Should we be permitted to use prescription drugs to upgrade our brain capacity?

My latest OpEd in our local paper, the Kingston Whig-Standard.

Let’s face it - most of us spend a lot of time competing against each other. It might not be a terribly nice thing to do, but what choice do we really have in a world that has decided to shoot for progress through competition?

We try to look better, usually not just for ourselves, but also to look better than whomever we have chosen as our favourite competitor. If we have the financial means we send our kids to take extra lessons so they compete more successfully at school. It seems many professional athletes resort to doping in order to compete more successfully.

When I look at the other middle-aged blokes at the gym, it is clear to me that they do it not just to push death away by a year or two, but also to stay fit in the daily competition at their workplace. Anyone who has ever wondered why so many law and medical school students manage to pull 24- to 48-hour stints in the library close to exam time should be disabused of the idea that it was just coffee or the occasional energy drink that kept many of them going.

In the United States, drugs approved to assist children with Attention Deficit Hyperactivity Disorder, or ADHD, are prescribed by doctors to many children, as well as adults, who don’t actually suffer from that condition. Why? Well, despite the absence of conclusive clinical evidence, parents - as well as many students in high-pressure, high-stakes fields of study - have long voted with their feet and decided to move heaven and earth to upgrade their kids, or themselves, respectively, by means accessing these same ADHD drugs.

They believe these drugs increase our attention span as well as our knowledge retention capacity for significant periods of time. Studies suggest that about 5-10% of high school students and up to 35% of college students use these drugs for non-medically approved purposes.

A large number of society’s best-educated take a gamble on such drugs actually working. Clearly, after they try them once, many students continue to use them, because in their best judgment they do the trick.

Many doctors are opposed to the prescription of drugs for what they describe as non-medical purposes. Being able to focus better in college and to retain your knowledge for longer periods of time are such non-medical purposes. But what is a medical and what is a non-medical use of a particular medication?

This, of course, isn’t purely a clinical question. It’s inextricably linked to this question: what should the purpose of medicine be?

In my view, medicine should aim to achieve the twin objectives of keeping us alive as long as possible at as high a quality of life as is feasible. You can, of course, try to achieve that by fending off disease. Disease certainly impacts negatively on our lives, and all too often it cuts them short.

However, if there were drugs out there that could improve how our brains function, we would undoubtedly be able to improve the quality of the lives of many of those who choose to use them. Assuming that such drugs work – and it doesn’t matter whether the current drugs actually work for this purpose, because a future drug, inevitably, eventually will – our enhanced brain capacity would also mean that we would be more productive and more creative.

Yes, we could do more with our lives for a longer period of time. And this is one of the reasons why doctors who limit their professional activities to fighting disease as opposed to working toward the maximization of our biological and psychological well-being have a wrong understanding of what their job should be all about.

Today you can’t blame them, because the regulatory frameworks we have in place limit their professional activities, in quite conservative ways, to disease-fighting. A few attempts are made to prevent the occurrence of disease - for instance, by way of vaccinating us. The idea, though, that our health and well-being could also be improved from a status quo currently considered healthy is not something seriously considered by the medical profession. That is a profound mistake.

Worse, because of this conservative understanding of the nature of what it means to be a health care professional, no serious research is currently under way with a view toward upgrading our minds. Any such knowledge would be an accidental byproduct, likely of ADHD- or Alzheimer’s-related research.

There are obvious problem with the kind of change that I am proposing. For starters, we should be concerned that access to brain-capacity enhancers isn’t limited to those already well-off, because otherwise we would continue to increase the gap between society’s haves and the have-nots, with a nasty and harmful societal fallout eventually coming our way.

We should also be worried about fairness in the societal marketplace with regard to those who choose not to upgrade their mental capacities. They might do so because they could be, in principle, opposed to 21st-century medicine, or they might be worried about the long-term side-effects of the medication, or for any number of other reasons.

Given that we do compete on a global scale, these choices could well have ramifications for our national ability to compete against other nations. It will be a difficult regulatory balancing act, but I suspect that it is one we will eventually have to confront.

There is something of more immediate concern, and that is the current use of such drugs by students for non-medically approved purposes. Arguably, the playing field between students with access to such drugs and those who do not have access is not level any longer. It is a matter of fairness that we ensure that students with access do not gain a competitive advantage over those students who do not have access. I do think administrators of higher-education institutions should look carefully into the question of whether it is possible to test students for the use of such drugs in order to ensure that the playing field is level again.

No doubt privacy advocates will be up in arms against this proposal. I actually sympathize, but we do need to find a way to ensure that no competitive advantage is gained by those who access memory-enhancing drugs for not currently clinically approved purposes.

Udo Schuklenk holds the Ontario Research Chair in Bioethics and Public Policy at Queen’s University. Follow him on Twitter @schuklenk

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

Developing World Bioethics Special Issues on ARVs

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 EDITORIAL 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 ARTICLES 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

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.

Pay?

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.

Opt-out?

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

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.

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

Medical cannabis use? Sure!

I received an invite a few weeks ago, by a medical user group, to present my take on the issue of medical cannabis use in Canada . Unlike the Brockville General Hospital, that cancelled my keynote address in response to pressure from well-connected religious pressure groups, the medical cannabis folks didn't cancel my presentation, even though they had no idea whether I would be supportive of their cause. Truth be told, they probably did not like much of what I had to say, but attending their meeting permitted me to learn quite a bit about the bizarre status quo in Canada.

Here's what I learned (small detail might be slightly off, but the gist of this is correct, as far as I can tell). Some years back the Canadian courts forced the federal government to permit access to medical cannabis users. This decision was made in the absence of conclusive medical research demonstrating that THC (the biochemical substance at the heart of it all) works. There are a bunch of studies suggesting that THC works as a complementary substance in palliative care, that it helps people with appetite issues to get hungry again, etc. The thing is though, no conclusive research was undertaken that would have determined what dosage should be given to what patients for what duration. So, medical cannabis is NOT a prescription drug.

Strangely, under the current system (to be changed in March 2014) doctors must confirm that a patient suffers from a condition listed by Health Canada in response to the court finding. This, of course, is a quasi-prescription for a non-medication. Doctors were rightly concerned about this. After all, why should they fill in such a form? If Canadian courts want biochemical substances made available to particular patients - in the absence of conclusive clinical research evidence - why should doctors oblige them? Well, the thing is, THC clearly does some patients good. So, doctors obliged government - when, to my mind, the profession should have declined. How can you participate in getting someone access to non-drug drugs in the absence of uncontroversial clinical evidence?

Well, the current system sort of worked. Patients could either get permission to grow their own cannabis or purchase it from a government facility. Comes in the Canadian Tea Party, ie our current federal government. A new system will kick in. Crucially, the government facility that produced medical cannabis will shut down, and self-produced cannabis - ie self-produced by users -  will be a thing of the past. Commercial enterprises (because government is pro-business, even when it comes to cannabis!) will now sell cannabis to approved medical cannabis users. According to evidence presented by medical users during said meeting, their bills would increase from 200$ (self-produced) to in excess of 50,000$ commercial-enterprise produced. Even if you take that claim with a pinch of salt, you can see that users will be taken for a ride here by government approved commercial producers, and you can also see that a whole bunch of users likely won't be able to access medical cannabis any longer. Giver the current government's ideological commitments... ein Schelm were boeses dabei denkt.

Clinical research to investigate whether cannabis actually works uncontroversially for particular patient groups is not on the horizon, after all, cannabis is a prohibited substance, so for clinicians to undertake the necessary research would be truly difficult. It goes without saying that this is a pretty bad status quo, but that's where we are.

I suggested during the conference that medical cannabis users should take a leaf out of early AIDS activism's book and engage in activism aimed at bringing political pressure to bear on government and research funding agencies so that the necessary research is undertaken. Turns out, the users were primarily concerned to get the right back to grow their own cannabis. They didn't care about much else. This is understandable, if you think the drug works for your pain, appetite issues etc, but it is bad health policy. It is also understandable on the background of the conservative government's pernicious attempt at increasing prices for medical cannabis to such an extent that only the very wealthy can access it. Surely there is an equity issues here, as far as the Charter of Rights and Freedoms is concerned.

Well, I began my talk by saying that I thought access to cannabis ought to be decriminalised, because a) there isn't a hell of a lot of evidence that cannabis is harmful, b) there isn't a hell of a lot of evidencethat it is an entrance drug, leading users to move on to more dangerous substances, c) the war against drugs has been a dismal failure in any case, and d) last but not least, more dangerous drugs (alcohol comes to mind) are currently legally available, which doesn't seem sound policy. Conveniently, the Sun Media journalist (for you outside Canada, that's a conservative media organisation) forgot to mention this and proceeded to quote me at great length about the need to undertake the necessary clinical research (which is something I did actually emphasise). Here's the newspaper report in the Ottawa Sun. 

Natural? Yes! - Abnormal? Yes!

Goodness, reading stuff from gay activists is sometimes as annoying as reading stuff from religious fanatics. There has been this fight between the two sides over two questions: 1) whether homosexuality is natural; and 2) whether homosexuality is normal.

Well people, let me settle it for ya. Homosexuality is, of course, natural unless you assume that something that has been occurring in nature for as long as we can trace natural history back isn't natural. Oh, your god says 'unnatural'. Well, that proves it then, doesn't it? Umpf, your god, natural or unnatural? Just asking. - Anyhow, admit it: you really have a normative understanding of naturalness, not a scientific understanding of nature. Let me put it to you then: You're cheating. Surely in physics you wouldn't suddenly redefine laws of physics to suit your bible stuff, or would you? Well, may be you would do even that.

The good news for you Bible people out there is that it actually doesn't matter whether homosexuality is natural or unnatural. There is so much nasty stuff going on there that is natural (rape being just one of those things) and that is immoral, that you can stick to your righteous condemnation of homosexuality. Enjoy!

Now, is homosexuality abnormal? Well, I must say, likely much to the horror of my fellow gays, of course homosexuality is abnormal. Any sensible understanding of normality would acknowledge that normal must refer to a statistical average. The statistical average behaviour, last time I checked, is heterosexuality. So, we are abnormal.

God people, hold your guns. The problem is that this ain't going to win you anything. I'm a university professor, my job security is higher than that of our prime minister, pretty abnormal wouldn't you say? I'm also someone who lived all his life without ever holding a driver's license. Pretty abnormal. I love collecting really expensive watches. Pretty abnormal. I do own a smartphone based on android, pretty normal. I'm Caucasian living in a town that is overwhelmingly Caucasian as far as its population is concerned, I'm pretty normal here. Try for your own person and ask yourself which features by the standards of your local community are average and how many of the features (or dispositions) are abnormal. You are the only Caucasian person in a rural area of sub-Saharan Africa? Abnormal! Anyhow, do the exercise for yourself. You will find that it's probably going to be a mixed bag. You will likely find that much of what you do is normal, that is, most around you, or even most around the globe do what you do (eat every day, for instance). If you are honest to yourself (or honest to your god) you will also find that some of the stuff you do (watching the Met Opera performances in your local cinema in a live broadcast) is pretty abnormal. Hell, for  all I know you might be driving a Rolls Royce around town. Abnormal!

The thing is, whether something is normal or abnormal tells us nothing, zero, zilch about the question of whether that something is a morally good or bad thing. It would be a naturalistic fallacy (ie a logic error) to assume that we could deduce from how certain things are like (or the majority of things) that they are morally good or bad or neutral. The same, incidentally applies to the naturalness questions I addressed earlier.

So, can we all move now on from here and argue our respective cases without engaging in these skirmishing activities?

'Gays Made, Not Born' - On the Confused State of the Religious Mind

Call it an easy target, blame me for going after the intellectually weak, but what is it about the Catholic pre-occupation with other people's sex lives and identities. And why are they consistently so confused both about the meaning of facts when it comes to sexual orientation as well as about the normative issues?

Jamaican Catholic Deacon Peter Espeut is as good an example as any to show what I am concerned about. Jamaica being a militantly anti-gay country where anti-gay discrimination was recently even enshrined in the country's constitution, courtesy to a large extent of campaigners like Catholic-Deacon-sociologist-turned-sex-expert Peter Espeut. Espeut writes in today's edition of the Jamaica Gleaner that gays are made, and that we are not born that way. Do read his contribution to public debate on that island to make sense of what follows below.

He takes the current absence of conclusive evidence of a genetic causation of homosexuality as evidence of a non-genetic causation of homosexuality. To give you just one example to illustrate how absurd this view of the nature of scientific inquiry is: According to Espeut's logic, HIV could not have been the cause of AIDS when it hadn't been discovered. Now, I am not suggesting that there is a genetic cause of sexual orientation, but to claim, as Espeut does, that it cannot have one because there isn't conclusive evidence at a certain point in time (ie today), is remarkably stupid. Perhaps that level of critical thinking skills is what predestines one to become a columnist for one of Jamaica's daily papers. Let's just note that this view on the causation issue constitutes a basic logic error and move on.

He then makes another logic error, and compounds it with plenty of excited exclamation marks. The exclamation marks have to do with not-blameworthy human characteristics such as the colour of our skin. As Espeut notes, 'we are born that way.' Implied is that we didn't choose to be that way, and that we are what we are in an immutable sense. Well, the thing is, there's plenty of things we have not chosen, yet they are immutable. Think about our language. Did we consciously choose it? Can we consciously dump it? Not quite. So, immutability is quite unrelated to the 'born that way' proposition. I do apologise for not using exclamation marks here, but do feel free to add them for emphasis in your mind.

Not surprisingly, Espeut being a sociologist, he then moves on to the next mistake, namely seeing the cause of sexual orientation in some parental behaviour. After all, having unjustifiably excluded genetic factors (and presumably, even though he doesn't say it, any number of possible non-social environmental factors), Espeut moves right on to his favourite possible causes of sexual orientation. Being a good sociologist he offers a lot of possible - but entirely speculative! - stuff, just in case.

He writes, 'But what causes gender-conforming and gender-non-conforming behaviour? Hormone imbalances may be one explanation. Others suggest that domineering mothers and ineffectual fathers may interfere with socialisation; and still others suggest that homosexuality may be triggered by having sexual encounters with members of one's own sex at an early age that prove to be very satisfying.'

As I noted before, Catholic Church staff and lay people have a perverse fascination with other people's sex lives. For the fun of it, let me note that 'hormone imbalances' invariably would invariably have causative genetic components. But hey, sociologists... - It is also worth noting that the language that is deployed here isn't exactly descriptive sociology, rather it is Catholic theology dressed up in pseudo-academic language. 'Domineering mothers', 'ineffectual fathers', plus (we are in Jamaica after all, so this still flies in public discourse) the invariable bullshit about pedophile homosexual grooming. Who, among serious sociologists or psychologists suggests the latter? Nobody that I'm am aware of. What is remarkable about Espeut's pet causes of homosexuality is that there is no more evidence for any of them then there is for his much-hated genetic causes. But that's what he believes in, so with all the weight that a degree in sociology and deaconessing in the Catholic Church provides, much credence is given to these baseless claims about the causes of homosexuality.

Espeut concludes thus, 'Let us not fall into line with 'gay-rights' propaganda by speaking as if LGBT behaviour is normal and natural. Unless you want to say that improper socialisation and dysfunctionality are normal and acceptable.' I have alerted you already to the Deacon's favourite rhetorical tool of using pejorative language ('improper', 'dysfunctional' etc) where argument would be required. Let me address the issue of homosexuality being abnormal and unnatural issue by copying here content from a Hastings Center Report article I published back in 1997. It's still true and shows us how little progress has been made on this subject matter. The fundamentalist religious in the world will turn around and continue their little flat-earth tirades as if nothing had happened at all. And mass media still give them outlets to vent their rage instead of asking them to seek professional help.

'Why is there a dispute as to whether homosexuality is natural or normal? We suggest it is because many people seem to think that nature has a prescriptive normative force such that what is deemed natural or normal is necessarily good and therefore ought to be. Everything that falls outside these terms is constructed as unnatural and abnormal, and it has been argued that this constitutes sufficient reason to consider homosexuality worth avoiding.[16] Arguments that appeal to 'normality' to provide us with moral guidelines also risk committing the naturalistic fallacy. The naturalistic fallacy is committed when one mistakenly deduces from the way things are to the way they ought to be. For instance, Dean Hamer and colleagues commit this error in their Science article when they state that "it would be fundamentally unethical to use such information to try to assess or alter a person's current or future sexual orientation, either heterosexual or homosexual, or other normal attributes of human behavior."[17] Hamer and colleagues believe that there is a major genetic factor contributing to sexual orientation. From this they think it follows that homosexuality is normal, and thus worthy of preservation. Thus they believe that genetics can tell us what is normal, and that the content of what is normal tells us what ought to be. This is a typical example of a naturalistic fallacy. Normality can be defined in a number of ways, but none of them direct us in the making of moral judgments. First, normality can be reasonably defined in a descriptive sense as a statistical average. Appeals to what is usual, regular, and/or conforming to existing standards ultimately collapse into statistical statements. For an ethical evaluation of homosexuality, it is irrelevant whether homosexuality is normal or abnormal in this sense. All sorts of human traits and behaviors are abnormal in a statistical sense, but this is not a sufficient justification for a negative ethical judgment about them. Second, 'normality' might be defined in a functional sense, where what is normal is something that has served an adaptive function from an evolutionary perspective. This definition of normality can be found in sociobiology, which seeks biological explanations for social behavior. There are a number of serious problems with the sociobiological project.[18] For the purposes of this argument, however, suffice it to say that even if sociobiology could establish that certain behavioral traits were the direct result of biological evolution, no moral assessment of these traits would follow. To illustrate our point, suppose any trait that can be reasonably believed to have served an adaptive function at some evolutionary stage is normal. Some questions arise that exemplify the problems with deriving normative conclusions from descriptive science. Are traits that are perpetuated simply through linkage to selectively advantageous loci less 'normal' than those for which selection was direct? Given that social contexts now exert 'selective pressure' in a way that nature once did, how are we to decide which traits are to be intentionally fostered? Positions holding the view that homosexuality is unnatural, and therefore wrong also inevitably develop incoherencies. They often fail to explicate the basis upon which the line between natural and unnatural is drawn. More importantly, they fail to explain why we should consider all human-made or artificial things as immoral or wrong. These views are usually firmly based in a non-empirical, prescriptive interpretation of nature rather than a scientific descriptive approach. They define arbitrarily what is natural and have to import other normative assumptions and premises to build a basis for their conclusions. For instance, they often claim that an entity called "God" has declared homosexuality to be unnatural and sinful.[19] Unfortunately, these analyses have real-world consequences. In Singapore, unnatural acts are considered a criminal offence, and "natural intercourse" is arbitrarily defined as "the coitus of the male and female organs." A recent High Court decision there declared oral sex "unnatural," and therefore a criminal offence, unless it leads to subsequent reproductive intercourse.

In the United States, several scholars and lesbian and gay activists have argued that establishing a genetic basis for sexual orientation will help make the case for lesbian and gay rights. The idea is that scientific research will show that people do not choose their sexual orientations and therefore they should not be punished or discriminated against in virtue of them. This general argument is flawed in several ways.[23] First, we do not need to show that a trait is genetically determined to argue that it is not amenable to change at will. This is clearly shown by the failure rates of conversion therapies.[24] These failures establish that sexual orientation is resistant to change, but they do not say anything about its ontogeny or etiology. Sexual orientation can be unchangeable without being genetically determined. There is strong observational evidence to support the claim that sexual orientation is difficult to change, but this evidence is perfectly compatible with non-genetic accounts of the origins of sexual orientations. More importantly, we should not embrace arguments that seek to legitimate homosexuality by denying that there is any choice in sexual preference because the implicit premise of such arguments is that if there was a choice, then homosexuals would be blameworthy.

Bioethics 11th World Congress Special Issue

Volume 27, Issue 6 Pages 291 - 355, July 2013 Special Issue: International Association of Bioethics 11th World Congress SPECIAL ISSUE PAPERS IAB Presidential Address: Contextual, Social, Critical: How We Ought to Think About the Future of Bioethics (pages 291–296) Angus Dawson Article first published online: 29 MAY 2013 | DOI: 10.1111/bioe.12037 Global Health and Justice: Re-examining our Values (pages 297–304) Solomon R. Benatar Article first published online: 29 MAY 2013 | DOI: 10.1111/bioe.12033 Climate Change is a Bioethics Problem (pages 305–308) Cheryl Cox Macpherson Article first published online: 29 MAY 2013 | DOI: 10.1111/bioe.12029 Grandparents' entitlements and obligations (pages 309–316) Heather Draper Article first published online: 29 MAY 2013 | DOI: 10.1111/bioe.12028 They Can't Have My Embryo: The Ethics of Conditional Embryo Donation (pages 317–324) Lucy Frith and Eric Blyth Article first published online: 29 MAY 2013 | DOI: 10.1111/bioe.12034 Not the Usual Suspects: Addressing Layers of Vulnerability (pages 325–332) Florencia Luna and Sheryl Vanderpoel Article first published online: 29 MAY 2013 | DOI: 10.1111/bioe.12035 Vulnerability in Research Ethics: a Way Forward (pages 333–340) Margaret Meek Lange, Wendy Rogers and Susan Dodds Article first published online: 29 MAY 2013 | DOI: 10.1111/bioe.12032 Toward a Critical Ethical Reflexivity: Phenomenology and Language in Maurice Merleau-Ponty (pages 341–347) Stuart J. Murray and Dave Holmes Article first published online: 29 MAY 2013 | DOI: 10.1111/bioe.12031 The New Genetics and Informed Consent: Differentiating Choice to Preserve Autonomy (pages 348–355) Eline M. Bunnik, Antina de Jong, Niels Nijsingh and Guido M.W.R. de Wert Article first published online: 29 MAY 2013 | DOI: 10.1111/bioe.12030

Egypt well on its way to becoming a decent Middle Eastern theocracy

Given the drama currently unfolding in Turkey, a significant development affecting a critic of Islam in Egypt has probably been missed by many of us. The German news magazine DER SPIEGEL has reported prominently about the case, alas only in German language, thereby not exactly helping the situation.

The German-Egyptian intellectual and author Hamed Abdel-Samad gave a talk in Cairo last week where he publicly criticised the ideology of Islam (the religion as much as what goes under the label of political Islam). He specifically criticised tendencies in this ideology that he described as 'religious fascism' and that he suggested are a direct result of its prophet Mohammed's teachings.

Abdel-Samad might be right, he might be wrong, I am not an Islam expert. Whether this political scientist and Islam expert is right or wrong is neither here nor there to be honest. What happened subsequently is the real scandal: Just to prove him wrong close allies of Egypt's President Mursi were quick to denounce him on national TV and called for him to be killed. True to form this sort of stuff goes these days down well in Egypt's academia, namely in its centre of Islamic academic excellence, al-Azhar university. Mahmud Schaaban, professor of rhetoric and himself an explicit opponent of secularism in any form, calls Abdel-Samad an apostate and notes that even if he regrets what he has said, he must be killed. His regret might help him in his afterlife, but meanwhile he just must get killed. Noteworthy perhaps that the university has not called its rhetoric expert to order over his call for mob justice. I kinda doubt that this is covered by academic freedom and might just constitute a form of academic misconduct conducive to bringing the institution where he works into disrepute. It's a firing offense elsewhere. But hey, perhaps I am assuming too much here.

Welcome to Egypt 2.0, where this sort of stuff can be propagated on various national TV channels without any critical comment from government officials. Calls from the German government's human rights czar upon the Egyptian government to distance itself from this call for mob justice remain until now unanswered.

Abdel-Samad has since gone underground, knowing that there are now folks out there to get him, in the name of Islam.

On Not Speaking at Brockville General Hospital - and, Why Re-scheduling and Cancelling Are Different Things

Something pretty outrageous happened to me today, I have essentially been cancelled as the keynote speaker at Brockville General Hospital's Annual General Meeting in mid June. How did I find out? Its new CEO, Tony Weeks, called me at home early this morning.

He explained to me that the reason for the 're-scheduling' was that there's so much interest in said keynote presentation that they'd need a bigger room. I was a bit surprised, but it is true that the topic in question (assisted dying) tends to generate a lot of interest and large turn-outs. Well, shortly thereafter I received an email with a press release from the hospital. It turns out that the 're-scheduling' actually was a bit of a euphemism, cloaking what's actually a cancellation of the event in question. Here's an excerpt from the medial release:

'“We received a mixed response to our keynote presentation,” says BGH President  and CEO Tony Weeks. “Naturally, people are divided on this important issue. The clear message from our community was that a debate is needed, not just a single presentation. As our AGM cannot accommodate a full debate, we have decided to reschedule Dr. Schuklenk’s presentation to a larger venue as part of a community information and debate event on this topic.”'

So, my keynote lecture is transformed from a single presentation to one with several presentations. Because even during the AGM a Q&A session was planned. In other words, the event I was invited to as keynote speaker was not re-scheduled, it was cancelled. A new event is seemingly now envisaged with a debate format (for and against, that sort of thing). There's nothing wrong with having for and against type of events (I recently debated the activist chief of the Euthanasia Prevention Coalition at Queen's, so I've been there, done that sort of event, too). However, it is disingenuous (I can think of stronger terms) to pretend that a re-scheduling is taking place when really a different event altogether is envisaged.

Now, what was the bone of contention, ie what was I invited to speak about? I meant to present in about 30-35 min the main arguments from the Royal Society of Canada Report on the issue of assisted dying. In those 30-35 minutes I proposed to present the positive case for decriminalisation and deal with two serious concerns about such a policy change, namely the risk of abuse and the question of whether or not assistance in dying is compatible with health care professional roles.

It seems at Brockville General Hospital such a presentation must not be given without someone disagreeing, as part of a panel debate. It is disconcerting that the hospital has given in to activist pressures (aka 'community concerns') to accommodate the anti-choice views. How often speak folks like anti-choice academic Margaret Somerville in health care settings without anyone requiring that the other point of view must be heard exactly at the same time. It is pretty silly stuff to be honest.

This whole thing begs also the question why the hospital didn't ask me to present arguments for and against the decriminalisation of assisted dying, as any decent ethicist would be able to do. I also wonder why no effort was made to communicate the activists' concerns and discuss what I could do in my presentation to address them. Nope, just give him a ring roughly a fortnight before the event and call the cancellation a re-scheduling. Should do the trick.

None of this reflects well on Brockville General Hospital. I hope they will be able to source speakers for their next events, because who of sane mind would prepare a presentation (scheduled for many many months ahead of the event) knowing that anything can happen if the right people call and email the right people.

Yay! We are 'Available' - Sort of

 Another milestone on the road to the final release of our up-coming '50 Great Myths About Atheism' ... it is available for pre-order on amazon.com. Check out the wonderful praise it has received: “It has been my lot to have encountered all but three of the 50 Great Myths about Atheism listed by Blackford and Schüklenk, most of them many times. It is useful to have them all listed in one book – and so readably and authoritatively refuted. The long final chapter treats theological arguments with more respect than I would have bothered with, but the refutation is all the more convincing for that. The whole book builds inexorably to its conclusion: the Reasonableness of Atheism.”

—Richard Dawkins, author of The God Delusion

“With humor, wisdom and sound philosophy, Blackford and Schüklenk dismantle 50 important myths about atheism.  In doing so, they have done atheists and religious believers a great service, for putting aside the myths enables us to see where real differences remain.”

—Peter Singer, Princeton University

"Atheists are routinely called ‘aggressive,’ but their strong values include a tolerance rarely shown them by the religious. This book's calm ripostes defend atheists everywhere against unreasoned assaults from the dwindling faithful. " 

—Polly Toynbee, The Guardian

“Busted! Fifty times over! So say Blackford and Schüklenk — the New Mythbusters—with reason, conviction and style. I enjoyed this book immensely.”

—Graham Oppy, Monash University

“A brilliantly wide-ranging exploration of misconceptions about atheism and their relationship to our ideas about minds, human nature, morality – for pretty much everything we care about.”

—Ophelia Benson, co-author of Does God Hate Women?

“This is a book that’s as enjoyable to read as it is informative. Sharp, clever, and witty, it systematically dismantles misconceptions about atheism. Even God could learn something from it!”

—Ronald A. Lindsay, President, Center for Inquiry