more fundamentally, the need to earn a living.

“Housing precarity within this system is compounded by a capitalist and financialized housing landscape for which the State is increasingly being called to action. To become un-precarious, or experience housing stability in the context of the Canadian State, expectations typically culminate in idealized, individualized participation in the rental market, or private homeownership narrow and commodified forms of housing stock.”

“This market model sustains colonial structures of relations where people live alone and without community support; it also implies that an individual should be earning a living to pay for their housing and, hence, should where possible, participate in the formal labour market.”

“In expecting those who are vulnerable to housing precarity to only participate in market housing, we expect them to participate in the perpetuation of the very system leading to their housing precarity in the first place.”

The authors overtly question government authority.

“… anarchist thought rejects the inevitability of State interventions as the solution to homelessness, since the State necessarily represents an unjust hierarchy of power and resources.”

And there’s intersectionality. The unhoused have a lot of oppressed allies.

“… State housing responses perpetuate an individualized narrative of housing that fails to reckon with Indigenous understandings of home. This narrative upholds colonial narratives of private property and Indigenous dispossession that simultaneously sustain settler models of heteronormativity, monogamy, sexism, classism and racism. Critiques of individualized and normative notions of home and land from First Nations, Inuit and Métis communities in Canada connect to broader calls to reconsider narrow understandings of home from a number of communities facing precarity, racist, gendered, homophobic and ableist discrimination from the capitalist State.”

There’s an appeal to direct collectivist action.

“We argue that to build just housing futures, responses to homelessness must ensure that those who are currently considered precariously housed and homeless are served, immediately, as best we can – even as we work to build alternative responses based on mutual aid, solidarity, and agency. When considering housing precarity, anarchist theory asks us to shift our focus from individual responsibility, in favour of building mutual capacity to meet the housing needs of everyone.”

Paradoxically, despite the anarchist value of “self-management”, which implies that people ought to determine for themselves how they reach their shelter goals, the homeless, in this case, are absolved of individual responsibility for their plight and its solution, favoring the building (by someone) of “mutual capacity”.

The authors themselves purport to speak on behalf of the unhoused. Their expectation that the unhoused be “served, immediately” does imply a hierarchical relationship in which somebody serves somebody else. Paternalism, however, is to be avoided.

“In order to keep this systemic grounding, we can borrow from anarchist approaches to ensure that increasingly intersecting responses do not mirror paternalistic interventions of the past but are grounded deeply in a ‘politics of solidarity’.”

It’s not clear how any of this might translate to immediately satisfying the housing needs of everyone. Whatever the authors are proposing, it can’t be commodified, government-run, or paternalistic.

“… commodified housing cannot be a means to achieve housing justice. Additionally, voluntary and direct participation is necessary to build anarchist futures, so advocacy and change that is dictated by ‘experts’ (e.g. researchers or elected officials) and paternalistic decisions being made by a select few cannot achieve housing justice. Within a prefigurative politics of addressing housing precarity, we must eschew capitalist State systems – which are predicated on the precarity and displacement of particular groups as well as the commodification of housing – in order to create systems that are inherently just.”

Having presented that example, I can suggest any number of other situations in which Anarchist values and tactics appear.

For example, in the debate about drug policy:

• there are those who remind us that addictions disproportionately affect “the oppressed”

• language is manipulated, such that addiction is reframed as a “brain disease”

• in that vein, supplying addictive drugs to addicts becomes “safer supply” or “harm reduction”, in theory modelling a “better” approach

• some go so far as to model different ways, such as directly supplying “safer” drugs to addicts, in defiance of the law

• expert opinion is discounted, in favour of those with the “lived experience”

In the debate about gender:

• language is manipulated (i.e. “trans women are women”)

• accepting someone’s self-proclaimed trans identity (and proceeding with medical and surgical interventions) is framed as “affirming”, lifesaving, etc.

• research into the long-term effectiveness and consequences of the new approach is discouraged, effectively favoring anecdote over more rigorous ways of developing and testing medical interventions

• those who question any of the above are “cancelled”, being labelled as “oppressors” (transphobic, etc.)

In each case, when the basic assumptions differ, all of the rules of discussion and debate fall apart:

• a conversation about environmental policies will be challenging when one group bases their arguments on science and the other group relies on their verbal history, ancestral lived experience, and “traditional ways of knowing”.

• it will be difficult to decide how to make housing affordable when one of the parties questions whether landlords (or indeed anyone) should “own” property and expect any return on their investments, or indeed whether those who supply the raw materials for housing and/or assemble those materials deserve to be paid for their efforts.

• the conversation about tent encampments for the homeless changes when one side believes that government has no right to dictate how public space will be used, or by whom.

• a conversation about women’s rights is difficult when the discussants can’t agree on the defining characteristics of a woman.

For those of us who aren’t Anarchists, dealing with those who are, Jasmin Laine offers some helpful advice:

“There is a profound difference between someone who is confused and someone who has already decided who you are. One is open. The other is armed. One asks questions to understand. The other asks questions to corner you, frame you, or catch you in something they can use later.

And while you may not always be able to recognize the underlying intent… often masked with disingenuous behaviour or words to lure you in and make you want to plead your case and explain, you can feel the difference if you’re honest with yourself.

You can clarify forever. You can provide context. You can soften your tone, over-explain your thought process, bring receipts, cite dates, and offer nuance. Still, it won’t matter. Because the goal was never clarity. The goal was control. Or chaos. Or the validation of a story they’ve already written about you and sent off to the press.

You don’t owe explanations to people who are committed to misunderstanding you.”

“Sometimes stepping out of the ring isn’t losing. It’s finally realizing you don’t need to fight.”

Why are these things important?

Imagine there’s a problem out there.

You may be unaware of it, in which case, perhaps, you need to become aware of it. To be clear, however, we don’t need every person in the world aware of every problem in the world. For one thing, none of us has that much brain capacity or compassion.

Even when you are aware of the problem, you may be uninterested, because it doesn’t affect you personally and/or you believe there’s nothing you can do about it.

Once you are aware of the problem and think you can play a role in solving it, you have to decide that you want to. Any solution has to be compatible with your interests, skills, values, availability, etc.

After all that, you have to decide to actually take action. Whatever you do can be effective or ineffective, helpful or unhelpful, sustainable or unsustainable, etc.

In short, a lot happens between seeing the problem and implementing the solution. Experts, advocates, activists, and others all take different approaches.

Experts know what they are talking about and, so long as they stick to what they know, can offer you informed opinions and expert advice. That assumes you’ve become aware of a problem, think it needs addressing, and realize that you need help from those who know more than you do.

Often, experts get involved on request, for a fee, because it’s their job. We call them professionals. If you want to know how to construct a bridge that won’t fall down, you might hire a structural engineer. If you want to know why your joints hurt and what can be done about it, you might consult a doctor.

Other experts hang out in academia, where they earn a living doing research and teaching. Some do consulting work on the side, linking theory with practice.

Advocates offer unsolicited opinions. In essence, they’ve become aware of a problem, decided it’s of interest to them, looked at the evidence, formed their own opinion as to what should be done, and now seek to convince and recruit others.

Some advocates are subject-matter experts. In becoming advocates, they give up a bit of their objectivity, and they may also start to overlook the fact that many decisions are value-based, at least in part. There might be many types of bridge that would work in a specific location without falling down, but the engineer who insists on a suspension bridge may have a conflict of interest (his company builds suspension bridges) or a particular bias (she likes the way they look). The surgeon who suggests replacing your achy hip joint might not understand the alternatives (in part because those who get better without surgery don’t see surgeons).

Experts who advocate may or may not have any expertise in advocacy, which can limit their effectiveness as advocates. To get around that problem, there are experts in advocacy, lobbyists for example, who can be hired to advocate on behalf of others. These professional advocates may know little or nothing about the thing they advocate for, beyond the “key messages” they’ve been given, but (presumably) they know how to get the message across. They are salespeople.

Either way, advocates tend to play the influence game according to “the rules”. Lobbyists, for example, are often required to register, and they seek to convince through dialogue, petitions, etc.

“Tactically, advocacy’s approach is usually diplomacy; gaining support for ideas and amplifying the voices of people drawing attention to their own issues.”

“… advocacy is usually associated with professionally acceptable behaviour and poses few negative consequences to the advocate…”

Nursing advocacy and activism: A critical analysis of regulatory documents, by Lydia Mainey et al

Advocates, therefore, seek to convince, rather than coerce. They raise awareness, build interest, recruit problem-solvers, and marshal resources. They are team-builders.

Put another way, experts and advocates rely on “social capital”. Their effective functioning depends on their interpersonal relationships, shared sense of identity, shared understanding of how things work in their world, shared behavioural norms, and shared values, including trust, cooperation, and reciprocity.

And this brings us to the next category of opinionated people, Activists.

While some confuse activism with advocacy, they are different. The goals are the somewhat the same, but the tactics are different.

“Advocacy and activism are dynamic terms and often used interchangeably. However, they represent a spectrum of political action; essentially, advocacy influences while activism overhauls, each with the aim of achieving political or social change.”

“Activism’s approach is often, but not always, confrontational, disruptive and subversive, taking more radical action to challenge ideas and working outside of the system to enact change.”

“… activism is more often associated with abject behaviour and has greater consequences.”

Ibid

Or, as another (less tactful) author put it:

“Do not give institutional power to activists, as activism—being power without responsibility that readily lauds bad behaviour—attracts manipulative ‘Cluster B’ personalities. Moreover, activism degrades realms of human action by imposing pre-conceived outcomes and constraints on them.”

Totalitarians and useful idiots, by Lorenzo Warby

For those unfamiliar with the term, the Cluster B personality disorders include:

• Antisocial personality disorder, describing people showing a lack of respect toward others, who generally don’t follow socially accepted rules.

• Borderline personality disorder, describing people who have difficulty regulating their emotions, resulting in low self-esteem, mood swings and impulsive behaviors.

• Histrionic personality disorder, characterized by intense, unstable emotions and a distorted self-image, resulting in an overwhelming desire to be noticed and being easily influenced by others.

• Narcissistic personality disorder, describing people who feel they are better than others, including an intense need for praise and a lack of empathy for others.

Activists, in other words, struggle to build and leverage social capital. They seek “change” without bothering to develop expertise, and they’re too impatient to play by the rules. Expertise, discourse, dialogue, debate, advocacy, institutional structures, and processes are all inherent features of “the system”. Activists, for various reasons, challenge the system, even (or especially) when the system includes checks and balances. They can’t agree among themselves.

“Many activists seek to distance themselves not only from the regime, but also from opposition political parties. All parties, these critics argue, are part of the regime because they play by the regime’s rules, and thus any real resistance must take place elsewhere. Some activists mock those who eschew grassroots organization in favor of mobilization on social media. Others are skeptical of institutionalized activism, either via non-governmental organizations or other forms of civil society. They argue that institutionalized opposition is beholden to foreign donors as well as the bureaucratic demands of running an office in ways that trade the uncertain horizon of radical opposition for the routine politics of relative stability and security.”

What Is Activism?, by Jillian Schwedler and Kevan Harris

So, activists are passionate people seeking power and influence without responsibility. Activists challenge the status quo in things they know little about (they are not experts), have little experience of (they are outside the system), and often are not personally affected by (they appoint themselves to speak for others). They want to jolt you into awareness and force you to take behave differently, regardless of your interests, skills, availability, etc. They don’t really care whether you share their concerns, values and beliefs.1 In consequence, they’ll readily speak on behalf of others, without any specific mandate to do so. Nobody elects activists.

“The [activist] forever speaks about speaking for various marginalised groups. But their speaking for is self-appointed, it does not mean representing. On the contrary, [activists] are ever-ready to judge who is an acceptable, or not, member of such groups and to define the proper role members of the designated marginalised or oppressed groups should play, regardless of members of such groups actual views. Activists are almost never chosen by the group they purport to speak for.”

Totalitarians and useful idiots, by Lorenzo Warby

Activists can be professional or amateur, skilled or unskilled, paid or unpaid.

“Some activists may be trained scientists, but this is less common. Professional activists probably have training in media and communications, which scientists often lack.”

“Amateur (unpaid) activists may have scientific or communications training (especially those that do so as volunteers for NGOs), but the majority of amateur activists are concerned members of the general public.”

‘Advocacy’ and ‘Activism’ Are Not Dirty Words, by E.C.M. Parsons

Why do activists do what they do? The answer is that they see themselves as “superior deciders”, endowed with moral superiority. They have an exaggerated sense of their own ability to tell the difference between right and wrong, coupled with a sense of urgency and an unwillingness to waste time listening to and/or convincing others. Cluster B traits, in other words.

In the words of Thomas Sowell, activists have an “unconstrained vision”.

“Those with an unconstrained vision distrust decentralized processes and are impatient with large institutions and systemic processes that constrain human action. They believe there is an ideal solution to every problem, and that compromise is never acceptable. Collateral damage is merely the price of moving forward on the road to perfection. Sowell often refers to them as ‘the self-anointed’. Ultimately, they believe that man is morally perfectible. Because of this, they believe that there exist some people who are further along the path of moral development, have overcome self-interest and are immune to the influence of power and therefore can act as surrogate decision-makers for the rest of society.”

A Conflict of Visions, by Thomas Sowell, as summarized on Wikipedia

In the final analysis, despite claiming to represent others, activists represent themselves. Their “morality”, in their view, justifies their social aggression. They seek to accomplish their goals through disruptive tactics, including demonstrations, protests, sit-ins, strikes, marches, and even riots. Collateral damage is inevitable. It may even be the point. The end justifies the means.2

Not all activists are created equal. There are degrees of activism.

At the benign end, we find “slacktivists”, otherwise known as “armchair activists” or “performative activists”, who perform token displays of support for a cause, without any effort to enact meaningful change. These are, if you like, “inactive activists”, for whom being seen may be more important than being effective.

“Slacktivism has often been derided, as simply sharing and ‘liking’ information on social media, or signing and sharing an online petition. These acts might make the slacktivist feel that they are contributing to a cause, but their actions may have negligible real-world impact.”

‘Advocacy’ and ‘Activism’ Are Not Dirty Words, by E.C.M. Parsons

Some slacktivists are individuals, others are groups or even corporations.

“…the term “performative activism” began circulating even more widely as an accusation describing shallow, ineffective, or insincere attempts to jump on the antiracist bandwagon mainly to self-promote and build one’s own personal or corporate progressive credibility. Corporations may use rainbow branding simply to sell merchandise. Cities or National Football League teams may fund Black Lives Matter murals but do little else to foster racial equity. Individuals may want to appear virtuous to their friends and colleagues. Performative activism—sometimes called slacktivism, performative allyship, or performative wokeness—is not necessarily conducted through social media. It is, however, a label that has arisen in the context of activism that works through social media and other digital technologies. Performative activism is typified by reposting movement memes and slogans on social media platforms while doing little or nothing to promote those same social justice causes in other ways. Performative activism talks the talk but doesn’t walk the walk.”

What Is Performative Activism?, by Freya Thimsen

Some slacktivists are “useful idiots”. They criticize the culture that allows them their freedoms, while refusing to apply the same standards elsewhere.

“Observers today speak of “useful idiots,” using the same term to describe liberal intellectuals who enjoy freedom and prosperity, yet undermine both, by giving moral and material support to revolutionary movements hostile to “bourgeois” values. That’s actually a mild accusation against useful idiocy.”

From Useful Idiot to Useful Infidel, by Richard Landes

“It’s crucial to understand that not all useful idiots are stupid – not in the ordinary sense. Often they’re educated and articulate. The most committed useful idiots tend to have PhDs and introduce themselves as doctors. Yet all that education can obscure truths and blur moral clarity while making terrible ideas look attractive. As Orwell remarked, ‘Some ideas are so stupid only an intellectual could believe them’.

Nevertheless, some useful idiots really are just stupid…. What unites all of them is a lack of courage – the courage to trust their own eyes, ask uncomfortable questions, and pay social costs for being right rather than staying comfortable by being wrong.”

10 Traits of a Useful Idiot, by Frederick Alexander

Useful idiots, in other words, sit comfortably where their rights and freedoms are protected, while protesting against the very structures and institutions that protect them. Billie Eilish, who lives in a mansion while making comments about “stolen land”, might be one example. Another might be the groups who sit in the Western world protesting about Israelis killing Palestinians while ignoring the murder of Iranian protestors by the Iranian government.

At the opposite end of the activist spectrum, we have the “whacktivists”.

“The term ‘activist’, however, makes many scientists (and the lay public, for that matter) immediately think of more extreme activists.”

“This is exacerbated by a growing sub-category of activist, the so-called ‘whacktivist’: ‘someone who tries to convert the public into caring about an issue using inappropriate means, such as insulting those who do not agree with them and using arguments that are illogical or factually incorrect. Whacktivists often do not respect the rights of those who are opposed to them—they use bullying, harassing, and threatening violence and other criminal acts. Whacktivists often see issues in black and white and are resistant to opinions and facts that do not fit their world view.’”

“Ironically this approach is counter-productive, as Bashir et al. (2013) found that information presented by someone that is portrayed as a stereotypical environmental activist, i.e., being militant and over righteous, is actually less likely to persuade the public….”

‘Advocacy’ and ‘Activism’ Are Not Dirty Words, by E.C.M. Parsons

“The more morally grandiose the aims, the greater the cover, and the greater the sanctification of social aggression.”

Totalitarians and useful idiots, by Lorenzo Warby

Whacktivists, in other words, manipulate your behaviour using threats, including “cancellation” and public shaming.

In short, activists seek to draw public attention and concern to issues they consider to be important, even though that concern may not necessarily be evidence-based or valued by society. Their goals can be hard to determine. Some want to “raise awareness”, others to “block” something (pipelines, for example). Often, the connection between their actions and their aims is tenuous at best, as when activists glue themselves to works of art to protest our dependance on fossil fuels.

Because they distrust institutions, structures, and other people, activist groups tend to be disorganized. Individual members and sub-groups will have different opinions as to the desired outcome.3 For some activists, the disruption itself is the point! (Taken to the extreme, this chaotic approach becomes Anarchy, which will be the subject of my next post.)

“…activists on the ground know intuitively that social movements are never unified.”

“Some social movements are relatively cohesive and more skillfully advance a consistent message. But many others are fragmented, riven by divisions over strategy and vision.”

“the refusal to adopt more established forms of activism—that is, the purposeful avoidance of a framing and unifying program—is also a form of ideology.”

What Is Activism?, by Jillian Schwedler and Kevan Harris

“… we should also avoid any romantic assumptions of some authentically ‘pure’ field of activism. The activists I have encountered have all had complex, and occasionally self-serving, agendas. As we all occupy multiple subject positions, so activism is a field of contradiction and diversity.”

Activism and the Academy, by Nicholas Blomley

Activism and the Academy

It’s become increasingly fashionable for academics to claim that they are also activists. Indeed, some argue that it’s their duty.

Their arguments tend to be flawed, however.

First, some “activist academics” confuse their various roles as experts, advocates, researchers, teachers, and faculty members with activism.

“… academics may produce knowledge that, intentionally or not, informs progressive social change. Academic research may be taken up by activist and advocacy organisations for their own campaign work. Academics may contribute to policy debates and political change by participating in public debate or by direct submissions to policymakers.”

Combining academia and activism, by Michael Flood et al.

Producing knowledge, contributing to policy debates, and making submissions to policymakers, however, are clearly things that experts and advocates do. They are not activism, even when the research findings are co-opted by activists. Inventing dynamite didn’t make Alfred Nobel a warmonger, even though dynamite can be used to make bombs.

Similarly, research about activism is not activism. Done properly, it provides an objective outside perspective on the effects and consequences of activism. Done poorly, it’s not really research.

“Second, academics’ conduct of research itself may involve social change. The term ‘action research’ describes a family of research methodologies that involve simultaneously pursuing social change (‘action’) and scholarly understanding (‘research’). Action research typically is participatory, with all relevant parties in a particular community or organisation involved in examining current practice in order to change and improve it. Thus, academics may conduct activism as academic work, validating (particular forms of) activism in the name of their intellectual value.”

Ibid

Some academics consider it their role to “teach” activism, even though, at best, it’s an ill-defined body of knowledge.

“Teaching and learning are the bread and butter of university business, and pedagogy – the practice and philosophy of teaching – itself is an important site of activism. Some teachers seek to use and rework teaching and learning practices in university classrooms to foster critical self-reflection, political empowerment and collective mobilisation.”

Ibid

Finally, the plight of the academic as a dissatisfied cog in the university bureaucracy is sometimes used to justify activism.

“Finally, universities can be criticised for their inflexible bureaucratic systems and for their subordination to state and corporate agendas, for example via military and corporate funding. Challenging these agendas, for example by pushing for greater student-staff participation in university decision-making, is the fourth sense in which academia is a site of activism.”

Ibid

However, there are collective agreements and other structures in place through which universities can be changed. Renegotiating a contract is not activism.

So, is it reasonable to combine academics with activism? Personally, I think not. Others agree with me.

Ultimately, academics (and academic institutions) are there to foster critical thinking, promote knowledge, and encourage open-minded debate.

“This foundation relies on an environment where ideas can be freely explored, even if they challenge dominant ideologies or accepted norms. However, when activism intertwines with academia, it creates biases in research priorities, course content, and faculty hiring, shifting focus from intellectual rigor to ideological conformity.

Activism does not Belong in the Academy, by Rebekah Wanic

Fundamentally, the goals and tactics of activism are antithetical to the goals of academia.

“Instead of teaching students how to think critically, activism-driven education teaches them what to think, framing certain perspectives as morally or ethically superior—namely, leftist perspectives. This approach stifles debate and discourages intellectual diversity, as students and professors feel pressured to adopt or conform to dominant activist viewpoints. Over time, this erodes academic integrity and limits students’ exposure to a balanced and comprehensive education.”

“When activism guides academic discourse, academic freedom suffers. Professors and students alike often feel that they cannot freely express ideas that diverge from prevailing activist narratives without risking backlash. In fields like history, political science, and social studies, where multiple interpretations of complex issues exist, debate is shuttered, compromising the search for truth. A culture that enforces ideological conformity discourages professors from pursuing certain research avenues or proposing courses that challenge dominate activist perspectives. As a result, students miss out on a well-rounded education that includes exposure to multiple viewpoints, weakening the robustness of their education and the overall intellectual climate.”

Ibid

In conclusion…

“While activism has its place in encouraging societal change, it does not belong in the academy. Academic institutions need to balance social engagement with intellectual integrity. Universities should aim to create an environment where a diversity of viewpoints is respected and where students are encouraged to explore ideas without fear of judgment or reprisal. Maintaining a clear boundary between activism and academia allows universities to fulfill their mission of fostering critical thinkers who are prepared to engage thoughtfully with complex issues. It also protects students’ mental health by relieving the pressure to conform to activist norms, thereby encouraging a more genuine exploration of ideas.”

Ibid

Going back to the beginning…

Imagine there’s a problem out there.

Following the guidance of Frederick Alexander in his 10 Traits of a Useful Idiot, you’ll know you’re probably dealing with an activist when:

• they’re telling you that you must do something about a problem that you weren’t aware of, don’t care about, and/or have no influence over

• there’s no debate

  • they bombard you with slogans, rather than opinions and well-reasoned arguments

  • they rely on props (placards, hashtags, keffiyehs, pronouns), rather than principles

  • they manipulate language and redefine words (“Hamas are freedom fighters. Israelis are Nazis.”)

  • they’ll shoot the messenger, when the message isn’t aligned with their cause (such as calling JK Rowling, a woman, “genocidal” for her defense of women and their spaces)

  • they resort to emotional blackmail (“If you don’t affirm trans kids, they’ll kill themselves”)

• they are illogical and inconsistent

  • they support causes that would destroy them (like Queers for Palestine)

  • they keep the crisis alive and demand the impossible (partial solutions are never enough, as when the desire for equality for gays and lesbians has broadened to the entire LGBTQ2SI…. spectrum, leaving gays and lesbians feeling abandoned and, at times, on the “wrong side”)

  • they trust and quote “progressive” institutions that lie (consider WPATH and those “evidence-based” transgender care guidelines)

• they’re certain they’re right (and you’re wrong), and they face no consequences for being wrong (those who championed safer supply in BC are still employed)

To recap, experts, at least in theory, know what they are talking about. Some limit their role to “informing”, ensuring that the best information is in the right hands, at the right time and in the right format. Others offer informed opinions, spontaneously or on request, because they know the subject better than many. Of course, for any given question, there is rarely a single “right” answer, in part because things like values and esthetics enter into the equation.1 Hence, many experts present options, explain the pros and cons, and leave it to the decision-maker(s) to make the final decision.

Some experts argue this isn’t enough. They see their role to include recommendations for specific actions, such as management or policy changes. As a result, some experts appear to have an agenda; they offer their opinion AND expect others to do what they’ve recommended. This becomes advocacy. The fundamental question is whether this is something experts should feel compelled to do, because they are (more) knowledgeable, or whether it’s something they should try to avoid, because, having declared their preference for a specific course of action, they lose their objectivity and risk being wrong (hence, less credible). Some experts have actual conflicts of interest and are, by definition, no longer objective; they recommend solutions which are, in some way, personally beneficial.

Many experts are professionals, in the business of selling their knowledge and offering advice. Those who fail to meet the standards of their profession, including failures to acknowledge conflicts of interest, can be disciplined by their professional society. When they are wrong, they can be sued. A bit of professional humility is a good thing.

Advocates, by definition, offer opinions and have an agenda. Everyone has opinions; the advocates are those who make their opinions public AND push for society to change accordingly. Some are experts. Others don’t really know what they are talking about. Either way, they aren’t necessarily humble.

Let’s dig into this more deeply.

The dictionary definition of advocacy is two-pronged.

First, advocacy can describe the act or process of advocating for someone or something.

Let’s call this small-a “advocacy”, because it often acts on behalf of the individual, or a small group, within a larger system.

Lawyers, for example, having completed legal education and being qualified to provide legal services, act as advocates when they represent clients, argue cases, and work to ensure that justice is served. They bring expertise (knowledge, experience, and skills) in courtroom and legal procedures, which most individuals lack. As such, lawyers as advocates not only defend their clients’ rights but also contribute to the overall integrity of the legal system.2

This form of advocacy is expected for many professions.

Doctors advocate on behalf of their patients to ensure that tests or specialist consultations are done in a timely fashion, or that the patient’s health insurance pays for a needed medication (in accordance with the negotiated terms of the insurance policy).3

Accountants advocate on behalf of their clients to ensure that the tax laws are applied correctly.

Engineers and architects advocate on behalf of their clients to ensure that the zoning and building regulations are fairly applied to a proposed new development.

Biologists, having knowledge of an endangered species in a particular habitat, might advocate to protect that species and habitat from harm, in the context of existing legislation.

In this form of advocacy, and in each of those examples, it’s important to note that:

• the rules exist within a defined system

• the professional has expert knowledge of the system and the rules, particularly as they apply to individuals and situations

• the professional works on behalf of their client to ensure that those rules are fairly applied, and that the system therefore works as designed

As such, in each situation, expertise is essential, as long as it’s the right sort of expertise. Your lawyer doesn’t need to be an expert in the various forms of criminal behaviour, but should be an expert in criminal law and courtroom procedures. You’ll get further with your health insurer when your doctor explains your condition and why you need that particular medication, even though your doctor may not understand how insurance policies are written (y lawyers) and insurance fees are calculated (by actuaries).

Notably, in this form of advocacy, questions about the design of the system, and whether the rules should be different, generally fall outside the relationship between the professional and their client. The courtroom is generally not the place to argue that the Criminal Code needs to be amended. Tax court is not the place to argue that the tax code should be overhauled. System and rule changes require a different form of advocacy.

Alternatively, ADVOCACY can describe the act or process of supporting a cause or proposal.

We can think of this as large-a “ADVOCACY”, because it seeks to remedy larger societal issues, the sorts of things where the rules and/or the system need changing.

Tactically, ADVOCACY involves diplomacy and dialogue, providing information, arguing convincingly, and seeking support for specific courses of action.

ADVOCACY is common.

Our governments are constantly tweaking the laws and associated regulations to “fix” problems with the system, often in response to “lobbying” by affected individuals, the professionals who represent them, and/or others who feel that things should somehow be different. Lobbying is a form of ADVOCACY, targeting legislators.

However, this is where the link between expertise and ADVOCACY can break down. When you hire a lobbyist to ADVOCATE for your cause, that lobbyist is probably going to be an expert in lobbying, but there’s no guarantee they’ll have expertise in the specifics of your chosen cause.

So, it’s complicated! Individuals who ADVOCATE at this level have knowledge of their own situation, experience, values, and opinions (or those of their clients), but may not understand how others face different realities, nor do they necessarily grasp the larger (societal) issues. Those wanting more flexibility in the Criminal Code might feel that a life sentence for murder is overly harsh, without understanding the opinions of the families of the victims, the risks of recidivism, the realities of rehabilitation, etc. The doctors arguing for “safer supply” may grasp the realities of addiction as they see it in their daily practice, without considering the effects on the broader community. Those who seek increased government funding for infertility treatments, for example, may not appreciate the other ways in which limited tax dollars could be used for greater benefit.

Professionals, when ADVOCATING in this way, should ideally have a broader understanding of the system, and how the rules operate within it. However, often they don’t grasp the consequences beyond their area of expertise.

In other words, it’s possible to ADVOCATE, and people often DO ADVOCATE, without relevant knowledge or expertise. ADVOCATES are individuals or groups with an opinion and an agenda, who may or may not have access to all the facts. They may not understand or correctly interpret the facts they have. They may or may not grasp that others have different values and therefore might interpret the facts differently. There’s no guarantee that they understand the system, the rules, and “how things work” (beyond knowing how to ADVOCATE).4

Ideally, this form of ADVOCACY operates in a system of checks and balances. Professional lobbyists are often required to “register”, which makes it somewhat more obvious that they have an agenda and that they are being paid to represent the views of others. Laws are amended and regulations are changed through a defined process, often in an effort to ensure that diverse viewpoints are considered and that changes don’t have unanticipated consequences. The tax code, building codes, and zoning regulations evolve. Whole systems, including the health care system, are constantly being “tweaked”, in an effort to make them work better. These changes are often incremental, ideally following processes involving broad input and subsequent evaluation.

In short, ADVOCACY of this sort operates within a system (often including laws and the government which enacts them), and that system has rules. (Some, including activists and anarchists, choose to ignore those rules. They’ll be discussed in the next post.)

So, what’s the problem?

I’ve suggested that advocacy is a feature of many professions, while ADVOCACY is something different.

Let’s consider this in the context of my former profession, the practice of medicine.

As I’ve already said, individual doctors regularly advocate for individual patients in countless ways, every day, to ensure that they get the care, the investigation, the consultation, the procedure, the drug, the financial support, or whatever else they need for their medical condition, when needed. This advocacy is and always has been part of the job description.

Similarly, medical organizations often express the collective opinion of their physician members about societal issues, ADVOCATING for changes in the laws, the workings of the health care system, health care financing, etc. In many cases, this was why those organizations were established.

“Many physicians and medical educators agree that the medical profession has a responsibility to voice its collective expertise on the social determinants of health and illness whether or not they, as individual physicians, are personally engaged”

Health advocacy, by Maria Hubinette et al.

Historically, professional organization membership was voluntary. Organizations had to be somewhat responsive to the wishes of their members, or they would find themselves without members. Humble organizations recognized the diversity of member opinion, rather than presenting simple unitary solutions to complex problems. Sadly, as membership in some organizations has become mandatory, these organizations have become more dogmatic, less humble.

So, advocacy was individual, while ADVOCACY was collective. The first was the job of every physician, the latter the role of the profession as a whole, with some physicians more engaged than others.

Unfortunately, advocacy and ADVOCACY have become conflated, as the following quotes show:

“In the medical profession, activities related to ensuring access to care, navigating the system, mobilizing resources, addressing health inequities, influencing health policy and creating system change are known as health advocacy.”

Ibid

“A proposed definition of physician advocacy should integrate both individual and societal facets of advocacy: Action by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise.”

The essential role of physician as advocate: how and why we pass it on, by LeeAnne Luft

Furthermore, the training and licensing bodies are now pushing individual doctors to publicly express their views about various societal issues, going beyond the routine individual advocacy and collective but optional ADVOCACY to become individual ADVOCATES.

“Although Canadian certifying bodies and regulatory associations have placed increased emphasis on advocacy skills, the described skill set has shifted from ADVOCACY by the medical profession as a whole, to an expectation placed on each individual physician, and also from policy-level interventions to pursuing individual patient issues, as well as community and population needs by individual physicians.”

Ibid (emphasis added, for clarity)

It’s no longer enough to point your patient in the direction of Social Services when you realize they can’t afford food. Now, you’re expected to ADVOCATE for solutions to the affordability crisis and, perhaps, world hunger. To that end, individual physicians are being told that it’s their duty to develop ADVOCACY expertise.

“On a larger scale, consideration must be given to the physician’s duty to work towards eliminating societal causes of health inequity on a population level. This can include educational programs highlighting a need or an unfounded social stigma, petitioning the public and private sector for direct health care resources and to help address societal inequities, lobbying government for financial and legislative reform, and many other activities elaborated upon elsewhere”

Ibid (emphasis added)

At the same time, the disciplinary and licensing bodies advise caution.

“Physicians have an important role in public discourse. Physicians may leverage their professional credibility to publicly address important issues. The public gives significant weight to the opinions of physicians. Accordingly, these opinions must be offered in a responsible fashion.

The CMA Code of Ethics and Professionalism states that ‘physicians must provide opinions consistent with the current and widely accepted views of the profession when interpreting scientific knowledge to the public. They must clearly indicate when they present an opinion that is contrary to the accepted views of the profession.’ ”

Advocacy and public communications by physicians, by the College of Physicians and Surgeons of Nova Scotia (emphasis added)

“Medical regulatory authorities (Colleges) have established expectations for physicians and generally require that physicians engaging in health advocacy act in a respectful and thoughtful manner. Failing to communicate respectfully may lead to allegations of defamation, College complaints and/or human rights complaints.”

Participating in health advocacy, by the Canadian Medical Protective Association (emphasis added)

Clearly, the message is that doctors should (perhaps even must) say what they think, but only if they think what everyone else thinks (or, more precisely, what those willing to speak publicly say they are thinking)! Honesty can be career threatening. Doctors and nurses opposing “gender-affirming care”, for example, risk discipline if they speak their minds publicly.5

The implication is that doctors are credible experts with opinions that should be listened to, simply because they are trained and licensed to practice medicine.

However, “health”, as defined by the World Health Organization, requires complete mental, physical, and social well-being (and not just the absence of disease). The health of the individual therefore reflects a lot of things, including income, education, diet, living arrangements, working conditions, etc. The health of populations depends on a great many other things, including the design of our cities, the quality of the air we breathe, etc.

So, it’s not a given that expertise in the care of and advocacy for individual patients actually makes doctors experts in the broader societal issues affecting individual and population health. Doctors, by and large, are trained to look after and advocate for individual patients. ADVOCACY is a different skill set, based on a separate (and poorly developed) body of knowledge.

“Although it is clear that efforts to improve the health of an individual or population must consider ‘upstream’ factors, how this is operationalized in medicine and medical education is controversial. There is a lack of clarity around how health ADVOCACY is delineated, how physicians’ scope of responsibility is defined and how teaching and assessment is conceptualized and enacted.”

“Health ADVOCACY remains one of the most difficult domains of medicine to teach, learn, assess and evaluate.”

Health advocacy, by Hubinette et al. (emphasis added, for clarity)

When everything (literally everything!) is relevant to health, then it’s an obvious understatement to say that we don’t know how to train, assess, and support physicians as they ADVOCATE for societal change, even assuming that they have time and energy to do it.

Finally, even though it’s expected that physicians will learn ADVOCACY skills, there’s no evidence that ADVOCACY training works. People take the courses, and say they’ve learned something, but it’s not clear that they behave any differently afterward, or that their ADVOCACY efforts are successful.

“The evaluation data is sparse beyond reported gains in knowledge or skill. In other words, very little evidence exists about the effect of curricular innovations on behavioral change (i.e. a physician sustaining health advocacy activities once in practice) and, ultimately, on patient and population health outcomes.”

Ibid

It’s not just a problem in medicine

This problem, as I’ve described it, isn’t unique to the practice of medicine.

There are questions, for example, about whether conservation scientists should be ADVOCATES.

“Whether scientists should be advocates for conservation has been a matter of debate in the scientific community and literature”

“Advocacy” and “Activism” Are Not Dirty Words–How Activists Can Better Help Conservation Scientists, by Parsons

There are questions about whether their activity as ADVOCATES compromises their academic integrity.

“Lackey… considers that while scientists should be involved in the policy process, they should not show any preferences for conservation policies, nor even use value laden terms in their work, such as good, healthy, or degradation. On the other side of the spectrum, Noss… argues that everyone has opinions and values and, when it comes to making policy recommendations, who better to do so than scientists, who are closest to the facts?”

“However, for many scientists, advocacy is still almost a ‘dirty word’ and they are staunch in their belief that scientists should remain in the ivory tower and remain ‘pure’… , and that scientists who engage in advocacy are not being objective and/or are no longer a ‘real’ scientists.”

Ibid

There are concerns in the academic community about discipline and conflicts of interest.

“For scholars who explicitly identify as activist-academics or policy entrepreneurs there is a recognition that their research interests align with their political values and beliefs resulting in advocacy being entrenched in their very approach to research. For such faculty, direct advocacy doesn’t present much discomfort. However, understanding whether they should expect indifference, support or discouragement from the administration can present anxiety.”

Advocacy, activism, and lobbying: How variations in interpretation affects ability for academia to engage with public policy, by Nasreen Jessani et al

And, unsurprisingly, there are concerns about whether scientists can be effective ADVOCATES.

“Faculty willingness and likelihood to engage with decision-makers and advocate for change in a meaningful way was sometimes inhibited by their ability to do so. Several respondents expressed that a significant barrier to advocacy was simply a discomfort with the skills and traits needed to be a successful advocate.”

Ibid

In conclusion…

Experts have knowledge and can offer opinions about options. Their expertise is specific, not general. Knowing the effects of starvation on the individual does not automatically make one an expert on food production, grocery prices, or world hunger.

When experts push for a specific option, they become ADVOCATES. In doing so, they lose some of their objectivity and credibility, even more so if they go beyond the boundaries of their expertise.

ADVOCACY primarily involves dialogue, using information, debate, and argumentation to convince decision-makers. It operates in a system of checks and balances. Those who ignore the rules are activists or anarchists, as will be discussed in the next post.

The knowledge and skills required to ADVOCATE successfully are different from those required to practice as a scholar, academic, professional, etc. Subject matter experts, therefore, are not guaranteed to be effective ADVOCATES.

Professional ADVOCATES are called lobbyists. They may or may not have expertise regarding the techniques of ADVOCACY. It’s even less likely that they will have actual expertise in the things they lobby for.

There are amateur ADVOCATES, often with less expertise regarding the techniques of ADVOCACY. Some of them also know nothing about what they are ADVOCATING for. They have opinions. There’s no guarantee those opinions are “informed”.6

Increasingly, professionals are being encouraged to leverage their knowledge and expertise to ADVOCATE. It’s not clear that they can be trained to do so, that the training alters their behaviour, or that their ADVOCACY will be effective. It is clear that ADVOCACY for the “wrong” things can land them in hot water.

Part of the issue is that our information sources have become sloppy in their selection of experts. Another part of the issue is that, in a bid to become more “relevant”, experts are being encouraged to assume new roles, such as advocacy. Many are shameless self-promoters.

As one author put it:

“… if expertise is a club, it’s one that should have more stringent entry requirements. The criteria for being labelled an “expert” on a TV panel, in a news article, or during a public debate have become alarmingly loose and flexible. Often, the label of ‘expert’ hinges on a plethora of increasingly dubious credentials based on esoteric or narrowly focused theories, rather than on practical or productive experience. Credentialism is the art of knowing everything about nothing, and nothing about everything.

This problem is exacerbated by the media’s tendency to start with a predetermined thesis and then seek out ‘experts’ biased in their favour, constructing arguments around this shaky foundation. Those with opposing views are often dismissed as foolishly anti-expert if their position is acknowledged at all.”

The cult of expertise has gone too far, by Stephen Staley

In short, it’s not always clear what makes one person an expert and their pronouncements “the truth”, while the next person is labelled as a purveyor of misinformation. The biases of the reporter, the media outlet they work for, and society in general all play a role. The system is rigged to feed you intellectual junk food.

“Polarized media ecosystems, algorithm-driven information feeds, and rampant misinformation have eroded public confidence in experts and created ideological echo chambers. False narratives often spread faster than truth, distorting public discourse and weakening the authority of science.”

Epistemic humility for physicians and scientists, by Leo Anthony Celi, et al.

Obviously, this raises plenty of questions.

What makes a person an expert? Are experts necessarily academics? Are academics automatically experts? Does expressing an opinion make you an advocate? Can you advocate without having expertise? If you are an expert, can you maintain objectivity and credibility once you’ve advocated for a particular point of view or course of action? What’s the difference between advocacy and activism? Why do some people wave placards, yell through megaphones, and block traffic, while others write polite editorials? Why are some perspectives acceptable and others not? Who’s allowed to speak? Who should be listened to? Who should we believe?

To parse this out, over the next few posts I’ll look at the various roles available to us as information-holding and information-seeking members of society.

Let’s start with Experts and Academics.

The Expert

“The question of who an expert is may seem a simple one, but it is far from trivial.”

Who Exactly is an Expert? On the Problem of Defining and Recognizing Expertise, by Pavol Hardoš

In essence, we think of experts as people who know a lot about their chosen field, having the ability to provide and/or acquire credible answers to questions in that field as they arise.

“It bears emphasizing that experts, as opposed to novices or laypersons, not only have more knowledge but have a situational ability to gloss and acquire new knowledge rather quickly. What truly differentiates them is not what and how they know or how they use this extra knowledge in decision-making, but their ‘capacity for learning’. Their epistemic standpoint gives them the extra ability to learn and develop new concepts and new understandings in their domains.”

Ibid

Experts, in other words, should know what they know, know what they don’t know, and know how to find the answers to the things they don’t know, whether that be through further reading, structured research, or interactions with colleagues. Importantly, experts should be aware of, understand, and manage their own thought processes, a skill known as metacognition.

“Because the fast, intuitive pathway dominates human cognition, conscious effort and self-regulation are required to engage slower, more analytical reasoning. This means resisting first impressions, seeking out diverse perspectives, and remaining open to the possibility of error.”

Epistemic humility for physicians and scientists, by Leo Anthony Celi, et al

Ideally, expertise comes from training and experience, theory coupled with practice, both in the subject at hand and the ways of thinking about it.

“In most professional domains, such as medicine, science, and law, extensive knowledge and skills must be acquired, typically in a college or university setting before an individual is allowed and able to be engaged as a participant in the domain. Once in the domain the individual often works as an apprentice and is supervised by an experienced professional until they are capable of acting independently without supervision. During this learning period they get many opportunities to learn how to apply the knowledge and rules efficiently in professional contexts until the appropriate actions in a context have been so often repeated that the actions are immediately accessed by intuition.”

Expertise, by Anders Ericsson and Tyler Towne

However, it’s not enough to have been there and bought the T-shirt. Having experienced malaria does not make one an expert in malarial diseases. Raising a child does not make one an expert in parenting. Interacting with homeless people on the street doesn’t make you an expert in mental health, addictions, homelessness and/or housing policy. Expertise requires deeper understanding across a range of situations. Increasingly, this involves entire systems, not just their component parts.

“Systems thinking complements this mindset by breaking down complex problems into constituent parts and then reintegrating these into a broader context—recognizing interdependencies across variables and scales. This approach is especially relevant today, as science constructs increasingly sophisticated models, from the molecular level of biology and genetics to the macroscale in the design of health systems and care delivery.”

Epistemic humility for physicians and scientists, by Leo Anthony Celi, et al

In our daily lives, we’ve all acquired skills where we are competent or proficient but not expert. I’m a competent driver, but by no means expert. I can cook a meal, but I’m no chef. Having learned enough to get the car from A to B, or the ingredients into the pot, many of us reach a plateau, where we settle into a pattern of automatic behaviour and our performance doesn’t improve any further. We know what to do, without necessarily understanding why we do it, and we lose the ability to adjust and modify over time, as circumstances change. We lack metacognition.

As a result, the length of experience or the number of repetitions don’t necessarily predict performance. Having done something for a long time (or many times) doesn’t make one an expert. My mother’s cooking kept us from starving, but it never really improved over her lifetime, nor could she stray beyond the recipe as printed. In many professions, it’s been shown that performance and expertise actually decrease over time, due to things like forgetting the theory, failure to keep up with new developments, automaticity (the reversion to that fast, intuitive thinking), and decreased flexibility.

Expertise, therefore, is not black-or-white; it comes in many shades of gray. As the sociologists Collins and Evans observed, there’s a continuum from competence to proficiency to expertise, from general knowledge to specialized knowledge.

Having a bit more knowledge than your neighbor about something is one thing. Maybe you’ll know enough to help them out! The “true” experts, meaning the ones we turn to when we want “correct” answers to our questions (or good solutions to new problems), are those who’ve read the literature (and knew which literature was worth reading), interacted with others in their field of study and, ideally, added something to the overall body of knowledge, perhaps through research or creative thought. Their authority derives from what they know, how they acquired their knowledge, who they interact with, and what they do with their expertise.1

Even so, experts can be wrong, particularly when they stray beyond what is “known” to matters of “expert opinion”.2 Being “embedded” in a community of people who study the same thing, experts, like everybody else, are not immune to “group think”.3

Importantly, expertise is situational and specific. An expert in something is not automatically an expert in everything, or even in related things. The expert who understands the effects of a specific virus on the individual, or even the transmission of viruses between individuals, does not necessarily have the expertise required to advise the government on public policy governing the daily activities of the citizenry. Infectious disease, public health, and public policy are different (albeit related) bodies of knowledge. Systems thinking is important, and experts rarely understand entire systems.

“However, when it comes to policy decisions related to public health, rather than individual medical cases, the past five years have shown that being a skilled physician does not automatically equate to expertise in public health policy.”

“One of the reasons those of us with experience inside government were so suspicious of giving complete dominion over our lives and societies to public health bureaucracies is because we knew that by and large these ‘experts’ are merely policy advocates. Sure, they have training and experience, but that doesn’t mean their ideas and policies were written on stone tablets that emanated from the summit of the Mount of Objective Scientific Truth.”

The cult of expertise has gone too far, by Stephen Staley

Finally, expertise outdates and expires. Maintaining expertise requires maintaining currency of knowledge, including ongoing interactions with colleagues. The senior physician administrator who no longer treats patients rapidly loses their expertise in clinical medicine.4 The retired researcher loses touch with their colleagues and the state of the art.

Where and when are experts helpful?

So, practically speaking, if we turn to experts when we want “correct” answers to our questions or good solutions to our problems, it’s worth thinking about which problems might actually benefit from expert input.

As I’ve explained in previous posts, there are basically three types of systems: simple, complicated, and complex.

You don’t need an expert to tell you how to turn on the lights in your living room, how to change a light bulb, or even how to rewire your table lamp. Those are simple systems, where the skills and knowledge are commonplace. Problem-solving generally involves competence or proficiency, but not expertise. If you don’t know what to do, you can probably find a family member, neighbor, or YouTube video to put you on the right path.

Building a bridge is complicated. There are many steps in the procedure and many components in the final structure. Some steps and components are simple and time-tested. Others require varying degrees of problem-solving (applying existing knowledge to this specific situation) and creativity (making educated or value-based judgments about the best way to proceed when nobody has previously encountered this exact situation). You won’t find a single expert who can deal with everything. You’ll need multiple experts. They may disagree about things, but they should be able to reach a consensus. Even so, because each step or component has its own failure rate, and complicated systems have so many steps and components, failures are inevitable, but hopefully rare. Most bridges stay standing, but some don’t. For those that fail, it’s possible, after the fact, to figure out why.

Raising a child is complex. There’s no simple recipe that will reliably turn an unruly infant into a responsible adult in each and every case. Some things are known, but a great many things aren’t known and aren’t predictable. Values play a large role, so there’s not always a right answer. Is it preferable to leave things unstructured and let children “learn from experience”, or to structure the learning to avoid having children repeating the mistakes of others, which might involve exposure to possible harm? The experts can and will offer opinions, but very little will be based on immutable fact, and their values might differ from yours. Most of us turn out OK, but some of us don’t. For those who don’t, it’s usually NOT possible, after the fact, to figure out why, despite the best efforts of defense attorneys and psychiatrists to blame everything on the parents.5

Purists will tell you that there are also “chaotic” systems. These aren’t true systems, in that they aren’t really functional or stable. They are, in fact, situations in which you don’t really know what’s going on, which makes it hard, if not impossible, to know which sort of expert help you need. The first step in solving a problem in a chaotic system involves “experimentation”, testing various interventions to how the system responds. Sure, experts might suggest things to try, but it will all be based on opinion. If you pick the wrong expert or they suggest the wrong thing, things will get worse. The fact that things got worse will be useful information, if only because it tells you that you need a different expert.

For all of these reasons, and more, single experts are less reliable than groups of experts, and it’s better to expect and acknowledge that experts will disagree, rather than implying that they are of one mind. You should be highly skeptical of any situation in which large numbers of experts tell you that they agree on one thing, whether it’s the best brand of cigarette to smoke or the effect of carbon dioxide on the weather.

“… opinions of multiple experts should provide better aggregate judgements. However, in some circumstances, such as policy decisions, it may be preferable to represent the diversity of expert judgements for effective and informed decision-making and planning, rather than presenting an aggregated unified position. In most cases though, individuals are chosen for elicitation exercises simply because they are deemed to be expert in some aspect of the problem of interest.”

What is an expert? A systems perspective on expertise, by Michael Caley, et al.

In short, when confronted with the views of an Expert, it’s best to ask a few questions:

• what is the problem to be solved? Is it something so simple that you don’t need an expert, or something so chaotic that they’ll be more harmful than helpful? Is it complicated (in which case experts might reach consensus and reduce the risk of failure), or complex (in which case experts should present a range of opinions with no guarantees of success)?

• does the problem need one expert, or a group of experts? If a group, what efforts were made to avoid group think?

• for each expert, what is the subject on which they are speaking?

• do they have recent and ongoing education and experience in that field?

• are they recognized by their colleagues as an expert?

• are they talking about what is known, or what they think? Facts, or opinions? Do their values align with yours?

• are they presenting a range of options, or have they endorsed a specific course of action to the exclusion of reasonable alternatives?

• are they straying beyond the limits of their expertise?

The Academic

One particular subgroup of Experts is the Academics.

Because expertise involves studying, internalizing, thinking about, researching, and (hopefully) advancing a field of knowledge, it’s not surprising that a number of experts hail from academia. Where better to find a group of colleagues with similar skills and interests, in an environment where people contemplate, share and (hopefully) grow what is known about the subject?

Beyond that, one’s credibility as an expert is enhanced by holding a degree from and/or being on the faculty of a prestigious institution. This reliance on a person’s paperwork and position, rather than their performance, is termed “credentialism”.6

For cynics (like me), it’s hard to forget that there are two meanings for the word “academic”. One relates to “higher learning” (as in “Dalhousie University is an institution of higher learning”), and the other implies an inappropriate preference for theory over practical relevance (as in “this debate is largely academic”).

Traditionally, the roles of Academics involved teaching and research; some were primarily teachers, others primarily researchers, and some did a bit of both. It is, of course, possible to teach and research things that are highly theoretical with little practical relevance. Beyond that, the isolated nature of academia meant that potentially practical research discoveries sometimes went unnoticed.

Furthermore, people who are experts at “doing” in their field are not necessarily experts at “teaching” or “researching”. The best medical clinicians (or physicists, or whatever) are not always great teachers. The great teachers are not always brilliant clinicians (or physicists, etc.). Medical researchers are often neither great clinicians nor great teachers. Great doctors are often terrible hospital managers or department heads. It’s hard to be proficient in every domain. Teaching, research, administration, and professional practice involve different skills and bodies of knowledge. It’s hard to teach what you do or research better ways to do what you do without actively thinking about what you do (metacognition, again).

To make matters more complicated, the landscape has shifted, in an effort to ensure that academia supports higher learning and avoids irrelevance.

“With respect to academia, historically, universities were reputed as institutions conducting theoretical, abstract research accessible primarily to the intellectual elite. Over time they have begun to shed this perception by demonstrating emphasis and efforts towards policy and social impact, dissemination and communication of research, through formal institutional vision and mission statements. The changing landscape of academia reflects on the evolving role of a researcher… from academia to encompassing activism, advocacy, or lobbying: a researcher that is perhaps more assertively engaged, and perhaps, more impactful.”

Advocacy, activism, and lobbying: How variations in interpretation affects ability for academia to engage with public policy, Nasreen Jessani, et al.

In other words, it’s no longer enough to understand the subject matter, teach students, publish research, and/or run the department. In an effort to be more “relevant”, universities are increasingly pushing their researchers to link their research to the “real world” through knowledge translation, advocacy, activism, etc. It’s no longer enough to live a quiet life behind closed doors in the hallowed halls of higher learning. Academics are expected to put themselves out into the broader community.

These new roles require additional skill sets. Unsurprisingly, there are challenges. Beyond the difficulties with developing and maintaining competency in these diverse roles, conflicts of interest arise.

“The conflict faced by academics in universities has been captured in several studies. These studies highlight that such conflict is laden with (amongst others):

• Personal values about the role of researchers,

• Professional apprehensions about where to draw the line between communication of research findings and activism so as to preserve one’s credibility as a scientist, and

• Legal concerns about where personal and professional boundaries intersect and how that is perceived by the academic institution where one is employed.”

Advocacy, activism, and lobbying: How variations in interpretation affects ability for academia to engage with public policy, by Nasreen Jessani, et al.

So, in addition to the questions to consider with Experts in general, when you encounter an Academic, there are other questions to be answered:

• does the fact that they have an advanced degree and/or are associated with a university really mean that they know what they are talking about? Don’t assume that their credentials imply expertise or credibility.

• is their university appointment related to their subject matter expertise, their teaching ability, their research skills, or their administrative/political skills?7

• do they have recent and ongoing education and experience in the subject they are discussing? Are they straying beyond the limits of their knowledge?

• are they respected by their colleagues as an expert in their field of study?

• are they talking about what is known, or what they think? Facts, or opinions? Do their values align with yours?

• what is the basis for their advice? Are they presenting options, based on their knowledge of the subject, or are they promoting their latest research in order to enhance their reputation (or that of the university)? Are they selling something?

Conclusion

Clearly, Experts and Academics are beasts we all encounter as we consider how to understand and solve thorny problems. Unfortunately, they come in many forms, and it’s not hard to find situations in which the “wrong” expert was chosen for the job. Care is needed.

And, as I’ve alluded to briefly, there are more and more situations in which Experts and Academics morph into other creatures, known as Advocates, Activists, or even Anarchists. Some explicitly acknowledge their metamorphosis, while others don’t. These “wolves in sheep’s clothing” add to the confusion. More on these in the next post.

But what is harm reduction? Where did the idea originate? Is it better?

A brief history of harm reduction

In 1996, a paper summarizing the proceedings of a 1995 Drug Policy Foundation conference triumphantly announced, “Harm reduction is coming to the U.S.A.”. The author explained it as follows:

“Based on principles of public health, harm reduction offers a pragmatic yet compassionate set of strategies designed to reduce the harmful consequences of addictive behavior for both drug consumers and the communities in which they live.”

[There are] “…four basic assumptions central to harm reduction: (a) harm reduction is a public health alternative to the moral/criminal and disease models of drug use and addiction; (b) it recognizes abstinence as an ideal outcome but accepts alternatives that reduce harm; (c) it has emerged primarily as a “bottom-up” approach based on addict advocacy, rather than a “top- down” policy established by addiction professionals; and (d) it promotes low threshold access to services as an alternative to traditional high threshold approaches.”

From: Alan Marlatt, Harm reduction: Come as you are, 1996

Let’s parse that out, one step at a time.

Harm reduction is not new

A reminder. That conference was in 1995, 30 years ago.

During the conference, speakers discussed various harm reduction initiatives already underway in Europe, including the Netherlands (decriminalization, needle exchanges, opioid replacement programs, housing supports) and Merseyside, England (safer supply, opioid replacement programs).

In short, the concept and practices of harm reduction have now been around for decades!

Harm reduction is “pragmatic”

Pragmatism is rooted in practicality, rather than “theory” or “idealism”. Pragmatists believe that the proof of an idea lies in the practical consequences. If your idea “works”, accept it. If it doesn’t, reject it. The same goes for the other guy’s ideas.

For a start, harm reduction advocates believe that the use of psychoactive drugs is “normal”, something you can choose to do, or not.

“Consumption of psychoactive drugs is a normal human activity, and fundamentally a personal choice, based on informed consent about the potential risks and benefits to themselves and others.”

From: A Public Health Approach To Drug Control in Canada, 2005

The definition of what’s normal human behaviour and what isn’t is a bit of a gray zone, insofar as normality can describe what is typical, usual, common, ordinary, and/or healthy. When it comes to drug use, one medical historian summarized it thusly:

“Some potentially addictive drugs have been used by a significant proportion of the population on a regular basis, to the point that they have been considered staple commodities. Alcohol, nicotine, and caffeine, being palatable for their mild psychotropic properties, are examples of widely consumed drugs. As licit psychoactive drugs, they are used mostly by “normal” people, in contrast to illicit “hard drugs,” which are traditionally viewed as the province of the deviant. Alcohol, nicotine, and caffeine have permeated our culture, serving as vehicles for social interaction, shaping our urban landscape, from the Japanese teahouse to the British pub, stimulating the opening of international trade routes. Similarly, hashish (cannabis) has been largely consumed—eaten and later smoked—in Islamic cultures. All these substances have a long history, intricately interwoven with myth, bearing witness to man’s predilection for psychoactive substances.”

From: Historical and cultural aspects of man’s relationship with addictive drugs, 2007

In effect, the recreational use of SOME psychoactive drugs in some forms is normal in some cultures, but the use of those same drugs in other forms isn’t. Drinking alcohol is normal in the Western world, not so much in Muslim countries. The inhalation of vaporized alcohol hasn’t really caught on anywhere!1 So, definitions of normality evolve over time and vary from one country/culture to the next.

Merely pronouncing that something is now normal doesn’t necessarily make it so. If nothing else, some drugs didn’t exist in the past, so clearly their use has not always been normal. Consider, for example, Bob Newhart’s classic routine about Sir Walter Raleigh and the use of tobacco. Chewing coca leaves is common and normal (where coca plants grow) but smoking crack cocaine is (perhaps) more problematic. Opium has been cultivated for centuries, but fentanyl is a new invention.

Beyond that, while the USE of drugs might be normal, there are mixed opinions about the accepting the effects as normal. Choosing to take a glass of wine could be normal, but drunkenness or alcoholism might not be. Perhaps the difference is that, at some point, some people cease to make rational choices when they become inebriated or addicted, which aren’t healthy. Also, consider the public health approach to “denormalizing” smoking (and, more recently, alcohol), in which the possibility of adverse health effects is seen as sufficient cause to limit the use of the substance. In effect, it is (or was) normal to choose to use nicotine and alcohol, but not normal to choose to place your own health at risk.

Psychoactive drug use has benefits

Harm reductionists take it as a given that psychoactive drugs have benefits, individual “pleasure” foremost among them. They also allude to the positive economic impacts of a well-regulated drug industry2, expecting governments to protect users from harm. It all seems pretty straightforward!

“Society has the right to enjoy the benefits derived from psychoactive drugs’ production, distribution, use, and regulation while being protected from harm consequent to use and dependency.”

“Consumers have a right to receive accurate information about drugs and their effects and a responsibility to use this information in a way that reduces the probability of harms. This includes the right to know the quality, purity and concentration of drugs they intend to take.”

“Citizens should insist that all levels of government undertake their responsibilities regarding psychoactive drugs according to their mandates.”

From: A Public Health Approach To Drug Control in Canada, 2005

Clearly, then, the aim is NOT to reduce or eliminate drug use, but simply to reduce the negative consequences of intermittent or continuous drug use, while accepting (pragmatically) that we can never eliminate ALL harms. Harm reductionists support personal choice, as long as it’s “informed”. That requires government regulation of the drug marketplace. How else can users know the quality, purity and concentration of drugs they intend to take?3 Once informed, drug users have the “responsibility” to use drugs in a way that reduces the risk of harm.4 Left unstated is how we respond to the irresponsible users.

At this point, it seems to me, harm reduction, as described, actually ceases to be pragmatic and becomes idealistic. In an ideal world, the ideal user makes an ideal, well informed, carefully considered, autonomous decision to use a specific substance with known properties, in the ideal setting, by the ideal method, with appropriate safeguards in place, knowing that, ideally, the government has done everything in its power to ensure that things are as safe as possible.5

… and it also has harms

There’s another important point to consider, which is that the harms of drug use are not evenly distributed across all drug users. Most drug users experience no harm or minor harm, most of the time.

For example, despite the public health insistence that there’s no totally safe amount of alcohol to drink, that glass of wine with supper is, in all likelihood, going to do you absolutely no harm.6 In deciding to use alcohol or any other drug right now, the benefits are immediate and generally predictable, while the risks are abstract possibilities, things that happen to some people and not others, sometimes unpredictably, sometimes far off in the future. Whether they are uninformed or in denial, nobody uses drugs believing that they’ll be harmed, that they’ll harm others, or that they won’t be able to control their intake, tonight or for the rest of their life.

However, despite good intentions, “using more than intended” is one well-recognized form of harm, because drug use impairs rationality and control. You choose to take the first drink, and the next, and the next, but at some point your ability to choose rationally becomes impaired. Some who overuse will be harmed.

Even with informed, seemingly responsible use, some folks will suffer unexpected consequences. That one glass of wine might make you a little clumsy, and then you fall down the stairs. A minority will become addicted, and an even smaller minority will suffer fatal consequences, including immediate things like overdoses and long-term things like liver failure, etc.

All that being said, at what point can we say that we’ve given enough information, drug users are sufficiently informed, they’ve used the information responsibly, and their choices are to be respected? How much harm is unpreventable? How much harm reduction is enough? What level of use is “normal” and healthy, and what level is not? To what extent are people held responsible for their choices? What if those choices harm others?

Harm reduction is an alternative to the moral/criminal and disease models

The fundamental claim of harm reduction advocates, pragmatically speaking, is that harm reduction works better than the alternatives, the moral/criminal and disease models, both of which, in their view, are (a) cause harm because they are based on unsound theoretical principles and assumptions, and (b) have been shown not to work very well.

To further emphasize the practical rather than theoretical nature of harm reduction, it is framed as a “bottom-up” approach, based on the user experience, rather than a “top- down” policy, based on morals, theories, and abstractions.7

The moral/criminal model holds that some drug use is “wrong” (i.e. emphatically NOT “normal”) and therefore should be prohibited. Despite prohibitions, however, drug use and its attendant harms persist. Beyond that, it’s hard to argue from first principles that some drugs are more wrong than others, which leaves you wondering why some are legal and others aren’t.

While simple consumption of psychoactive drugs can be framed as a normal human activity, a personal choice, the disease model holds that problematic drug use (“substance use disorder” or “addiction”) is a brain disease, to be treated, like any other disease.8 Just as hypertension is a risk factor for heart attacks, but not all hypertensives suffer heart attacks, drug consumption is a risk factor for addiction, but not all drug users become addicts. Other factors, like genetics or environmental factors, make some people more prone to heart attacks and addictions and others resistant. For addicts, some treatments aim for abstinence, while others (i.e. opioid agonist therapy) aim not to stop the drug use but rather to alleviate its harmful effects, turning dysfunctional addicts into functional addicts, so to speak. Despite available treatments, however, addictions and their attendant harms persist, and that’s seen as a failure of the disease model. However, the “relapsing, remitting” aspect of addiction is a well-known fact. It doesn’t negate the need for or the validity of treatment, nor does it prove the invalidity of the model.9

And so, however, harm reductionists dismiss both the moral/criminal and disease models as incorrect, insufficient and/or ineffective, claiming that they both add to the burden of harms. The moral/criminal model stigmatizes, criminalizes, and marginalizes drug users. The disease model invokes unrealistic expectations of sobriety and abstinence, denying users the benefits of their chosen drugs. Harm reduction is offered as a more compassionate and effective approach, based on the “principles of public health” (in a “bottom up” way, of course).10

There’s another, slightly more pragmatic, way to look at it.11 Some believe that prohibition and treatment are preferable but accept that they are overly expensive, only partially effective, and /or unenforceable. Alternatively, when reasonable people cannot agree whether or not some drug use is “wrong”, based on their deeply held values, they might “agree to disagree”, while trying to mitigate the consequences of risky drug use. Either way, you pragmatically end up with harm reduction as “one more tool in the toolbox”, alongside, rather than instead of, the other models.12

Harm reduction is designed to reduce the harmful consequences of drug use and addictive behavior for drug users AND their communities

This is where things sound simple in theory but get complicated in practice.

The 2005 document, A Public Health Approach To Drug Control in Canada offered the following overarching goal and explanation:

“Proposed Goal of Framework: Minimization of the harms derived from the use, policies, and programs associated with psychoactive drugs including alcohol and tobacco, and a realization of benefits, for individuals, families, communities and society.

This goal emphasizes that harms and benefits at many different levels are associated with psychoactive drugs, and that balancing these is the aim. It also emphasizes that harms are due to policies and programs as well as from use. Finally, the goal acknowledges that realizing desired benefits from psychoactive drugs is also a component of the strategy, as that is a main reason people produce, trade, and consume these substances.”

Here, we see that it’s not exclusively about harm reduction. At least for some advocates, there’s a desire to realize the benefits and/or balance the harms and benefits. Those are actually three different objectives, unless you believe that denial of benefit is a form of harm! Things which reduce harm might also reduce benefits; all harms would be eliminated if recreational drug use was completely eliminated, for example, but that would deprive users of the benefits. Things which increase benefits, like legalization, might increase harms. Things which strike a balance might increase, rather than reduce harms.

Another part of the problem is that harms can be broadly defined or narrowly defined, individual or collective. In an effort to prove the need for and the worth of harm reduction, the tendency is to list everything as a possible harm.

“The direct harmful effects from the drug itself can be physical, psychological and social. For the individual, some of the physical harms could include death, toxic effects, dependency, communicable diseases, injury, violence, malnutrition, fetal damage and neurological damage. Psychological harms can include depression, psychosis, and impaired thinking. Social harms include, stigmatization, marginalization, criminalization, family breakdown, social system breakdown, lost productivity, workplace time loss, injuries and production loss, and direct health care costs.

The indirect harmful effects to society occur primarily due to two mechanisms: first the loss of fully functioning individual members due to harmful drug use; and secondly the unintended subsequent harms to society that arise from the fact that certain drugs are criminalized. Harms to society that can occur with most psychoactive drugs, both legal and illegal, include increased health and social services costs, increased criminal justice system costs, and lost productivity of workers.

Additional harms to society occur with illegal drugs. These include: marginalization of populations and loss of social cohesion; criminal activity such as theft to support drug addictions; local violence and international political instability related to the black-market drug trade; adverse economic impacts on businesses and neighbourhoods; direct enforcement costs and opportunity costs (from ever growing government enforcement expenditures that could be used elsewhere); unemployment; and limited implementation of demonstrated public health programs for drug users because of the illegal status of certain drugs.”

From: A Public Health Approach To Drug Control in Canada, 2005

Those three paragraphs describe dozens of types of harm!

Reducing harm, therefore, obviously involves trade-offs, and those trade-offs involve value judgments, even before you start balancing benefits and harms! Whose values do we consider? How much should we increase health and social services expenditures (a harm) in order to reduce the stigmatization and marginalization of the heroin addict (a benefit)? Do we accept the increased societal drug use and harms that follow decriminalization, which reduces criminal justice system costs? Do we prioritize reducing the harms to the individual, or the harms to their friends, family, and community? How do we respond to users selling their harm-reducing safer supply to others (who might be harmed), in order to illegally obtain more harmful and powerful drugs? There’s an acknowledgement that rampant drug use can have adverse economic impacts on businesses and neighborhoods. Is it OK when the supervised injection site drives other nearby businesses into bankruptcy? Do we arrest the entrepreneurial drug dealers who hang around outside the pharmacy buying up the safer supply? Is it better to lower legal tobacco or cannabis costs, to maintain the quality of the supply, or drive-up costs to deter overuse, even though that pushes users toward the illicit market? Do we make cigarettes less available, putting corner stores out of business? Do we allow corner stores to sell alcohol and cannabis instead, bearing in mind that they might be more willing to sell to minors?

So, when you see a graph that looks like the one below, you have to wonder who decided which harms were being counted, what values were ascribed to those harms, whether and how the benefits are included (the y-axis refers only to “problems”), and whether the authors were at all biased against gangsters and corporations and in favor of public health practitioners. Still, it’s nice to imagine that there’s a sweet spot in the middle, where drug policies are not too loose and not too tight, but “just right” (i.e. perfectly balanced).13

Harm reduction is a proven set of strategies

As harm reduction has become the preferred “mantra” in the world of substance use, many things have been reframed as harm-reducing.

Remember, treatment and prevention don’t work, but harm reduction does! The path to funding, therefore, is to say that what you do is harm reducing! Opioid-replacement therapy, for example, long considered to be the “gold standard” treatment for the brain disease of opioid addiction, now finds itself on the list of harm reduction strategies.14 Drug education, once considered a preventive measure, is now also listed as a harm reduction strategy.

Bearing that in mind, the list of harm reduction strategies has become lengthy, including:

• needle and syringe exchange programs

• education, about drugs themselves, the policies that regulate them, or the harms that might occur (i.e. overdose)

• naloxone distribution

• supervised consumption sites

• safer supply programs

• opioid agonist and antagonist therapy

• drug testing

• decriminalization

Each of these strategies targets a specific harm (or harms), and each comes with its own set of risks. It’s also worth noting that, despite the fact that the concept of harm reduction dates back to the 70’s or 80’s, the “proof” that these interventions actually “work” better than the alternatives is not always indisputable. Because some strategies will reduce one form of harm while increasing others, what “works” depends on what you measure and what you choose to ignore, and that depends on what you value. Some outcomes happen quickly; others take years. Some affect the users; others affect their families, friends, neighbors, or even descendants. Some can’t easily be measured. Much of the research describes small-scale initiatives by committed and well-trained staff in controlled circumstances, not what happens when the same interventions are pursued on a large scale by amateurs working with limited resources. And, as with most things in the medical literature, there’s a tendency to publish the things that look good and bury the evidence when things don’t work as well as hoped.

“Among researchers, a widespread approach for analysing drug policies is the public health approach. In its “puristic” form, this would judge policies exclusively by their effects on population health and longevity, but in practice most researchers will expand its scope to reflect a broader set of outcomes and concerns valued by policy stakeholder groups. As the adjustment is typically judgement-based, however, the resulting approach may still fail to reflect the full set of values relevant to ongoing policy debates.”

From: Drug policy, values and the public health approach - four lessons from drug policy reform movements

Does drug education reduce harms?

To illustrate the point, consider the following:

“A significant amount of education about drugs has been proven to be ineffective. A post-prohibition model of education will be inclusive, engaging and will provide factual information about the harms and benefits of psychoactive drug use, including the harms and benefits of current policies and strategies. This is the cornerstone to achieving a rational, holistic, ethically sound, comprehensive, effective and efficient approach, and is fundamental to all preventive strategies.”

From: A Public Health Approach To Drug Control in Canada, 2005

To paraphrase, it’s been proven that education doesn’t work, but only because it wasn’t the right sort of education. In reality, education is fundamental. We’ll just have to keep educating until we get positive results!15

Do needle and syringe exchange programs reduce harms?

As another example, needle and syringe exchange programs (SEPs) provide sterile needles and injection equipment to persons who inject drugs and might share their needles with others, to prevent blood-borne infections like HIV and hepatitis. Studies have demonstrated that these programs successfully reduce the risk of infections and are cost-effective and safe. Furthermore, persons who use exchanges are perhaps more likely to enter treatment, even though that’s not the goal of the exchange. In real life, however, when SEPs are set up, their outcomes are typically reported in terms of the number of sites, the number of users, and the number of supplies exchanged. These are what’s known as “process measures”. They reflect how busy the program is, but don’t reflect the desired outcome, which requires knowing how many cases of HIV and hepatitis did or did not occur. Furthermore, at least one author has reviewed the literature and concluded that syringe exchange programs also cause harms, being associated with increased opioid-related morbidity (including emergency visits and inpatient admissions) and mortality. The author postulates:

“In other words, because the aim of SEPs is to prevent needle sharing, and not to provide substance abuse treatment, it is possible that even if SEPs reduce bloodborne illness, they will be ineffective at curbing drug usage. Three arguments support the notion that SEPs could promote continued or increased drug use, leading to more fatal overdoses. First, programs distribute free supplies, including needles, sharps containers, and personal hygiene items, which lowers the expected cost of using injection drugs. Second, SEPs provide a safe space to interact with other users, increasing networking opportunities, expanding access to new potential partners and substances, and reducing stigma. Third, communities that build a SEP may attract nearby drug users and/or signal that they also support more police leniency for drug users, lowering the legal risk of using opioids. In turn, if SEP openings increase drug use, it is possible that bloodborne illness rates might also increase.”

FROM: Syringe Exchange Programs and Harm Reduction: New Evidence in the Wake of the Opioid Epidemic, 2022

So, we assume that some harms are reduced, while others increase. Of note, the increased harms (more users, more substances, more blood-borne illnesses) can be mistaken for a signal that the need for the SEP is greater than ever! The model is so effective that it generates its own customer base!

Do overdose prevention and treatment reduce harms?

Overdose education and naloxone distribution involve teaching nonmedical community members how to recognize, reverse, and prevent overdoses, including the administration of the opioid overdose reversal agent, naloxone. Again, success is typically defined by process measures, including the number of education sessions given, the number of naloxone kits distributed, and the number of doses of naloxone given. There’s an assumption that each dose given represents a possible life saved. Some studies report reduced overdose rates in the community, counting ambulance transfers and emergency visits. There is a concern, however, that the message that overdoses can be reversed might lead more people to start taking opioids, causing more overdoses, requiring more overdose prevention.

Do supervised consumption sites reduce harms?

Supervised consumption sites (SCSs) provide a safe space and clean equipment for drug users, aiming to reduce infections and overdoses, while linking users to treatment options and social supports. Some limit themselves to injection drug use, while others allow other routes of ingestion.

Overall, the evidence that these reduce harm is limited, in part because the number of actual SCSs is pretty small, considering the target population.16 “Success” reports are based on the number of sites, the number of users, and the quantity of supplies consumed, all of which are process measures. There’s an assumption that overdoses managed safely “in house” would otherwise have occurred more harmfully in the community. If there is a beneficial effect (and that’s debatable), the effect is limited to a fairly small geographic area - at least one study suggested fewer overdoses within a 500-meter radius of the site, but not outside that radius! If that’s true, we would need a lot of SCSs, maybe one next to each Tim Horton’s coffee shop.

There is limited evidence that SCS users are more likely to access treatment, but it’s hard to measure the effect, and not all sites are equally committed to drug treatment options. Conversely, as with the syringe exchanges, SCSs lower the cost of using injection drugs, lower the legal risk of using substances, expand access to new drug-using partners and substances, and reduce stigma, thereby recruiting more drug users. More than author has concluded that the benefits have been exaggerated and the societal harms ignored, including the adverse effects on the surrounding neighbourhoods. Indeed, those who dare to complain about the SCSs are often gaslighted (at best) or intimidated (at worst).

Except for Edmonton, stakeholder feedback predominantly suggested that the SCS have had a negative social and economic impact on the community. In Edmonton, however, there were reports that stakeholders felt intimidated and were prevented from expressing their true sentiments and opinions about these sites out of fear of retribution from site supporters. The Review Committee also learned about questionable practices (for example, introducing non-injection users to injection practices by SCS staff); the use of 40 naloxone reversal kits by a single client; the alleged misrepresentation of site statistics; and an apparent under-utilization of the full scope of care while inappropriately favouring harm reduction. The Review Committee also noted that there were several potential liability issues for sites and staff arising from the information that had been provided.

FROM: Impact: A socio-economic review of supervised consumption sites in Alberta, 2020

Yet again, whether or not harm reduction works depends on what harms you measure.

Does safer supply reduce harms?

Safer supply provides users with prescribed pharmaceutical-grade drugs, freeing them from the harms of the illicit drug supply (adulteration, cross-contamination, criminality). Again, the evidence is limited and unconvincing. One recent study from British Columbia concluded that “…neither the safer supply policy nor the subsequent decriminalization of drug possession appeared to alleviate the opioid crisis. Instead, both were associated with an increase in opioid overdose hospitalizations. The observed increase in opioid hospitalizations, without a corresponding increase in opioid deaths, may reflect greater willingness to seek medical assistance because decriminalization could reduce the stigma associated with drug use. However, it is also possible that reduced stigma and removal of criminal penalties facilitated the diversion of safer opioids, contributing to increased hospitalizations.”

In short, while safer supply might benefit the individual user, the total harms seem to increase.

Where to from here?

At this point, it seems pretty obvious that harm reduction is a belief system. In order to have faith in harm reduction, you have to accept certain things as truth, with or without evidence, including:

• psychoactive drug use in all its forms is normal,

• psychoactive drug use has meaningful benefits,

• the harms are manageable,

• individual drug users can rationally weigh the benefits and harms in order to make informed choices about their personal drug use, and

• the psychoactive drug market can be managed by government, according to public health principles, to balance societal benefits and harms.

You also have to ignore certain inconvenient and self-evident truths:

• harms will occur even with “responsible” use,

• individual humans aren’t great at decisions involving definite short-term gains and possible long-term harms, and

• the evidence that harm reduction “works” (or works better than the alternatives) is pretty shaky.

At this point, rather than accepting harm reduction as an alternative to the moral/criminal and disease models, I’m going to suggest that they all have their place.

Surely, some drugs and some behaviours are morally unacceptable and/or excessively dangerous and should be banned. Others should, perhaps, be legalized and regulated (bearing in mind that we haven’t had great success in shutting down the illegal tobacco and cannabis markets). Some drugs work for medical purposes and should require medical supervision, while we continue to restrict their non-medical use.

Those who use drugs problematically will always need help, often from the health care system, whether or not we label their problem as a “disease”. We need to keep exploring which forms of help work best. Treatment services must be adequately funded.

And, in the middle, there is, perhaps, room to reduce some of the more direct harms of drug use, without normalizing anything and everything. However, we need more well-designed research about harm reduction, with more honesty about the harms, particularly societal harms.

Our government makes a lot of money taxing and selling alcohol, tobacco, and cannabis, while spending money to remind you that they are bad for you. They spend a lot of money trying to block the sale of illicit opioids, while experimenting with decriminalization (allowing possession for personal use) and safer supply (in which pharmaceutical-grade opioids are provided free of charge to addicts). Clearly, somebody in charge recognizes that all drugs can be harmful, but they can’t decide which should be legal to manufacture, sell, possess and use, and which should not.

Similarly, some drug-related behaviours are criminalized (in some provinces, drinking alcohol isn’t allowed in public parks), while others aren’t (banning injectable drug use in public parks is considered “stigmatizing” and dangerous). What’s the logic in that?

If this variability was based on differences in the fundamental properties of the drugs themselves, then it might make sense. However, broadly speaking, psychoactive drugs are more alike than different:

• psychoactive drugs are those that exert some sort of effect on the brain. Some are “pharmaceuticals” (i.e. SSRI’s or benzodiazepines), some aren’t even thought of as drugs (i.e. caffeine), and some are DRUGS (i.e. cocaine and meth).

• because those effects are “pleasurable”, at least in some ways, people are inclined to use them “recreationally” (for “fun”).

• in most cases, a single dose or even intermittent doses of a psychoactive drug has/have no observable or measurable lasting effect on the brain. As such, when used intermittently (and, some might say, “responsibly”), psychoactive substances, in and of themselves, are actually pretty “harmless”.

• however, the psychoactive effects can indirectly increase the risk of various harms. They alter behaviour, which can be problematic if severe (as described by the terms “inebriation” or “drunkenness”). Even at lower levels, alcohol and cannabis can impair alertness and coordination, for example, increasing the risk of accidents. Many drugs depress brain activity, including the part that controls respiration, so a big enough dose can cause you to stop breathing.1

• some psychoactive substances, but not all, also have harmful effects elsewhere in the body. Alcohol, for example, affects the liver. Smoking (but not nicotine, the psychoactive drug in tobacco) harms the lungs. Some injectable drugs harm the veins. Methanol kills your liver, as do some types of mushrooms. Cocaine causes heart attacks.

• to that extent, there is no use of drugs without any risk, although in some (maybe even most) cases the risks truly are minimal, trivial, or both.2 In a few cases, though, they can be lethal.

• when used regularly, psychoactive substances induce “tolerance” (higher doses are required to produce the same effects) and “withdrawal” (users develop symptoms when the drug is no longer taken, those symptoms being relieved by resumption of use).

• tolerance and withdrawal aren’t necessarily problematic, beyond the fact that they make it harder to quit using the drug. Coffee drinkers and smokers, for example, generally have tolerance and experience withdrawal symptoms.

• some users develop substance use disorders (SUDs), characterized by impaired self-control over substance use, social or personal disruptions, and risky behaviors. Tolerance and withdrawal are sometimes associated with SUDs, but not always.

• at various points in history, and in different religions and cultures, psychoactive substance use has been seen as a moral failing, a legal transgression, and/or an illness. In other cases, it’s accepted as a fact of life, or even a religious ritual.

• looking at the population, there’s a range of usage patterns. Some people abstain. The majority of psychoactive drug users use lesser amounts (for recreational purposes). A minority use larger amounts, and some of those have substance use disorders. For example:

  • the top 20% of drinkers consume 80% of the alcohol (and the top 10% consume over 50% of it!),

  • 20% of cocaine users consume 70% of all cocaine, and

  • 22% of cannabis smokers consume 67% of all cannabis.

ALL of the above are more or less true for ALL psychoactive drugs. In effect, you’ve got a whole bunch of substances which can deliver pleasure but sometimes also cause harm, with some people more susceptible to the harms than others. The details, of course, vary from drug to drug.

“Supply chains” exist for all psychoactive substances, but they are inconsistent:

• grape-growing, winemaking, brewing, and distilling are seen as welcome additions to the local economy,

• coffee shops are found on every street corner,

• governments have long held a monopoly on alcohol sales in Canada but are now allowing privatization,

• cannabis plantations and shops are now legal but tightly regulated, while the illicit cannabis marketplace lives on,

• pharmaceutical opioids are tightly regulated, medically prescribed, and distributed through pharmacies, and

• it’s a criminal offence to manufacture and sell illicit opioids, which are euphemistically referred to as “unregulated” or “unapproved”, to reduce stigma. This “alternative drug supply” is also sometimes described as the “toxic drug supply”, although the substances it distributes are not invariably toxic.

Significantly, legal or not, regulated or not, approved or not, LOTS of people have tried drugs and lived to answer questions about their past drug use! For example, the Canadian Substance Use Survey for 2023 contains the following data:

At a societal level, the questions are, therefore:

• Should psychoactive drug use be permitted, allowing individuals to make their own informed choices? Knowing drugs can be harmful, shouldn’t they just be banned outright? Or do we regulate the market, so as to optimize the benefits and minimize the harms?

• Should some psychoactive drugs be legal, and others illegal? How do we decide?

• Do we prohibit the drug use itself, or focus on the undesirable drug-related behaviours (drunkenness, impaired driving, etc.) and consequences (addiction, overdoses, infections, etc.)?

• At what point does drug use cross the line from free choice (for which the individual is responsible) to pathology (a “brain disease”, for which treatment is needed)? If users have a brain disease harmful to themselves and others, are we justified in “forcing” them to accept treatment?

• Do we base our decisions on moral standards (“drugs are evil”) or the objective evidence of harms (legal alcohol kills more people than illegal opioids)?

• What do we do with the transgressors, those who can’t or won’t take good advice and/or follow the “rules”? Do we ignore them, leave them to suffer the consequences, pity them, penalize them, or try to protect them?

• What’s the balance between reducing use, limiting harms to those who choose to use, and reducing the secondary harms to society?

• What makes sense?

In practice, our various drug policies over-emphasize problematic use (as with opioids), downplay it (as with alcohol and cannabis), or completely miss the target (as with nicotine, where the problem is not the nicotine but rather the route of ingestion, smoking tobacco).

In part, this reflects our public health approach to policymaking. Psychoactive drugs are seen as environmental hazards for all, to be controlled so as to minimize or even eliminate the risks. There’s little or no consideration of any possible benefits in drug use, individual susceptibilities to problems, the right to autonomy, the right to “live at risk”, etc. There’s no acceptance that individuals should be free to make their own choices. “Policy” affects everyone!

“A spectrum of policy approaches exists for drug control. In Canada, tobacco and alcohol exist towards one end of the spectrum in a legal, for profit economy. Illegal drugs such as … heroin and cocaine exist towards the other end of the spectrum in a criminal-prohibition, black-market economy.… We argue for a more centrist public health approach to currently illegal drugs, where policies are set to minimize harms. The balance point for determining public health policies for currently illegal drugs would be that which minimizes the prevalence of harmful use and negative health impacts, and also minimizes any indirect or collateral harms to society from regulatory sanctions.”

From: A Public Health Approach To Drug Control in Canada, 2005

Since 2016, Canada has had the following “drug policy”:

Having spent many years in medical administration, I can tell you that this “pillar and foundation” approach is pretty generic and generally useless. Having multiple pillars demonstrates that you want to be “comprehensive”, covering all the bases without declaring your priorities (because that might alienate someone or some group). Stating that whatever you do will be innovative and based on evidence implies that you are being “scientific”, even when you aren’t. More specifically:

• they talk about “drugs and substances”, but what’s the difference?

• it’s unclear what prevention strategies will be used, bearing in mind that the evidence tells us that we haven’t had much luck preventing alcoholism, smoking addiction, “casual” drug use, underage drinking, etc.

• we’ve already explored any number of approaches to treatment and rehabilitation, with varying degrees of success. The literature tells us that quite a lot of addicts actually “age out” of their addiction, with or without treatment, often following some sort of “intervention” or “crisis”.3 The current wisdom is that “mandatory” treatment doesn’t work, but it doesn’t seem compassionate to leave sick people untreated and suffering.

• enforcement, including the “war on drugs”, has criminalized many users while failing to interrupt the drug supply and curtail drug use. Even now, in the tightly regulated centuries-old tobacco market, illegal cigarettes are easily obtained and far cheaper than the legal ones. British Columbia championed the idea of decriminalization for the “harder” drugs, and just recently their Premier admitted that the experiment was a failure.

• the recent focus has been harm reduction, the pragmatic premise being that if drug use is going to happen, then we should do everything possible to reduce the risk of harm. However, the presence of “risk” does not inevitably translate to “harm”, while harm can occur even in low-risk situations.4

In the end, we put a lot of time and resources into this, but what are we accomplishing? If prevention and enforcement worked, we wouldn’t need treatment and harm reduction. If they don’t work, then why spend so much time and money on them? If there’s reasonable disagreement about what works best, then we should be (scientifically) gathering more evidence, not continuing to do what we’ve always done.

However, we have a strategy! Check the box and move on.

Why do people take psychoactive drugs?

Ultimately, we are faced with individual users making individual decisions to use or not use specific drugs, individually or combined, at specific points in time, availing themselves (or not) of the available protections.

This is true of any “risky” behaviour. Without even thinking about it, we all face countless decisions about potentially risky activities every day. I choose whether or not to get out of bed, take a shower, eat bacon and eggs for breakfast, leave the house, drive at the speed limit, wear my seatbelt, cycle in the bike lane, wear a bike helmet, use the crosswalk, skydive, BASE jump, get screened for colon cancer, take my prescribed medicines, etc. Each decision is mine, based on my personal priorities and assessment of the risks (including, in some cases, legal sanctions).

Depending on the activity, the societal approach to risk can be permissive, regulated, or prohibitive.

“There is no controversy over enforcement in two, diametrically opposed kinds of cases. First, in cases in which a practice is seen as entirely innocuous, or even admirable, and carrying no risks, the question of prohibition and enforcement obviously does not arise. Call these cases of clear permission. Second, in cases in which a practice is clearly and uncontroversially wrong, and with respect to which prohibitions are known to be effective, prohibition is clearly called for. Call these cases of clear prohibition.”

From: “Disagreement, Unenforceability, and Harm Reduction”

OK, there’s a spectrum. Harmless things are (usually) a matter of free choice. Other things are “uncontroversially wrong” and not a matter of choice, many of them involving harm to others, including, for example, robbery, murder, pedophilia, bestiality, etc. We prohibit them, but they still happen. Prohibition, in other words, isn’t always effective. Laws punish the offenders but may not prevent the offence.

Most things in life, of course, are neither completely harmless nor uncontroversially wrong. In between, you find all sorts of things with a mix of benefits and harms.

Even when it comes to psychoactive substances, those public health experts acknowledge that there’s a spectrum:

In formulating drug policy, therefore, it is fundamental but generally overlooked that some use actually is non-problematic (maybe even beneficial!) while other use is clearly problematic (even if we won’t call it “wrong”, because that would be stigmatizing).

For most psychoactive substance users, the decision to use the drug reflects their assessment that the immediate benefits (as they define them), outweigh the harms (as they see them). When it comes to alcohol, for example, there are quite a number of plausible reasons to take a drink:

Of note, drinking motives vary by individual and the circumstances, and change with age; young folks are more likely to drink to get drunk or to fit in with their peer group, whereas “grown-ups” drink for other reasons, including the simple fact that they are more likely to enjoy the flavour.5

Presumably, even though there’s surprisingly little written on the subject, there are similar plausible reasons for taking all psychoactive substances, and those will vary from one person and one moment to the next.6 This includes the cup of coffee to start the day, the cigarette to calm the nerves, the glass of wine with a meal, the beer while watching a sporting event, the toke or the psychedelics at a concert, etc.

“According to this perspective, people have a right to control their bodies and minds and a ‘right to be different,’ and these rights encompass a right to use drugs for “self-defined” purposes, including intoxication.”

From: The Virtues of Pragmatism in Drug Policy

We acknowledge that “freedom of choice” (or autonomy) matters, the buzzwords being “individual responsibility”, “responsible use”, and “informed choice”. Sooner or later, however, despite the individual being responsible for their own freely made choices, others start to judge them on whether or not their reasons are valid, their drug use is “responsible”, their choice was freely made, and whether or not they were truly “informed”, particularly when their drug use carries adverse consequences for themselves or others.

Can we leave people alone, or should we be “parental”, stepping in to protect them against “poor” choices? This plays out every day! Those warning labels on cigarettes are there to ensure that smokers are informed, in the belief that they’ll then make the responsible decision not to smoke, assuming their brain hasn’t been “hijacked” by nicotine. There are those who wish for a similar approach to alcohol. And what of the opioid tablet of dubious provenance taken at a party? Must the user understand and accept the risks, avail themselves of free “drug testing”, take the drug with friends, ensure that naloxone is on hand, etc., etc.

So, while those who set drug policy are obsessed with the harms (individual AND collective), individual users may see the harms, such as they are, as unintended, manageable, avoidable, unlikely, insignificant, irrelevant, and/or “off in the future”. When your goal is to test the limits, get high, and do what your friends are doing, you are unlikely to follow some arbitrary set of rules in doing so. It’s hard to find rule-following rule-breakers!

However:

“Since there is no use of drugs without risk, their consumption in most cultures has been tightly restrained by cultural or even religious norms that specify the situation, context of use, and who can consume them.”

From: Framing substance use as “recreational” is neither accurate nor helpful for prevention purposes

“The current regulatory regime in Canada places most of these individual substances in either legal (e.g. alcohol and tobacco), prescription (e.g. morphine, benzodiazepines, ritalin) or illegal (e.g. … cocaine, heroin) drug status. It is important to recognize that this taxonomy is not based in pharmacology, economic analysis or risk-benefit analysis, but is derived from historical precedent and cultural preference.”

From: A Public Health Approach To Drug Control in Canada, 2005

And so, as cultural and religious norms become less consistent, drugs become more accessible, individual identity more important, and laws more difficult to enforce, we end up with inconsistent and illogical drug policies that reflect history, not the facts.

We end up with something that looks like this.

Unfettered access causes harm by encouraging rampant, irresponsible use. By this logic, if booze was free, we’d all be drunk all the time! Prohibition actually drives up demand while adding a whole new category of harms. When you ban something pleasurable, the pleasure seems greater! The assumption is that there’s a Goldilocks-like sweet spot in the middle where we are neither too permissive nor too prohibitive, the balance is “just right”, and harms are minimized.

Coffee drinking is seen as innocuous, so it’s permitted. Plenty of businesses make money selling it. Caffeinated energy drinks, however, are seen as risky, so there are lightly enforced regulations about their caffeine content. Caffeine pouches are banned.

Smoking used to be like coffee, permitted and commercialized. However, the anti-smoking lobby now characterizes smoking as clearly and uncontroversially wrong. In their view, it’s harmful to others (being unpleasant and irresponsible, when done in public) and dangerous, with even a single cigarette (or side stream smoke) presenting an unreasonable risk. They’ve decided for you! Smoking is now tightly regulated, although there’s a growing black market. In public health’s perfect world, nobody would smoke! They resist the idea that nicotine can have pleasurable effects and that it can safely be taken in other, “harm reducing” and less offensive ways, like vaping.

Alcohol was, at one time, seen as clearly and uncontroversially wrong, and so it was prohibited (unsuccessfully). We’ve since softened our approach, so it’s permitted but regulated. Most people don’t have a drink of alcohol with the intention of becoming inebriated, acting obnoxious, starting a fight, or causing a car accident (i.e. doing things which harm others). They imagine that they’ll be “responsible” or, at a minimum, that their friends will “look out for them”. When things go wrong, the individual pays the price, up to and including jail time. Nobody anticipates becoming an alcoholic, losing their job, alienating their friends and families, or developing hepatitis or cirrhosis. We don’t describe alcohol as a drug, or its use as “recreational”. The entire alcohol industry stands on the foundational belief that alcohol ingestion is pleasurable and mild intoxication is “fun”. We believe, rightly or wrongly, that alcohol consumption sites can be regulated and made “safe”, and “responsible drinking” will prevent any complications, including harms to others. Still, there are those who want it dealt with the same as smoking, with warning labels on every dose, the message being that “no amount is completely safe”. In their perfect world, nobody would drink, or at least very few!

Cannabis, of course, was once illegal (as shown on the graph), but then became legal. In theory, it’s tightly regulated, so as to minimize harms, but in reality the regulations aren’t so tight, and the harms persist. They may even have increased! See my previous post. We have the worst of both approaches.

Generally speaking, we’ve disallowed cocaine, opioids, etc. Presumably, in that perfect world, nobody would use these, because they are “too dangerous”, but what does that mean, and how do we decide? Some argue that alcohol and tobacco are actually more harmful. The classic approach is “zero tolerance”, criminalization and enforcement, exemplified by the “war on drugs”, the objective being to eliminate demand by “supply reduction”. However, demand persists, as does supply! The majority use recreationally, a minority become addicted. Some addicts end up in jail (as “wrongdoers”, simply because they possess drugs and/or because of what they do to finance the habit), while others end up in treatment (as “victims of disease”). Decriminalization diverts drug users from the “punitive and “stigmatizing” legal system while seeking to connect them with the “helpful” health care system, the idea being that the legal penalties and stigma are simply another form of “harm”. Decriminalization and treatment both seek to “reduce demand” and reduce the harms. However, decriminalization is not the same as legalization, and so we aren’t saying these drugs are “OK”. We have government-run cannabis stores in Canada, but those stores aren’t selling opioids.7

Where’s the unifying logic? Is there really a spot in the middle of the curve where we have “just enough” regulation to minimize the harms, while still allowing people to make their own choices? Who decides? Who listens?

In Canada, our public health experts have been leading the charge. They want to decide. Should we listen?

“To move forward from our current regulatory regime, the Health Officers of BC propose that drug control policies should aim to reduce harmful use, minimize negative health effects to the individual, and limit secondary drug-related harms to society (e.g. crime, violence, corruption, excess medical costs).”

From: A Public Health Approach To Drug Control in Canada, 2005

Clearly, they believe in that U-shaped curve, where harms are at a minimum. Is the system they’re designing “just right”, or is it perfectly designed to get the (not very good) results that it gets?

And that leads into a discussion of harm reduction, the subject of my next post.

To recap…

• Caffeine is psychoactive and addictive, but relatively harmless, so it’s minimally regulated and widely available. Nobody objects to having a(nother) coffee shop in the neighbourhood.

• Alcohol is psychoactive and addictive. It can be harmful in the short term (when used in quantities that cause behavioural issues) and over the long term (particularly when used regularly and in larger quantities). It’s fairly strictly regulated, but still widely available, the premise being that the harms can be avoided through responsible use, even though the harms we see suggest that a lot of people aren’t “responsible”. Alcohol is big business!2

• Nicotine is psychoactive, addictive, and harmless, except when it’s smoked. The act of smoking is, therefore, strictly regulated, as is the marketing of tobacco products. There’s a thriving market for illegal cigarettes, largely due to high levels of taxation on the legal product. For sundry reasons, nicotine-containing products, particularly vapes, are also regulated, largely out of fear that they’ll act as a “gateway drug” for the smoking of tobacco and cannabis. Without tobacco (and lottery tickets, another addictive product), a large percentage of the corner stores would go out of business.

And this brings us to cannabis. Cannabis is psychoactive. Here in Canada, it was legalized a few years ago, the assumption being that it was relatively harmless and non-addictive, so possessing it and selling it was, in effect, a “victimless crime”. As with alcohol, proponents of legalization argued that all possible challenges and harms related to cannabis use could be addressed by encouraging responsible choice. To that end, the government set up a regulatory framework and government owned (and/or licensed) cannabis stores, but there’s still a thriving illegal market, together with emerging evidence that cannabis can be harmful and addictive.

Cannabis pharmacology

There are dozens of cannabinoid compounds in cannabis, Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) being the most active. Given that THC and CBD coexist in varying proportions in cannabis, they are usually consumed together, so there really isn’t as much evidence as you might imagine regarding their separate effects. The picture is further complicated by the fact that many psychoactive substance users “mix and match” their drug intake, so it can be hard to know which effects are due to cannabis, which are attributable to other drugs, and which reflect drug interactions.

All that being said, THC is felt to be the primary psychoactive ingredient, accounting for the “recreational” aspects, and as such it also accounts for the risk of misuse. As with nicotine and tobacco smoking, the inhalation of cannabis smoke introduces THC directly into the bloodstream, where it travels rapidly to receptors in the brain. The immediate effects can include euphoria, laughter, relaxation, increased appetite, augmented mood sensations, and altered time perception. When cannabis is eaten, the absorption is delayed, so the psychological effects are deferred, less intense, and more persistent.

CBD is reputedly not psychoactive3 and therefore does not seem to have much potential for misuse, nor does it produce psychotic effects. CBD has been promoted as having “medicinal” effects, including reduced seizures in epileptics, improved chronic pain across different conditions, decreased spasticity in multiple sclerosis, reduced nausea and vomiting in some conditions, and improved sleep. However…

“CBD has not displayed meaningful activity on its own in a double-blinded, placebo-controlled clinical trial. Trials that underlie claims of a wide range of health have predominantly used CBD as minor ingredient or part of adjunctive therapy schemes that co-administer other substances/preparations, often seeking to leverage “botanical synergy”…

The Essential Medicinal Chemistry of Cannabidiol (CBD), 2020

Overall, therefore, while much is claimed, the research base on the health benefits of cannabis in general, and THC and CBD in particular, is largely observational and poor quality.4 Nonetheless, the notion that cannabis has both recreational AND medicinal applications has been taken as evidence that cannabis use is harmless, perhaps even therapeutic.

Theoretically, cannabis taken for therapeutic purposes should be like hemp (high in CBD and low in THC), whereas cannabis sold for recreation should be higher in THC. In real life, however, the argument that people smoking street cannabis will see medical benefits ignores the fact that they are almost always getting more THC than CBD, so the euphoric effects of the THC mean they’ll likely “feel” better even if their medical condition isn’t objectively improved. And, as with every drug, there’s a placebo effect.

“CBD has a strong “meaning effect”: individuals expect it to work.”

The Essential Medicinal Chemistry of Cannabidiol (CBD), 2020

Importantly, cannabis is different from alcohol

Alcohol is water-soluble, taken orally as a beverage, and widely distributed in the body (which is 95% water). Ethanol is the active ingredient. Effectively, it’s marketed in three different strengths; beer (5-6% ethanol), wine (10-15%), and hard liquor (40-45%). Theoretically, you could inhale or inject ethanol, or you could drink surgical ethanol (95%), but the flavor seems to be an important part of the experience, especially for the recreational users. Some folks enjoy a sip of wine, without taking enough to get any meaningful brain effects.

Ethanol’s absorption, distribution in the body and subsequent elimination are quite predictable, with blood and breath samples accurately reflecting the amount consumed, the levels in the brain, and the extent of impairment.

In contrast, THC can be taken orally or by inhalation, in various forms and degrees of purity. I suppose some folks will argue that the flavor is part of the experience, and/or that there’s a meaningful difference between one batch of cannabis and another (beyond the THC content), but, at the end of the day, getting the THC to your brain is the goal. No brain effects, no point! 5

THC is fat-soluble, so ultimately it gets into and persists in fatty tissues, including the brain and body fat. With chronic use, it accumulates and is gradually released from these tissues, such that it exerts effects and can be detected days to weeks after the last cannabis use. As such, there is no consistent relationship between plasma THC levels and those in the brain, and the blood levels don’t necessarily reflect the degree of impairment. THC cannot be detected in breath samples, so you have to test saliva. All these factors make it more difficult for cannabis users to know how the cannabis they use will affect them, and for police (or employers) to determine whether cannabis use is contributing to accidents (or reduced work performance).

Cannabis can cause harm

THC and CBD are not “clean” drugs. their effects are not all “good”, nor are they all confined to the brain. So, even though cannabis is presented as being fairly harmless, there’s good evidence that its use causes harm.

The benefits and the harms both increase with the dose, so it’s relevant that the THC content of cannabis has increased substantially over the years. Cannabis cigarettes used to be about 2% THC by weight back in the 80’s, but they currently average 20% THC, so a 1-gram joint now contains 200mg of THC. Some extracts are 70-80% THC!

At a minimum, there are adverse effects on the immune, cardiovascular, and reproductive systems, as listed below.

More specifically, there are the obvious acute effects of THC on alertness, concentration, coordination, and cognition, all of which combine to increase the risk of accidents, particularly when driving. After alcohol (and often in combination with alcohol), cannabis is the second most frequently found substance in drivers involved in impaired driving cases and fatal MVAs.

Repeated cannabis impairs prospective memory, verbal delayed recall, verbal learning, and visual immediate recall, so the general advice is that cannabis should be avoided in adolescents and young adults (up to the age of 25), when the brain is still developing and cognition is important for learning.6

Most mental health disorders have their onset in adolescents and young adults, and cannabis use carries an increased risk of psychosis, so again the general advice is that cannabis should be avoided in adolescents and young adults.

For all ages, there is an association between cannabis and general psychiatric symptoms, including depression and mania, as well as increased rates of relapse in people with a psychotic disorder. While some argue that they are “self-medicating” with cannabis, it’s most likely that the cannabis is making things worse, not better.

Those who use cannabis for several years can develop cannabinoid hyperemesis syndrome (CHS), characterized by cyclical nausea, vomiting, and abdominal pain after using cannabis, every few weeks to months, relieved by hot baths or showers. This resolves after stopping cannabis use.

It has also been noted that cannabis smoking, the most common route of cannabis consumption, exposes users to many of the same toxins contained in tobacco smoke. However, cigarette smokers use 10–20 cigarettes per day, on average, while cannabis smokers may only use 50–150 joints per year, so the risk to the airways is perhaps not as great.

And, finally, even though most individuals who try cannabis will either stop using it within a short period or remain occasional users, some will get addicted.

Cannabis Use Disorder (CUD)

As with all substance use disorders, the diagnosis of cannabis use disorder implies a problematic ongoing pattern of cannabis use leading to clinically significant impairment or distress, sometimes with evidence of tolerance (the need for increasing doses to achieve the same effect) and/or withdrawal symptoms.

Despite the perception that cannabis use is near universal, Statistics Canada also reports that only 38.4% of adults aged 18 to 24 years, 34.5% of adults aged 25 to 44 years, and 15.5% of adults aged 45 years and older reported using cannabis in the previous 12 months. Flip those numbers around, and you’ll note that two-thirds of the adult population haven’t touched the stuff in the last year. For students in grades 7-12, Health Canada shows 18 % reporting cannabis use in the past-year, so 82% aren’t using it.

In short, even though Canada has one of the highest rates of cannabis use in the world, most Canadians still aren’t using it.

Among cannabis users, however, CUD is not a small problem! Fully one-fifth of people who use cannabis meet the diagnostic criteria for CUD. That rate increases to 1-in-3 among those who use cannabis multiple times weekly7, and 50% (or maybe even 75%, according to this study) among those who use it daily. Those daily users are a fairly significant group, according to Statistics Canada. In 2023, about 1-in-10 of ALL adults aged 18 to 44 years reported using cannabis daily or almost daily in the previous 12 months, compared with 1-in-20 of adults aged 45 and older. For students in grades 7–12, data from the 2023/24 Canadian Student Tobacco, Alcohol and Drugs Survey (CSTADS) shows 4% using cannabis 5+ days a week in the past 30 days; that’s one or more students in every classroom!

Overuse, therefore, is a problem, particularly at the younger end of the age spectrum. The younger you are when you first use cannabis, the greater your risk of developing a CUD within the first 24-months. That risk substantially diminishes after age 25. By contrast, subjects who start drinking alcohol at an early age also have a higher risk of developing alcohol use disorders, but they make the transition much more slowly. Ditto for nicotine.

“Almost 30% of cases with cannabis abuse had occurred at 1 year after onset of [cannabis use], 50% at 2 years, and 70% at 3 years. In comparison, 10% of all alcohol abuse cases had occurred at 1 year after first alcohol use, 30% at 2 years, and 60% at 4 years. Only a few new cases of abuse occurred 10 years or more after onset of use of the respective substance.”

Transitions from first substance use to substance use disorders in adolescence: Is early onset associated with a rapid escalation?

So, it doesn’t take long for addicts to go from first use of cannabis to addiction, particularly for the age group who are trying to complete their education and make a start on their careers. Solmi et al report that, for cannabis use disorders, 66% of people will have onset by age 25 years, with age of peak onset at 20.5 years.

Interestingly, rather than being a chronic (lifelong) relapsing condition (as seems to be the case for alcohol and tobacco), cannabis use disorders are, for many, time limited. In one study of those with CUDs prior to the age of 30, 54% fully recovered (without a relapse) by age 30. Based on Global Burden of Disease 2019, Solmi observed that disability related to CUDs is measurable at ages 10-14 years, peaks at ages 20-24, and then gradually decreases.

So, disability related to cannabis use is largely limited to individuals aged 10-24 years, whereas alcohol causes disability from the early stages of life, increasing continuously to age 35-39 years, and then very slowly decreasing to age 80+.8

However, given that cannabis is becoming more potent and more readily available, nobody really knows how this will play out in the future.

Legalization

Against that backdrop, the decision to legalize cannabis in Canada has an interesting history.

In Canada, cannabis was legalized for medical purposes in 2001, with regulatory changes in 2014-15 that made it easier to obtain. Physicians were expected to certify that the individual had a medical condition that benefitted from cannabis use, while specifying the daily dose (in grams of dried cannabis) and treatment duration. There being little or no good quality evidence to support any of this, it usually came down to the patient attesting that they had some complaint which was relieved, in whole or in part, by using cannabis in some quantity. In my practice, in most cases, the patient’s complaint and cannabis use were previously unknown to me. Few were interested in any investigations or other (more proven) forms of therapy. In other words, cannabis wasn’t the drug of last resort for a well-investigated problem for which all other therapies had failed. From the patient’s perspective, its use and my “prescription” were foregone conclusions. My suspicion was that many were using it recreationally, using the medical exemption as a means to avoid prosecution. Without going into detail, this raised all sorts of ethical and medico-legal concerns.9

Recreational cannabis was legalized in Canada in 2018.10 The stated purposes of the relevant legislation were to protect public health and public safety and, in particular, to:

• protect the health of young persons by restricting their access to cannabis,

• protect young persons and others from inducements to use cannabis,

• provide for the licit production of cannabis to reduce illicit activities in relation to cannabis,

• deter illicit activities in relation to cannabis through appropriate sanctions and enforcement measures,

• reduce the burden on the criminal justice system in relation to cannabis,

• provide access to a quality-controlled supply of cannabis, and

• enhance public awareness of the health risks associated with cannabis use.

Put another way…

“The Liberal Government’s policy rationale was clear: consumption of cannabis was widespread and use rates were rising, and yet Canadians could only access cannabis from illicit sources, putting themselves at risk.”

“Despite concerns about health harms in some quarters, the Government argued that it was considered preferable to create a legal market so that, firstly, consumers could be better protected from adulterated products; secondly, cannabis production and distribution could be closely regulated; and thirdly, the criminal supply chain could be competed against and gradually supplanted, offering wider benefits in terms of new sources of tax revenue and fewer social harms.”

“Any assessment of whether Canada’s legalisation experience has been successful depends on the value that is placed on these different goals. For example, the priority of protecting public health, compared to the legitimate goal of displacing the illicit market and the crime and harms associated with it. Invariably, the balance is difficult to strike, and there is no magic formula for guaranteeing a good policy outcome whereby illicit cannabis consumption is significantly eroded, while overall prevalence rates stay stable (or even fall), especially given the inevitable novelty of a new legal market involving branded products marketed and sold by for-profit entities (either private or government-owned).”

Cannabis Legislation; Canada's Experience, 2021

Initially, the recreational product line was limited to dried cannabis and ingestible oils, but one year later it expanded to include edibles, vapes, and concentrates.11

Now, as with tobacco and alcohol, the federal government regulates cannabis production nationwide, while the provincial and territorial governments regulate the supply and distribution logistics in their respective jurisdictions. For cannabis, some provinces allow private retailers, others do not. Municipalities, through zoning regulations, can limit where cannabis stores were located. Accordingly, there are many different systems for distribution, and access varies from one province to the next.

At one end of the spectrum, Quebec has been resistant to cannabis legalization. It has prohibited home cultivation, the legal age for cannabis use is 21 (vs. 18 for alcohol), and cannabis use is prohibited in all public spaces. The state-owned monopoly Société Québécoise du Cannabis (SQDC) offers a relatively narrow range of products across a limited number of storefronts. The message is mixed; cannabis is legal for some people in some places, but there are many situations where purchasing and using it remain illegal.

Other provinces have been more lenient. Alberta, for example, set the legal age for cannabis use at 18, licenses private cannabis retailers (with a relatively large number of stores), and allows private cultivation.

All of this, you would think, would be the perfect setting for some research into the effects of different policy frameworks on cannabis use. Some has been done, but not much. That might expose uncomfortable truths!

In view of the potential unknown impacts of the change, Parliament required a review of the Act three years after it came into force. That report was published in 2024, 6 years after legalization, having been delayed by the Covid pandemic. Unsurprisingly, there were concerns, some of them quite predictable, some preventable:

• “Youth and young adults are more vulnerable to the adverse effects of cannabis.”

• “While the data indicates that youth use has remained relatively stable since legalization, Canada continues to report among the highest rates of youth cannabis use in the world, and cannabis use among young adults has increased.”

• “More needs to be done to drive change in youth behaviour to reduce prevalence of use and discourage harmful use.”

• “Increasing reports of poisonings among children who have unintentionally consumed cannabis, notably edible cannabis, were troubling.”

• “We are also increasingly concerned with the apparent shift toward the consumption of higher-potency cannabis products, since these products carry greater health risks, and there have been recent reports suggesting increases in cannabis-related health care presentations.”

• “While the Act contains serious offences and penalties to deter criminal activities with cannabis (such as unauthorized production and sale to youth), enforcement action has been limited due to shifting police priorities, inadequate resourcing and gaps in authority.”

• “The illicit cannabis market remains entrenched, and too many illicit retailers continue to operate both online and physical stores.”

• “There are challenges for the sustainability of companies, particularly smaller-sized licensed cultivators and processors. Industry representatives expressed concerns about the cost burden that the excise tax imposes on them, particularly the excise tax for dried cannabis, as well as the costs associated with regulatory fees and regulatory requirements that are imposed at both the federal and provincial and territorial levels.”

In short, while it was known that cannabis use is particularly hazardous in those up to the age of 25, Canadian youth and young adults were consuming worrisome (indeed, world-leading!) quantities of cannabis.12 Furthermore, the cannabis they consumed was increasingly potent. It’s not entirely clear whether these trends resulted from legalization or simply reflect the continuation of trends that started before legalization. Either way, it’s a problem.

Conflicts of interest

As with alcohol and tobacco, our governments have now become financially dependent on the cannabis industry. They have an obvious conflict of interest! According to Statistics Canada, in 2023 “Two of every five dollars spent on legal cannabis enter government coffers”.

A large segment of our government financing (and economy) depends on our “bad habits”! They would love for you to quit smoking, and to use alcohol and cannabis responsibly (or not at all), but they would suffer significant financial consequences if we did. In 2023-24, we spent a combined $31.4 billion on legal alcohol and cannabis, with governments pocketing $418 from alcohol and $68 from cannabis per person of legal age. Bearing in mind that a lot of people aren’t using cannabis at all, and that over one-third of users still access the illegal market, that’s a lot of money!13

Normalizing “recreational drug use”

Against that background, I’m going to suggest that the legalization of cannabis is a textbook example of psychoactive drug policy that doesn’t make sense.

The root of the problem is the concept of “recreational drug use”, the buzzwords being “responsible use”, “individual responsibility”, and “informed choices”. These terms date back to the 90’s and collectively reflect a narrative (and assumptions) about the prevalence of drug use, the rationale for use, the decision-making process that precedes use, and the willingness of the individual (and society) to accept the consequences (good or bad) of individual decisions.

It’s a tried-and-true marketing tactic! The implication is that all possible harms related to cannabis use can be prevented by encouraging responsible use by informed and rational users whose motives are pure (they are simply seeking enjoyment), in the context of a well-regulated marketplace.

“This positive “recreational” representation follows up perfectly on those created and promoted previously by the tobacco industry and still by the alcohol industry.”

Framing substance use as “recreational” is neither accurate nor helpful for prevention purposes, 2023

Is “fun” a sufficient rationale?

“The problem with the current use of “recreational” is that it suggests that - without differentiation - any non-medical use of cannabis or other psychoactive substances brings mental, emotional, social or somatic benefits, alike other recreational activities, such as sports, relaxation, sleep, sex or food. Yet, this is not correct for most consumption patterns.”

“Currently, either due to ignorance, misinformation, or vested interests, the media uses and adopts concepts created and disseminated by pro-cannabis interest groups who subtly have embedded in the public opinion the idea that smoking a joint is harmless or even therapeutic.”

Framing substance use as “recreational” is neither accurate nor helpful for prevention purposes, 2023

There aren’t many widespread recreational activities that carry a 20% risk of harm. Much smaller risks trigger much greater governmental concern; the risk of head injuries in bicycle accidents is actually tiny, and yet we legislate helmet use!

Are decisions to use substances for “fun” fully informed and rational?

We know cannabis is harmful, and that more than a few people have trouble controlling their use, and yet we assume that encouraging “responsible use” is a viable approach. Our experiences with alcohol, nicotine, and other drugs have shown that “educational’ approaches aren’t sufficient to prevent problems. Drug use isn’t always rational. Why would it be different with cannabis?

“Since there is no use of drugs without risk, their consumption in most cultures has been tightly restrained by cultural or even religious norms that specify the situation, context of use, and who can consume them. Therefore, human cultures seem to have always been conscious that the pathways from initiation of substance use into problem use depend firstly on the environment (access, social norms, social networks, media, laws, and regulations), secondarily on individual characteristics (personality traits, genetics, physical, and mental health), and lastly on the characteristics of the drug itself (addictive potential, toxicodynamic, toxicokinetic, quality, quantity, and route of administration)”

“Alcohol use is a useful example of how much the use of a substance has been so deeply ingrained in social and cultural practices that it is implicitly and by default seen as “recreational”. Hardly anyone would speak about “recreational” alcohol use: it is taken for granted that it is. And if it is not, the users are stigmatized.”

Framing substance use as “recreational” is neither accurate nor helpful for prevention purposes, 2023

We know that cannabis is particularly harmful to youth and young adults, as specifically recognized in the legislation, and yet the legal age of use is as low as 18 in some provinces. We also know, based on our experience with smoking and alcohol, that people below the legal age can easily access substances14, and that they follow the lead of their peers.

Legalization “normalizes” substance use behaviors, sending the message that “it is normal and most people do it”. It puts a thumb on the scale, influencing rational decision makers in the direction of use rather than avoidance. For fear of “stigma” (discriminating based on non-modifiable conditions or behaviors), we fail to set societal standards about unhealthy cannabis use behaviors (like daily or near-daily use).

“The perception of “most friends doing it” increased tenfold the [odds ratio] of binge drinking, but hundredfold the [odds ratio] for cannabis use.”

Framing substance use as “recreational” is neither accurate nor helpful for prevention purposes, 2023

Do individual cannabis users know and accept the potential consequences?

We know that cannabis intoxication impairs driving, but we have no good way to measure or document the impairment. Legislation prohibits driving while cannabis impaired. How could we hope to enforce that? Even in students in grades 7-12, who are too young to buy the stuff legally, a Statistics Canada survey showed that “In the previous 30 days, 2% of students had driven within two hours of smoking or vaping cannabis and 11% had been driven by someone who had been smoking or vaping in the previous two hours.”

We operate under the assumption that recreational drug use reflects a conscious individual choice influenced by societal norms, and that substance use disorders reflect a loss of control over rational decision-making. Beyond education, we do nothing to prevent addiction, while claiming to favor prevention over treatment. We assume (naively) that people with substance use disorders can and will eventually make a rational decision to quit.

Has our government taken a prudent approach?

Some argue that decision to legalize was “ideological”. If cannabis is fun and harmless, then why criminalize the users?

But it’s not harmless! We know cannabis is harmful, and yet we’ve framed its use as “recreational” (or “fun”), which downplays the potential severity. We talk about “harm reduction”, we know the harms increase with the dose, and yet we’re allowing (or even encouraging) the sale of increasingly potent formulations, rather than limiting them, as was done with alcohol.

We’ve adopted an “industry” approach to cannabis, as if regulation is sufficient to maximize the fun and mitigate the harms. Alcohol is a legal and highly regulated industry, and yet it causes plenty of harm, even as it continues to be marketed as “fun”.

Others argue the decision was “pragmatic”. If cannabis use is widespread, and prohibition doesn’t work, then why waste resources trying to control it?

But cannabis use isn’t as widespread as it seems, and it’s a big jump from prohibition (which doesn’t stop ALL use, while sending a message that “it’s not OK”) to legalization (which removes MOST obstacles to use, while sending a message that “it’s OK”).

We know, from painful past experience, that it’s hard to reverse legalization, and yet, in legalizing cannabis, rather than taking a graduated approach, we’ve plunged right in at the deep end, with no checks and balances. Undoing legalization is difficult, if not impossible. We’ve spent decades trying to roll back tobacco use.

Besides that, where do you stop? Having legalized cannabis, then why not ecstasy, LSD, or even opiates? Whatever arguments were made about promoting the safer use of cannabis could also be made for other drugs.15

After all, caffeine is the active “natural” ingredient in various foods and beverages and it’s regulated here in Canada under the Natural Health Products Regulations. When added to a food or beverage, it’s a “supplemental ingredient”, something added for purposes other than nutrition.

Alcohol sold in Canada is subject to both the Safe Food for Canadians Act (and Regulations) and the Food and Drugs Act (and Regulations). Interestingly, for the purposes of those Acts, “A food does not have a poisonous or harmful substance in or on it”. With other government departments warning us about the health risks of alcohol, you wouldn’t think the legislation would apply!

In short, even though they are psychoactive, caffeine and alcohol aren’t legally considered to be drugs. They’re “food” and/or “natural health products”!

This raises an interesting point.

There are “non-drugs”, “medicines”, and “DRUGS”

The experts in substance use (and abuse) tell us over and over again that language matters, particularly as it relates to the responsibility of the individual for their actions while under the influence or addicted1.

“While it is tempting to think that medical language surrounding addiction provides liberation from the moralized language, evidence suggests that this is not necessarily the case. On the other hand, non-disease models of addiction may seem to resuscitate problematic forms of the moralization of addiction, including invoking blame, shame, and the wholesale rejection of addicts as people who have deep character flaws, while ignoring the complex biological and social context of addiction.”

Addiction and Moralization: the Role of the Underlying Model of Addiction, Frank and Nagel, 2017

However, when it comes to discussing the many different psychoactive substances, the language is amazingly imprecise.

Consider the following:

The non-drugs

Some substances (like alcohol and caffeine) are ubiquitous, and we don’t consider them to be drugs. They are “legal psychoactive substances”.

The idea that they are NOT drugs is reinforced by our language. We commonly refer to “alcohol and drugs”, as is they were different, rather than “alcohol and other drugs”. The United States, for example, has the Bureau of Alcohol, Tobacco, Firearms and Explosives, which is separate and distinct from the Drug Enforcement Administration. Alcohol and tobacco have more in common with explosives than with cannabis, I guess!

By labelling these as “food” or “natural health products”, we reinforce the belief that they are not dangerous in and of themselves. As their use is a matter of personal choice, those who use them and get into trouble must be uniquely susceptible (a matter of “bad luck”), “flawed” (from a moral perspective), or “diseased” (if you subscribe to the “brain disease model of addiction”).

Alcohol itself is “fun”, so it’s not the problem. You can be punished (i.e. held responsible) for “disgusting” things you do when drunk (like driving, fighting, and causing injury or death), and yet you aren’t to be stigmatized for things you do when addicted. At that point, the alcohol has “hijacked” your brain’s internal reward circuitry and you are “no longer in control”. The experts will say you need treatment, not punishment, and compassion, not condemnation. So, while alcohol isn’t legally (or linguistically) a drug, it sure behaves like one!

Nicotine, by the way, also falls in this group, but its usual delivery method (smoking tobacco) is harmful, so its status is ambiguous and evolving. More about this later.

The DRUGS

At the other extreme, we have psychoactive substances that we consider inherently bad or dangerous. These are “DRUGS”, as in “drugs of abuse”, “the war on drugs”, “drug dealers”, “drug trafficking”, “drug addicts”, “Drug Enforcement Administration”, etc.

The underlying assumption is that the substances themselves are so dangerous that making them, selling them, and even possessing them is bad. There’s no way that they could be taken nonproblematically or “responsibly”, as a matter of personal choice! They are all-powerful, having the power to over-ride your free will! For that reason, they are illegal. When seized by the authorities, they are displayed as ”…a symbolic spectacle of conquest over the adversary”2.

Cannabis used to be in this category, but now it’s not! More about this later.

The medicines

In between, we have psychoactive substances that we use as medicines. We call these “pharmaceuticals”, although they might be manufactured by a “drug company” and sold to you at a “drug store” by professionals once known as “druggists”.

Medicines you feel better (when taken as prescribed), but they aren’t to be taken for pleasure (because that could be bad), or by those without a prescription (because that would be illegal). There are, of course, many other medicines that aren’t psychoactive.

So, the language is inconsistent. Many of the distinctions between non-drugs, pharmaceuticals, and DRUGS are cultural, historical, religious, and/or philosophical, having little or nothing to do with the actual pharmacology of the substances:

• At various times in the past, caffeine, alcohol, and smoking have all been considered “medical” or “therapeutic”.

• Alcohol is “food” in Canada, but “DRUG” in many Islamic countries.

• In Canada, cannabis has been in all three categories. It was once an illegal DRUG but has since been legalized. During the transition it was permitted for medical use, based on a physician’s prescription. Indeed, while it has been used medicinally in many cultures throughout history, you’ll not find great “scientific” evidence that it works, in part because researchers won’t be able to patent it.

• Opioids are “medicine” and “pharmaceuticals” when marketed by Big Pharma and taken as “opioid agonist therapy” or “safer supply” for a diagnosis of “substance use disorder”, but “DRUGS” when they are taken for pleasure, having been purchased on the street from “drug lords” and “pushers”. Context matters!

Non-stigmatizing language

To top it off, in referring to the users of some substances, we are supposed to use “people first” language, which is intended to decouple the behaviour from the identity of the person. A smoker should be referred to as “a person who smokes”, with modifiers to indicate whether their consumption occurs occasionally or daily, previously or currently, with or without other substances, etc. People do disgusting things when drunk, but we can’t call them drunkards (or alcoholics) — they are “people experiencing alcohol intoxication” or “people experiencing alcohol use disorders”.3 We love the sinner but loathe the sin, but in doing so we ban the behavioural sin of smoking in public places while allowing the behavioural sin of injection opioid use in the same settings. The avoidance of stigma (and love of sinners) applies more at one end of the spectrum than the other.

Responsible use

To add to the confusion, we have the idea that individual substance use can be “responsible” (or “prudent) or “irresponsible”, which implies some sort of external judgment. Some argue that irresponsible substance use is only that which endangers others (i.e. drinking and driving), whereas others argue that it also includes substance use which endangers the health of the user (i.e. the cancer risks of smoking). In terms of the latter, because ALL activities, including substance use, have both benefits and risks, nothing is completely “risk free”, and therefore EVERYTHING is in some way irresponsible. As such, it could be left to the individual to make an informed and rational decision whether the personal benefits outweigh the personal risks, and/or whether they are willing to accept any possible consequences. The alternative is paternalism; if the state decides that no-one should place their personal health “at risk”, then the state ends up decreeing in detail what each and every person can and cannot do. We see elements of this in seatbelt and bicycle helmet laws.4

Recreational use

To further complicate matters, we also see some substance use described as “recreational”, implying that responsible use for pleasure carries minimal (or mitigatable) risks of harm, and therefore is (or should be) acceptable. Drinking alcohol, for example, is seen as recreational, although, for about one-fifth of drinkers, the consumption pattern is actually problematic. Intermittent use of opioids at parties, concerts, etc. is sometimes described as recreational use, often in conjunction with suggestions that the users have access to drug testing, safer supply, and supervised consumption facilities, all of which aim to mitigate the risks (in effect “bubble wrapping” the user) without interfering with the pleasure. The implication is that recreational use is acceptable, manageable, less harmful, and “the norm”, all of which makes it likely that individual users will underestimate the risks.

Harm reduction

One policy approach to dealing with risk is “harm reduction”, a pragmatic alternative to the moral/legal model of drug use and the “brain disease” model. The moral/legal model assumes that substance use is morally “wrong” and therefore deserving of punishment. It calls for “eliminating the supply” (i.e. the war on drugs). The disease model sees substance use as a consequence of disordered brain function, which should, ideally, be “corrected”. It aims for “demand (or use) reduction”. Either way, drug use is seen as a form of deviance, and the end goal is to eliminate drugs and their use, through individual abstinence eventually leading to a drug-free society. Centuries of history have shown that these goals are unattainable. Even in countries (and religious groups) where alcohol is banned, there are people who consume alcohol.

Harm reduction aims to reduce the negative consequences of psychoactive substance use without requiring abstinence. Accepting that psychoactive substances exist, will be used by some members of our society, and can never be completely eliminated, it is based on a number of principles5:

• Humanism - respecting the dignity of the individual, while accepting that they do the things they do for a reason. Even harmful or risky substance use provides some benefit to the individual, and that benefit must be assessed and acknowledged to understand their decisions.

• Pragmatism - None of us ever achieves perfect behavior, nor will we ever reach the point at which everyone agrees on what makes one perfect. We each have our own goals, and abstinence can never be assumed to be the goal for every patient.

• Individualism - We each have our own strengths and weaknesses. We each respond to different types of messaging, and to different types of treatment.

• Autonomy - individuals ultimately make their own choices about medications, treatment, and health behaviors in accordance with their abilities, beliefs, and priorities. Care should be patient-driven and decision-making shared.

• Incrementalism - change can take years, requiring many tiny positive steps interspersed with some backward ones.

• Accountability without termination - Individuals are responsible for their choices, and they have the right to make harmful health decisions. Providers should not “fire” patients for failing to achieve goals.

In short, harm reduction advocates accept that the individual benefits and harms of any activity lie along a continuum. While any movement toward the less harmful end is a step in the right direction, the underlying premise is that individuals make their own decisions (including which direction is “less harmful”), and they own the consequences.6

Perhaps most importantly, harm reduction is not and never can be “harm prevention”. There will always be risks associated with everything we do. People wearing seat belts in cars equipped with air bags will still, at times, die in motor vehicle accidents. Cyclists wearing helmets and riding in bike lanes will still, at times, die in accidents. Recreational and casual drug users will still, on occasion, die of overdoses.

Conversely, some non-smokers will get lung cancer or develop COPD, because risk is relative, not absolute.

Language defines policy

Our policy responses to psychoactive substances reflect all of this imprecise language. Pretending that the language is consistent and scientific, we end up with nonsense.

In focusing our so much of our attention on the malevolent substances (and their effects when inside people), rather than the users and the choices they make when ingesting psychoactive substances, we overlook any number of other ways to deal with the problems that arise from their use.

“Thus, policy makers (and the general public) often infer that the availability of drugs per se is the crux of the drug “problem,” and that their extirpation from human societies—through the twin pillars of international control, supply reduction, and demand reduction—the obvious solution.”

Tupper, 2012

Demand-side efforts affecting drug users are generally condemned as “stigmatizing” and “unfair”. “Treatment” is generally restricted to those with substance use disorders - everyone else is expected to use responsibly. Supply-side efforts, like alcohol prohibition and the war on drugs sought to eliminate supply. When those failed, we regulated how, when, and where substances can be used, and by whom, only to see the regulations ignored. Now, in a world of harm reduction, we pay lip service to the acceptance of substance use as an individual choice, while seeking to protect informed users from any and all consequences. It’s all very confusing!

To illustrate some of these points, let’s talk about nicotine and then, in the next post, cannabis.

Nicotine: Formerly acceptable, still legal non-drug

Nicotine, a naturally occurring pesticide found on tobacco leaves, is the psychoactive drug found in tobacco, which can be sniffed, chewed, swallowed, or smoked. Nicotine can be isolated as a drug and delivered through e-cigarettes, heat-not-burn systems, chewable gum, oral pouches, and transdermal patches.

In Canada, the Tobacco and Vaping Products Act regulates the manufacture, sale, labelling, and promotion of tobacco and vaping products, reflecting the government's strategy to protect Canadians from tobacco-related death and disease. Corresponding provincial legislation in Nova Scotia refers to tobacco and smoke-free places. Nicotine is mentioned only in passing.

Nicotine induces pleasure and reduces stress and anxiety. By improving concentration and reaction time, it improves performance. When it wears off (as it does several times a day, due to its short half-life), users experience withdrawal symptoms including irritability, frustration, anxiety, difficulty concentrating, restlessness, depressed mood, insomnia, increased appetite, weight gain, and cravings.

The fastest way to get nicotine to your brain is to smoke it — it takes about 10 seconds to hit your brain after puffing on a cigarette (or e-cigarette)! The resultant “nicotine rush” is intense, immediate, and short-lived. Smoke is beyond question the most effective carrier of nicotine and (by design, not by accident) the cigarette is the most effective dispenser of smoke. Smokers can easily adjust the dose by adjusting how much they smoke, how deeply they inhale, and how they inhale (i.e. covering the venting holes on the cigarette). Lower the nicotine content of cigarettes and people smoke more cigarettes, to maintain their nicotine dose. Raise the nicotine content and they smoke less.

The rapidity of effect, the fairly short half-life (1-2 hours), and the fact that users fairly quickly develop tolerance all combine to make inhaled nicotine from smoking quite addictive. In a way, it’s like crack cocaine — it hits you hard and fast, and then it wears off quickly, leaving you wanting more (and more, because your brain becomes less sensitive to it over time)!

Smokers, therefore, ultimately continue smoking not so much because smoking makes them feel better but rather because they need to treat the (multiple times daily) nicotine withdrawal symptoms, which make them feel worse.7

It’s true that, over time, smokers learn to perceive some “rewards” from the conditioned reinforcers associated with smoking, such as the taste and feel of smoke, the smoking “ritual”, and the associated activities (meals, coffee, alcohol, time with friends, etc.). This is the same conditioning effect seen in Pavlov’s dogs, which were trained to salivate in response to the sound of a bell, once they learned to associate the bell with food. Just as the dogs eventually stopped salivating when food no longer appeared following the bell, experiments have shown that smokers eventually stop smoking when the nicotine rush is taken out of the equation. Smoking nicotine-free cigarettes just isn’t pleasurable enough to become a habit. Without nicotine, there would be little or no smoking.

In contrast to users of other psychoactive substances (where most users are NOT abusers, and most DON’T suffer substance-related harms), it’s alleged that the majority of nicotine users/smokers DO fit the definition of abusers, in that they smoke enough to damage their health. As one author put it:

“Cigarettes are uniquely lethal, eventually killing up to two-thirds of people who smoke throughout their lives. While there is no safe level of consumption, the risks are greater for people who smoke more cigarettes per day.”

Jackson et al, 2025

However, that may be an overstatement of the facts.

There’s a marked tendency over the past several decades to lump all smokers together, as if the risks were the same for all, and then say that quitting is the only answer. However, Smoking and Mortality: A Prospective Study, for example, shows a clear relationship between the cumulative “dose” of cigarettes and the associated risks. Other literature confirms what we all know — there are many different patterns of tobacco use (and levels of risk), ranging from “casual” and “social” (i.e. “recreational”) smokers at one end to “chain smokers” at the other. Smokers who “smoke throughout their lives” may well die of smoking-related illnesses. Occasional smokers may well die of something else.

Of note, as with other psychoactive substances, many users of cigarettes are “self-medicating”, hoping to regain some sense of control over their mental state, and therefore may not respond to the standardized messaging. For them, nicotine may be better than the alternatives.

“Tobacco use is two to three times more prevalent among patients with other psychiatric disorders, including anxiety, attention-deficit, mood, and other substance use disorders. Forty-four percent of all cigarettes in the United States are consumed by smokers with mental illness, and in mental health and addiction treatment settings, 50% to 95% are smokers. Unfortunately, smoking rates in this vulnerable population remain high despite the general trend for decreasing smoking rates in the United States as a whole.”

Tobacco use disorder and treatment: new challenges and opportunities, Ziedonis et al, 2017

Smoking, therefore, reflects a unique, nuanced, complex addictive behavior, reflecting the interplay between the drug (nicotine) and the route of delivery (smoking):

• Smoking is harmful, but it’s not that pleasurable and not addictive in and of itself.

• In theory, each and every cigarette smoked carries a small risk of harm, and the risk is cumulative, so smoking less is better, even if abstinence isn’t possible.

• Nicotine can be harmful or even fatal in high doses, but it’s generally innocuous in daily use.8 It is addictive, especially when inhaled, smoking being the main way to inhale.

• Each smoker makes their own assessment of the benefits and harms of their smoking pattern. Some are self-medicating.

• For people with tobacco use disorder, the nicotine addiction is one thing that keeps them smoking, in the absence of other ways to feed the habit.

If we took a harm-reduction approach, we would either (a) encourage people to smoke less (and accept that they’ll relapse from time to time), and/or (b) encourage them to get their nicotine from other sources. We wouldn’t judge them.

“One of the distinguishing features of harm reduction as it was originally construed as an approach to drug use is its non-judgmental character. The deployment of harm reduction strategies is not predicated on a negative moral assessment of the character of those who engage…. Nor is cessation of the practice viewed as an objective of the practice.”

Weinstock, 2020

Harm reduction by smoking less, or by using “smokeless” tobacco

It’s true that there is no “safe dose” of cigarettes, but reducing the number and frequency does lower the individual risk.

Encouraging people to smoke less should be an acceptable message, but it’s not! Pretty well any published advice you can find about “smoking less” presents it as a step on the path to quitting. For the individual smoker, the target is abstinence. Societally, the goal is prohibition.

While the “smokeless” products, like snuff and chewing tobacco, are associated with various diseases of the nose and mouth and can cause cancers of the mouth, pharynx, larynx, esophagus, and pancreas, they are still far less harmful than cigarettes. A case could easily be made that chewing or sniffing tobacco is preferable to smoking it, another form of “safer supply” or “tobacco harm reduction”. Again, however, the expert guidance is to completely avoid tobacco in all its forms.

In almost every single tobacco harm reduction publication reference is made to the importance of abstinence, and that harm reduction is applicable only to those individuals unable or unwilling to cease smoking. This contrasts with the alcohol and illicit drug harm reduction literature where such statements are not used.

Ritter and Cameron, 2006

There are psychological consequences to this approach. First, the message is that cutting down, in and of itself, isn’t a worthy objective. It’s the first step on the journey to quitting, and why start the journey if you don’t plan to finish it? Second, those who do cut down and don’t succeed in quitting have, in effect, “failed”, and they are stigmatized for doing so. The prevailing approach is inherently judgmental.

By contrast, with alcohol, even though the experts are starting to say that there’s no safe dose of alcohol, we still encourage people to “drink responsibly”, which implies drinking less without requiring abstention. Similarly, in talking about opioids, Bonnie Henry, the Provincial Health Officer of British Columbia, warned against an over-emphasis on abstinence9, saying:

“I believe evidence both in the literature and the data from BC and elsewhere supports that recovery must be understood as a process (not a false dichotomy of use or abstinence). Recovery is rather a process through which people improve their health and wellness, live self-directed lives and strive to reach their full potential. This process is individually defined, and abstinence may be a cardinal feature for many, but the process is non-linear and relapse is common.”

A Review of Prescribed Safer Supply Programs Across British Columbia: Recommendations for Future Action

So, for alcohol and opioids, the message is that abstinence may be unattainable or even unnecessary, because users are believed to retain the ability and autonomy to regulate their doses at a “less harmful” level. By that logic, it should be fair game to encourage smokers to reduce their tobacco consumption (or “use tobacco responsibly”), even if they can’t stop altogether.

To that end, while there has been a slow decline in the reported average number of cigarettes smoked per person per day, progress is very slow. Many casual, social, and recreational smokers don’t self-identify as smokers, for fear of the stigma, so the statistics may well be inaccurate. Furthermore, many smokers are simply smoking fewer legal cigarettes and more illegal (or hand-rolled) ones.10

Why?

The problem is that it’s framed as an “all or nothing” moralistic choice — you smoke (which is bad) or you don’t (which is good). Alternatively, perhaps smokers (and others with substance use disorders) really aren’t that good at self-regulating. After all, addiction has been described as a compulsion, in which conscious control and rational judgment are “hijacked”. If so, then the “choice” about whether and how much to smoke isn’t really a choice.

Harm reduction by nicotine substitution

Perhaps, then, the solution lies in separating nicotine from smoking? Smoking kills. Abstinence or even cutting down should be easier if there’s a safer, equally effective way to satisfy the nicotine habit, which doesn’t kill.

We should compromise, making nicotine readily available by routes other than smoking, and without expecting eventual abstinence from nicotine. The message could be “use nicotine responsibly”.

Unfortunately, in part due to tobacco manufacturer public relations campaigns in the past, the message about the harms of smoking has come to include nicotine.11

It is relevant to note that for decades most of the treatments for tobacco use disorder involve nicotine replacement therapy, using patches, gum, pouches, etc. Unfortunately, the pharmacology limits the effectiveness. Oral nicotine is absorbed slowly and takes 10-15 minutes to reach the brain. Patches, gum, and pouches maintain steady state nicotine levels, avoiding the withdrawal symptoms and craving, but they don’t provide the same nicotine rush that one gets from smoking. Historically, many of these products have been presented as being “for short term use” while quitting smoking, rather than being acceptable for long term use.

If you really want people to give up or avoid smoking, you have to mimic the nicotine rush. Public health authorities in some countries support this approach, while others don’t. Most still see it only as a short-term solution. The dose of nicotine in e-cigarettes and vapes is restricted, which limits the effectiveness. There’s reluctance to endorse e-cigarettes, because they are seen as a “gateway drug” to smoking and then other psychoactive drugs.12 Research has shown, however, that users of inhaled nicotine, which most closely mimics the nicotine-related effects of smoking, DO NOT inevitably end up smoking tobacco. Finally, with vaping being a fairly new activity, we don’t know the harms of long-term use. However, evidence to date suggests that e-cigarettes (especially the “heat-not-burn” types) ARE less harmful than cigarettes and MORE effective than other forms of nicotine replacement therapies.

Finally, another concern for some is that e-cigarettes mimic the look and sensation of smoking. Accepting e-cigarette use as normal, some argue, could re-establish the normality of smoking. It’s not clear, however, that we are justified in restricting all activities that merely look like smoking.13

Technocratic harm reduction, on the road to prohibition

In summary, when it comes to smoking, our government response has been to remind people that smoking is harmful while expecting that they will quit. Their clearly stated goal is individual smoking cessation and the eventual complete prohibition of smoking for all. This runs contrary to the principles of harm reduction.

One author refers to this regulatory approach as “technocratic harm reduction”:

• We try to convince smokers that what was once considered “normal” is in fact harmful, a strategy known as “denormalization”. We see this in the prohibition on advertising and well as the ever-increasing limits on where and when cigarettes can be consumed. The (sometimes exaggerated) concerns about secondhand smoke have been used to justify some of these measures, which can be draconian. What’s not made clear, however, is that smoking is the problem, not nicotine. Many of these efforts drive smokers “underground”. By contrast, the emphasis on responsible use and recreational use of other psychoactive substances has a deliberate “normalizing” effect, seeking to reduce the harms of stigma. Overall, it’s inconsistent!

• Education plays into this, including the health warnings on each packet of cigarettes (and now on each individual cigarette as well). While warnings on packages and cigarettes may raise awareness of smoking-related harms, they may not affect smoking behaviour, due to denial (“It won’t happen to me”) and the discounting of long-term effects (“My pleasure today matters more than some theoretical risk of future harm”). There’s a move to add similar labelling on alcohol products, even when it’s not clear that a single glass of wine, for example, actually has any significant long-term consequences. Warning labels are something we can add, but they don’t necessarily work.

• We have plenty of regulations, such as controls on the manufacture, packaging, advertising and sale of tobacco products. Legal cigarettes are no less harmful than illegal ones, however, so it’s a mixed message (“it’s legal but harmful, so don’t do it”)! Clamping down on the illegal tobacco market is expensive and ineffective.

• As we’ve limited smoking in First World countries, the tobacco companies have targeted markets in the Third World. We shut down the mines and stopped exporting asbestos, but we still farm tobacco and export cigarettes! We complain about other countries sending us drugs of abuse, and yet we send our tobacco products to them!

• The government collects tax revenues from smokers, and taxes the companies that produce the cigarettes, which leaves them financially dependent on harmful/lethal cigarette sales, which seems hypocritical. They aspire to reduce demand by raising the price, and yet one-quarter to one-third of the cigarettes consumed are illegal, selling at a much lower price. As consumers, smokers are making a rational decision to save money. Government efforts to reduce demand by raising prices don’t work!

• The persistent and progressive negative messages about smoking (the behaviour) have created stigma against those who smoke (the sinners). This spills over into health care, where victims of diseases commonly due to smoking (like lung cancer and COPD) are “blamed” for their illness in a way that other cancer victims (breast cancer, for example) might not be. Even non-smokers with lung cancer experience stigma!

• And, all the while, there’s little or no appetite to support nicotine use in any context other than smoking cessation, even though it would reduce harms.

In summary, the public health approach to smoking involves many tactics that have been deemed ineffective and/or unacceptable when applied to other psychoactive drugs. Most fundamentally, the experts ignore the fact that the psychoactive substance involved is nicotine, which can easily be provided in other less harmful formats.

On top of that, there’s a move to apply the many of the same restrictive approaches to alcohol!

Conversely, they’ve legalized cannabis, and they are normalizing the use of other drugs.

Tell me this all makes sense!

Let me explain.

There are many psychoactive drugs

Psychoactive substances are those that affect the function of the central nervous system, altering subjective experience, behaviour, or both.

The list is long, including caffeine, nicotine, alcohol, cannabis, benzodiazepines, opioids, amphetamines, SSRI’s, cocaine, LSD, ecstasy, psilocybin, etc.

The history of psychoactive drug use is probably as old as mankind. And, as long as we’ve been using drugs, we’ve been experimenting with ways to increase their potency and/or find different routes of administration.1

Where are we now? Some drugs are “legal”, others aren’t. Some are “medical”, others aren’t. Some, like caffeine, are so well assimilated into our daily routines and culture that we no longer think of them as drugs. (More on this later, as it’s one of the things that makes little or no sense.)

Different psychoactive drugs have different effects

Prescribed or not, legal or not, psychoactive drugs are consumed specifically for their effects on various functions of the brain. If they didn’t affect the brain, we wouldn’t take them — it’s as simple as that! The effects for each drug depend on which specific parts of the brain are affected. Some drugs increase brain activity (i.e. stimulants and hallucinogens) while others decrease it (i.e. sedatives).

There’s no way to ensure that the drug taken will find its way only to one specific area of the brain. That being the case, all psychoactive drugs come with both useful effects (which we’ll call “benefits”) and unwanted side effects (which we’ll call “harms”). The distinction can be contextual — hallucinations may be desirable when drugs are taken for “fun”, but not when they are given to a hospitalized patient for pain. There is no situation in which the use of drugs comes without some sort of risk — this is why pragmatists talk about “harm reduction” rather than “harm prevention”.

While no listing is going to be all inclusive, a 2011 international survey of drug users suggested the following “benefits”:

• Sociability (Lose inhibitions, be more sociable, feel more confident, feel closer to people, have more empathy, feel part of a social group)

• Enjoyment (Enhance activities, enhance sense of fun or humour, help with creativity and abstract thinking, increase sexual function and enjoyment, feel elated and/or euphoric)

• State of mind (Open up to new experiences, alter senses, increase existential awareness, find meaning in the self and the world, alter consciousness, help to get out of your head, escapism)

• Relieve physical pain and symptoms

• Relieve anxiety and depression

• Feel more relaxed, relieve stress

• Change appearance of body (bulk up or lose weight)

• Help wake up, have more energy

• Help to get to sleep

• Improve attention, memory and concentration

Of note, the benefits vary from drug to drug, user to user. With a few exceptions, they are immediate, personal, and idiosyncratic. One man’s pleasure can be another man’s poison — your experience may differ from mine, in terms of both the actual effect of the drug and your interpretation of that effect as pleasurable or not. Some take drugs to wake up, others to get to sleep, some to escape, others to be more engaged.

That same survey also listed the following harms:

• Short-term physical risks (like overdosing and accidents)

• Long-term physical risks (like cirrhosis of the liver)

• Risks associated with injecting (including hepatitis, HIV, etc.)

• Physical dependence (including the development of tolerance and withdrawal effects)

• Psychological dependence (cravings)

• Risks to society (damaged relationships, crime, car accidents, etc.)

• Bingeing (using more than planned, for longer than intended)

The harms also vary from drug to drug, user to user. They can be immediate or long term, trivial or fatal. Many are personal, but several affect others. A number of them are reflected in the diagnostic criteria for substance use disorders, but you don’t necessarily have to reach the state of problematic use to see the harms — drunk drivers can kill people even when they aren’t alcoholics.

Balancing benefits and harms

Drug users (and doctors) can all agree that some drugs are more harmful than others, individually and collectively, and some harms are more consequential than others. The drug users who were surveyed saw it this way:

Things like cannabis and ecstasy seem to be “high benefit, low harm”.

The hallucinogens are “low benefit, low harm”2. Caffeine wasn’t surveyed (probably because drug users, like everyone else, no longer consider it a drug), but I’m guessing it would be in that quadrant as well.

Pretty well everything else is “high benefit, high harm”.

Given the emerging evidence about cannabis3, now that it’s been legalized in a number of places, with a corresponding increase in usage, I’m wondering if its harms weren’t underestimated. If so, it would move a bit to the right on the graph, and the surveyed drugs would then all fall more or less on a line where the risk and benefits increase together, as shown by the arrow. In other words, unsurprisingly, the more a drug affects your brain, the more likely it is to have both benefits and harms. The perfect drug (all benefit, zero harm) has yet to be invented!

Interestingly, and this is one of the things that makes no sense, there is no correlation between the users’ harm ratings and the legal classifications of the various drugs. The fact that those legal classifications vary from one country to the next is another thing that makes no sense.

Psychoactive drugs are used for different reasons

Depending on the context, different drug effects assume greater or lesser importance.

Hallucinogens seem to have religious uses and are, as such, often consumed under the guidance of spiritual and religious leaders. I’m assuming this is a “niche” market.

Analgesics and sedatives have medical uses and are prescribed by doctors. While you would think that everyone has access to the same “science”, the prescribing patterns and the specific drugs used vary enormously from one country to the next and over time. This variation is another thing that makes no sense! The increasing use of opioids in chronic pain, for example, is seen as a contributing factor in the opioid crisis, perhaps because the benefits were exaggerated and the risks downplayed or ignored. I’ve written about that in previous posts.

Where things get even more interesting (and illogical, in terms of the societal response) is when individuals choose to use psychoactive drugs either because those drugs are seen as “normal” or for their own personal reasons, including “self-medication” and “pleasure”.

Socially accepted “normal” drug use: caffeine

Some drugs have become part of our culture, to the extent that we no longer see their use as anything out of the ordinary.

Caffeine, for example, is ubiquitous, occurring naturally in many plants (most notably tea, coffee, and cocoa) and more recently as a synthetic additive in many foods and beverages (including “energy drinks”). Known to promote arousal, alertness, energy, and elevated mood, with some weak analgesic properties, it is used by 80% or more of the inhabitants of affluent countries, making it the most widely consumed psychoactive drug in the world. However, caffeine users don’t think of themselves as taking caffeine — they focus on the beverage, not the active ingredient.

Caffeine use, as a result, seems “normal”, an integral part of the daily routine. Who doesn’t start their day with a cup of coffee (or tea) and socialize with others over a caffeinated beverage during breaks? Entire business empires have been built on the sale of caffeine-containing products! A Tim Horton’s franchise is a license to print money.

Interestingly, caffeine can be manufactured and packaged in tablet form. Conversely, coffee, tea, and cocoa can be decaffeinated, and the caffeine, in and of itself, probably isn’t contributing much to the flavour (although purists will probably disagree). As such, it’s theoretically possible to divorce the psychoactive effects of caffeine use (which peak 15 minutes to 2 hours post-ingestion) from the immediate sensory experience of drinking the beverage. Even so, the vast majority of the caffeine consumed in the world is taken in the form of food and beverages, rather than pills. Perhaps, at least in part, the sensory and social experience matters as much or more than the psychoactive effects? Popping into Tim Horton’s or Starbucks for a caffeine pill just wouldn’t be the same, would it?

Regardless of the form in which it’s ingested, caffeine is physically and psychologically addictive, which may explain why there’s a coffee shop on every street corner! We start drinking it for the taste and keep craving it because we’re hooked. Those who quit using caffeine will, within 18-24 hours, develop headache, drowsiness, impaired concentration, work difficulty, depression, anxiety, irritability, nausea or vomiting, and muscle aches and stiffness, all lasting up to a week. Resuming regular caffeine intake will take all that misery away.

So, you think you need that morning cup of coffee to perk you up, or because you like the flavour and experience, but in part you need it to stave off your caffeine withdrawal symptoms! Being physically and psychologically dependent on caffeine, technically speaking you’re actually an addict! You’re not alone, however. A 1998 survey of caffeine users, based on the generally accepted criteria for substance use disorders, found that:

• 56% described a strong desire and/or unsuccessful attempts to stop using caffeine

• 50% spent a great deal of time supporting their caffeine habit (driving miles and sitting in lineups at the Tim Horton’s drive-through, for example)

• 28% used more caffeine than intended

• 18% had recognizable withdrawal symptoms

• 14% continued using caffeine despite knowledge of its harmful effects

• 8% had developed tolerance, and

• 1% had even foregone other activities to facilitate their caffeine use.

Even so, because caffeine is generally not thought to be associated with any “significant” health hazards when taken in “typical” doses, you won’t hear the experts recommending “responsible use” of caffeine or advocating for “safer supply” (i.e. decaffeinated beverages).4 Coffee drinkers are not sent outdoors to indulge their habits in isolation! Tea drinking in parks or public spaces isn’t banned! While pregnant women, children, and individuals with mental illness are considered vulnerable to caffeine’s harmful effects, you won’t see warning labels on coffee cups. There are no age restrictions, and the makers of energy drinks can market their products to youth. The Red Bull isn’t hidden behind the counter at the pharmacy. Even though, in high enough doses, caffeine can induce fatal cardiac arrhythmias, you won’t hear any argument for safe ingestion sites including defibrillators!

Our societal response is restrained. Acting as if they’re aware of the risks and doing something about them, our governments “regulate” caffeine, but not really. We have regulations limiting the caffeine content of various foods and beverages, added caffeine must be listed as an ingredient on food packaging, and there are, believe it or not, recommended daily limits for caffeine intake. For the most part, however, these are widely ignored.

Caffeine use, for better or for worse, is simply a fact of life.

Socially accepted “recreational” drug use: alcohol

As with caffeine, alcohol use, at least in non-Islamic societies, has come to be seen as “normal”, an integral part of life. Entire business empires depend on the sale of alcohol-containing products. Now, some even sell caffeine-laced alcohol!

As with caffeine, alcohol is the active ingredient in various beverages. Sure, you can get “pure” (95%) alcohol, such as “surgical ethanol”, but it’s not readily available. The closest thing on the open market would be vodka, which is essentially 40% alcohol in water, with no impurities (which makes you wonder how companies can market their particular vodka as being “better” — alcohol is alcohol and water is water, after all!). Alcohol by itself is relatively flavourless, so the pleasurable experience of alcohol consumption comes from (a) the immediate taste of the additives and various impurities (why we prefer one brand of beer, one variety of wine, or one specific type of hard liquor), and (b) the slightly delayed psychoactive effects of the alcohol you absorb.

Our governments are heavily dependent on revenues related to the sale and taxation of alcohol. In 2023-24, for example, the Nova Scotia Liquor Commission sold $753.4 million worth of alcohol, amounting to about $1,000 per person per year5 for those of legal drinking age, about 1/3 of that being profit. In 2016-17, Canada collected $1.6 billion from excise taxes on alcohol, and $634 million from goods and services tax (GST) applied to alcohol.

The belief is that alcohol use brings mental, emotional, social and/or physical benefits, as you might see with other forms of recreation, and so we consume it with meals, entertainment, and sports, seeking additive benefits. Alcohol advertising, overt and covert, reinforces the pleasurable linkage with artistic, cultural, and sporting events. A good meal plus a good glass of wine is more enjoyable than either alone. Spectator sports are more enjoyable when taken with beer. The picnic in the park will be better with alcohol, now that the laws are being relaxed. For those so inclined, there are even drinking games, wherein alcohol becomes the entertainment!

“Alcohol use is a useful example of how much the use of a substance has been so deeply ingrained in social and cultural practices that it is implicitly and by default seen as “recreational”. Hardly anyone would speak about “recreational” alcohol use: it is taken for granted that it is. And if it is not, the users are stigmatized.”

Framing substance use as “recreational” is neither accurate nor helpful for prevention purposes, Sanchez et al., 2023

Through it all, we assume, for the most part, that most alcohol is used “responsibly”, for “pleasure”. The alcohol industry would have us believe that alcohol in and of itself is unproblematic, maybe even healthy, as long as drinkers drink “moderately” and behave. Marketing campaigns, while reminding us that alcohol and pleasure go hand in hand, remind us to “drink responsibly” and “don’t drink and drive”. The implication is that the harms are entirely avoidable.

There’s a naive assumption that this recreational use of alcohol involves individuals making decisions based on their rational consideration of the benefits and the harms. However, when choosing to have a glass of wine with supper, where the benefit is immediate and the risks minimal, people aren’t drinking with an eye on their health, they’re drinking for pleasure! Things become less clear, perhaps, when they head out with friends for an evening of partying, or when they spend every evening in front of the TV, drinking alone.

Drinking, in other words, doesn’t necessarily involve a rational decision. For one thing, once consumed, alcohol affects the ability to make decisions (decision quality decreases as the amount consumed increases), and it’s worse in the face of peer pressure! Furthermore, it’s fairly well known that people making decisions tend to value immediate personal gains over long term pains and the possibility of harm to others. Besides, the majority of casual drinkers do not experience individual or immediate harm. As such, they can be intellectually aware of the potential harms and still see the risk of harm as being negligible or irrelevant to them. They don’t take a drink with the intention to later wreck the car. After all, they’ve never crashed the car before! They might start off with the intention to have a single drink but then find themselves having a good time, unable to refuse the second and subsequent drinks. For the addicts, it’s no longer a choice; they’ve “lost control”.

“Additionally, from an evidence-based prevention perspective, focusing on a public discourse on the warning about harms and health risks is useless. Although accurate and balanced information on these aspects is an essential educational right, it is an — albeit very popular — illusion to believe that better knowledge about harms would — by itself — have a mitigating effect on substance use behavior, even less in young people and even lesser if the potential harms are long-term.”

Framing substance use as “recreational” is neither accurate nor helpful for prevention purposes, Sanchez et al., 2023

For all those reasons, and more, public education about responsible drinking doesn’t really work. You can’t avoid all the possible challenges and harms related to substance use by improving and fostering individual choices and responsibility. Controlled and carefully considered “recreational” use might be the reality for some people, but it’s a delusion for many.

Despite the evidence, the latest Canadian Low Risk Drinking guidelines suggest that “Drinking Less Is Better”, offering guidance which they say is based on the principle of autonomy in harm reduction and the fundamental idea that people have the right to know that all alcohol use comes with risk. In short, they want you to be informed and make your own decisions!

Societal standards might play a role, but they can be misleading. While drinking seems to be something that “everyone is doing”, less than 80% of Canadians report alcohol use in the past year, and that drops to about 60% for the past 30 days. In this context, it’s worth remembering that there are entire countries where alcohol use is completely prohibited. The extent to which your social circle drinks, therefore, depends in part on how much you drink and how it fits in with your social life. You won’t see your non-drinking friends not drinking, for example, because they’ll be doing other things (possibly with other people) when you are drinking. When drinking, you’ll likely be with other drinkers. It’s a self-fulfilling prophecy — it will inevitably appear to you that you are doing what everyone else does.

While we have laws specifying where, when, and to whom alcohol can be sold, and where, when and by whom it can be consumed, the official rules are getting more relaxed over time. Again, the theory goes that drinkers can make wise choices, and that they’ll listen to the advice that “less is better”. However, underage drinkers have no trouble obtaining a supply and drinking ages have been lowered, making it even easier. Government-operated stores with strict sales policies are being supplanted by privately-run stores with looser standards. Drunks face few obstacles to getting drunk. Bars and restaurants that break the rules are punished, but it’s rare. Drunken brawls are common. Drunk drivers still kill people, despite laws saying they shouldn’t be driving. Problematic drinking is a big problem!

Alcohol consumption in Canada was associated with approximately 15,000 preventable deaths, 90,000 preventable hospital admissions and 245,000 potential years of life lost in 2014. The collective impact of alcohol use on health care, crime and lost productivity was estimated at $14.6 billion, higher than the costs of tobacco use and the costs of all other psychoactive substances combined, including opioids and cannabis.

(source)

Of course, there’s a spectrum of alcohol use, ranging from abstinence through very occasional drinking to regular drinking to constant harmful drinking, unable to stop (otherwise known as alcoholism, or alcohol use disorder). Harm can occur anywhere along the spectrum, whether alcohol is used responsibly or irresponsibly, regularly or not, recreationally or habitually, a lot or a little. The occasional drinker can over-indulge and have an accident. The regular drinker might be drinking once a week and getting fall down drunk every time. The daily drinker can end up with liver disease.6 The alcoholic can lose their job and family.

While there is stigma associated with public drunkenness, drunk driving, and alcoholism (the harms that affect others), addiction advocates argue that the stigma itself represents an additional form of harm (affecting the addict), a barrier to their getting help when needed. They would prefer you to avoid expressing your disgust, using more neutral terminology such as “persons living with alcohol use disorders”. Conversely, some argue that the unfavorable opinions of others (and legal consequences) can be a motivating force.

Where things get interesting is when you break down the patterns of alcohol use in relation to the total consumption. Research done in the UK (and there’s no reason to believe that Canada would be different) shows the following:

• The top 4% of drinkers (the “harmful” drinkers) account for 30% of the total consumption of alcohol, and 23% of the revenue. (Unsurprisingly, I guess they favour the cheap stuff!)

• The next 21% of drinkers, the “hazardous” ones, account for 48% of the total consumption, and 45% of the revenue.

• Together, the top 25% of drinkers consume almost 80% of the alcohol and incur 2/3 of the costs!

• Most users are not abusers (they don’t use it at all, or maybe they use it mostly for pleasure?), but most of the alcohol used is used “irresponsibly”, (assuming that’s a fair conclusion to make about somebody else’s usage pattern).

Pause! Think about that for a minute! Despite their caring messages about drinking “responsibly”, our governments are making a heck of a lot of money selling alcohol to people with significant alcohol problems, as are the companies that manufacture and distribute liquor. 78% of the alcohol supply isn’t really being used primarily for pleasure, is it? If it is, then a small group of people are having way too much fun! While it seems good that the government takes more money from those most at risk, is it really ethical for government-owned liquor stores to keep selling addictive substances to addicts? Taken as a whole (i.e. including societal and health care costs), do the revenues really exceed the expenses?

So, as with caffeine, alcohol use, for better or for worse, is a fact of life for a good-sized chunk of the population. Recreational alcohol use is heavily promoted. Unlike caffeine, however, alcohol can be harmful. While some use alcohol responsibly, purely for pleasure, it becomes a personal problem for a lot of people. Their problems affect everyone, through the consequences of their behaviours, the effect on their health, and the associated costs. Acting as if they’re aware of the risks and doing something about them, our governments regulate and operate the alcohol business, while encouraging alcohol users to make wise decisions before imbibing. Paradoxically, at the same time they are relaxing the rules.

There are ways to reduce our overall consumption of alcohol. I won’t go into them in detail, but you can read about them here. Suffice it to say that many of the things our government is doing fall into the “ineffective” and “potentially harmful” categories.

In the next post: nicotine and cannabis

In this post, I’ve introduced the concepts of psychoactive drug use and discussed the situation with caffeine and alcohol, both of which are seen as a “normal” fact of life. Caffeine seems harmless. Alcohol is well known to be harmful.

In the next post, I’ll talk about nicotine, the use of which is legal but increasingly stigmatized, in part because smoking is harmful. There are, however, other ways to use nicotine.

I’ll also talk about cannabis, which was illegal but is now legal. The theory goes that it’s pretty innocuous, but is that really true?

“In modern healthcare, decision-making favours neatly delineated, categorical imperatives. We prefer to say: ‘This practice is good’ and ‘That one is bad’, believing that each decision has a straightforward yes-or-no resolution. However, medicine thrives in uncertainty, partial improvements and small steps that can lead to life-altering gains.”

Beyond all-or-nothing: why binary thinking undermines harm reduction in addiction medicine, Manietta and Drake, 2025

These days, there’s far too much binary thinking in healthcare. We go from saying “this is bad (or useless)” to “this is good (and should be mandatory)”, with nothing in between. We’ve lost the nuances! There’s no room for debate (or dissenting opinions)!

While the changes are sometimes (rarely?) brought about by new evidence, in many cases they result from ethical or legal shifts. Things which were “wrong” become “right”, without any real change in “the science”, by which I mean what we know about the benefits and harms and/or how best to do things.

One example is “medical assistance in dying” (MAiD), otherwise known as euthanasia. In Canada, before 2015 it was illegal (and also considered unethical). The Supreme Court of Canada then declared that the legal prohibition on MAiD violated the right to life, liberty, and security of the person. As a result, it became legal (and therefore ethical), initially under restricted circumstances while following strict policies, but later under a broader range of circumstances, following more relaxed policies. Nothing materially changed in terms of how the dying could be assisted to die — you still have one person doing something to end the life of another, using drugs and “technology” which aren’t new. Legally and societally, however, over a decade, things shifted from “this is bad” to “this is good in specific situations” to “this is good”. For some individuals, that ethical shift presents a conundrum — how is it that something which was so obviously bad yesterday become good today? Patients might say “it’s not for me”, and their choice is respected. Some doctors might want to say, “I don’t want to be involved”, but their professional colleges say that they cannot conscientiously object. For them, there’s no middle ground! The MAiD train has left the station, and you’re either on it or under it!

Another example involves harm reduction versus abstinence approaches to drug use and addictions. The people on both sides of the debate are equally convinced that they are “right” and the others are “wrong”. The fundamental technology hasn’t changed — methadone programs were developed in the 1960’s, and needle exchange programs in the 1980’s! Some doctors still don’t support harm reduction approaches, but their professional colleges now say they cannot conscientiously object. Again, there’s no middle ground, and there’s precious little room to debate the issue on its scientific merits, leaving aside any matters of conscience!

So, why is it that we’ve become so binary in our thinking?

Let’s go back to the basics

In my previous post, I talked about the four equally weighted and supposedly universal principles upon which medical ethics are based: beneficence, non-maleficence, autonomy, and justice.

The application of these four principles is rarely straightforward. There are frequent conflicts.

The framework is not binary. There’s very little “black or white”, “yes or no”, or “right or wrong”. There are many shades of gray, many examples of maybe, and plenty of cases where things are right for some (some of the time) and wrong for others. There’s a lot of middle ground, and yet we can’t talk about it!

Consider the following:

From a purely utilitarian perspective, at the left end of the spectrum we have things that offer clearcut benefits and minimal or no harms, things we could label “safe and effective”. An example might be oral contraceptives for women who do not wish to get pregnant at this point in their lives. Other things are “innocuous”, in the sense that the benefits are debatable but the harms, if any, are trivial. These are “safe” (or at least “harmless”) and may or may not be “effective”. This might include the use of ginger for the relief of nausea.

For these, there’s generally not much ethical debate. Morally, they are deemed to be “okay”. The usual collective approach is “permissive” — we allow individuals to make their own autonomous decisions, with or without input from their physicians or others. Sometimes these things are paid for publicly (because we don’t want anyone to miss out on the benefits because of financial barriers), other times privately (because we believe that people can factor in the personal financial consequences when assessing the benefits and harms).1

At the other end of the spectrum, when looking strictly at the balance of benefits and harms, there’s also not much need for ethical debate. For things are clearly far more harmful than helpful, the response is “prohibition”, through either an absolute ban or onerous rules. Medical examples would include long discredited practices such as frontal lobotomies, or the administration of laxatives and emetics to purge evil humors. As a society, we’ve labelled plenty of things as purely harmful and then banned them (including murder, slavery, drug trafficking, etc.).

However, things can get murky at this end of the spectrum. There are other forces at work, beyond the simple questions of whether people should be allowed to make their own choices, and whether the intervention harms, helps, or even “works”. One consideration is “disgust”, the gut feeling that something is just “unacceptable” — more on this in a future post.

It’s not black or white, all or nothing, yes or no. Killing someone is bad, but may be excusable if you do it in self-defense or in the context of war, or it may be “less bad” if you do it without intent (i.e. manslaughter, rather than murder). Even so, those who kill in self-defense or war, or without intent, may still feel revulsion at what they’ve done.

Things can also change over time, for reasons beyond utility! Medically speaking, some things that were once prohibited are now permitted. We could always do them safely and effectively, using available drugs and technology, but they were illegal.

For example, there was a time (within my lifetime), when you couldn’t choose to have an abortion. Ditto for MAiD, pre-2015. The broad consensus, at the time, was not just that the harms far exceeded the benefits, but also (and perhaps more importantly, at that time), abortions and MAiD were simply considered “wrong” (morally repugnant, so to speak). Despite the societal shift, some people still consider abortions and MAiD to be “disgusting”.

Supplying opiates to known addicts was also once prohibited but now permitted, as was the prescribing of opiates for “minor” pain. It used to be malpractice to prescribe opiates when they weren’t clearly indicated for pain (you could have your license revoked), and there was no shortage of rules and procedures to limit their supply and distribution (triplicate prescription pads, locked cabinets, etc.).

Societally, some activities that were once considered morally repugnant or unacceptable have become less so (like the consumption of alcohol and cannabis, sex work, etc.). Sometimes, but not always, the shift reflects a fundamental change in our collective beliefs. Homosexuality, for example, was once considered a form of deviance, but has come to be accepted by many as a variant of normal.

However, for any example you care to name, there’s still a wide range of opinions, even if those who disagree (i.e. still find something morally repugnant or disgusting) find themselves unable to publicly state their opinion, for fear of censure or prosecution.2

The role of pragmatism

Sometimes, the shift in thinking is pragmatic, even when it’s not universally supported.

For example, despite our best efforts to prevent unplanned pregnancies, some still occur, and so a consensus of sorts was reached in which abortions were permitted in limited circumstances, generally where the health of the mother was endangered, with a subsequent gradual loosening of the concept of endangerment. We shifted from “prohibition” to “maximal regulation”, and later to something more permissive. The backlash in some US states suggests that some people think it’s become too permissive. The consensus regarding abortion rights was neither as broad nor as durable as some people imagined!

Similarly, the “war on drugs” failed (as did Prohibition in the 1920’s — laws completely banning alcohol, cigarettes, drugs, etc. are, practically speaking, unenforceable), and abstinence-based treatments for addiction don’t work for everyone. As a result, more pragmatic approaches to opiate prescribing for addicts have been developed, shifting away from legal restrictions and abstinence-based approaches toward decriminalization and opiate-replacement therapy.

These shifts don’t mean we’ve all changed our opinions about what’s good and bad. Some, maybe most, pragmatists pursue the “least bad” options, while continuing to prefer and seek other “more preferable” options.

For example, surgical abortions are avoidable when we can offer medical abortions, and abortions in general can be avoided through use of the “morning after pill”. Surgical abortions are more harmful than medical abortions, which in turn are more harmful than the morning after pill. This is a harm reduction approach — if you must do something, do that which is least harmful. However, all of those options would be less needed if we could prevent unwanted pregnancies, as with improved availability, reliability, and acceptability of contraception — this would be the preferred approach, “prevalence reduction”.

Likewise, most people would agree that people with opiate use disorder are best off if they stop using opiates3, so effective approaches to abstinence (prevalence reduction) are theoretically preferable to replacement therapy (harm reduction). That being said, a lot of the harm reduction advocates won’t admit that abstinence, at the end of the day, is actually better. They’re overly invested in (and rewarded by) their preferred approach!

Reasonable disagreement

For everything in between the two extremes (and even, as I’ve described, for things out at the far right end of the spectrum), there exists a lot of room for discussion and debate. There are harms and there are benefits, there are varying degrees of right and wrong. How anyone decides on the balance depends on their personal values, priorities, etc. Sensible, well-informed people can look at all the available evidence and arrive at opposite conclusions! Reasonable disagreement is a fact of life!

“Many of these practices engage deeply held values that are, on the face of it, irreconcilable.

For example, those who defend the right of sex workers to practice their profession in safe and respectful conditions will invoke considerations of individual autonomy and consent. According to this view, persons who engage in sex work should be allowed to make their own choices as to how to use their bodies, and they should be allowed to do so free from moralistic policies that criminalize what are essentially victimless crimes. Those who oppose it will emphasize dignity, and the fundamental importance of not treating bodies like commodities. There seems little way of bridging the conceptual gap between these two views.

…debates over medical assistance in dying pit against one another those who believe that a society committed to rational autonomy cannot deny its citizens the right to decide for themselves how they will face grave illness and death, with those who argue that human life should be treated by the state as inviolable.”

Disagreement, Unenforceability, and Harm Reduction, Weinstock, 2020

In other words, it’s not simple (or binary)! It’s complicated!

In short, in looking at any medical intervention, new or old, there’s a role for both “the science” (meaning whether or not we can do it safely and effectively, maximizing benefits and minimizing harms) AND “the ethics” (meaning whether or not we, as a society, agree that it’s a reasonable thing to do). You can’t base those decisions purely on the published research and you can’t make ethical decisions based exclusively on overly simplistic utilitarian (benefits > harms) calculations.

In practice, the decision-making framework looks more like this:

Clearly, it’s NOT binary, but we pretend that it is! It’s become impossible to take a nuanced position on anything.

Take breast cancer screening, for example. As I’ve discussed in previous posts (here and here), there are benefits for some (early detection sometimes leads to easier treatment and greater likelihood of cure) and harms for others (overdiagnosis, excess biopsies, the costs). Different people have different risks, they value things differently, and they’ll make different decisions! The question about who should be screened is not simply a matter of describing the benefits, ignoring or downplaying the harms, and declaring that everyone beyond a certain age should (or must) get screened. Last year, the experts in the US lowered the recommended age threshold for screening to 40. Those in Canada did not, pointing out that the evidence was unclear and people should be allowed to make their own decisions, as follows:

Sadly, earlier this year, rather than accepting the reasonable diversity of opinions, our Federal Health Minister (a professional politician, not a doctor!) paused the work of the Canadian Task Force on Preventative Health Care. In his view, it’s got to be black or white, there can be no gray! Reasonable disagreement has become oficially unacceptable. People must be told what to do, they cannot be trusted to make their own decisions!

Other examples are easy to find, often in Clinical Practice Guidelines, where panels of carefully selected experts (some with undeclared conflicts of interest) review carefully selected research articles (often with the assistance of industry representatives), expressing clear opinions about what to do, even when (by their own admission) there’s little or no actual data to support their conclusions.4

What the guidelines do, generally speaking, is express black or white (binary) advice. What they should do is acknowledge the limitations of the data, explain the pros and cons of the alternative courses of action, and leave room for the users of the guidelines to make their own decisions, based on their own values.

“The quality of evidence supporting the majority of recommendations is usually low (compared with the number and diversity of guidance that clinicians seek). This low quality, along with the fact that added rigour can lead to strict inclusion criteria of evidence, can both result in a guideline that is out of context or lacking implementation details. Therefore, for a guideline to be useful, clinical experts are needed to contextualise evidence, extrapolate evidence from indirect sources and interpret low-quality evidence. In addition to using the correct label for evidence (ie, indirect evidence instead of [expert opinion]), guidelines should provide an explicit explanation for how the experts were selected, how they reached consensus and what problems experts were asked to address (eg, to weigh in on strength and limitations of evidence, to contextualise evidence and recommendations, to assess and further inform the guideline through indirect evidence, to offer opinions based on their personal clinical experiences, or to enrich and support the guideline text with good practice statements).

What does expert opinion in guidelines mean? a meta-epidemiological study, Ponce et al, 2017

All that being the case, you have to ask:

• Why do we expect clinical guidance to be binary? Why can’t the advice be nuanced?

• Why do we expect clinicians and patients to follow the guidelines unquestioningly?

• Why are professional colleges, public health practitioners, and our political leaders making it harder to openly disagree, no matter how reasonable that disagreement might be?

Despite the fact that we’re all carrying computers in our pockets, we’re getting dumber, not smarter! Then again, computers rely on the binary system!

In the end, how does this over-simplification affect clinicians?

I suspect it explains why they’re getting burned out and losing the joy in their work. There’s no longer any room for creativity and imagination. Those who colour outside the lines (or on a blank sheet of paper) will be punished!

Imagine a new medical discovery.

The media will tell you that it “works”, which generally means that:

• based on at least one research paper (rarely more),

• in a carefully selected group of patients,

• in carefully selected circumstances,

• it confers a carefully specified set of benefits,

• often enough to outweigh whatever harms the researchers chose to measure.

From a utilitarian perspective, for that group of patients, in those circumstances, assuming we can somehow agree on the relative weights of the benefits and the harms, the innovation improves the “greater good”. However, you won’t hear about all those provisos. You’ll only hear that it works!

These days, that’s often where the analysis and reporting stops. We’re told that “the science is settled”, as if we have all the information we’ll ever need. We’re told that it should be publicly funded, no matter the cost. We’re told that everyone should be able to take advantage of it, even if they aren’t exactly like those carefully selected patients in the research study, no matter their personal values and beliefs. Panels of experts will incorporate the new discovery into guidelines and standards of care, even when they don’t know all the downsides, and even though others rightfully remain skeptical. Eventually, professional Colleges will tell doctors and others that they must include the newly available treatment option in their conversations with patients, even if providing such information conflicts with the physician’s conscience (or interpretation of the evidence).

We profess to practice shared decision making, in which patients work with their physicians to make the choice that’s right for them in the moment. However, paternalism is still disturbingly common. Behind the scenes, well-intentioned forces are at work doing everything possible to ensure that you, as a patient, make the “right” choices, through an oxymoronic concept described as “libertarian paternalism”.

“The libertarian paternalist holds that it is possible and desirable for both public and private institutions to influence people’s choices so as to increase their welfare while at the same time respecting their freedom of choice. An institution endorsing libertarian paternalism will thus steer or move people to choose in ways that will increase their welfare without blocking or fencing off choices.”

To nudge or not to nudge: cancer screening programmes and the limits of libertarian paternalism, Ploug et al, 2012

You might note the inherent assumption that “public and private institutions” know what’s best, leaving you free to choose only that which they consider to be good for you. As Henry Ford once said, “any customer can have a car painted any color that he wants so long as it is black”. Our health care system may not be limiting your options to quite that extent, but it’s getting there — the “steering” is getting more aggressive, and the invisible fences are being built.

The times have changed!

Back in the day when most, if not all, medical interventions benefitted the individual patient, and the harms affected the same individual, the utilitarian approach worked. As an autonomous individual, deciding whether or not I would have a hip replacement for my osteoarthritic hip, I would balance off the pain, inconvenience, and cost of the surgery with the alternative (ongoing osteoarthritis pain, daily medications, limitations on my activities, etc.). My surgeon could advise me about recovery times, success rates, complications, etc. In paying for the surgery, I was purchasing services, and, assuming the services were available, the decision was personal — based on what was most important to me, would I benefit enough to justify the cost and inconvenience?

Once we moved to a system in which the public pays for my surgery, my hip replacement became a public good, subject to the wider debate about how many hips should be replaced, at which hospitals, in which patients, by what method, using which hip implants, based on what evidence, etc. Those decisions are public, and the cost/benefit analysis is more complicated. When resources are constrained (and they almost always are), which patients benefit the most? As a society, how do we get the most bang for our buck? How much choice should individuals have? Should they choose their surgeon, the timing of their surgery, and the type of prosthesis?

Either way, on the face of it, it’s a utilitarian decision, requiring that the benefits exceed the harms. The difference lies in whether we assess the benefit/harm balance for the individual or for the group. What’s best for the group may not be best for every person in the group, and vice versa. The thinking can go either way. It can be used to justify doing things to individuals for the greater good (as in mandatory vaccination programs), or it can be used to refuse or limit services to people who need them (as in the rationing of hip replacements). Both examples limit patient autonomy.

In short, the science might tell us what we CAN do (assuming we have ALL the facts), but it doesn’t tell us what we SHOULD do, and what we SHOULD do depends on whether we are making individual or group decisions.

How do we decide what we SHOULD do?

In general terms, medical decisions about what we SHOULD do are said to be guided by four equally weighted “universal”1 ethical principles:

• BENEFICENCE, the expectation that decision-makers (individual or collective) should do whatever is “right” and “good”.

• NON-MALEFICENCE, or “least harm”, requiring that decision-makers strive to do the least harm possible, to the fewest people.

• RESPECT FOR AUTONOMY, which assumes that rational and reasonable individuals can and should make their own decisions, based on their own values, unless those choices trespass on another person’s decisions and actions. By this logic, paternalism and coercion are inherently bad and wrong (but may be necessary in some trespass situations).

• JUSTICE, or “fairness”, the obligation to fairly balance competing claims. This takes three forms:

  • distributive justice (fair distribution of scarce resources),

  • rights based justice (respect for people's rights), and

  • legal justice (respect for morally acceptable laws).

Of note, these principles bridge different philosophical theories:

• Beneficence and non-maleficence reflect Utilitarianism, which seeks to maximize good and minimize harm, in effect balancing the CONSEQUENCES of action (or inaction). To the extent that we believe that benefits and harms are observable and quantifiable, this approach also aligns with the Objectivist approach to medicine, in which we believe we can understand the whole through a detailed and values-free study of the parts.

• Respect for autonomy comes to us from Deontology, in which ACTIONS are judged based on whether or not they adhere to a set of rules or duties, rather than the consequences of those actions.

• Justice comes to us from Virtue Ethics, which focuses on INTENT (as defined by character and virtue), rather than rules or consequences.

Unsurprisingly, the application of these four principles is rarely straightforward, and there are frequent conflicts.

Well-intended actions sometimes have bad consequences (e.g. thalidomide). Rules sometimes have to be broken, to avoid harm (e.g. killing someone in self-defense).

At the individual level, benefits and harms take many forms and cannot be reduced to a single unit of measurement. Sometimes you are balancing today’s side-effects against the chance of a future harm. Besides that, the data can be questionable — early research findings almost always over-estimate the immediate benefits and underestimate the long-range harms. Real-life patients often differ from those in the research studies, in which case we don’t always have actual data about harms and benefits — in these cases, we rely on the “consensus opinion of the experts”, which is, as it says, opinion, not evidence.2

Collectively, things that are thought to benefit some individuals within a large group (like mass vaccination programs) may harm other individuals, leading to questions about whether individual autonomy should be allowed. Wait lists for scarce publicly funded care may mean that individuals can’t always make their own choices (even if they have the money to buy their own care), while the harms of excessive waiting receive less consideration than the alleged benefits of fair distribution.

So, in considering any decision about what we SHOULD do, individual or collective, we are told to consider each principle in turn, weigh the conflicts, and then decide, on balance, the best course of action.

So, what’s the problem?

There is research to show that the people who profess to value the ethical principles do not always use them directly in their decision-making process, perhaps because they are relying on something even more fundamental, like moral norms. They leap to a conclusion, based on their internal moral compass (thinking fast, in effect), then, if questioned, justify their conclusion by selective (and retro-active) application and interpretation of the four principles (thinking slow).

As no two individuals are alike, it’s inevitable that rational and reasonable individuals often arrive at different conclusions.

At the individual level, involving individual treatments for acute problems carrying individual benefits and harms, this underscores the need for autonomy. In considering my hip replacement, my values affect my decision, and it doesn’t have to be all about me. I might decide that I’m too old to tie up valuable resources that should benefit others. Conversely, I might decide I’m worth it, even though I’m old and feeble. Ultimately, nobody else can decide for me.

When it comes to harmful things, John Stuart Mill (1806-1873), said (emphasis added):

“The object of this essay is to assert one very simple principle, as entitled to govern absolutely the dealings of society with the individual in the way of compulsion and control, whether the means used be physical force in the form of legal penalties or the moral coercion of public opinion. That principle is that the sole end for which mankind are warranted, individually or collectively, in interfering with the liberty of action of any of their number is self-protection. That the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinions of others, to do so would be wise or even right. These are good reasons for remonstrating with him, or reasoning with him, or persuading him, or entreating him, but not for compelling him or visiting him with any evil in case he do otherwise. To justify that, the conduct from which it is desired to deter him must be calculated to produce evil to someone else. The only part of the conduct of anyone for which he is amenable to society is that which concerns others. In the part which merely concerns himself, his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign.”

On Liberty, 1859

Granted, that’s one man’s opinion (which I happen to share), but it supports my point that my health problems, generally speaking, are mine and mine alone, unless they harm others (i.e. “trespass” on their rights). Even though they may (or even will) be harmful to me, I make the decisions.

This concept is well recognized in health care, where we talk about accepting and respecting a patient’s decision to “live at risk”, respecting the patient’s life context, goals, and values. The onus is on health care providers to justify any decision to override the patient’s wishes, and it must be based on SIGNIFICANT risks, not the things that are highly likely but minor (like getting influenza), or major but so unlikely as to be almost theoretical. After all, risk can NEVER be totally eliminated, and we ALL choose to live with some degree of risk.3 Some folks even seek it out!

For collective decisions, you have a large group of people holding different moral, religious, professional, and political beliefs and values. To add to the confusion, modern medical decisions more often involve population-wide interventions for chronic problems or prevention, things which benefit some people and harm others. With high blood pressure screening, for example, you’ll assess hundreds and then treat dozens of people for years on end to prevent a few heart attacks and strokes in a tiny fraction of the group. How do you quantify and balance the harm of today’s medication-induced impotence in one man against the avoidance of another man’s future non-fatal heart attack?

All that being the case, in deciding what advice we should offer to the group, the best we can hope for is something I’ve seen described as “a broad and durable consensus”:

• A significant portion of the affected group, community, or population must support the consensus, including and respecting individual autonomy and diverse perspectives.

• In this context, consensus means a general agreement, reflecting a shared understanding of the issue. It involves finding the common ground, rather than a simple majority vote.

• Durability implies that the consensus is not easily overturned or challenged, implying a level of commitment and stability that allows for long-term planning and implementation.

Clearly, deciding what we SHOULD do requires more than somebody declaring that “the science is settled”. It involves much more than a small group of experts coming together behind closed doors to hammer out a clinical practice guideline, in the expectation that practicing physicians and their patients will comply. The experts should describe the available options, rather than prescribing a “one size fits all” course of action.

Our current ethical decision-making processes have become grossly over-simplified. In the interests of “the greater good” and “distributive justice”, we’ve over-emphasized the collective (rather than the individual) balance between benefits and harms. We do so because we imagine it’s the fair and virtuous thing to do. The classic justification is “nobody else should ever have to experience this!”

Rather than letting individuals make their own decisions (and mistakes), there’s a belief that nobody should be allowed to miss out on a potential benefit and nobody should be exposed to an avoidable harm, no matter how improbable or inconsequential those benefits or harms might be. We don’t want anybody to live at risk!4

Personal values no longer apply — it’s public! We’re actually more paternalistic than ever, but the paternalism is applied at a different level, determining which conditions are worthy of study, which interventions should be researched, which outcomes are considered important, what results get published, and which treatment plans are officially sanctioned.5 Individual autonomy takes the back seat. You can have (or refuse) any health care intervention you choose, as long as the experts feel that you’re doing what’s good for you (or, more accurately, good for your group).

Don’t believe me?

I’ll leave you with a few examples.

Canada is now facing its lowest rates of hypertension treatment and control in more than a decade, and we cannot afford to remain complacent. With an aging population, the number of people living with hypertension is growing, and the number of adults with hypertension who remain untreated or uncontrolled will only increase if we do not act, which will lead to greater rates of preventable disability and death. Renewed interest in blood pressure control is needed, with resurrection of previous implementation efforts to provide effective care and re-engagement of the federal government with health and scientific sectors to enhance monitoring and evaluation.

Refocusing on hypertension control in Canada, Leung et al, 2021

Consider this. High blood pressure is a risk factor for atherosclerosis, which is a risk factor for heart attacks and strokes, the treatment of which has improved over the past 20-30 years. In fact, mortality rates are dropping! Still, everyone is at risk for heart attacks and strokes, some more so than others, and we all have different tolerance for risk. Some choose to take medication to lower their blood pressure. Some choose not to, perhaps because the target keeps shifting, the medications cost money and have side-effects, and the benefits are uncertain and decreasing. With more people choosing to live at risk, these authors suggest that we need “re-engagement of the federal government”, among other things. In their opinion, the moral coercion of public opinion would be wise, or even right.

“The US Preventive Services Task Force (USPSTF) updated their breast cancer screening guidelines in April 2024 to recommend starting screening mammography at 40 years of age and continuing biennially until 74 years of age, or 18 screening mammograms during a woman’s lifetime.”

Screening Mammography for 40-Year-Old Women — Whose Decision?, Kerlikowske et al, 2024

Consider this. The Task Force didn’t want anyone to miss out on the possible benefits of early detection, even though the likelihood of benefit for a 40-year-old woman from starting biennial screening mammography at 40 years of age rather than at 50 years of age is almost theoretical, like a lottery ticket (about 1 in 1000). There was no new or compelling data to support their new recommendation. Breast cancer mortality for women of all ages has been decreasing for the last 30 years, in part due to improved treatment. The Task Force ignored the harms of their advice, which include more benign biopsies (65 per 1000 women), false-positive mammography results (50%!), and over-diagnosed breast cancers (2 per 1000 women). They aren’t saying it should be available for those who choose it, they are recommending it, another example of the moral coercion of public opinion.

Clinical practice guidelines (CPG) are written with the aim of collating the most up to date information into a single document that will aid clinicians in providing the best practice for their patients. There is evidence to suggest that those clinicians who adhere to CPG deliver better outcomes for their patients. Why, therefore, are clinicians so poor at adhering to CPG? The main barriers include awareness, familiarity and agreement with the contents. Secondly, clinicians must feel that they have the skills and are therefore able to deliver on the CPG. Clinicians also need to be able to overcome the inertia of “normal practice” and understand the need for change. Thirdly, the goals of clinicians and patients are not always the same as each other (or the guidelines).

Why are clinical practice guidelines not followed?, Barth et al, 2015

Consider this. CPGs are written in the hope that they’ll include all of the relevant information about a clinical scenario, thereby guiding clinicians to provide the “best care”. Healthcare administrators, regulators, and policy-maker payers often consider CPGs to represent “standards of care”.6 The widespread expectation is that clinicians and their patients will comply. However, there are plenty of articles out there bemoaning the fact that they don’t! Some authors are self-aware enough to recognize that the guidelines themselves are flawed7. Others, like those quoted above, mention in passing that individual clinicians may rightfully disagree with the expert advice, or that the clinicians and patients may not have the same goals as the authors of the CPG. They acknowledge autonomy but end up wanting to beef up the guidelines (and compliance). Moral coercion, again.

“An appraisal of international guidelines for care and treatment of children and young people with gender incongruence found that that no single guideline could be applied in its entirety to the NHS in England.

While a considerable amount of research has been published in this field, systematic evidence reviews demonstrated the poor quality of the published studies, meaning there is not a reliable evidence base upon which to make clinical decisions, or for children and their families to make informed choices.

The strengths and weaknesses of the evidence base on the care of children and young people are often misrepresented and overstated, both in scientific publications and social debate.”

The Cass Review, Final Report, Hilary Cass, 2024

Consider this. The Cass Report and other publications, including The WPATH Files, have demonstrated that the published guidelines for gender dysphoria are not built on solid evidence. Even so, medical organizations in Canada, including the Canadian Medical Association, are fighting against any attempts to dial back the harmful “gender-affirming” model of care. Individual physicians can and often do disagree with the model of care, either due to conflicts of conscience arising from their belief structure or religion or simply because they rightfully dispute the evidence. Even so, they still must “… discuss all available treatment options with the patient and must not withhold information regarding a procedure or treatment relevant to the patient’s condition, even if providing such information conflicts with the physician’s conscience.” In short, even when there’s no good quality evidence, and even when the consensus of opinion is neither broad nor durable, individual physicians are required to discuss harmful treatments with their patients and then make effective referrals to others. Ideology, in this case, trumps beneficence, nonmaleficence, and autonomy.

Why? Because somebody wants to feel important!

“Half the harm that is done in this world is due to people who want to feel important. They don't mean to do harm; but the harm does not interest them. Or they do not see it, or they justify it because they are absorbed in the endless struggle to think well of themselves.”

The Cocktail Party, T.S. Eliot, 1950

For example, the 2025 Canadian “pragmatic” and evidence-based guidelines for primary care state “Pharmacotherapy initiation for hypertension is recommended for adults with BP ≥ 140/90 mm Hg and for adults with systolic BP 130–139 mm Hg at high cardiovascular disease risk.”

Based purely on numbers, drugs are prescribed!

But how do we determine that your BP is ≥ 140/90 mm Hg

(or your systolic is 130–139)?

Assuming your BP is measured correctly, your BP for the visit is the average of three measurements taken at 1-minute intervals. All three readings AND the average are to be recorded, for reasons unspecified.1

Whether or not you are diagnosed with hypertension and then treated depends on a fairly complex algorithm involving various permutations and combinations of repeat measurements in the office (OBPM, or AOBP, if “automated”), while ambulatory (ABPM), or at home (HBPM), sometimes combined with an estimation of your cardiovascular disease risk (which itself is somewhat “pseudoscientific”, as explained in my previous post).

Don’t spend too much time trying to decipher this flow chart! Despite the intention to be primary care–focused, pragmatic, and efficient, it’s almost impossible to understand! 2 More importantly, it makes fundamental assumptions about the knowability of your BP, so it’s a bit like a building built on quicksand!

In short, you could find yourself diagnosed and treated based on:

• as few as three office BP readings (if your BP is >= 180/110),

• perhaps a few more readings, if your BP is 140-180/90-110 and your doctor rechecks it over a few visits,

• as few as 20 daytime and 7 nighttime readings over a single 24-hour period, if you resort to ambulatory monitoring, or

• a 7-day series comprised of the mean of home-based morning and evening measurements.

No matter how you slice it, that’s not much data to work with, especially when you could end up on medication for the rest of your life.

Is it really that straightforward? Hint: most things in medicine aren’t!

Let’s back the bus up a bit!

What is Blood Pressure?

First, some basic physiology.

Your heart beats 60-100 times a minute, ejecting about 70ml of blood with each contraction. The blood flows into arteries, which are stretchy, like those collapsible garden hoses.

The only way to know the actual pressure of the blood inside a blood vessel is to insert a tube, or “catheter”, into the blood vessel and connect it to a pressure-measuring device, or “manometer”. This started with experiments involving Stephen Hales and horses:

So, allowing for the fact that the picture doesn’t match the words (the crural artery isn’t in the neck!), that horse’s BP was enough to raise a column of blood 8’3”. Clearly, you need high ceilings to measure BP that way, even higher if the horse was upright and you used optimal technique! Moving things indoors, later physiologists used tubes full of mercury (chemical symbol Hg), which is heavier than blood, measuring the height of the column in millimeters (mm), rather than feet and inches. To this day, we report BP readings in mm Hg, even though (a) we have been phasing out the mercury manometers, and (b) it would be far more scientific to use standard scientific units of pressure, such as kilopascals.

Because blood flow is pulsatile, not steady, and because those arteries are stretchy, not rigid, the pressure of the blood in the arteries oscillates, as Hales observed. The peak pressure following a contraction of the heart is the systolic reading. The diastolic reading is the trough reading just before the next contraction. Even though the BP is somewhere between the peak and the trough most of the time, we over-simplify by reporting only the peak and the trough, saying that the BP is 120/80 mm Hg, for example.

Measuring Blood Pressure

Because it’s more convenient and less invasive than sticking a catheter into one of your arteries, we generally measure BP “noninvasively”. The “gold standard”, time-honored way to do this is sphygmomanometry3, using a BP cuff on the upper arm connected to a mercury manometer on the wall, while listening for “Korotkoff sounds” with a stethoscope. These days, the mercury manometer might have been replaced by a spring-loaded dial, and the stethoscope by an electronic sensor, but the principle is the same.

Unfortunately, this method provides only a rough approximation of the number we are actually interested in, which is the pressure inside the brachial artery. It’s a proxy or surrogate measure, subject to error, which can be quite significant! A systematic review found that, for the majority of patients (those with BP 120-160/80-100), the cuff BP:

• underestimates the true systolic BP (by 5mm Hg or more in 2/3 of cases and at least 15 mm Hg in 1/4 of cases), and

• overestimates the true diastolic BP by similar amounts.

So, even under ideal conditions, the cuff BP isn’t accurate (meaning “free from error” or “conforming exactly to the truth”).

This isn’t really surprising. After all, the cuff method involves determining the amount of pressure required to compress the brachial artery, which is less than 5mm in diameter and buried between the muscles of your upper arm. To get a sense of the challenge, wrap your garden hose in several inches of bone-in steak and then try squeezing it all hard enough to stop the flow!

Even allowing for that fundamental inaccuracy, much depends on who does the measuring. I won’t go into the details, but there’s a lot of room for imprecision4, part of which explains the “witchcraft” of the optimal technique.

Regardless of who is measuring BP or the method used (e.g. auscultatory or oscillometric), the accuracy of the BP readings relies on standardized techniques and appropriate observer training. Sources of BP measurement error include patient-related (e.g. recent food consumption, movement), device-related (e.g. using a noncalibrated or nonvalidated device) and procedure-related (e.g. talking during the procedure or miscuffing) factors. The use of an inaccurate measurement technique is common, and a systematic review found a large bias associated with 27 of 29 potential sources of BP measurement error.

Measurement of Blood Pressure in Humans: A Scientific Statement from the American Heart Association, 2019

In case you were wondering, that “large bias” ranged from -23.6 to +33 mm Hg for the systolic BP, and -14 to +23mm Hg for the diastolic BP5. Those are not small errors!

To recap:

• cuff BP measurements are indirect and inaccurate (they don’t necessarily reflect the actual BP inside the artery), and

• they are also imprecise (no two people or devices are going to get the same result).6

The importance (?) of validating BP devices

Here’s the funny part!

The international standard for validating BP devices specifies that they all be compared to “mercury sphygmomanometers or accurate non-mercury devices”, even though sphygmomanometry is proven to be inaccurate and imprecise.

Furthermore, the new devices don’t have to produce exactly the same numbers, but they are expected to be close. It’s “good enough” that they produce an approximation of the approximation of the real BP.

Even at that, the majority of BP measuring devices available on the market have not actually been subjected to any independent validation using an established protocol. To do so might result in them being taken off the market, and what manufacturer would risk that?

Going one step further, devices now appearing on the market purport to measure BP at the wrist (or even in the finger). It’s not known how those readings compare to brachial artery readings, or what they even mean. For a wrist device, for example, …

First, BP can be measured only if the sensor of the monitor is directly over the radial artery, and there is a tendency for the device not to maintain the proper positioning on the wrist. Wrist flexion may enhance the problem of obtaining the optimal position. Second, an accurate reading is obtained only if the wrist is at heart level; readings will be too high or too low if the wrist is below or above heart level, respectively. Some users prefer to measure BP while sitting on a chair with their arm on a desk, which may be an easier position, especially for older adults. Thus, although convenient for the consumer, wrist monitors provide many challenges with precision, and strong reservations have been raised about their use in routine clinical practice, unless measurements in the upper arm are not feasible.

Measurement of Blood Pressure in Humans: A Scientific Statement from the American Heart Association, 2019

To recap:

• while new BP devices are supposed to be validated, most have not been,

• the scientifically recommended validation process involves comparing to an inherently inaccurate and imprecise device, which seems unscientific, and

• some new BP devices are measuring BP in non-standard locations, the meaning of which is unclear.

Blood pressure is a moving target!

While you might imagine that the true BP is fixed, we know for a fact (from intra-arterial readings) that it varies by 5-10 mmHg from one beat to the next. The reasons too numerous to mention but include unavoidable things, like breathing.7

So, if your heart beats 72 times a minute, that gives you over 100,000 different BP readings in a 24-hour period.

As if that’s not complicated enough, BP also varies throughout the day (generally lower at night), from one day to the next (higher on Mondays), and with the seasons (lower in summer than in winter), with a gradual trend to higher readings as you age!

In other words, your BP is sort of like the Nova Scotia weather — if you don’t like it, wait five minutes and it will be different!

What we record as your office BP, therefore, depends on which three of those 100,000 different daily readings we happen to sample (and then average), and it also depends on whether the five minutes you were in the office were a reasonable reflection of your day, week, month, or even year.

If you think about it, this probably explains why no two people will ever get exactly the same BP reading, even if they measure the BP on the same patient in the same arm using the same device within minutes of each other! Despite the witchcraft about “proper” technique, “real world” office BP readings are not really reliable!

Because BP varies beat-to-beat, perfect reproducibility of mean office BP is not possible. Routine office BP measurements obtained in clinical practice with the auscultatory method demonstrate substantial variability. Therefore, low reproducibility is present over visits conducted days to weeks (short term) and months to years (long term) apart.

Measurement of Blood Pressure in Humans: A Scientific Statement from the American Heart Association, 2019

To make matters worse, 15-30% of the population have high BP in the office but not elsewhere (“white coat hypertension”), while another 15-30% of the population have normal BP in the office and high BP elsewhere (“masked hypertension”)8. In short, it’s a coin toss whether or not your office BP reflects your out-of-office or any other form of “reality”.

Some experts suggest that BP measured by 24-hour ambulatory BP monitoring (ABPM) is preferable. However, in contrast to the rigid protocols for measuring office BP, people are “on the go” while wearing the ABPM device, so it’s not surprising that over the 24-hour cycle there are marked variations in BP related to physical activity, emotions, and sleep, among other things. Furthermore, wearing the device affects people logistically and emotionally, so it’s reasonable to conclude that the readings aren’t necessarily typical! While ambulatory BP monitoring obtains more BP readings, over the full 24-hour cycle it still samples less than 0.1% of those 100,000 readings, and there’s a lot of variation in the results that are sampled. Finally, while it’s considered normal for BP to drop overnight, we’ve discovered that not everyone follows that pattern, perhaps because the ABPM device messes up their sleep. Up to 20% of whites and 40% of blacks therefore have “nocturnal hypertension”, another thing you wouldn’t detect in the office!

Then there’s home BP monitoring (HBPM), the “do-it-yourself” approach, which is better tolerated, more widely available, and cheaper. It might even be better — HBPM readings allegedly show a stronger association with CVD risk than those obtained in the office! While there are concerns about patient’s having “selective” recall of their BP (i.e. “forgetting” the bad readings, or “rounding off” to better-sounding lower numbers), this can be addressed by using HBPM devices with built-in memory and having patients bring their devices to clinic visits. On top of that, you still run into the same problems (recent food consumption, movement, using a noncalibrated or nonvalidated device, talking during the procedure, miscuffing, etc.).

Regardless of the method, no matter how many BP readings you obtain, you are faced with the decision about which to ignore (as unrepresentative “outliers”), and which to include as “true”. You also have to decide whether each individual number has meaning, or whether they should be averaged.

To recap:

• your BP varies constantly,

• office BP is inaccurate, imprecise, and irreproducible (it’s a very small random sample),

• ambulatory BP is supposed to be better, but still has problems (more numbers, but still a very small sample),

• home BP is also supposed to be better, but also has problems, and

• no matter what, you end up trying to use a single number (or small group of averages) to summarize a lot of numbers.

In the end, we revert to the mean!

Let’s assume that you graph a bunch of your personal systolic BP readings, spread out over several weeks. You’ll see something approximating a bell curve distribution, like this:

Let’s assume that today’s the day you get that reading of 180. You decide to recheck it later, maybe tomorrow. Assuming things are more or less random, there’s a far greater chance that tomorrow’s reading will be lower (i.e. closer to the mean), rather than higher. After all, your systolic BP is less than 180 most of the time!

A similar thing would be true if today’s reading was 100. Statistically speaking, tomorrow’s reading is likely to be closer to the mean, because most of your readings are greater than 100.

This phenomenon is known as “reversion to the mean” — extreme values tend to revert back towards the average (mean) over time. The more readings you take, the more you get the true picture, which is that most of your readings are in the 100-150 range!

Think about what happens if your BP today is 180 and your doctor prescribes medication, as suggested by those guidelines. When you come back for a recheck, the next reading is almost certainly going to be lower. Indeed, most of your future readings will be less than 180, by pure chance alone, because the 180 was an outlier! Unfortunately, it’s pretty easy to attribute the apparent reduction in your BP to the drug9, in which case you might be on it forever.

It’s for this reason that many doctors (especially family doctors) like to watch your BP for a while before they start treatment. After all, if your BP isn’t really elevated most of the time, then your cardiovascular risk isn’t really higher. You don’t want to commit to a lifetime of treatment if your readings today, this week, this month or maybe even this year are outliers. To the extent that there is a “risk”, it isn’t immediate, it’s long-term. There is time to make certain that your BP is truly and persistently high.

Furthermore, it’s well known that BP improves slowly but steadily over several months after BP meds are started, possibly because the meds work slowly, or perhaps another reflection of regression to the mean. For that reason, many doctors like to start one drug, wait a while to see what it does, and then add another only if needed. This has the added advantage of making it easy to see whether the new drug is causing side-effects. Sadly, the newer guidelines suggest starting two drugs together (“single pill combination therapy”), which risks overtreatment and makes it hard to tell which drug is causing any side-effects that arise.

But what about the risk?

How do we “know” that high BP means “high cardiovascular disease risk”?

What we think we know is based on epidemiological studies, in which scientists gather data about large populations of people observed over long periods of time. One example is the Framingham Heart Study, which has been gathering data about 15,000 people over 75 years. In a nutshell, those with higher blood pressure were found to have an increased risk of cardiovascular events.

However:

• as big as it is, the study only involved 15,000 people,

• those people lived in a specific geographic area (Massachusetts),

• many of the original participants were of European descent,

• the BP readings they obtained were subject to all the problems I’ve described (cuff BP, etc.),

• there’s no guarantee that high BP causes heart attacks (it may simply be a non-causal association), and

• there’s been a lot of progress in terms of the diagnosis and management of cardiovascular events over the years.

While the Framingham data has been translated into a “risk calculator”, it’s been shown that the calculator typically overestimates risk in low-risk patients and underestimates risk in high-risk patients.

Other calculators, based on data from other populations, give different results, but no calculator is perfect, perhaps because there’s a lot of variation in people and because the calculators are based on inherently inaccurate data (a phenomenon known as “garbage in, garbage out”).

In conclusion…

The BP experts would like you to believe that your BP is knowable, your future risk of cardiovascular events is knowable, and that it’s vitally important that you lower your BP and your risk, by doing what they say. They’ve become fixated on numbers, forgetting that those numbers are unreliable approximations. In treating numbers, they’ve lost sight of patients.

The experts keep tweaking those guidelines, because (in their view) family doctors aren’t checking BP enough, diagnosing hypertension early enough, and treating to target. However, those family doctors are often balancing the complex needs and values of their patients, things which can’t be reduced to overly simple numbers.

In all things medical, there’s a balance between the art and the science. Despite what the experts think, BP measurement and management is more far more art than science.

5

I’m not making this up, nor is this some “fringe” theory! The reference is Sources of inaccuracy in the measurement of adult patients’ resting blood pressure in clinical settings: a systematic review. It includes the following detailed table.

In terms of blood pressure (BP), the current expert consensus is that the ideal value for adults is less than 130/80 mm Hg. If your BP is at or above those values, you are considered to have “hypertension”, a “chronic disease”2! You are “at risk”! Your condition needs “managing”! Having departed from the ideal, you’re a deviant!

This view of hypertension as a clearcut departure from the norm is pervasive in medicine. It implies that there are normal patients, there’s a deviant minority, and we can tell the one group from the other.3

However, as pointed out by Geoffrey Rose, long since deceased eminent professor of epidemiology at the London School of Hygiene and Tropical Medicine, there are significant problems with this line of thinking:

It is commonly supposed that there is a clear distinction between normality and deviance, whether the attribute is physiological (like blood pressure), behavioural (like eating or drinking), or social (like aggression). This view is attractive because it focuses attention on individuals who clearly have problems and at the same time reassures the majority: they are all right and not responsible for the deviant minority. Thus, … hypertension is still widely felt to be something different from the normal variation of blood pressure.

The population mean predicts the number of deviant individuals, Geoffrey Rose and Simon Day, 1990

What was he getting at? Let’s take this step by step.

What is “normal variation”?

For any physiological parameter, there is normal variation.

For example, if you round up a random bunch of normal people and measure their height, you'll find a range of values, with men (blue) being taller, on average, than women (red), in what’s known as a “normal” distribution, which can be depicted as a bell curve.

The bell curve is a well-recognized statistical phenomenon. It can be described mathematically in terms of its “mean” (the center of the curve, around which the measurements cluster) and its width, which is described as the “standard deviation”4. 95% of the readings fall within the big bump in the middle, described mathematically by the mean +/- 2 standard deviations. The other 5% are not necessarily abnormal — they are simply “uncommon” within the population you are describing. Men 6’6” and up are uncommon in the general population, but relatively common in the population of NBA basketball players.

As suggested by the numbers on the horizontal axis of the graph (which include both metric and imperial measurements), the bell curve distribution does not depend on the units of measurement. The curve would look exactly the same whether you measured people in cubits, yards, feet, inches, centimeters, meters, or light years, although the mean and standard deviation would have different numerical values, of course.

As suggested by the legend on the graph, we sometimes assign arbitrary labels to people who deviate from the mean — in this case, somebody decided to say that “tall” people are those taller than 97.8% of the population and “extremely tall” people are taller than 99.9%. Going back to my point about different systems of measurement, the threshold for being “tall” is just over 190cm, which is a nice-sounding round number5, or 6’3”, which is not so clean and tidy sounding. Same threshold, different systems of measurement, different numbers, some easier to remember than others.

Being tall carries some risk. Everyone is at risk of bumping their head on something, and that risk increases with height, with those who are extremely tall being more likely to bump their head on door frames or low-hanging light fixtures, for example. Even so, while there’s relatively greater risk, the absolute risk can still be quite small - even extremely tall people don’t go around with perpetual bruises on their foreheads, nor do we recommend that they wear helmets. Furthermore, we don’t generally label tall people as deviants, because there’s no clear physiological distinction between people of normal height and those who are taller (or shorter).6 Other than the actual height readings (and the risk of head bumping), everything else about tall people, normal people, and short people is much the same. Height is simply the end product of the complex interplay between individual genetics and the environment, with a wide range of “normal” outcomes.

As with height, so it goes with each and every other quantifiable bodily measurement, including weight, waist size, intelligence, inseam length, resting pulse, hemoglobin level, serum potassium levels, and (yes) blood pressure. Regardless of the measuring system used, there’s normal variation within the population, most readings cluster around the mean, and some folks are at the extremes of the range, with or without some added risk of something. There’s also variation between populations — for example, people of different ethnic origins living in different countries or regions have different “normal” ranges. And all of this is true for the individual measurements that are more or less “fixed” (like adult height) and for those that vary over time (like weight and blood pressure).

Blood pressure is just like everything else!

For blood pressure, then, you see exactly the same sort of variation within the population, between populations, and even within individuals.7

Borrowing again from Dr. Rose, you see the same Bell curves, with the left curve showing the distribution of systolic BP readings in the five countries with the lowest readings, and the right curve applying to the five countries with the highest readings.

Interestingly, as I was researching this post, I was struck by the fact that it is very hard to find graphs showing this normal distribution of blood pressure readings, even though it’s a fact of life. The experts seem to have lost sight of the fact that blood pressure shows normal variability. There are a couple of consequences to this!

First, because of the shape of the bell curve, as the experts set lower and lower thresholds for the diagnosis of hypertension, the number of people labelled as hypertensive increases dramatically. The following graph, from 2005, shows what happens when the threshold is set at 140 mmHg systolic — almost half of the population are labelled as hypertensive! 8

Second, in ignoring the normal variability, the blood pressure experts continue to look for some clear distinction between normality and deviance. They seek to know what sets apart the person with a systolic of 142 from his neighbour with a systolic of 138, other than the number itself. They hope to find some pathophysiological difference between the two people (say, for example, a higher level of Substance X in the guy with the higher BP), so that they can manipulate that difference to cure the problem (i.e. “block” the production or effect of Substance X to “fix” the BP).

Unsurprisingly, this turns out to be a fruitless search — after over a century of research, articles describing the pathophysiology of hypertension usually conclude that blood pressure, like height, is simply the end product of the complex interplay between individual genetics and the environment, with a wide range of possible outcomes.9 In other words, people with hypertension aren’t deviants — they’re just normal variants! You can set an arbitrary threshold, but there’s no magic number below which the risk is zero and above which it becomes a problem.

“Furthermore, clinicians often seek thresholds to trigger certain interventions. This concept is at odds with the fact that risk is a continuum, particularly for risk factors such as blood pressure and cholesterol, and there is no threshold at which certain interventions are automatically indicated.”

What Is the Best Mix of Population‐Wide and High‐Risk Targeted Strategies of Primary Stroke and Cardiovascular Disease Prevention?, Feigin et al., 2020

Third, there’s an assumption that reducing the BP eliminates the risk. It doesn’t! There’s also an assumption that the risk of high BP is large. It isn’t! Sure, there is evidence that reducing higher BP readings, like 160/100, toward a target of 140/90 results in lower numbers of heart attacks and strokes.10 However, the risk is not completely eliminated, and you have to treat dozens of people to prevent a single event. Furthermore, over time the experts have recommended starting treatment at lower levels (like 130/80), while aiming for lower targets. Unfortunately, there’s no good evidence to support this approach.

For the general population of persons with elevated blood pressure, the benefits of trying to achieve a lower blood pressure target rather than a standard target (≤ 140/90 mm Hg) do not outweigh the harms associated with that intervention. Further research is needed to see if some groups of patients would benefit or be harmed by lower targets.

Blood pressure targets in adults with hypertension, JA Arguedas, 2020

Fourth, by definition, this “high-risk” strategy ignores the people with low and moderate risk, who, as Rose stated, are falsely reassured that they are “all right”. However, 80% of all strokes and heart attacks occur in low and moderate risk people, simply because they are far more numerous. In essence, we’ve gone after the low hanging fruit (people with high BP), while leaving most of the crop unpicked.

Lowering the threshold means treating far more people (at added cost, with lots of side-effects) with diminishing returns. You could, in the end, treat everybody individually (which is where we’re headed, with those ever-lowering targets), but that would be prohibitively expensive and more harmful than helpful.

“… even if CVD screening systems are effective and identify all individuals in the population with a 10-year CVD risk of ≥30% (6% of the population), and all of these individuals are appropriately treated, the incidence of major CVD is estimated to be reduced by, at most, 11%”

What Is the Best Mix of Population‐Wide and High‐Risk Targeted Strategies of Primary Stroke and Cardiovascular Disease Prevention?, Feigin et al., 2020

At the same time, individuals who previously thought they were “well” (or “normal”) are re-defined as “diseased” (or “deviant”), which comes with consequences, including stigmatization, increased medical expenses, differential life insurance premiums, and altered self-image, to name a few.

Finally, when the experts focus on the variation within the population, they lose track of the variation between populations, focusing interventions on individuals rather than populations.11

Looking again at Dr. Rose’s graph, comparing systolic BP readings in the five countries with the lowest readings to those in the five countries with the highest readings, you might ask why the curves are different. Is it possible that the prevailing “Western diet” in some countries explains why their population has higher BP’s? If so, is it best to individually treat each hypertensive patient with dietary advice and/or pills, or would it be better to promote healthier patterns of eating for the entire population? There is evidence that that individual screening and treatment is less effective than population-wide approaches.

What really matters?

In medical terms, we talk about “the outcome that matters”. To illustrate the point, there was a cynical joke with the punchline being “the operation was a success, but the patient died anyway”. In surgery, the outcome that matters is “living”. Dead people don’t derive any benefit from a “successful operation”. The successful operation, however you define it, might be required to continue living, but it’s just a “surrogate marker” for what really matters — it’s not the entire story.

The outcome that matters (for most people) is living a reasonably long life, free of suffering and disability. When it comes to cardiovascular disease, that means not dropping dead at an early age, not having congestive heart failure after a myocardial infarction, and not ending up paralyzed on one side after a stroke.

We hopped onto the hypertension bandwagon decades ago, with the objective of preventing fatal or disabling heart attacks and strokes, the outcomes that matter. The prevailing assumption all along has been that prevention is better than treatment.

High blood pressure is but one of many risk factors for atherosclerosis (“hardening of the arteries”, in layman’s terms), which is, in turn, a risk factor for heart attacks and strokes, only some of which are disabling or fatal.

Smoking is a much more significant risk factor, and it might actually be a cause of atherosclerosis. Thankfully, fewer people are smoking these days.

Other risk factors, like age and being born male, have a large effect, but they are not modifiable.12

Because high blood pressure has replaced smoking as the #1 “modifiable risk factor”, we’ve put a lot of emphasis on it. To up the ante, it’s described as the “silent killer” (even though you can have it for a lifetime and die of something else)!

However, the interesting thing about risk factors is that they aren’t necessarily “causal”. Being tall puts you at risk for bumping your head, but it’s not the cause of head injuries — you can be tall and not bump your head, or you can be short and suffer a head injury for other reasons.

Whether or not high BP causes atherosclerosis (and, in turn, heart attacks, strokes, and death), your BP is still only a surrogate marker, it’s not the outcome that matters. We claim success when we’ve lowered your systolic BP to 130, but that’s just a number. You won’t feel any better. In fact, given the side effect of the drugs, you might feel worse.

We all die only once, so it’s the rule, rather than the exception, that the operation (hypertension treatment) is a success, and the patient dies anyway! Despite the lower BP, you might still have a heart attack or stroke. Alternatively, you could have an accident or develop some other disease, like cancer.

More people die with high blood pressure than because of high blood pressure.

Is it better to prevent or treat?

In a perfect world, we would drift back toward population-wide strategies, seeking to control the determinants of high BP in the population as a whole. This “primordial prevention” is not a totally alien concept. For example, smoking rates have dropped. The societal changes that made this happen, such as higher taxes on tobacco and restrictions on public smoking, proved to be far more effective than decades of one-on-one screening and smoking cessation advice in doctors’ offices.

Similar attention could be given to other behavioral and lifestyle risk factors, including excessive salt and sugar intake, lack of fruits and vegetables, physical inactivity, and the harmful use of alcohol. A societal approach of this sort would reduce not only hypertension (shifting the bell curve to the left and thereby reducing the risk for the entire population) but also other common diseases, including dementia, diabetes mellitus, cancer, and pulmonary diseases.

What we do now is “primary prevention”, identifying “at risk” individuals and trying to reduce their risk. It involves a significant investment of time and money, a cost here and now measured against an uncertain future return. It works, but it has limits! The experts already bemoan the fact that not everyone knows their blood pressure, those with high BP aren’t all being treated, and those who are treated aren’t all “at target”. If we haven’t been (and never will be) 100% successful with blood pressure, then it’s not going to be possible, effective, or affordable to screen and then counsel every single person regarding their intake of salt, sugar intake, fruits, vegetables, and alcohol, as well as their physical activity levels.

It might be more helpful to screen individuals for actual atherosclerosis, so that we could intervene at that point (one step closer to the outcome that matters), but we don’t yet have a good way to do that.

Even while the experts bemoan the seeming lack of progress and need to do more about hypertension, it’s worth noting that we’ve greatly improved the early recognition, diagnosis, and treatment of heart attacks and strokes. As a result, when they happen, they aren’t as life-threatening or disabling as they used to be.

It’s estimated that at least half of this decline reflects improved treatment options at the time of the event (i.e. thrombolytics and stents) and subsequently (lifelong therapy with ASA, statins, etc.). Of the other half, relating to improved prevention, a good chunk can be ascribed to the reduced rates of smoking.

In other words, “operation stop hypertension” wasn’t a complete success, but more patients lived anyway, because “operation stop smoking” and “operation better treatment” worked better!

To recap

Getting back to Dr. Rose:

• there is no clear pathophysiological distinction between normal and high BP

• people with high BP are normal, not deviants

• to focus attention on individuals with high BP, labeling them as high risk and then treating them individually, is an ineffective approach — you end up treating a lot of people at great cost without preventing many events

• the low risk and medium majority are also at risk, and in fact contribute the majority of cardiovascular events — it is impossible to treat them all individually

• it would be more effective to focus BP interventions on those with “moderate to severe” high BP, while dealing with the population-wide risks, like physical inactivity, poor diet, and obesity

• we need to continue to improve treatment options for heart attacks and strokes

We’re still fighting the hypertension battle, even while we’re winning the cardiovascular disease war. It’s time to refocus.

But are these assumptions correct?

The officially blessed term for that “essential work that only it can do” is “medical necessity”.

Essential = necessary. Unique to health care = “medical”.

Food and water are necessary, but they’re not really medical.1 Breast enhancements and Botox injections are medical, but not really essential.2

The term “medical necessity” is pervasive, as if we all agree on what it means, but it’s used in subtly different ways in different situations:

• in a clinical setting, it can be used to explain why a given procedure, medication or surgery has been ordered, or, if NOT deemed medically necessary, why it has been denied.

• in terms of healthcare insurance (or a government-funded healthcare plan), it is used to explain why some things are insured and others are not.

• in political discussions, medically necessary services may be afforded priority over other services that are deemed less necessary and/or non-medical. Health care gets more of the budget than housing or roads, for example.

• in ethical arguments, medical necessity may justify exceptions to otherwise generally applicable moral rules, as, for example, the rules limiting bodily interference with persons who lack the capacity to make their own decisions.3

Regardless of the setting, once something is labelled as medically necessary, there’s an understanding that it’s needed (by someone, because it somehow improves their health) and therefore must be provided (by someone else, of course, because there’s no point in telling you that you must look after your own health). Conversely, any suggestion that something is NOT medically necessary will trigger strident protest. Needs, after all, take precedence over wants (or desires), and medical needs take precedence over most other needs, including housing, food, education, etc., even when the latter might actually be more important, for some people in some situations.

“… medical necessity often functions, in effect, as a kind of rhetorical intensifier in policy arguments. In other words: to say that a need is a health need is to say it is an important need; and to say it is a matter of medical necessity is to say it is a very important need indeed.”

The paradox of medical necessity, Godwin and Earp, 2023

In effect, to say that something is medically necessary is to say that it MUST be made available and paid for, particularly if it’s expensive. To that end, some, including the World Health Organization, go so far as to say that there’s a “right” to medically necessary services, claiming “The right to health for all people means that everyone should have access to the health services they need, when and where they need them, without suffering financial hardship.”4 They don’t, however, define “health services”, nor do they tell us how to determine which health services are “needed” or how much financial hardship is too much. They mean what they choose them to mean.

“When I use a word,” Humpty Dumpty said in rather a scornful tone, “it means just what I choose it to mean — neither more nor less.”

“The question is,” said Alice, “whether you can make words mean so many different things.”

“The question is,” said Humpty Dumpty, “which is to be master — that's all.”

Through the Looking-Glass, Lewis Carroll

In practice, most conversations about medical necessity end up being somewhat like Alice’s conversation with Humpty Dumpty. There’s an assumption that everyone can agree that some things are “medical” (i.e. properly in the realm of “medicine”) and “necessary” (to accomplish something). Conversely, there’s an acceptance that some things are not necessarily “medical” while other things are not strictly “necessary”. In between, there’s a massive grey zone, where the distinction (medical versus non-medical, necessary or not) depends on the situation, who’s got the problem, who has the money, and what they hope to achieve!

For example:

• warts are a disease, caused by a virus, which can be treated by doctors. Somehow, it’s deemed medically necessary (and therefore publicly funded in Nova Scotia) to treat warts on the soles of the feet (plantar warts) or on the genitals (venereal warts) but not warts elsewhere on the body. Why?

• many conditions, like the common cold, resolve without treatment, and yet it’s considered “necessary” for them to be diagnosed and treated, at public expense, by “medical” professionals (including doctors, nurse practitioners, and pharmacists), even when the diagnosis is obvious and/or trivial, and the treatments on offer make no difference to the natural history and outcome. Again, why?

• sore backs can be “treated” by massage therapists, physiotherapists, or chiropractors (arguably because a sore back is usually a self-limited condition). However, many insurance plans require that such treatments be “ordered” by a physician, in effect “certifying” that the treatment is medically necessary.

• here in Nova Scotia, our Department of Social Services would ask social benefits recipients to have a form filled out by doctors, certifying that certain household expenses were “necessary”. This could include a supplemental allowance for a specific diet, or an allowance for a phone, implying that basic activities like eating properly and socializing with others were somehow “medical”.

• as some procedures become simpler, there comes a point at which they can be done in office settings, rather than in hospitals, including things like cataract surgery, gastroscopy, CT scans, etc. Whether or not an insurance plan, government funded or not, is willing to pay for the procedure to be done in the office is often decided on the basis of some abstract consideration (dare I suggest “rationing”?), rather than “necessity”. If it’s necessary, it shouldn’t matter where it’s done!

What’s “medical”?

Whether something is “medical” implies that medical institutions, personnel, and/or processes are required, but it’s a question of definition and degree.

If, as the World Health Organization claims, "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity", then the health care system could have a very broad mandate! Social well-being involves your income, housing, and relationships. Even if you don’t agree that those things fit within the realm of health care, there’s a move to define social impairments (like shyness, inattentiveness, poverty, etc.) as diseases, the end result of which will be that everyone is “unhealthy”.

Even when we’ve decided that something is in scope for the health care system, there’s an additional layer of controversy concerning which specific health care workers should provide it.

To narrow it down, we could say that medical needs are those which:

• can ONLY be addressed by medical means (like a heart transplant), or

• COULD be addressed by other means, but are BEST addressed by medical means (say, for example, delivering babies), or

• are BEST addressed by other means, but COULD be addressed by medical means (like, perhaps, addictions counselling, or arranging housing and personal care for the frail elderly).

“It should also be obvious that the mere fact that healthcare workers do something does not imply that they ought to, or that what healthcare workers ought to do should be limited to treating the set of conditions they happen to classify as diseases.”

The paradox of medical necessity, Godwin and Earp, 2023

Clearly, the “medical” aspect of “medical necessity” is subject to a lot of interpretation and negotiation. Why does our public system pay doctors to do marital counselling, but not psychologists or marriage counsellors? If, hypothetically speaking, family doctors are better equipped than nurse practitioners to manage some specific diseases, should we pay nurse practitioners to manage those problems? If, in low-risk pregnancies, midwives are more cost-effective than family doctors, then why pay doctors for that work? If colds get better without treatment, why pay anyone to diagnose and treat them? And why do we have hospital beds full of old people who need long-term housing and personal care?

Beyond that, there’s the problem of “medicalization”, by which the jurisdiction of medicine has been extended far beyond the diagnosis and treatment of disease (meaning disordered anatomy and physiology) into the medical “management” of everyday life, including routine and inevitable life events (birth, adolescence, menstruation, fertility, menopause, senility, and death) and things which are common but undesirable (baldness, overweight, impotence, worrying, difficulty concentrating, insomnia, etc.).

These days, no matter what the problem might be, there’s a group somewhere trying to have it labeled as a “health” issue, in order to bring the seemingly infinite resources of the health system into play! Often, those groups are supported by Big Pharma, pushing a pill for every ill, a related problem termed “pharmaceuticalization”.

What’s “necessary”?

So, even if it’s not easy to say what’s medical, then maybe it’s easy to say what’s necessary?

“Medically necessary is a term that seems straightforward enough on the surface. If you are sick, whatever makes you well again is medically necessary. If you are in good health, what’s medically necessary is what keeps you well.”

From an Issue/Survey Paper prepared for the Commission on the Future of Health Care in Canada (the “Romanow Commission”) in 2002

OK! The antibiotics prescribed for your bacterial meningitis or pneumonia are clinically effective — they will make you well, and without them you might die. They’re medical and they’re necessary!

In theory, medically necessary things are those considered “reasonable, appropriate and acceptable” according to something called “the standard of care”, which is supposedly based on “empirical evidence and the interpretation of that evidence”. For a long time, that meant that we trusted doctors and other health care professionals to make the right choices. Unfortunately, it’s easy to be misled, and that system is breaking down.

When your child is sick with an ear infection (Acute Otitis Media, or AOM) and they’re given antibiotics, they’ll be better within a few days. In that context, antibiotics appear to be clinically effective. For much of my practicing lifetime, antibiotics for AOM were considered “medically necessary”, and it was the standard of care (in North America) to see children with sore ears urgently, look in their ears, diagnose AOM, and prescribe antibiotics.5 But it wasn’t that way everywhere! Eventually, some wise people re-examined the literature and concluded that “most cases of AOM spontaneously remit without complications” and “clinical management should emphasize advice about adequate analgesia and the limited role for antibiotics.” In other words, kids with AOM recover not because the antibiotics make them well, but simply because their immune system fights off the infection, as it’s designed to do.

There was evidence that kids with earaches got better when given antibiotics, and so that became the standard of care, until people realized that the kids with earaches who weren’t given antibiotics also got better (better quality evidence). We were overtreating AOM for years, while following the standard of care! The evidence you use has to be gathered and interpreted correctly!6

While it’s tempting to imagine that this sort of reversal of the standard of care is a rare event, there’s good evidence that it isn’t!

Our review of 10 years of publications in a high-impact journal involved examining 2044 articles in duplicate to identify 146 medical reversals. Reversals included medications, procedures, diagnostic tests, screening tests, and even monitoring and treatment guiding devices. We were unable to identify any class of medical practice that did not have some reversal of standard of care.

A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices, Prasad, et al, 2013

Medical research is expensive. Nobody wants to spend millions doing a study involving hundreds of patients over several years, only to prove that an intervention is useless. The journals don’t like publishing studies that show that something doesn’t work, because they don’t generate headlines and they don’t attract readers. And once a drug becomes the standard of care, the drug company won’t sponsor any trial that might prove their drug is not needed after all, or that their competitor’s product is better.

As a result, much of the evidence that gets published shows some sort of positive result, implying that some drugs (or treatments) work (somewhat) for certain symptoms, under certain conditions. Because most of this research is funded by the companies that create and sell the treatments, you’ll see very little research about things that aren’t patentable, because there’s no profit in the end!7

Most interventions are supported by a small number of studies, and much of the research isn’t that well done — there’s a bias toward exaggerating the benefits and minimizing the harms.

“… very few medical interventions have high quality evidence in support of their effectiveness and very few of them also have relatively thorough assessments of their potential harms. Therefore, evidence on the risk-benefit ratios carries almost always very large uncertainty.”

Medical necessity under weak evidence and little or perverse regulatory gatekeeping, Ioannidis, 2023

It’s been like this for decades, and we should be learning from our mistakes. We shouldn’t start doing things before they are well proven, because it’s hard to stop. However, the trend is in the other direction — interventions are approved faster, based on weaker evidence, and once things are on the market they rarely disappear.

“Regulatory approval ends up being the key arbitrator, but over the years the regulatory process has been subverted.”

“Over the last two decades, the concept of regulatory approval evolved in ways that aimed to expedite the approval of new interventions. The main reasoning was that effective interventions can save lives and improve quality of life, and their adoption should not be delayed. Therefore, approval or authorization has been granted usually based on surrogate marker information or soft clinical outcomes, with the anticipation that hard clinical benefits, in particular survival benefits, will also be secured downstream.”

“Regulatory approval currently does not mean that an intervention has a favorable risk-benefit ratio, but simply that it can be marketed, sold and made profit from.”

Medical necessity under weak evidence and little or perverse regulatory gatekeeping, Ioannidis, 2023

Sadly, I think it’s pretty safe to say that there are plenty of things that meet today’s standard of care that will be proven useless (or even harmful) at some point in the next few years.8

Evidence-based medicine to the rescue?

As the published medical literature was rapidly expanding, and assuming that the published research was reliable, it was suggested that medical necessity could be determined by “proof of effectiveness”. Ineffective things would simply not be done.

This idea was called “evidence-based medicine” (EBM), involving “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patients”.

So, imagine that you think you are in good health, and discover that you have high blood pressure. Want to know what to do about it? Ask your doctor to look at the evidence and apply it to your situation! After all, we’ve been looking at high blood pressure for decades. If anything is clearcut, this should be it!

These days, it’s considered reasonable, appropriate, and accepted to treat high blood pressure, usually with medication. Indeed, it’s the standard of care, supported by any number of clinical practice guidelines. It’s necessary, because even though you are in good health, lowering your blood pressure will keep you well. Doctors who don’t “manage” their patients’ high blood pressure are frowned upon, to say the least. After all, there’s evidence to show that people with higher blood pressure are at higher risk for things like heart attacks and strokes, and there’s evidence that shows that lowering the blood pressure with drugs reduces that risk.

However, even if it’s high for years, there’s a darn good chance that your high blood pressure won’t ever make you unwell. Furthermore, for various reasons, you might have nothing in common with the people who enrolled in those research studies.

The evidence doesn’t necessarily tell you how you personally will benefit or be harmed by the treatment. It shows what effect medications have when given to a group of people — when you treat 1,000 carefully selected people with high blood pressure for 10 years, their blood pressures will be lower, and you’ll predictably see fewer heart attacks in the group.9

Individually, however, the results will be mixed and unpredictable:

• some people who were never going to have a heart attack take the medication for ten years, without having a heart attack (no benefit)

• some people who were never going to have a heart attack take the medication for ten years, and end up having a heart attack or some other nasty effect of the medication (harm)

• some people who were going to have a heart attack take the medication for ten years, without having a heart attack (benefit)

• some people who were going to have a heart attack take the medication for ten years, and end up having a heart attack anyway (no benefit)

So, there’s the evidence, which shows benefit at the group level, and there’s the reality, which tells us that the medication lowers blood pressure for most people while helping some individuals and harming others. Whether antihypertensive therapy is medically necessary is a matter of who’s looking at the data and how they interpret it, and that, in turn, depends on their values and priorities. Are more people helped than harmed? Is it better to prevent a heart attack, or just treat it when it happens? Do the benefits justify the expense? Do all people share the same values and priorities?

Clearly, the consensus opinion of the experts is that, beyond a certain level, blood pressure should be lowered, because some, but not all, heart attacks can be and should be prevented. However, those experts are often the people who treat heart attacks, so they have a somewhat distorted view of the frequency and severity of the problem, and they are often influenced by Big Pharma. As a result, they keep setting the treatment threshold lower, because there are always more heart attacks to prevent and more drugs to be sold.10 They never see and therefore don’t consider the people who have high blood pressure for years and never have a heart attack, or the people who are somehow harmed by their medications!

Individually, it’s a question of whether you are more comfortable living with the risk of a heart attack or taking pills every day for years on end, while being labeled as having a chronic disease (hypertension).11 Are the drugs medically necessary, or just something you take because you personally want to reduce your (already small) risk of a heart attack?12 What does it mean if you choose NOT to do something that the doctor says is necessary — can something be necessary AND a matter of personal choice? Conversely, what if you are highly risk-averse and demand blood pressure-lowering medication at a point where most experts agree medication is not justified? What happens if you want some other, more expensive drug and your insurer won’t pay for it? And what if you would rather spend “your” health care dollars on something else more important to you (like breast enhancements)?

In short, we’ve medicalized long-term prevention, defining risk factors like high blood pressure and high cholesterol as diseases, and the experts (egged on Big Pharma) have decreed that those risks must be reduced, at any cost. Not wishing individuals to face financial hardships (meaning they might decide to do what they choose, based on their own values), the push is to have preventative interventions publicly funded, using the rationale of medical necessity.

Ultimately, that’s not realistic or sustainable! When you are basically healthy, it’s not at all obvious what will keep you “well”, or what’s medically necessary. We are all “at risk” for dying of something, some time! If we prevent your heart attack, you’ll die of cancer, old age, dementia, or something else.

Recognizing that different people have different perspectives and different values and therefore might reasonably interpret the same data differently, the definition of EBM has softened over time, to something more like “EBM is a systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values”. EBM doesn’t provide definitive answers. You cannot simply “follow the science”.

Even if good quality evidence actually exists, it may or may not apply to each specific situation, because no two patients are clinically identical, and all patients have their own values and priorities. The INTERPRETATION of the evidence matters as much as the evidence itself.

That being the case, some have returned to a “person-centered” approach, placing greater emphasis on individual clinician expertise and patient values. Even so, you have to know what works. We can’t simply do whatever each patient wants, although there are days when it seems like that’s the way we are headed!

So, where does that leave us?

As I said in the beginning, we like to imagine that our publicly funded health care system is doing essential work that only it can do, the “medically necessary” stuff that makes you well or keeps you well.

It isn’t! And there are no longer any checks and balances.

A great many things have been re-classified as “medical”, even when they aren’t things that can only be dealt with medically. They’re taking up time, money, people and resources.

Medical or not, many things can and probably should be treated with so-called “lifestyle” interventions, things you really can do for yourself without involving the health care system. Weight loss, sensible eating, regular exercise, and moderation in all things go a long way towards improving high blood sugar, high blood pressure, overweight, indigestion, sleep disorders, fatigue, and a host of other complaints. Nonetheless, you’ll find the literature (and the health care system) heavily biased in favour of expensive medications, surgery, and other interventions. It’s much easier to get a prescription for semaglutide than it is to work on your diet with a dietician. In some parts of Canada these days, I dare say it’s easier to get safer supply than it is to enroll in a comprehensive abstinence-based addictions program.

Even when the regulatory bodies or insurers impose some parameters, like requiring you to try lifestyle interventions before resorting to medications, there is often pushback. For example, breast reduction surgery guidelines suggest that removing excess breast tissue surgically isn’t appropriate in those who are obese, because breasts, after all, contain a lot of fat. However, no matter what target BMI is set, you’ll find women arguing that those guidelines shouldn’t apply to them — they want the surgery even though they are fat. The same applies for guidelines relating to gastroplasties and weight-loss drugs, in part because obesity has been re-branded as a disease, unresponsive to anything other than surgery and drugs.

Typically, for every malady and every possible intervention, endorsement by regulatory authorities (insurers and/or government) is seen as proof of “medical necessity”, after which you’ll see widespread adoption of new standards of care, because there are powerful marketing forces at work.

“Eventual use of the intervention still remains usually at the discretion of physicians and patients, but under the vast influence of the marketing and advertising forces it is unlikely that this independence has much power.”

“If one expects that patient groups and physicians will offer gatekeeper functions that can block the widespread use of interventions that are unlikely to offer clearly favorable risk-benefit, this is probably a misguided expectation. Patient groups can easily have their advocacy powers manipulated by the industry to serve the industry agenda. Industry-sponsored advocacy groups can exert pressure for licensing with weak (or even negative) evidence, and this creates precedents for facilitating the licensing of additional drugs with even weaker (or even more negative) evidence. Citizens can be massively influenced by media and social media where messages are aligned and filtered according to the interests of powerful private players. Physicians and their professional societies are also naturally excellent clients and allies of the overall industry plans. Their specialties and their volume of practice are often in close symbiosis with the industry. Even if evidence is bad, this may not matter, if the ‘experts’ say that a treatment should be used. This is increasingly likely when there is asymmetry of power between evidence and finance bias.”

“The process leads to a tragedy of commons where the final victim is society at large: medical necessity is invoked as an alibi for medicine to absorb societal resources.”

Medical necessity under weak evidence and little or perverse regulatory gatekeeping, Ioannidis, 2023

In short, the prevailing mantra is that nobody is healthy, everybody has something that “must” be treated by the health care system, the “best” treatments are those that turn a profit for somebody, and whatever’s “medically necessary” must be paid for, at public expense.

In other words, when it comes to health care, that which can be done must be done.

But that’s a myth! There are alternatives.

Discretionary power is commonly defended by denial of its existence, the allegation of inevitability. Objective external conditions and forces are claimed to dictate policy decisions…. In health policy, such forces include the aging of the population, the extension of technology, and the demands of ethical standards. Taken together, these forces create relentless upward pressure on costs, to levels which society “cannot afford”….

Yet quantitative analysis of these forces does not sustain the argument; in each case the source of cost escalation is not external pressure but the way in which the health care system itself reacts. Less costly and equally effective options are demonstrably available, but would threaten provider interests and broader ideologies. A spurious cloak of inevitability serves to promote and justify political choices.

Robert G. Evans, University of British Columbia, 1985

You’ve no doubt heard the story that the “aging of the population” is relentlessly and inevitably driving our ever-increasing healthcare costs to levels we “cannot afford”.

It’s an “oldie but a goodie”, dating at least back to the 80’s, when Robert Evans wrote the paragraph quoted above. It’s a story still being told around campfires today, particularly when provincial politicians gather to demand more money from the federal government.

Quoting from a Fraser Institute Bulletin from 2021, the story generally goes like this:

• “Health care is the single largest budget item for every provincial government in Canada.”

• “Per-capita spending on health care is substantially higher for individuals aged 65 and older than for younger individuals, and the disparity increases consistently as average age increases beyond 65 years.”

• “Canada’s population is projected to age substantially in the years ahead. Specifically, while individuals aged 65 and older accounted for 16.2 percent of the total population in 2018, they are projected to account for 23.4 percent of the population in 2040.”

So, in a nutshell, the older you get, the more it seems to cost to keep you alive. There are ACTUALLY more old people (because good health care means people live longer) and RELATIVELY more old people (because the baby boomers are aging and the younger generations haven’t been having as many children). As a result, health care costs for those 65+ are about to go through the roof! It’s inevitable; we can’t do anything about it! We also can’t afford it!

That logic is flawed! The story’s a myth!

Let’s take it line by line.

Health care is the single largest budget item for every provincial government in Canada

This is true.

In 2024, Canada spent more than $370 billion on health care, equivalent to about 12.4% of our GDP and, averaging $9,054 per person, the second highest among OECD countries.

Over 70% of that is publicly funded through general tax revenues, 78% from the provinces and territories and 22% from the federal government. The rest comes from individuals and insurers.

Some people seem to think health care is free. It isn’t! Regardless of which pocket it comes out of, we the citizens pay for 100% of it.

That we spend as much as we do is a reflection of choices we’ve made as a society, including what “health care” services we provide, who we provide them to, and what we’ll pay for them, among other things. Other countries made different choices, even though their population, like ours, is aging.

Average individual health care costs increase with age

This looks true, but it’s misleading.

AVERAGE annual health care expenditures ARE higher for individuals aged 65+, and the disparity DOES increase with age, as illustrated by the following chart, using data from that same Fraser Institute report.1

However, this is one of those cases where the AVERAGE is extremely misleading, because health care expenditures are VERY unevenly distributed across the entire population.

Imagine you went out for dinner with nine friends. One friend orders the surf and turf with a bottle of fancy wine, for a total of $100. The rest of you have the burger combo, at $10 each. The bill totals $190, so the average cost is $19, and your high-cost friend suggests splitting the bill evenly. Good deal? It is for them, because they incurred over half of the total charges!

In health care, the disparities are even greater! In Ontario in 2007, for example, the top 1% of the population accounted for one-third of the total public health care expenditures, and the top 5% accounted for two-thirds of the total expenditures. By contrast, the bottom 50% of users accounted for only 1% of the total.2

Splitting the 2007 Ontario PUBLIC health care expenditure bill evenly means the average was $1679 per person3. However, a solid majority spent less than the average, and fully 50% of the population spent less than $181 each, barely enough to cover a couple of doctor visits, a flu shot, and a few prescriptions!

So, in any given year, half of us spend 99% of the health care money, the other half spend 1%. A very small number of “high-cost users” account for a very large part of the total budget.

Roughly two-thirds of those high-cost users have high costs in a single year, reflecting an expensive major time-limited health event, such as a round of in vitro fertilization, the birth of a child, an accident or illness triggering a hospitalization, a major surgery, or curative treatment for a cancer diagnosis.4

The remaining one-third of high-cost users show persistent high use over time, reflecting the ongoing demands of major chronic illnesses, multiple morbidities and accumulated physical deficits, incurable cancers, or the sheer bad luck of having multiple sequential acute health crises.

Either way, that’s what the publicly financed health care system is there for, to help you out when you need it.

Year by year, for all age groups, there is considerable variation in individual health care expenditures, and…

“Each individual faces a greater probability of incurring higher healthcare costs as he or she ages, but the greatest likelihood is that, even in advanced age, most individuals will incur relatively low costs.”

Variations in Lifetime Healthcare Costs across a Population

The following two graphs are a bit confusing, but they drive home a very important point. Most of us are healthy most of the time, except when we’re not!

Each graph shows the probability of incurring low, moderate and high health care costs as we age. Ignoring the first years of life (well baby care and all those vaccinations are expensive!), males are most likely to have low expenditures all the way up to the age of 76 (and by then they are more likely to be dead than alive!). As compared to men, women have a higher likelihood of moderate and high costs in the childbearing years, but even so they are still most likely to have low costs all the way up to the age of 71 (and by the age of 80 they too are more likely to be dead than alive!)

In short, at virtually any age, you are more likely than not to be relatively healthy and, therefore, a low-cost user. The odds of being a high-cost user DO increase with age, but, even so, more than half of high-cost users are younger than 65.5

It’s when we become unhealthy that things get expensive! While averages are very misleading, the “average” male will incur about 8 high-cost years in his lifetime, and the “average” female 11 high-cost years (blame childbirth for the difference).

Because there’s enormous variation in lifetime patterns, not just annual patterns, the year-to-year variations don’t average out over time. Totaled over their lifetime, some people incur high total health care costs (even though some of them die young), and others incur very low total health care costs (even though some of them live to a ripe old age). Some of us eat surf and turf all the time, others don’t!

Despite appearances, dying young is no guarantee that you’ll save the system money, nor is growing old a guarantee that you’ll burn through a lot of tax-payer money. It’s the individual patterns that matter, not the averages.

Old people are sicker

The story goes that the increased costs for seniors reflect the fact that those who are still alive have more numerous and more complex health needs than younger people. As a group, they are more likely to have stable but serious disabilities, chronic diseases which flare up frequently (like COPD), and/or gradually worsening frailty, with or without dementia.

That’s true, on average, but again the averages are misleading, and the individual patterns matter more.

There are different ways to spend money on health care. Four things account for two thirds of health spending: hospitals (26%), drugs (14%), physicians (13%), and “other institutions” which are mainly long-term care facilities (13%). Hospitals have a high cost per service, so even though you don’t spend a lot of days in hospital, the bill can be enormous. Drugs can be costly either because you take a lot of pills every day, or because the particular drug you take is enormously expensive. As with drugs, doctor bills add up either because you have many visits over the year, or because the particular service you get from the doctor is enormously expensive (like a heart transplant surgery). Long-term care facilities are expensive precisely because you are there long-term.

Unsurprisingly, the high-cost users are those who spend time in hospital, require surgery, consume expensive drugs (chemotherapy, immunosuppressants, etc.), and/or require some form of long-term maintenance therapy (like dialysis).

As a reminder, the fact that we spend as much as we do on these things rather than other things reflects the choices we’ve made as a society. We always have the option to make different choices.

Nursing homes are expensive, and full of old people

In most articles looking at the lifetime patterns of health care spending, it looks like long-term care costs are the single biggest driver of the rising costs for the elderly, as shown in the following graph!

However, if we include the full costs of long-term care, we are counting “basic room and board” as health care expenses.6 Some governments choose to pay the costs of room and board for the frail elderly. Others make people pay for it themselves, because these are basic costs of living that we all face every day from birth unto death. Your rent and grocery bills aren’t health care costs when you’re in your 20’s, nor are they when you are in your 80’s.

Many people in long-term care need “personal care”, meaning help with activities of daily living, rather than “nursing care”, “medical care”, or “health care”. For many folks in long-term care, some health care costs actually DECREASE, due to deprescribing (fewer drugs) and an emphasis on “comfort care” rather than expensive medical interventions.

As some (but not all) people approach their “best before date”, their personal care needs increase. Putting them into nursing homes is one option. There are alternatives, however, including home care, financial supports for family caregivers, etc. What options we provide, who we offer them to, how we pay for them, and who pays for what are not inevitable consequences of aging. They are all choices we’ve made.

Beyond that, just as a reminder, most of us, no matter how old, do not end up in long-term care. The small number who do are among the “high-cost users”. Their individual costs do matter but cannot be meaningfully averaged across the entire population 65+. The fact that my friend eats surf and turf doesn’t mean I have champagne tastes!

Even if we leave out long-term care costs, however, average health care costs still seem to rise with age, the next biggest driver being hospital care.7

Hospitals are expensive, and full of old people

This is true, but again its misleading. There are at least two things to consider.

First, at least where I live, there aren’t enough long-term care beds, so a number of frail old folks bumble along at home (aided by family, friends, neighbors, and the occasional home care provider) until they decompensate and end up in the emergency department, from which they are admitted to an inpatient bed.

In most cases, their acute problem, if any, is dealt with fairly quickly, but they can’t go home. The bulk of their hospital stay is then spent “waiting for placement”, but the accounting switch-over only occurs when they’ve actually been assessed and approved for long-term care and are “officially” on the waiting list, at which point they are labelled as “alternate level of care”. At any given point, these labelled ALC patients make up over 10% of the hospital population, but the actual number is higher, given the delays in assessment and approval. High numbers of ALC patients are generally considered to be a sign of inefficient use of hospital resources, because we’re using expensive hospital beds to warehouse people waiting for cheaper long-term care beds!8 Their costs are attributed to acute care hospitalization, but, in reality, they reflect the need for personal care, NOT health care per se.

Sure, we can say these costs are an inevitable consequence of the aging of the population, but the real problem is that we’ve chosen to build and pay for acute care beds in hospitals, rather than meeting the actual needs of the population. A small group is burning up a big chunk of the budget, a problem we’ve chosen to ignore, as shown by the following data from the 80’s!

“Data for Manitoba in 1980/81 showed that one-third of all patient days in public general hospitals… were accounted for by the 2 percent of separations that had lengths-of-stay of 60 days or more; for the total hospital population, the proportion was 37 percent”

Robert G. Evans, University of British Columbia, 1985

Second, it’s a fact of life that your risk of dying increases as you age. Multiple studies have shown that 10% or more of the high-cost users are in their last year of life. Looked at the other way round, 80% of deaths occur in people who’ve recently been high-cost health care users (the other 20% are those who “drop dead” or somehow manage to die quickly without racking up big bills).

Getting back to the issue of choices, a lot of Canadians die in hospitals, rather than elsewhere. Often, they don’t have any other option. Not only are we short of long-term care beds, but we’ve chosen not to provide enough palliative care beds, hospice beds, and home-based palliative care supports, all of which are cheaper than acute care beds.

That being the case, the group of high-cost users older than 65 is, by definition, going to include a larger percentage of people who died in hospital, simply because older people are more likely to die. Many of those older people who were bumbling along at home before ending up in the hospital will succumb in hospital while waiting for that long-term care bed.

Furthermore, a cohort of 90-year-olds will therefore include more deaths and appear even more “costly” (on average) than a cohort of 65-year-olds, not because the living elderly cost more to look after, but simply because dying in hospital is expensive and the death rate at 90 is higher than the death rate at 65.

As a result, we spend a lot of money looking after people in the last 30 days of their lives. In Ontario in 2010-12, for example, average individual health care costs in the last year of life were $53,661, for a total cost of $4.7 billion annually (fully 10% of Ontario’s total health care budget). Most of those costs accrue in the last 30-60 days of life in acute care hospital settings, as shown in the following graph.

Arguably, some of this is unavoidable, insofar as we make heroic efforts to save sick people and only know that our efforts were in vain when they’ve died. It does seem that the efforts are appropriately more heroic for younger patients; the average individual health care costs in the last year of life were $59,652 for those 65-74, but “only” $46,829 for those aged 95+. Nonetheless, we spend large sums hospitalizing older people as they die with “end stage” cancers and/or organ failures, like heart failure, COPD, renal failure, and/or dementia.

That our individual expenses in the last year of life are high is not an inevitable consequence of aging. It reflects the choices we’ve made. You only die once, and you do it all at once, not in instalments! And you don’t get much choice about where you die!

Once you’ve corrected for the higher rates of death as we age, there’s pretty good evidence that age alone has very little effect on health care costs9. Even in old age, it remains largely true that we’re more likely to be healthy than not, until we near or pass our “best before date”.

Those aged 65+ accounted for 16.2% of the total population in 2018, and they are projected to account for 23.4% of the population in 2040

This may be true10, but it’s irrelevant.

The problem is not that we have more old people, or that they make up a greater percentage of the population. Besides, as long as they are alive, they are probably paying taxes, and we’ve made the choice that they’re entitled to health care, like everyone else.

Individual health care costs don’t increase all that much as people age, as we’ve already seen. In fact (and this might seem paradoxical, so you might have to think about it), as health care improves and life expectancies increase, the probability of dying at any given age falls, and so the age-specific average individual costs of health care should fall as well.

In other words, it’s not staying alive that’s expensive, it’s dying! Living longer defers the high costs associated with dying.

So, what we need to do is to address the high costs of dying!

Putting it all together…

That AVERAGE annual health care expenditures for individuals aged 65+ appear to rise dramatically is, in fact, a “red herring”. It’s a statistical artifact due to increasing age-specific mortality and the high cost of dying, coupled with the misallocation of “room and board” expenses for those in long-term care.

Older people are NOT more expensive to keep alive. However, as they age, they are more likely to die, and we’ve chosen to spend (or, dare I say, waste) a lot of money looking after people who are approaching death.

That we spend what we do, when we do is not some inevitable and unavoidable effect of “population aging”. It is the result of how we chose to design, operate, and utilize our health care system.

Dying is a “one-time expense”! It’s entirely predictable. We all do it!

Individually, we could do a lot better at planning for our inevitable death, being clearer about what we do and don’t want to be done when the time comes. Do we really imagine death to be preventable? Does the desire for a longer life trump all other considerations? Do we really want to be transferred to a hospital bed for an acute illness when we are stuck in a long-term care facility, unaware of our surroundings, due to dementia? Or would we rather be left to die peacefully? Is it better to die quickly of pneumonia while in the later stages of dementia (retaining some semblance of dignity), or to die of advanced dementia long after you’ve stopped enjoying life?

We’ve also spent a lot of effort setting up a system for “medical assistance in dying”, which we then end up administering to those we’ve foolishly tried to save from their incurable illnesses. We would do far better to “right size” our long-term care, palliative care, home care, and hospice options, rather than over-building and then misusing expensive acute care hospitals, later “correcting” our mistakes with MAID. We need to get a lot better at moving people quickly to the right setting, where they can live (or die) in comfort.

Above all, we should stop blaming demographics for the spending choices we’ve made. We aren’t the hapless victims of “population aging”! In some cases, we’ve completely failed to make choices when choices were needed, and in other cases we’ve made wrong choices, which should be corrected. Either way, it’s up to us.

In short, chronic diseases are what’s killing us, even though they are preventable!2

Statistics Canada, for example, tells us that “In 2023, almost half of Canadian adults had one or more selected chronic diseases (46.1%)”, where “The chronic diseases considered in this trend analysis are arthritis, high blood pressure, diabetes, cancer (ever diagnosed), heart disease (ever diagnosed), stroke and mood disorders.” It’s not uncommon to have multiple problems; in their data, over 8% of people had three or more chronic conditions.

StatsCan left obesity out of those totals, even though later in the same report they tell us that “Obesity is also a chronic disease”. By their data, 30.2% of Canadian adults “had obesity”3 in 2023, which would make it the commonest chronic disease.

They also left out a host of other chronic diseases, including asthma, COPD (emphysema and chronic bronchitis), dementia (Alzheimer’s, etc.), chronic renal failure, inflammatory bowel diseases (Crohn’s and ulcerative colitis), and anxiety disorders, to name but a few. Many would argue that these are all pretty important.

In the end, you could make a convincing case that almost everyone has at least one chronic disease!

Google AI agrees! When asked, it helpfully told me that “It is impossible to show a man without chronic diseases, as the query asks for a depiction of a person free from any long-term, non-transmissible conditions. Chronic diseases are widespread and affect people of all ages, and while individual health varies, it's not possible to definitively portray someone who is never at risk of developing a chronic condition.” In short, because we’re all at risk, we’re all diseased!

As to the cause of this burgeoning crisis, StatsCan tells us that “A variety of factors affect chronic disease incidence and prevalence, including age and behavioural risk factors such as tobacco use, diet and physical inactivity.”

Age, of course, isn’t reversable; the longer people live, the more likely they’ll have chronic diseases. On the other hand, we all aspire to live longer! Smoking rates have been dropping for years, which should be helping. As we all know, the North American diet and physical activity levels are deplorable, hence the increase in overweight and obesity.4

The significance of all of this, we are told, is that “Chronic diseases can affect activities of daily living, reduce quality of life and increase the risk of mortality.” Interestingly, however, despite the alarming rise in chronic disease, mortality rates have been slowly dropping, outside of the post-2020 blip attributed to Covid (and its effects on health care in general).

So, even if we aren’t preventing chronic disease, we must be doing something right in treating it! Perhaps, as Google AI suggests, people are “… actively taking steps to maintain good health through healthy habits and regular checkups. This approach emphasizes the importance of proactive health management, regardless of individual risk factors.”

Then again, maybe not, given that “The share of Canadian adults reporting very good or excellent perceived health declined from 61.3% in 2020 to 52.2% in 2023.” Perhaps all those “healthy habits” and “proactive health management” take a toll!

What do we make of this?

So, it’s confusing, to say the least. Chronic diseases are preventable, but we aren’t having much luck preventing them. Even though they are on the increase, and they are what’s killing us, people just aren’t dying like they used to.

It really is a question of what you count and how you define it!

“One important element of effective communication is having a shared language or at least a shared understanding of the meaning of the central words used in a conversation. One term that is often used in discussions between patients and medical providers, in the academic literature, and in policy discussions, is “chronic disease.” There is not only tremendous variation in the diseases that are included under the umbrella term “chronic disease” but also variation in the time a disease must be present for something to be referred to as chronic. Furthermore, there is a move to include chronic conditions that are not indicators of disease, but long-standing functional disabilities, including developmental disorders and visual impairment.”5

I’ve discussed the question of “What is a disease?” in two previous posts (here and here), so I won’t repeat myself, other than to take the pragmatic view that a chronic disease is an observable disturbance of bodily structure and/or function that cannot be corrected, causing some sort of symptoms and/or impairment. When a disease is correctable (or curable), then it’s not chronic. If it doesn’t cause some sort of symptoms or impairment, you don’t know you have it, as, for example, a very slow-growing and totally asymptomatic non-fatal cancer in some part of your body. When things don’t cause symptoms, threaten your life, affect your activities of daily living, and/or reduce your quality of life, is it worthwhile knowing you have them? Is it worth treating them? Some folks say yes, others no.

Along those lines, it’s true that some things have come to be labelled as diseases, even though they cause no symptoms or impairment, usually because they place you at increased “risk” of something down the road. I prefer to think of these not as “diseases” but rather as “risk factors”. In these cases, the goal of treatment is not the relief of symptoms or impairments (because there aren’t any). The goal, they say, is to reduce your “risk of mortality” (which, in truth, is always going to be 100%). Perhaps it would be more correct to say that the goal is to defer your inevitable demise.

All that being said, let’s look at StatsCan’s list of chronic diseases, one by one.

Arthritis is a catch-all diagnosis. There are many different types, the commonest by far being osteoarthritis, which more or less describes the life-long accumulated wear and tear on your joints, made worse by injuries, occupational or recreational overuse, overloading due to obesity, etc., with some people being more prone by virtue of their genetics. It’s not really a “bodily malfunction”, it’s a “fact of life”. Just as the tires on your car wear out over time, if you live long enough, you’ll probably develop osteoarthritis, whether it’s symptomatic or not.6 Beyond the fact that people are getting heavier (and older), there’s no reason why arthritis would be more common, although what used to be accepted as “aches and pains” may now be diagnosed as “arthritis”, because diagnoses sound more impressive than symptoms.

Yes, osteoarthritis may affect your activities of daily living and reduce your quality of life, but it’s unlikely to kill you. However, there’s no biological solution to fix, reverse, or prevent the defects. The treatment is mostly common-sense, self-management stuff, like analgesics, exercise, pacing yourself, etc. Some people do need joint replacements, but most don’t. So yes, arthritis is a chronic disease, but if you insist on including osteoarthritis in the chronic disease statistics, then you’re pretty well guaranteed to include everyone beyond a certain age, with many of them having minimal disabilities and little need for medical care.

(Rheumatoid arthritis and psoriatic arthritis, by contrast, are inflammatory, destructive bodily malfunctions, with biological solutions to fix, reverse, or counteract the defects. They are much less common. They do require long term medical care.)

High blood pressure is a prime example of a risk factor that’s been re-branded as a disease. There are no symptoms. It causes no disability or impairment.

For any physiological parameter, blood pressure included, approximately 50% of people are above average. Because the risks of cardiovascular events such as heart attacks and strokes increase along with the blood pressure, having “above average” blood pressure simply means you have “above average” risks. Lowering your blood pressure reduces, but does not eliminate, your risk. 7

The goal of treatment, therefore, is not to relieve symptoms or make you function better. It’s to reduce your chance of a heart attack, etc.. However, you have to treat a lot of people for a long time to prevent a single heart attack. Whether it’s worth treating comes down to balance between the harms (costs of medical care and medications, side-effects, etc.) and the benefits (fewer heart attacks, etc.).

Individually, some people prefer to live “at risk”, accepting the added risk (which can be quite small) in exchange for not being labelled as “diseased”.

The experts, on the other hand, make the case that everyone with above average blood pressure carries a higher risk and therefore should be treated, as if there were no costs and no harms. Going even further, some zealots argue that everyone in the entire population should have their blood pressure lowered!8

Unlike other diseases (like cancer, where you either have it or you don’t) there’s no clear separation between people with high blood pressure and those without, other than the somewhat arbitrary and ever-shifting “line in the sand” drawn by the experts at consensus conferences. How many people have the chronic disease we call “high blood pressure” is, therefore, purely a matter of statistics; the lower the threshold, the more people get the diagnosis.

Over time, the thresholds for diagnosis and treatment have been slowly dropping, and therefore the prevalence is increasing. That could be bad, in that we are “over-diagnosing” the problem, or good, in that we are preventing heart attacks and strokes down the road. Either way, we are labelling asymptomatic people without any functional impairments as having a “chronic disease”, and we are driving up demand for medical care.

Diabetes comes in two varieties, Type 1 and Type 2.

Type 1 is fairly rare, involving a complete lack of insulin production due to the destruction of islet cells in the pancreas. The diagnosis is usually clear; you have it or you don’t! As with rheumatoid arthritis, it involves a clearcut and destructive bodily malfunction, requiring long term medical care and biological solutions (like insulin) to counteract the defect. Treatment saves lives, relieves symptoms and reduces future complications.

Type 2 Diabetes is far more common, reflecting an imbalance between the need for insulin and the ability to produce it or respond to it. As with high blood pressure, there are many shades of gray; those with “normal” glucose metabolism are not easily separated from those with “impaired” or “abnormal” glucose metabolism. Higher blood glucose brings higher risks, and lowering the blood glucose lowers those risks, at the cost of added medical care, medications, costs, and side-effects. The diagnosis, therefore, depends on another of more of those ever-shifting “lines in the sand” drawn by the experts.

How many people have the chronic disease we call “Type 2 Diabetes” is therefore also pure statistics; the lower the threshold, the more people get the diagnosis. And, as with high blood pressure, the thresholds for diagnosis and treatment have been slowly dropping over time, so the prevalence of Type 2 Diabetes is increasing, with most of the “sufferers” having no symptoms and no functional impairments. Again, that could be bad, in that we are “over-diagnosing” the problem, or good, in that we are preventing diabetes complications down the road.

Of note, once you’ve been labelled as having Type 2 Diabetes, your blood pressure target is set lower. Accordingly, it’s inevitable that the more Type 2 diabetics there are, the more people there will be with high blood pressure. This is one of the reasons why so many people have “more than one” chronic disease.

Cancer, of course, comes in many forms. Some forms are curable, some aren’t. Some will relapse, others won’t.

When StatsCan includes those who were “ever diagnosed” with cancer, they’ve lumped in everyone who ever had cancer and was cured, effectively labeling a whole cohort of people as having a chronic disease even though they no longer have the disease and don’t require medical care for it.

The better we get at treating cancer, the more people there are who once had it. In practical terms, this manifests in the ever-increasing number of people who identify as “cancer survivors”, clinging to a diagnostic label even when it’s not necessarily relevant.

What purpose does it serve to lump these people in with those having “chronic disease”? Many aren’t sick and don’t require treatment. Isn’t it more accurate to say that they were once ill and have been cured?

Heart disease also takes many forms, the commonest being ischemic heart disease (IHD), in which the underlying problem is a partial or complete blockage of one or more of the arteries supplying blood (and oxygen) to the heart muscle.

This truly is a chronic disease process, in that the arterial blockages develop slowly over time, becoming symptomatic when the oxygen demand intermittently exceeds the supply (angina) or when there’s a complete blockage causing tissue death (myocardial infarction, or MI). While we used to think of an MI as something you had and were treated for (i.e. an “acute” problem), we now recognize that the underlying blockages persist (and even progress, if untreated) and so it’s fair to include anyone “ever diagnosed”. Once you’ve had an MI, we know you have IHD. Beyond the interventions at the time of the MI, such as angioplasty, you’ll need long-term management, including drugs, to prevent further events, even if you have no symptoms or impairment. It’s a matter of “relapse prevention”.

However, as with cancer, we’ve gotten better at diagnosing and treating heart attacks, so there are more survivors than there used to be. Those who used to drop dead are now living long, productive, and often unimpaired lives. In this case, having a chronic disease is better than the alternative!

Conversely, there are a lot of folks out there with early blockages which are not yet symptomatic and are not causing any functional impairments. They have a chronic disease and are “at risk”, but don’t know it! They aren’t counted! If we magically developed a way to spot early blockages, there would be a corresponding increase in the number of people with IHD.

Strokes are the brain’s equivalent to IHD, in which the underlying problem is a partial or complete blockage of one or more of the arteries supplying blood (and oxygen) to the brain.

Everything I said about IHD is also true for strokes:

• the arterial blockages develop slowly over time, becoming symptomatic only when the oxygen demand intermittently exceeds the supply (transient ischemic attacks) or when there’s a complete blockage causing tissue death (stroke).

• while we used to think of a stroke as something you had and were treated for (i.e. an “acute” problem), we now recognize that the underlying problem persists (and even progresses, if untreated).

• beyond the interventions at the time of the stroke, you’ll need long-term management, including drugs, to prevent further events.

• it’s a matter of “relapse prevention”.

• we’ve gotten better at diagnosing and treating strokes, so there are more survivors than there used to be.

• there are a lot of folks out there with early blockages which are not yet symptomatic and are not causing any functional impairments.

The commonest mood disorder is depression.

While some patients suffer a single episode of depression and then recover, just over half follow a chronic or intermittent course. To that extent, then, mood disorders can be either acute or chronic. It’s not clear whether StatsCan was able to differentiate between those who were depressed, at some point in the past, and those who continue to struggle.

Because of changes in the survey tool used to gather data, such that they only had information for five of the ten provinces, StatsCan chose not to include anxiety disorders in their listing of chronic diseases. They do report that “A higher percentage of Canadian adults reported having a diagnosed anxiety disorder in 2022 (14.8%) than in 2021 (10.3%), and this share has been steadily increasing since 2015 (7.8%).” As high as those numbers are, they reflect only those who are “medically diagnosed”.

Anxiety disorders are symptomatic, by definition, and, in order to meet the diagnostic criteria, they must be somewhat disabling. Some resolve, others persist.

And, as we all know, when it comes to mental health disorders, including mood disorders and anxiety, many people self-diagnose, correctly or incorrectly. The self-reported prevalence will therefore greatly exceed the formally diagnosed numbers.

Finally, there’s been a big push in recent years to reduce the stigma associated with mental illness. It’s not clear how this affects the data, but it’s a fact that people are now more willing to report having anxiety and/or a mood disorder.

StatsCan states categorically that obesity is a chronic disease. That being said, they didn’t include it in the totals for people having one or more chronic diseases.

As with high blood pressure and diabetes, how heavy is too heavy is a matter of definition and expert opinion. Your risk of trouble increases along with your weight. Some heavy people are symptomatic (i.e. short of breath on exertion) and others have impairments (i.e. can’t reach their toes when they bend over), but others insist that they are fine. It’s a risk factor, but is it a chronic disease?9 If you get back to a normal weight, are you still diseased?

Finally, including obesity in the list of chronic diseases will inevitably result in double counting, in that obese people are more likely to have osteoarthritis, type 2 diabetes, high blood pressure, heart disease, stroke, arthritis and cancer. Again, once you have one chronic disease, you’ll probably be diagnosed with others!

So, why the increase in chronic disease?

While StatsCan tells us the number of people reporting one or more chronic diseases is increasing, they don’t supply all the data for all the diseases.

The following table, for example, includes arthritis, high blood pressure, diabetes, and heart disease, but doesn’t include cancer, stroke and mood disorders.

Note the increasing prevalence of obesity, high blood pressure, and diabetes, where the diagnostic criteria reflect the consensus opinion of the experts. As those experts lower the thresholds, more people are diagnosed, even when there are no actual changes in the weight, blood glucose readings, and blood pressure measurements of the population.

The increase in heart disease is likely an artifact, in that their question changed over time. They tell us, in the footnotes, that “From 2015 to 2017, the question was "Do you have heart disease?" (referring to a current diagnosis only). From 2018 to 2021, the question "Did you ever have heart disease?" (lifetime diagnosis) was added. From 2022 to 2023, the wording was changed to "Have you ever had a heart attack?" instead of heart disease.” As I said above, we used to think of an MI as something you had and were treated for (i.e. an “acute” problem), but we now recognize that the underlying problem persists (and even progresses, if untreated). The change in their question was reasonable, and it likely explains the jump from 5.0% in 2017 to 6.3% in 2018. So, it’s not that IHD is necessarily any more prevalent, it’s just that the question changed.

As for cancer, they provide the following graphs. The first shows that some cancers are being diagnosed more often and others less often. A lot of this reflects changes in our diagnostic capabilities. The rise and fall in prostate cancer diagnoses, for example, reflects the popularity of PSA testing from the early 90’s onward, followed by the realization that PSA screening was leading to over-diagnosis. Breast cancer is being diagnosed more often, due to mammography, but there are also questions about whether we are over-diagnosing it (see my earlier posts here and here).

The second graph confirms what I said earlier, which is that we are getting better at treating cancer. Fewer people die and therefore more will report that they were, at some time, diagnosed with cancer.

As for mood disorders, StatsCan tells us there’s been an increase. “In 2023, 13.0% of Canadian adults reported having been diagnosed with a mood disorder (e.g., major depression, bipolar disorder or mania), an increase from 2022 (11.7%) and 2021 (10.0%), as part of a trend seen since 2015.” Is this an actual increase, or just the effect of reduced stigma?

Putting it all together

It’s true! Depending on how you define them and which ones you choose to include, chronic diseases are common. They might be getting more common, but the definitions have been changing over time, so it’s not clear whether there’s an actual increase, or just more people being diagnosed.

Who cares? Put another way, what difference does this make?

For the individual patient and their provider

At the individual level, there’s a notion that the care of your chronic disease is better (and your outcomes will improve) if your doctor10 follows a structured plan of care, reflecting a “chronic care model”.

“In contrast to the traditional medical model management of acute conditions, management of chronic disease requires that patients take a more active role in the day-to-day decisions about the management of their illness. This new disease paradigm requires that there be a working patient-provider partnership that involves effective treatment within an integrated system of collaborative care. The essential ingredient of effective chronic care management is the partnership between the patient and health professionals because it offers the opportunity to empower patients to become more active in managing their health. When patients are more informed, involved, and empowered, they interact more effectively with healthcare providers and strive to take actions that will promote healthier outcomes. The patient is central to defining the disease-related problems and the self-management program assists them with problem solving and gaining the self-efficacy and confidence to deal with the problems.”11

The premise is that acute problems arise, are diagnosed and treated, and then resolve.

Chronic problems, on the other hand, are different. They never go away, so the approach is different, requiring consistent contact between an informed and empowered patient and their primary provider/team, who know the patient, the problem, and the plan. Care is to be guided by evidence-based guidelines and supported by a helpful clinical information system, including “decision support”.12

The theory behind chronic care models seems good, although the supporting evidence is a bit inconsistent. It’s fairly obvious that each chronic disease requires a customized approach. High blood pressure might require weight loss, medications, self-measurements of blood pressure, infrequent visits to the doctor, and annual blood tests. COPD, or a chronic cancer, might require a much different and more intensive approach.

In short, what matters at the individual patient level is not that the fact that the patient has “chronic disease”, but rather “which chronic disease (or diseases) do they have?”, with care being planned accordingly.

For the system

For the healthcare system, it’s important to get a sense of the prevalence of disease in the population, in order to plan which services are to be delivered.

Again, however, it seems obvious that what matters at the system level is not “how many patients have “one or more chronic disease(s)?”, but rather “which chronic disease(s) do they have?”, with care delivery being planned accordingly.

In some cases, there are efficiencies to be had. As Google AI noted, chronic diseases require that those afflicted “… actively [take] steps to maintain good health through healthy habits and regular checkups. This approach emphasizes the importance of proactive health management, regardless of individual risk factors.”

Whether you have high blood pressure, type 2 diabetes, obesity, ischemic heart disease, or something else, it’s generally advisable that you eat well, exercise regularly, try to achieve and maintain a healthy weight, stop smoking, etc. We don’t need separate programs for each disease grouping, all offering the same lifestyle advice. You might even ask whether this sort of advice is necessarily a function of the health care system! When over half of the population needs to maintain good health through healthy habits, is it efficient or effective to deliver that message one patient at a time?

In other respects, each chronic disease group will require some unique services. The disease-specific needs of those with chronic renal failure will be different from those who have had a stroke, for example.

For the statisticians (and the media)

It’s time to stop reporting aggregate statistics for people having chronic disease. They mean nothing, especially when we are lumping risk factors in with diseases, like apples and oranges!

Each chronic disease carries its own prognosis. Each has its own unique service needs.

Knowing how many people report “one or more chronic diseases” tells us absolutely nothing useful, any more than telling us how many canned goods there are in our local grocery store!

What matters is that actual diseases are diagnosed and treated, and that risk factors are identified and managed.

The good news is that, despite the “alarming increase”, people are, for the most part, living long enough to develop and eventually die with their chronic diseases.

1. telling family physicians what they must do (or must not do), and

2. off-loading family physician work to others.

Both approaches are wrong, insofar as they are overly simplistic solutions to a highly complex problem. They don’t address the root causes of the shortage AND they have the potential to create additional problems.

In this post, I’m going to focus on the second strategy, which is based on the belief that the work of family physicians can be and should be safely delegated to others.

There are plenty of examples here in Nova Scotia, most of which have been borrowed from other jurisdictions.

• Telephone Advice. Available 24/7, 811 Nova Scotia offers “trusted, everyday health information and advice” from registered nurses to an average of 325 patients a day. The top five most common complaints are abdominal pain / discomfort, chest pain / discomfort, children’s colds & coughs, adult colds & coughs, and adult nausea & vomiting.

• Virtual Care in Nova Scotia offers virtual access to a family doctor or nurse practitioner for “many common health needs” that don’t require a physical examination (beyond what can be done visually over the internet). Operating six days a week, primarily during daylight hours, providers diagnose, provide care, offer health advice, prescribe medications2, and “treat common symptoms”.

• Mobile Primary Care Clinics. A sporadic and “temporary” walk-in3 service led by nurses, apparently with backup access to nurse practitioners and doctors, these clinics address non-urgent, low acuity health issues including prescription renewals4, minor respiratory symptoms (cough, flu, or cold symptoms), earaches, fever, headaches, rashes, minor gastrointestinal concerns (vomiting & diarrhea), urinary tract infections, and “muscle pain”.

• Nurse practitioners (NPs) are registered nurses with advanced knowledge and education in primary health care. While the original intent was that primary care NPs would work collaboratively alongside family physicians, over time we have seen NPs working independently.

• Midwives, with expertise in low-risk pregnancy, birth, and healthy newborns. They can order blood work and ultrasounds, make referrals to specialists as needed, prescribe medications and treatments as appropriate, and provide ongoing counseling and education. While midwives are trained to attend birth in both hospital and home settings, most midwifery births in Nova Scotia take place in the hospital.

• Community pharmacy primary care clinics, intended to support more effective, efficient, and accessible healthcare for all Nova Scotians. These are retail pharmacy-based clinics in which pharmacists work to their “full scope of practice”, providing “effective care for patients”, including prescription renewals, chronic disease care (Heart Disease, Asthma and COPD, Diabetes, etc.), assessment and prescribing of birth control, shingles treatment, Lyme Disease prevention and treatment, uncomplicated bladder infections, ear infections, sore throats (including Rapid Strep Testing), “Mental Health and Addiction Services”5, and “Immunization and Injection Services”

Looking at our Department of Health and Wellness website, there are a few common themes:

• the rationale is most often something benign or even benevolent sounding, along the lines of “having the right provider for the right patient at the right time and place”, in which the “right provider” is anyone having the appropriate “scope of practice” for the problem at hand, and the “right time and place” is whatever is most convenient for the patient. In pursuing this, we drift away from family doctors as full service, cradle-to-grave, personalized/customized professionals toward a consumerist, fragmented, episodic, and depersonalized/standardized model of care, wherein the providers are interchangeable cogs in a big machine.

• the patients and their problems sit at the low risk, low acuity, and uncomplicated end of the spectrum, in some cases even assuming that the correct diagnosis can be made by history alone, without a physical examination. “Low-hanging fruit”, in other words. However, even the simplest health problems are rarely “standard”, so, when things get complicated, doctors are expected to be lurking in the background, available as required. Unfortunately, the referral pathways are tenuous, at best.6

• “convenient access” plays into it, under the assumption that any inconvenience is an unacceptable barrier to care. While many bemoan the trend for family doctors to increasingly work inconvenient “bankers’ hours”, several of these new services offer similarly restricted hours of operation at limited locations.

• beyond convenience, it’s implied that these options are more “cost-effective”, producing equal or better results at lower cost. Left unstated is the true cost, especially when comparing care for problems of similar severity and complexity.7

• there’s a suggestion, as yet untested and therefore unproven, that a robust clinical information system will compensate for the fragmentation of care inherent in these new models. “Continuity of care” and “patient-centered care” are known benefits of a long-standing and gradually evolving relationship between the patient and their family doctor. Increasingly, family doctors know nothing of the care delivered elsewhere, or they find out long after the fact.

• finally, while the goal is to free up family physicians from some of their tasks, these strategies all make use of healthcare workers who are also in short supply (see footnote 1). We’re training nurses as NPs, and then using nurses and NPs to replace FPs, all of which can only aggravate the shortage of nurses and NPs. Ditto for pharmacists. In some cases, we are replacing FPs doing in-person care with FPs offering telehealth services. We are madly rearranging the deck chairs on the sinking ship, but that doesn’t fix the shortage of deck chairs.

Let’s dig down further.

If it’s in your “scope of practice”, are you the “right provider”?

“Scope of Practice” is an interesting term, insofar as it applies to professional groups and to individuals within the group.

The scope of practice for doctors as a professional grouping includes all the services that may be offered by doctors who are appropriately qualified and experienced, including countless things all the way from brain surgery to the treatment of ingrown toenails.

The scope of practice for an individual doctor will likely be much narrower than the scope of practice for the profession as a whole. Each individual doctor is expected to be aware of, and only engage in, those activities for which they personally have the appropriate qualifications, knowledge, skills and experience to practice lawfully, safely and effectively, in a way that meets clinical and professional standards and does not pose any danger to the public or to themselves.

As your family doctor, it would be within my scope of practice to recognize (or at least suspect) that you need brain surgery, but like most family doctors I would not have the necessary skills, etc., to safely perform brain surgery. Hence, I would refer you to a brain surgeon. Conversely, most brain surgeons would not have the knowledge, skills and experience to treat high blood pressure, something I would do daily.

Each sub-group, and each individual within the sub-group, will therefore have their own scope of practice. Family doctors have a broad scope of practice (they know about a lot of things, some in greater depth than others), specialists have a narrower one (the standard joke is that they know more and more about less and less, till they know everything about nothing).

It’s also worth noting that within the medical scope of practice some things are pretty basic and other things are complicated. Some treatment decisions are trivial (what to do about the common cold, for example), and others require familiarity with the natural history of the disease, the rationale for treatment, the risks and benefits of the treatment options, etc. (i.e. treating high blood pressure).

Diagnosing and treating a viral upper respiratory infection (otherwise known as a “cold”) seems like a pretty simple task. You probably don’t need any medical training at all to get it right, most of the time. Arguably, it’s within the scope of practice of any adult and maybe even some children! The problems arise when you get it wrong!

Diagnosing pneumonia is a bit more complex, requiring skill in taking a history, the ability to use a stethoscope, the experience to know when to order other investigations (like x-rays), and the judgment to know when antibiotics might help. Knowing which patients have common colds and which might actually have pneumonia requires some expertise. In many cases, the diagnosis of pneumonia is only apparent after you’ve taken a history, done a physical examination, and reviewed the results of any necessary tests. This, after all, is why patients seek medical advice! They want to know if their problem is trivial or not, in need of medications or not. You often can’t determine that over the phone, or without examining the lungs! Sure, pharmacists can treat the common cold (once the diagnosis is known, to the extent it needs treating at all), but they can’t examine lungs and diagnose pneumonia. Their scope of practice includes only the shallow, unserious end of the pool of respiratory infections.

So yes, there are plenty of situations in which different professional individuals and groups have overlapping scopes of practice, but some have much deeper knowledge and skills than others. It might seem logical to leave the “minor” stuff to those with less knowledge, but sometimes you need expertise to decide what the problem isn’t (i.e. serious, like pneumonia), not what it is (minor, like the “flu”).

The pharmacists working in those community pharmacy primary care clinics assess and prescribe treatments for many “minor ailments”, covering a wide range of body systems.

• ears (ear infections)

• eyes (infections, allergies)

• nose (infections, allergies)

• throat (strep throat vs viral infections, thrush, oral ulcers, cold sores)

• neurological (minor headaches)

• gastrointestinal (nausea, vomiting, diarrhea, heartburn, hemorrhoids, pinworms)

• gynecological (menstrual cramps, contraception, yeast infections)

• urinary tract (bladder infections)

• skin (shingles, impetigo, fungal infections, acne, corns, dermatitis, eczema, hives, dandruff, warts, tick bites / Lyme disease)

• musculoskeletal (minor aches and pains)

• mental health (sleep disorders and various unspecified mental health conditions)

• smoking cessation

In short, pharmacists in those clinics need to know about a lot of body systems. Were they all trained in history-taking and physical examination?8 Are they all equally competent? Do they look in ears often enough to maintain their skills? Do they have the facilities to get you undressed to properly examine your rash, your abdomen, your hemorrhoids, or your vagina?

Perhaps the answer lies in the evaluation of those community pharmacy primary care clinics, where the pharmacists were asked about changes in their knowledge, skills, and confidence. It’s actually not clear what the percentages mean (i.e. 80% felt “confident, knowledgeable and skilled” at the end of the project, or 80% felt their “confidence, knowledge and skills had increased”). Either way, what about the other 20%? Were they “not confident, knowledgeable and skilled”? Did they not improve? What’s really worrying to me is that they weren’t asked about their physical examination skills!

For every complaint on that list of ailments that pharmacists allegedly treat, I can tell you a story about a patient whose problem turned out to be anything but minor.9 How often will the pharmacists be out of their depth? Will they know when they are? Are they treating you because you showed up in their clinic and they assume that your problem is minor, or do they actually have the skills to rule out more serious problems? As a patient, will you unquestioningly accept the advice they’ve given you (because you’ve been told they are “the right provider”), or will you be assertive enough to go further when necessary?

But do you really need to examine the patient?

There’s huge potential for problems when there’s no face-to-face contact (telephone advice or telehealth) and/or the provider has limited skills and facilities for examining the patient (pharmacy primary care clinics).

Back in the time of Covid, several medical organizations jointly published the Virtual Care Playbook for Canadian Physicians. It states:

“…if any patient seen virtually provides a history that leads to a physical examination maneuver that cannot be executed remotely, the physician must redirect the patient to an in-person assessment.

For this reason, the scope of virtual practice is presently limited to encounters that require only history, gross inspection and/or data that patients can gather with cameras and common devices (e.g., glucometers, home blood pressure machines, thermometers and scales).

In practical terms, you can safely use virtual care to… conduct any other assessments that do not require palpation or auscultation.

In contrast, the problems that are currently not amenable to virtual care include any new and significant emergency symptoms such as chest pain, shortness of breath and loss of neurologic function. They also include ear pain, cough, abdominal/gastrointestinal symptoms, musculoskeletal injuries or conditions, most neurological symptoms and congestive heart failure.

So yes, there are problems that you can safely manage without examining the patient, but it’s a pretty small number, especially when you are talking about “acute” problems in patients that you don’t know very well.

That being so, it’s worrisome that the top five most common complaints for 811 Nova Scotia include abdominal pain / discomfort, chest pain / discomfort, children’s colds & coughs, adult colds & coughs, and adult nausea & vomiting. Pretty well all of those are on the list of things that should not be dealt with remotely, which may explain why doctors in emergency departments complain about the number of referrals from 811. Being risk-averse and algorithm-driven, a great many 811 calls must end with the advice “you need to see a doctor for that”.10

Ditto for those pharmacist-led clinics. Do they actually examine things when an examination is indicated, or are they limiting themselves to the history and “gross inspection”?

And then there’s mental health!

The Department of Health website makes reference to the Bloom Program, something which provides pharmacy-based mental health care.

However, it’s hard to find any detail about the Bloom Program, beyond the fact that it involves a supposedly rigorous application process and a single day of training for the participating pharmacists.

Which mental health conditions are treated? What are the interventions used? Are the outcomes proven? Are we really supposed to believe that one day of training will translate to meaningful mental health services? If so, why are we short of mental health care providers?

What about chronic disease management?

For chronic diseases, like diabetes or hypertension, when a treatment was initiated by your doctor and you’re now running out of medication, it’s usually a good sign that it’s time to visit your doctor again, to see if the medication is working. The service you require might be a reassessment of your problem, not just a prescription refill.

Sure, appropriately qualified and experienced pharmacists, nurses and others can all legally, safely, and effectively counsel you regarding your medication, and several of those can refill the prescription. However, whether or not they are the right person to talk to you today about your specific medication depends on a great many things that they won’t necessarily know, including the exact nature of your problem, what other medical problems you have, why your doctor chose the medication that they did, what they hoped to see as a result, and what they were planning to do next!

Beyond that, physicians in Nova Scotia are expected to do additional work, beyond office visits, providing guideline-based care to patients with selected chronic diseases. Chronic disease management is complicated, involving a number of carefully coordinated activities spread over multiple visits on an annual cycle.11 Pharmacists might offer “chronic disease management”, but how will their contributions fit into the bigger picture?

In short, when you need a prescription refilled, the right provider is probably the person who wrote the prescription in the first place!

What about conflicts of interest?

For doctors in Nova Scotia, there are professional standards for Conflict of Interest and the Sale of Products and Services to Patients, both of which state that a conflict of interest exists where “The physician prescribes a drug to patients in situations where the physician has a financial interest to do so.” The advice is “Physicians must disclose to patients any financial interest they have with the manufacture or sale of a product or service. As with any clinical decision, the decision to sell products and services must be evidence based. Physicians must provide accurate information to the patient about the product or service to ensure the patients ability to make an informed decision.”

Pharmacists based in retail pharmacies, by definition, have a financial interest in the sale of any drugs sold in the pharmacy. To what extent does this influence their advice to patients seen in the community pharmacy primary care clinic? Are they held to the same standard as physicians? Do you trust them to prescribe what’s best for you, not what’s best for their bottom line?

One physician, based in Ontario, has half-jokingly suggested that physicians should be allowed to dispense drugs, if pharmacists are allowed to make diagnoses and write prescriptions. As they say, what’s good for the goose is good for the gander!

Is any of this actually helpful?

All of this raises a lot of questions.

Which individuals within which other professional groups in health care actually do have the appropriate education, knowledge, skills and experience to replace family physicians? Are they doing it lawfully, safely and effectively, in ways that meet clinical and professional standards, without posing any danger to the public or to themselves?

Do community pharmacy primary care clinics include properly equipped facilities for the safe and thorough examination of the body systems and problems they purport to treat? Do the pharmacists have the qualifications, knowledge, skills and experience required to differentiate between “the flu” and “pneumonia”? Examine ears properly? Diagnose vaginal problems without doing an examination? Accurately diagnose rashes? “Manage” chronic diseases like COPD or diabetes?

Are the various alternative providers all qualified, knowledgeable, skilled and experienced? Do they each know their limitations? When they are over their heads, are the referral pathways in place and robust?

Several of these services provide two types of service, which have been labelled “problem-solving” and “safety-netting”.

When you have a simple problem, such as a cold or an uncomplicated urinary tract infection, it’s likely that they can “solve” your problem in a single visit. But is convenience of access leading people to seek care for self-limiting and low risk problems that don’t need or benefit from professional involvement? When earaches in kids generally get better without antibiotics, do you really need someone to look in the ear? How does it help? Is this an inefficient use of scarce resources? The alternative is self-management support, encouraging patients to look after themselves, while knowing the warning signs of serious problems.

Other problems, with many possible causes, do require more advanced clinical skills, further investigations, and follow-up. It won’t be possible to make the diagnosis and formulate a plan in a single visit, even assuming that the provider has the right scope (breath AND depth) of practice. In these cases, alternative clinics end up “safety-netting”, managing things symptomatically while handing the patient off to the usual doctor or somebody with more appropriate skills. At best, this is inefficient. At worst, it can delay care.

So, with all these initiatives, are we actually taking the load off emergency departments and busy family physicians? The experience in other places suggests that we are not. Alternative services actually increase overall health care utilization!

Beyond the question of whether the technical work of family physicians can be delegated safely to others, there’s the question of whether it should be delegated.

There’s a fundamental misunderstanding of what family doctors actually do. Sure, part of their work is transactional and technical, addressing the problem you have today.

You might think it helps to free them up from dealing with “minor problems”, so they’ll have more time for the complex stuff, but the fact of the matter is that the minor problems are easy to deal with, and they don’t take up much time.

And, when it turns out that the problem isn’t minor, it’s easy for a family doctor to pivot to a different, more detailed style of problem-solving.

What we need, in other words, is what we are short of: family doctors!

1

A recent report by Health Canada shows that we are short of family physicians, as well as every other category of health care worker. In most cases, we aren’t training enough to close the gap.

However, I believe we’ve been far too cautious.

In 2022, for example, the Organization for Economic Co-operation and Development ranked Canada third out of the 38 countries included in total annual health care spending, at $8,119 per person, exceeded only by Sweden and France.

At the same time, Canada ranked 21st out of 34 countries on hospital spending, $1,858 per person, compared with the OECD average of $2,080.

Google AI tells me that

“Internationally, there's no direct correlation between hospital beds per capita and total health expenditures per capita, with some countries having high spending and fewer beds, while others have lower spending and more beds.”

In short, Canada has chosen to spend more per capita on health care, but less on hospitals. If we chose to, we could have MORE hospital beds without necessarily spending more on health care.

We’ve created an artificial shortage of hospital beds, leaving a cohort of patients in every community who could benefit from hospital care, if only they were able to access it.

To compensate, we resort to “bed management”, a pseudoscience based on fewer admissions (more outpatient treatments), shorter lengths of stay (earlier discharges), faster turnover (minimal bed “downtime”), and optimal bed occupancy (maximal use of resources). Because doctors decide who gets admitted and how long they stay, bed managers ultimately spend a lot of time managing (aka “nagging”) the physicians, while distracting them from their other duties!

Unfortunately, the intended cost-saving emphasis on “right-sizing” hospitals and “optimizing resources” does not necessarily reduce costs or improve efficiency.

Why don’t we just do the obvious and build more beds? Let’s explore this in greater detail.

In 1959, a health economist called Milton Roemer published a research paper claiming that “hospital beds that are built tend to be used”2. His conclusion was based on the observation (in a single hospital) that the percentage of beds occupied remained much the same after the hospital added a “substantial” number of beds.

The explanation suggested for this was fairly innocuous, namely that “there is a vast reservoir of conditions in the population of every community that could benefit from hospital service”, and therefore, when beds are more readily available, “conditions of lesser severity can be diagnosed and treated more effectively within a hospital”.

In other words, when patients are sick and a bed is available, sometimes it’s more efficient and/or effective to put them in the hospital to sort things out. Hardly rocket science! In fact, it sounds like sensible clinical care!

Under the circumstances, when there are too few beds, and you add some more, then it’s not surprising that the additional beds will be filled, up to the point where you have “enough”, after which any additional beds might sit empty. As Roemer put it, “there must be some desirable limit to the bed supply, but it is not known”.

Again, this is common sense. Hospitals aren’t five-star hotels. Healthy people aren’t lining up to try out the comfy beds and gourmet meals. You must, at some point, run out of people sick enough to consider the hospital preferable to their own bed and kitchen.

Unfortunately, Roemer’s observation has been elevated to the status of a “law”, in which excess bed capacity inevitably causes wasteful “overutilization”. In short, the theory goes that “if you build it, they will come”, implying that patients who don’t actually need to be in hospital will occupy beds and cost money!3

Why would that happen? It was (and still is) imagined that physicians, who control the admissions, respond (consciously and unconsciously) to the increased availability of beds by admitting more patients and/or keeping them in hospital longer, not because it’s best for the patients, but rather because there’s some sort of financial incentive to do so. Apparently, you can’t trust self-interested doctors to do what’s best for patients!

You might ask yourself where doctors would find an endless supply of patients willing to be admitted for no good reason, or to stay in hospital longer than necessary, and that’s a good question! Apparently, patients are “too trusting”! They’ll do as they are told.

One way or another, with greedy doctors and/or naive patients, excess bed capacity is considered something to be avoided at all costs. It’s become acceptable, even preferable, to have too few beds, rather than too many beds. We have to save the doctors and patients from their own worst instincts!

In consequence, hospitals are always full to overflowing. The symptom is blandly labelled “emergency department congestion” or “hospital overcapacity”, and the solution is “bed management” or “over-capacity management/OCM”. The actual problem, a structural mismatch between supply and demand, is misleadingly framed as a temporary, correctable aberration.4

To prove my point, in a 2020 article tellingly entitled “Working Against Gravity: The Uphill Task of Overcapacity Management”, a refreshingly honest group of Canadian authors said (emphasis in bold added):

“A major underlying problem was that overcapacity interventions were widely relied upon to cope with a perpetual state of excess demand.”5

and

“If demand habitually exceeds capacity…neither augmented processes nor capacity earmarked for short-term use can rectify a long-term mismatch between capacity and demand.”

and

“We were unable to determine to what extent regions’ overcapacity woes were attributable to shortfalls in acute and/or nonacute capacity vs inefficient use of capacity. Given the evidence that the policy of cutting inpatient beds has contributed to ED crowding, it would seem premature to rule out capacity increases as part of the solution.”

More simply put, micro-managing each and every patient in each and every bed won’t fix anything when there are always fewer beds than patients. Continuing the daily floggings (aka bed management meetings) until morale (hospital flow) improves doesn’t work!

Worst of all, however, those Canadian authors could not identify a single system in which the hospitals were actually the right size!

“To identify an optimal strategy, it would be necessary to study a sample of health systems in which all organizations maintain an optimal level of utilization and patients flow smoothly across the entire continuum of care; such a sample was not available to us.”

Going further, they recognized that all this pointless activity comes with a price!

“While our findings did not lend themselves to conclusions about patient-level risks, they did suggest that the “all-consuming” work of [Over-Capacity Management] may have unmeasured system-level costs. What other patient care and system-management activities are not accomplished due to the constant time demands and stress of “juggling”? What risks does directing so much effort into a non-curative “solution” present to the health system?”

Sadly, nobody computes the costs of undersized hospitals. As my British parents would have said, we’re “penny wise and pound foolish”, fussing over the small details while we miss the big picture. We spend a lot to save a little. Worse than that, we don’t consider the human costs.

Those patients who can’t get admitted, including those who leave the emergency department without being seen, don’t reap the benefits of hospitalization. They suffer various harms, including worsening of their condition, delayed treatment, and even death. If they end up seeking care in the community, they tie up additional resources there. If they return to emergency later, they’ve doubled the work.

When hospital occupancy rates are high, the patients who languish in emergency waiting for an inpatient bed to open up get delayed care, inferior care (more errors), and more complications, including longer overall lengths of stay, higher rates of hospital-acquired infections, and death.

Inpatients who are rushed home early can suffer additional complications, sometimes requiring readmission. Some end up seeking care in the community, consuming additional resources. Others return to emergency, again doubling the work.

Elective surgical patients who prepare for surgery, only to have it cancelled at the last minute, suffer worsening of their condition, financial losses, and inconvenience, while the operating room resources sit idle.

Beyond the effects on patients, hospital staff also suffer. Job satisfaction is lower, burnout is higher, and staff turnover is greater.

Meanwhile, bed management has become an activity unto itself, contributing little or nothing to the well-being of the patients, while consuming significant resources and aggravating the physicians.

Not only have we undersized our hospitals, we’ve extrapolated Roemer’s law to include nursing home beds.

With the aging population, of course, we see more and more frail old people who need personal assistance. When they cannot cope at home any longer, even with assistance (aka “home care”), then they require nursing home care.

The transition from “able to cope” to “no longer able to cope” is often triggered by an acute illness and hospitalization. As a result, many people needing nursing home admission occupy hospital beds. While sitting there, they decompensate further, making their need even greater, if they don’t die first.

In many jurisdictions, Nova Scotia included, there’s a perspective that nursing home beds that are built tend to be used, so, as with hospitals, the numbers are rationed, while the facilities themselves are bed-managed to run at 100% occupancy. New patients are admitted only when old patients die.6

The tragedy, in this case, is that nursing home care is cheaper than hospital care, so a frail older patient sitting in hospital for a nursing home bed is actually costing the system more money, while they continue to deteriorate for lack of more appropriate care. They are “blocking” the hospital bed, which contributes further to the shortage of available hospital beds and staff burnout, in that their needs are mismatched to the skills of the staff.

In short, the solution to “not enough beds” really is “more beds”!

Sure enough, as Roemer observed, if you build more beds, they’ll get used (up to a point). That’s not a problem! That’s a good sign that you’re addressing the actual problem!

If you’re short of nursing home beds, build more, because they are cheaper than hospital beds.

If you’re still short of hospital beds, build more, because that’s far better than all the complications of hospital over-crowding.

And remember, if we chose to, we could have more hospital beds and nursing home beds without necessarily spending more on health care.

By that logic, considering that the results aren’t great, Canada’s health care system must have a design problem.

As I see it, there are actually two related problems.

First, the Canada Health Act requirement for “public administration” has been misinterpreted to mean “public management”.

“Administration” is a high-level, organization-wide activity, involving making plans and setting objectives. The Act specifies that the administration must be done on “…a non-profit basis by a public authority appointed or designated by the government of the province”.

“Management” is actually a lower-level activity, organizing people, work, and resources. Under the Act, the public administration can designate “any agency” to carry out on its behalf “any responsibility” related to the receipt or payment of accounts rendered for insured health services. The requirement for “public administration”, in other words, does not imply or require “public management”. The “operation” (otherwise known as “management”) of the insurance plan, can be delegated.

The second problem is that the Act only pertains to, and therefore requires, “public administration” for the health care insurance plan (payments to doctors and hospitals), NOT the entire health care system.

Building on those two errors in interpretation and design, every weakness or failure of the Canadian health care system is seen as a failure of public administration, for which the solution is more and/or different public management. Our governments double down on their “more management” approach, even when it’s visibly failing.

Less public administration or less public management is never considered to be an option.

Other countries, like the Netherlands, get different results. Perhaps that’s because they chose less.

In this post, I’ll compare and contrast the governance structures in Canada and the Netherlands, linking it all back to the impact on care delivery.

In Canada, it’s all about government control

First, let’s consider the following representation of a health care system. You’ve got three groups (patients, providers, and payors), linked by three basic activities (looking after patients, paying providers, and providing “insurance”).

In Canada, the “health insurance market” involves three broad categories of “payor”:

• Medicare (the Canada Health Act’s publicly administered health insurance plan), which pays for selected services (doctors, hospitals, x-rays, lab tests, etc.);

• private health insurance, often but not always provided as a benefit of employment, which pays for other services (drugs, vision care, dental care, etc.); and

• self-insurance (out of pocket payments), for services not completely covered by public or private insurance.

Theoretically, all eligible citizens have Medicare coverage. Many have private insurance, and most, at one time or another, will pay out of pocket.

The “healthcare purchasing market” determines what the insurance pays for. Doctors and hospitals are paid almost exclusively through Medicare. In fact, by law, they cannot accept any payments from other sources for publicly insured services, nor can patients purchase hospital or doctor services privately (no “queue-jumping”). Pharmacies are paid though a mixture of public insurance (pharmacare), private insurance, and out of pocket (often in the form of a “co-pay”). Private providers, like physiotherapists and psychologists, are often paid through private insurance and/or out of pocket.

Unsurprisingly, this can be confusing for patients. You might have an x-ray and blood tests, then review the results with your family doctor, all at no cost to yourself.1 You then fill a prescription at the pharmacy, where the bill is paid partly through your public and/or private insurance and partly out of pocket. If you need physiotherapy, you may have coverage or not, and the extent of that coverage may be limited to a number of visits or a specific dollar amount.

Notwithstanding the stated aim of the Canada Health Act (“…to facilitate reasonable access to health services without financial or other barriers”), what you end up doing for any given health problem will almost certainly depend on what coverage you have and what you can afford. Some patients take drugs when they really need physiotherapy. Others see their doctors repeatedly for treatments that “fail” when the real problem is that they cannot afford to pay for them. Very few courses of investigation and treatment end up being free of financial barriers from beginning to end. It’s all a question of what’s “reasonable”, something the government decides for us, without consulting us.

And, as I explained in my previous post:

• over time our governments have gradually expanded their public coverage beyond the original doctor and hospital services, displacing private insurers. At the same time, governments add or de-insure specific doctor and hospital services, depending on the state of their finances and the political mood of the day. The rules constantly change; the details vary from province to province and one demographic group to another. Overall, patients are gradually losing the ability to choose their own insurer and coverage, the publicly insured costs of healthcare are climbing, and access is getting worse.

• beyond that, the governments are systematically taking over the provider market. They own and operate most hospitals and the diagnostic devices within them. They strictly regulate doctors by controlling how many there are, where they work, what they do, and how they are paid. They’ve decreed that some publicly funded services formerly limited to doctors can now be delivered by others, including nurse practitioners, midwives, pharmacists, psychologists, telehealth call centres, etc.

• finally, with control of the insurance and the providers, governments are in a position to dictate the patient’s choice of provider and the services provided (referred to in the graphic as the “healthcare provision market”), based on what they can afford, and what they think is best.2 One example would be the recent suggestion in Quebec that patients might have to contact a (government-operated) telehealth call centre to receive instructions on where to seek care for each and every problem, rather than just booking an appointment with their family doctor.

In Canada, therefore, the public health care system looks more and more like this, with the patient on one side of the red line and everything on the other side being “government owned and operated”, under the benign sounding “publicly administered” euphemism. The private parts of the system are disappearing.

While some might still believe that our governments are well-intentioned and know what they are doing, we can all see that our public health care system is expensive, inaccessible, and increasingly dysfunctional. And yet, every problem is met with increased government control and more central planning!

There’s no room for public input.

As a patient, you have little to no choice about anything.3

It’s different in the Netherlands

In the 70’s and 80’s, the Netherlands were going down the path of ever-increasing government control through cost containment, government-regulated tariffs, and limits on facilities and volumes of care. When “more” control wasn’t working, they chose “less”; the healthcare reforms of 2006 were designed around a more demand-driven, patient-centred system powered by market incentives.

Their government now supervises and facilitates (i.e. “administers”) their health care system, without directly controlling or managing each and every part of it.

The governance and oversight are shared between the government (representing patients), professional organizations (representing the providers), and health insurers. Policy decisions are based on expert advice from various advisory bodies, which balance the scientific evidence, societal needs, and the insurance benefit package.

Patient and public participation are priorities. Freedom of choice is essential; patients are reliably informed about their insurers and providers.

Patients purchase their own insurance

The Netherlands government requires that all residents purchase standard basic health insurance from the private insurer of their choosing. Citizens have the option to switch to different insurer once a year.

For adults, the basic health insurance premium is paid for 50% “out of pocket” (by a premium paid directly to the insurer) and 50% via an income-related employer contribution to a Health Insurance Fund. The government provides a supplemental “healthcare allowance” to help people with lower incomes.

Health care for children under the age of 18 is paid entirely by government contributions to the Health Insurance Fund (from taxes).

In other words, the Netherlands government plays a role in financing the healthcare system by subsidizing individual insurance premiums and regulating the benefit package, rather than by providing the insurance. They “publicly administer”. They don’t “manage”.

As a result, there’s competition in the health insurance marketplace

The Netherlands health insurance system involves several different insurance providers, most of which operate on a not-for-profit basis.4

Insurers compete, offering different kinds of policies, at different price points. “In-kind policies” restrict your choice of providers but cover the full costs. “Restitution policies” allow you to see the provider you choose, but the reimbursement limit is set by the insurer, meaning you pay any remaining balance.

Insurers can also offer “collective contracts”, for example to employers or patient organizations, with a reduction of up to 10% on the individual premium. Individual citizens can choose to join a collective health plan or buy an individual plan.

By law, health insurers must accept anyone who applies for the basic package5. The included list of services, based on advice to government by the National Healthcare Institute, includes services deemed “essential” (things that prevent loss of life or loss of quality of life), “effective”, and “unaffordable for individual citizens”.6

Again, the Netherlands government publicly administers but doesn’t directly manage or operate the basic health insurance system.

The basics are fully covered, more advanced services require a co-pay

GP consultations, care of children up to the age of 18, maternity care, and home nursing care are free at the point of care. For services beyond those (including drugs, tests, and specialist care), patients pay out-of-pocket up to a specified deductible per year.7 After that amount (plus any voluntary deductibles), the insurance pays full costs.

The compulsory minimum deductible is specified by government. Some patients choose to accept a higher voluntary deductible (in exchange for a lower basic premium).

Supplemental insurance is available

In addition to the uniform basic health insurance, patients can choose to purchase, from any health insurer, any supplemental Voluntary Health Insurance (VHI) that they desire and can afford.

Insurers have freedom to determine which VHI packages they offer, and they are not obliged to accept individual applications for VHI policies.8

Providers negotiate with the insurers, not the government

Health insurers negotiate directly with providers on price, volume and quality of care. The Dutch Health Care Authority determines the services for which prices can be negotiated, and monitors whether the competition is fair.9

Insurers may or may not choose to negotiate contracts with specific “preferred” providers (selective contracting). At all times, they must meet their duty to offer adequate care to their customers (who have the option to choose another insurer, if they aren’t satisfied).

Providers and hospitals are independent entrepreneurs

Entrepreneurial behaviour is encouraged. Health care providers are responsible for providing services that meet their patients’ needs, competing for patients by offering good access to quality care and for insurers by offering attractive (e.g. integrated) care arrangements.

GPs are generally paid through a combination of fee-for-service, capitation and pay-for-performance. Citizens are free to register with a GP of their choosing.

Specialists negotiate their remuneration directly with hospitals. One-third work in salaried arrangements, while the remainder form specialist partnerships with remuneration based on the volume and complexity of their workload.

Most Netherlands hospitals are non-profit institutions, licensed by the government. Decisions about construction and capital investments (like CT scanners) are largely left to the hospital administration. Each hospital negotiates with each insurer, based on either a lump-sum budget or the prices, volumes, and complexity of individual services.

Workforce planning is minimal

For physicians, the number of medical students and the size of training programs for specialties are set by government, aiming to prevent oversupply, control the costs of medical education, and (for the benefit of the profession) protect their position in society.

For all other healthcare personnel, there are no such planning mechanisms. Individual schools set their own volumes, without government control.

So, we’re the same…

The “building blocks” of health care in Canada and the Netherlands are much the same. You’ve got:

• doctors, dentists, nurses and other providers,

• working in offices, clinics, hospitals and other facilities,

• ordering and interpreting tests,

• providing consultations, surgeries and other services,

• prescribing medications and other therapies,

• all paid for by a mix of public and private funding.

I venture to say that if I was visiting the Netherlands and got sick, I would have no problem understanding what was happening, beyond the language barrier.

… but we’re different

Despite all that similarity, there’s a big difference in outcomes.

As Andre Picard (of the Globe and Mail) put it in a recent editorial entitled “The Dutch and Danes have much to teach Canada about better health care”:

In Denmark, 98 per cent of citizens have a family doctor. In the Netherlands, it’s 96 per cent.

Only 83 per cent of Canadians have a regular health care provider, meaning that approximately 5.4 million people don’t have ready access to primary care. (And some estimates place the number of “unattached” patients as high as 6.5 million.)

So, what are Denmark and the Netherlands doing differently that we could learn from?

Dr. Tara Kiran, a family doctor at St. Michael’s Hospital in Toronto and the leader of OurCare, a pan-Canadian initiative to engage the public about the future of primary care, decided to find out, and made lengthy visits to both Denmark and the Netherlands in recent months.

One of her key takeaways is that the health systems in these countries, while very different in structure, are both “very customer-oriented.”

Patients have agency, they have choice, and they have high expectations. There is also a lot of transparency and easy access to health data, for patients and providers alike.

The idea that someone would not have prompt access to primary care is unthinkable, because it’s the cornerstone of good health care.

While Canada has grand principles – “no one should be denied care based on an inability to pay” is the driving philosophy of Medicare – we do an abysmal job of delivering what really matters: the actual care.

Patients get more contempt than they do agency. Our health information systems are pitiful, marked by a lack of access and interoperability.

The other lesson we can learn from looking at other countries that do health care right is that public policy matters, and so does planning. And, of course, investing resources wisely.

Canada, Denmark and the Netherlands all spend roughly the same per capita on health care: US$6,207, US$6,332 and US$6,539 respectively, according to the latest World Bank data. But both Denmark and the Netherlands have many more physicians per capita than Canada – about 60 per cent more. Canada has 24.4 physicians per 10,000 population; Denmark has 44, and the Netherlands, 41.

Both European countries also have more family physicians per capita than Canada. Primary care is the priority, as it should be.

Family docs play a key role as gatekeepers. In the Netherlands, for example, short of having a traumatic injury, you can’t even go to the emergency room without a referral from a physician.

Then again, same-day appointments are virtually guaranteed for urgent matters. Home visits are the norm for people too frail to come to the office. All practices provide 24/7 care, with physicians in group practices all doing their share of nights and weekends.

“There is a cultural expectation of timeliness of care,” Dr. Kiran says.

Doctors do more in their offices than in Canada, including stitching people up, setting broken bones and the like. But they don’t do other things, such as cancer screening, which is all centralized.

Medical education is also different. In Denmark, for example, everyone is first trained as a general practitioner; then they can do specialty training (or not). And higher education is heavily subsidized, and often free.

One of the best lessons Canada can take from European and Nordic countries with great primary care is the importance of teamwork.

Nurses and practice assistants (who, unlike secretaries in Canadian doctors’ offices, are trained in communication) do a lot of triage and care, and physicians focus on more serious issues. Unlike Canada, you don’t see the nurse and the doctor – you see one or the other.

Dr. Kiran says this type of distribution of care duties would be a “game-changer” in Canada.

Canada, Denmark and the Netherlands all have mixed systems of physician payment – some fee-for-service, some capitation and some salaried.

But in the European countries, there are clear contractual obligations that must be met.

Physicians in Denmark and the Netherlands, in general, take home markedly less than those in Canada, but have far more administrative support and, it seems, better work-life balance. Unlike Canada, family doctors are paid the same, or more, than other specialists.

Over the years, many a health care leader has made a pilgrimage to these countries to marvel at how primary care can be provided to almost every citizen. (Almost, because every country struggles with providing care in rural and remote areas.) So, none of the lessons Dr. Kiran brought home are new. But at some point, she noted, we need to start acting on what we learn.

Why?

Buried in the middle of that editorial is a point that needs emphasis, “PUBLIC POLICY MATTERS, AND SO DOES PLANNING”.

Despite all the similarities between the healthcare systems in Canada and in the Netherlands, the biggest difference is PUBLIC POLICY, specifically our interpretation of the meaning and extent of PUBLIC ADMINISTRATION.

Both systems are indeed perfectly designed to get the results they get!

In the Netherlands, they’ve opted for high level public administration. Their government sets “minimum specifications”, trusting the complex adaptive system sort out the details. It works!

In Canada, our governments have gone down the rabbit hole of government micro-management, trying to fix complex problems with an ever-increasing array of “solutions” that are overly simplistic, unnecessarily complicated, or both. Unsurprisingly, it’s not working!

The problem is obvious, and so is the solution.

It’s a design problem.

To solve it, we need to do what the Dutch did in 2006.

DECREASE GOVERNMENT CONTROL; ADMINISTER, DON’T MANAGE.