Sunday, July 28, 2013

Kingston's weekly mess

Like pretty much everyone else in Kingston I have my weekly garbage collection. I duly separate my stuff into garbage and green and blue or grey bins. I’m actually all in favour of this, even though the stench emanating during summer from the green bins is truly from another world.
These days I plan my way to the office strategically on collection days, aiming to avoid as many residential areas as is feasible, because that stuff just stinks to high heaven. Is there really no way to collect the organic waste without making large parts of town no-go areas during collection time?
I do also wonder about garbage collectors having to pick up the green-bin content during the summer months. It must be absolutely awful to collect the organic waste during this time of the year. Is this really the best system that we can think of at the beginning of the 21st century?
Well, leaving this fault in the existing system aside, there is also a remarkably large number of inconsiderate neighbours to report. And I don’t mean those who send you notes asking you to leave town in the name of their god. That deserves a commentary in its own right, but enough has been said during the last week already.
No, my rant isn’t about the obviously morally challenged neighbourly type. Given where I live, it’s fair to say that those I am concerned about enjoy an above-average education and should know better. So, it’s yet another rant about students in Kingston, you say? Yes and no.
Here is the problem: Kingston city hall confirmed that we currently have no bylaw in place requiring that our garbage be placed in a secure container on the curb for the early morning collection. As a result of that, students, but not just students, dump their rubbish in the evening before the collection in black plastic bags and leave them on the sidewalks.
I don’t know whether you noticed, but that also happens to be when our friendly other neighbours, namely our legions of racoons, start having street parties. They move from plastic bag to plastic bag, carefully untie the knots, check the content, eat what’s eatable and tie the bags back up, lest the rubbish be strewn all over the place.
Ok, fine, that’s not quite what’s happening. What’s happening is that the racoons rip open the bags and rifle through their contents, followed by squirrels, pigeons and any number of other non-human Kingston residents. By the time they’re done, a couple of properly piled-up black garbage bags have been transformed into an area akin to a war zone.
The wind oftentimes sends piles of rubbish straight into the lake, into adjacent properties’ driveways, and the list goes on. It is a complete and utter mess on a good day. The environmental impact of the rubbish being dumped into the lake week after week after week can’t be insignificant. I wouldn’t be too surprised if there were public health implications, too.
You would think that being reasonably well-educated would enable us to learn from such a bad experience, and that we would get ourselves a bin and next time place the plastic bag into the bin to avoid such a mess. You would also think that, once confronted with the mess our ripped-apart garbage bag has caused across our neighbourhood, we would pick up our rubbish and place it into our newly acquired bins.
Well, in my experience, that is not exactly what happens. It happens on some properties, but certainly not across the board. It is not unusual at all that the rubbish literally remains where it is, or where the wind happens to blow it. The idea behind this clearly is that “Our work is done after we place the garbage bag at the curb. Who cares what happens after that?”
In defence of tenants, though, I also wonder what’s wrong with many of the downtown core’s landlords. I do appreciate that ultimately you are in it for the money, but would it be that expensive to place a sufficient number of garbage bins in your properties to avoid this kind of situation? I’m sure that if you lived down here you would not find this weekly mess tolerable. One can’t really blame tenants for not buying these bins, given that their time in Kingston is limited and that they likely would not be able to use these bins wherever they are going next.
I understand that our city councillors have discussed this matter on more than one occasion. The thing is, though, discussions are cheap and they tend not to resolve the problem at hand unless they are followed up by action. What would be wrong with a bylaw requiring us to secure our garbage in containers that prevent our non-human neighbours from going through our rubbish?
It is common sense to do this anyway, but common sense clearly isn’t what propels everyone's actions, so a bit of a regulatory nudge might not be a terribly bad idea. What we currently have is an unacceptable mess by any stretch of the imagination! Surely it is not beyond city council’s capacity to address this issue once and for all. As an aside, given that the local tourist bus tends to drive tourists through our beautiful historic downtown, the picture that tourists will get of our town on garbage collection days isn’t one to celebrate either, I’m afraid.
Udo Schuklenk teaches bioethics at Queen’s University and made downtown Kingston his home some seven years ago. He’s on Twitter @schuklenk

Sunday, July 21, 2013

Developing World Bioethics Special Issues on ARVs

Cover image for Vol. 13 Issue 2

Developing World Bioethics

Volume 13, Issue 2 Pages ii - iii, 57 - 104, August 2013

Special Issue: Anti-retrovirals for treatment and prevention – new ethical challenges


Anti-retrovirals for treatment and prevention – time for new paradigms in our response to the HIV/AIDS epidemic? (pages ii–iii)
Quarraisha Abdool Karim and Ronald Bayer
Article first published online: 18 JUL 2013 | DOI: 10.1111/dewb.12033


Separate Goals, Converging Priorities: On the Ethics of Treatment as Prevention (pages 57–62)
Florian Ostmann and Carla Saenz
Article first published online: 25 JUN 2013 | DOI: 10.1111/dewb.12021
Ethics of ARV Based Prevention: Treatment-as-Prevention and PrEP (pages 63–69)
Bridget Haire and John M. Kaldor
Article first published online: 17 APR 2013 | DOI: 10.1111/dewb.12026
From modeling to morals: Imagining the future of HIV PREP in Lesotho (pages 70–78)
Nora J. Kenworthy and Nicola Bulled
Article first published online: 25 JUN 2013 | DOI: 10.1111/dewb.12029
Ethical Use of Antiretroviral Resources for HIV Prevention in Resource Poor Settings (pages 79–86)
Stuart Rennie
Article first published online: 31 MAY 2013 | DOI: 10.1111/dewb.12022
Ethical Considerations in Determining Standard of Prevention Packages for HIV Prevention Trials: Examining PrEP (pages 87–94)
Bridget Haire, Morenike Oluwatoyin Folayan, Catherine Hankins, Jeremy Sugarman, Sheena McCormack, Gita Ramjee and Mitchell Warren
Article first published online: 31 MAY 2013 | DOI: 10.1111/dewb.12032
Ethical Tradeoffs in Trial Design: Case Study of an HPV Vaccine Trial in HIV-Infected Adolescent Girls in Lower Income Settings (pages 95–104)
J.C. Lindsey, S.K. Shah, G.K. Siberry, P. Jean-Philippe and M.J. Levin
Article first published online: 31 MAY 2013 | DOI: 10.1111/dewb.12028

Saturday, July 20, 2013

Ways to increase available transplant organs

Here's my OpEd from this weekend's Kingston Whig-Standard.

Ontarians die entirely preventable deaths every year because too many of us are simply too lazy to sign up as donors with our provincial transplant organ network. If Canada-wide statistics are anything to go by, about twice as many Ontarians are on a waiting list for transplant organs as there are suitable donor organs.
Reportedly, about 200 Canadians died last year while waiting for suitable organs. Most people on our waiting lists are desperate for kidneys. In Ontario alone, about 1,500 people wait today for suitable transplant organs. They could be a loved one, or it could be you. Some of those waiting today will die crude, premature deaths because the wait will be too long for them.
The current situation is not only unacceptable because people die preventable deaths when they could be looking forward to productive and happy lives. It is also unacceptable because of the unnecessarily high expenditure on kidney dialysis that is required to keep desperate patients alive while they are stuck on the system’s waiting lists. How can we close the gap between patients in need of transplant organs and the availability of suitable organs?
What we have in place at the moment is best described as an “opt-in” system. We need to opt-in pro-actively by registering as an organ donor. Typically, organs are removed from such donors after they have died.
In Ontario, living-donor donations are also possible, usually for kidney transplant purposes. Living-donor donation is feasible in the case of kidney donations because we can function perfectly with one healthy kidney. Unfortunately, unlike our – rightly so – highly paid transplant surgeons, and everyone else involved in the transplant process, the transplant source must not receive a financial reward for their decision to part with one of their organs.
Unlike in some other countries, we are unable to offer our spare kidneys for sale, despite the negligible health risk involved. No doubt this has a significant impact on the availability of transplant kidneys.
So, why should we not try and offer financial incentives to potential sources of transplant organs, i.e. people like you and me? Let me stay here with the kidney transplant business. We have reasonably persuasive data today suggesting that it is pretty safe for healthy people to donate kidneys. So, why should we, as the owners of our bodies, not be entitled to decide to put our spare kidney up for sale?
Clearly it isn’t the risk to the person who's the source of the kidney, given how very low that risk is, that could justify the current prohibition on organ sales. We are already permitted to undertake significantly higher-risk activities, including rock climbing, smoking ourselves to lung cancer, scuba diving in shark-infested waters, and the list goes on. So what’s morally reprehensible about accepting a small health risk for a handsome financial reward that would also help preserve a desperate Ontarian’s life?
For reasons I cannot comprehend, regulators expect donors to provide their organs for altruistic motives only. They are pretty much the only participant who isn’t handsomely rewarded for their participation in an organ-transplant procedure. Everyone else gets paid or receives a life-preserving organ. Isn’t it implausible, indeed, that patients should lose their precious lives because of an unreasonable societal squeamishness when it comes to paying people for their spare kidneys for transplantation purposes?
Desperate patients travel today overseas and obtain kidneys frequently under highly questionable circumstances, often exploiting vulnerable, impoverished people in developing countries. Surely one response to this challenge could be to develop a carefully regulated living-donor system that permits the sale of spare kidneys in Ontario.
We would, of course, ensure that vulnerable people are not subjected to the risk of exploitation or undue pressure. Benjamin Hippen, a U.S.-based transplant specialist, sums up what features a government-regulated market for transplant organs should have: It would prioritize the safety of both vendors and recipients; it would be fully transparent with regard to risks to vendors and recipients; it would safeguard institutional integrity regarding guidelines for co-operating with kidney vendors, and, last but not least, it would operate under a robust legal framework.
I suspect some people will find the idea of paying someone for their spare kidney unacceptable, and they will duly make noises about vulnerable people, as well as the wrongness of commodifying our bodies.
I do think that the first concern ought to be taken very seriously, but surely it is not beyond our capacity to legislate accordingly. As far as the commodification issue is concerned, my view would be that that decision is for the kidney owner to make, not for Tony Do-Good on her behalf.
Still, there is another way known to increase donor organs, and it is one that is being introduced in ever more countries. It is a proposition currently debated in Prince Edward Island. The idea is that we should switch from an “opt-in” to an “opt-out” system of consent.
This is based on a number of facts and a reasonable assumption: The facts are that many more of us would be happy to see our organs used for transplant (and even research) purposes after our death than there are people who actually opt-in to the current system. It is a fair assumption that people simply cannot be bothered to enrol themselves.
The idea here is that, for everyone who does not expressly refuse to donate their organs after their demise, the reasonable assumption is made that they would be happy to see their organs utilized to preserve a fellow Canadian’s life.
Now, before you shout theft, socialism and whatnot, opt-out systems operate in a significant – and increasing – number of countries worldwide, including Spain, Austria, and most recently, Wales in the United Kingdom.
Truth be told, I would be comfortable with either system, or even with a mix of both, as long as we end up increasing the number of transplant organs available, and as long as the end result is that nobody in Ontario or Canada dies an unnecessarily early death due to a lack of transplant organs.
Udo Schuklenk is the Ontario Research Chair in Bioethics and Public Policy at Queen’s University. Follow him on Twitter @schuklenk

Friday, July 12, 2013

Why a 'Pope John Paul II Day' is wrong

My latest column from the Kingston Whig-Standard. ... has also been reprinted in the London Free Press.

Former UK Prime Minister Tony Blair stipulated famously that “we don’t do religion,” meaning that his government would not let religion enter into its policy-making. There are very good reason for this. For starters, our religious beliefs – or their absence - are our individual, private affairs.
There is a multitude of religions out there, and evidence for the truth of any of them is notoriously hard to come by. For any government trying to survive politically within a multicultural, pluralistic society, it would be foolish to take sides in the religious-belief competition. After all, some religions don’t want you to eat pork (incidentally, that does not stop adherents of these anti-pork religions from serious disliking each other ), others tell you that homosexuality is terribly sinful while the next religion will happily marry gay couples, and so it goes in the religious-belief free-for-all.
Smart politicians have long understood that it is not good policy to drag religion from the private sphere, where it properly belongs, into the public domain. We rightly protect people’s rights to hold conscientious religious and other beliefs, but that surely is where it should end.
Not so in Canada. During the last session of Parliament, and again in the current Parliament, respectively, Liberal and Conservative MPs introduced private members’ bills aimed at inflicting a John Paul II Day on Canada. This is so obviously wrong-headed, it is difficult to decide where to start.
Looking back at this pope’s legacy, John Paul II was a highly conservative head of the Roman Catholic Church. Under his leadership, pedophilia in the church was not addressed seriously, and repeat offenders were busily shuffled through the worldwide church empire. He invariably made the noises about this behaviour being bad, but he did little to follow through as the man in charge.
His views on artificial insemination, abortion, euthanasia and homosexuality are considered offensive by the overwhelming majority of Canadians. This did not stop him from proactively lobbying Jean Chretien at the time against marriage equality, because the thought of providing equal rights to gay and lesbian Canadians was something this Catholic pontiff was not prepared to tolerate, not even in a country that was not his own. Well, that is if you accept that all-male Vatican as a country, of sorts.
John Paul II has rightly been criticized by public health and reproductive health experts for his absolute prohibition on condoms. He did not care that it could reduce the spread of HIV/AIDS, and he certainly did not like the idea of preventing the birth of unwanted children. Under his leadership his clergy campaigned in many developing countries relentlessly against sex-education campaigns involving the use of condoms. Deliberate misinformation, in the name of God, was not beneath many of these campaigners.
You could say that all this is all too well-known, so why drag the dirt on this pope out again on this occasion? Why speak ill of the dead?
Well, without good reason, the House of Commons has voted already in favour of establishing a John Paul II Day in Canada. The bill is now in the Senate. What is driving our parliamentarians to honour such a highly divisive figure, a man whose views on what constitutes a good life are clearly not shared by most of us? In fact, John Paul II’s views on these issues are not even shared by the majority of Catholic Canadians. He was a conservative radical, by any stretch of the imagination.
Now, even if you disagree with my characterization of John Paul II – and I do not quite see how you can without falsifying the historical record – there are other problems with honouring him in the way the majority of our parliamentarians propose.
The inevitable question this “honouring” business gives rise to is this: Where should we draw the line? What other religious figurehead is next? How about the founder of the Church of Scientology, the deceased science fiction author L. Ron Hubbard? Or perhaps we should next honour a Muslim cleric for good balance?
The bottom line is this: Religion is a private and typically highly divisive issue. The truth of religious beliefs cannot be established. It is bad public policy in modern, multicultural societies to honour religious figureheads. In the case of John Paul II, it is a slap in the face of secular Canadians, gays and lesbians, any woman who has ever had an abortion, people who avail themselves of artificial means of reproduction, and anyone who has ever dared to make use of a condom. That’s a lot of Canadians!
If our politicians want to honour people by dedicating a day to them, may I suggest they choose less-controversial figures such as Nelson Mandela, for instance.

Wednesday, July 10, 2013

Time to Regulate the Food Industry

I am reproducing below an Op-Ed I had in today's Kingston Whig-Standard, our local paper.

You might not be a big fan of New York City’s mayor Michael Bloomberg, but he was on to something when he tried to limit the size of soft drink containers. The stuff that’s in there is both terribly unhealthy, and delightfully addictive.
Let’s face it: we do have an obesity problem. The World Health Organization has identified obesity and being overweight as the fifth-leading cause of death worldwide. The cost to our economy comes in at a whopping $4.6 billion to $7.1 billion every year.
Academics love to argue about the question of whether obesity is a disease or – for most people – just a result of an unhealthy lifestyle. There are also legitimate arguments to be had about the question of what constitutes “unhealthy” obesity. It turns out that being a tad bit overweight might actually confer a survival benefit to those of us who are in my age bracket and older. However, it is beyond reasonable doubt that people who are significantly overweight run a higher risk for diabetes, heart disease and a host of other serious and expensive-to-treat medical conditions.
If you look at the comments sections under newspaper articles focusing on the growing obesity problem, you will find out quickly that there are plenty of weight Nazis among us. “Charge them by weight when they board planes so that the really big ones sit in the business class section and don’t squeeze me out of my seat in the back of the bus,” “make them feel crappy about how out-of-shape they look,” and any number of other punitive or stigmatizing proposals are generously bandied around by those of us who typically are at the lighter end of the weight scale.
Then there is the well-meaning type on the back of packages telling us everything we actually don’t want to know about carbs, salt content and whatnot. Frankly, I doubt that they have any significant impact on most people’s purchasing decisions.
A lot of obesity research that is undertaken discovers, to some extent, the obvious: kids who are subjected to junk food by their parents grow bigger faster than kids who are not subjected to junk food. Kids who experience a sedentary lifestyle courtesy of their parents’ way of life are more likely to live like their parents do, with predictable outcomes in terms of their girth.
Of course, public health people are quick to come up with their own predictable suggestions: nudge kids into the right behaviour, offer healthy foods in school, etc. It’s not that we aren’t trying, it’s just that we haven’t been terribly successful while at it.
There have also been more strident suggestions, such as stigmatizing big people as we stigmatize (well, ostracize) smokers. To be fair, the combination of high taxes, public health information on the effects of smoking on our life expectancy and stigmatization of cigarette use has worked. The number of smokers in Canada is significantly down from what it was 15 or 20 years ago. The same isn’t as straightforward for our eating habits, unfortunately. There are some parallels, though.
Believe it or not, but a lot of the stuff that we eat has been designed specifically to make us addicted to it. They have gone so far as to ensure that we crave more after we have had our fair share already, thereby increasing sales and wrecking our health in the medium- to long term.
Billions of food industry research and development dollars go into ensuring the addictive nature of the unhealthy foods that we eat. The research efforts include the right combination of that terrible trio of sugar, salt and fat, the consistency of the food while it melts in our mouths, the sounds the food makes when we eat it, the packaging, and who knows what else.
You might assume that a baker would the one to determine how the cookies you buy in the supermarket look, taste and feel. Think again. The cookies were likely created by highly sophisticated chemists, aided by psychologists or neuroscientists, all colluding to ensure that we eat many more of those cookies than we otherwise would if the baker down the road had created them. All this is an attempt to ensure that we come back for more once we are hooked on them.
You would think a government response that forces companies to include data on the amount of addictive content that they put into our foods would properly prevent us from making obviously bad choices, but the evidence suggests otherwise. We know it is bad, but we cannot quite help it because we are hooked already, courtesy of the refined product and marketing research and development that food manufacturers engage in.
The food labelling activity makes typically liberal assumptions whereby an autonomous individual makes informed choices about what is best for them. The thing is, many of us do not make informed choices - a situation not unique to food. Worse, many of us make choices that actually are comparable to those of other addicts. As with other addicts, the products we are addicted to are objectively not good for us.
We have little choice, of course, other than to purchase a significant amount of processed foods. What is problematic is that food producers are currently permitted to deliberately create addictive foods that are objectively bad for us and there is no warning label about that on the packages. There are no gruesome photos of obese people unable to move their bodies without assistance, or other physiological manifestations of obesity.
Worse, the nature of an economic system where more is always better forces companies to compete against each other by making us eat more than we should, and eat more unhealthy products than we should.
Typically, solutions to this issue are individualized. (“Eat responsibly?” Nice try!) Then there is plenty of talk about voluntary, public-private partnerships (the food industry cannot possibly be “responsible,” because producing healthy foods would reduce its sales and profits), and, last but not least, it has been suggested that we should levy taxes on unhealthy foods that are commensurate with the health care costs they cause.
Some of these features ignore that the poorest among us are also much more likely to be obese. Sadly, this is especially true for Canada’s aboriginal peoples. They also happen to be frequently stuck in so-called “food deserts” where access to healthy foods is hard to come by.
Isn’t it high time our regulators had a serious look at the food-producing industry with a view to regulating it in much in the same way that cigarette manufacturers are regulated? Considering the cost to our health and economy of so many of our food products, why not tax them as we tax cigarettes? That might be a good start! Just make sure that the money generated that way is diverted right back toward subsidizing healthy foods.
Udo Schuklenk is a Professor of Bioethics and Public Policy at Queen’s University. He’s on twitter @schuklenk

COVID19 and the ethics of hospital triage decision-making

There is a lot of talk these days about the predicted coming wave of COVID19 patients needing ICU beds and ventilators in particular, and th...