Maxwell Smith, PhD
@maxwellsmith
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Bioethicist, Associate Professor, and CIHR Applied Public Health Chair in Ethics & Health Emergencies @WesternU . Associate Director @rotmanphilo . Views my own.
London, Ontario
Joined September 2008
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Why should I cover my mouth when I sneeze? If others are afraid, they can cover THEIR mouths when I sneeze.
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I'm also an ethics prof at
@WesternU
. She calls herself an "authority on ethics". If she deserves this title, I must as well (though my area of expertise is *actually* public health ethics & I led WHO's policy brief on the ethics of vaccine mandates), & I disagree with her. 1/2
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It's ironic that decision-makers need to see mass infection, illness, and hospitalization to justify implementing *preventive* public health measures.
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With eyes wide open, public health officials are making moves that worsen our health and exacerbate inequities, the precise opposite of public health's mandate.
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Umm...for those that don't understand this is satire...it's satire.
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You can freely refuse the jab at a vaccine clinic. Your choice. This is the important moral sense in which consent is voluntary. A *job* requiring vaccination doesn't make your consent less voluntary, just like a job requiring a degree doesn't make going to college involuntary.
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If Pierre Poilievre so staunchly opposes mandates, maybe we shouldn't give him one?
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1/ Mask mandates are commonly justified in two ways. The first concerns population-level transmission dynamics. If a mandate is expected to have little or no impact on such dynamics, many will be quick to dismiss a mandate. But this ignores the second justification: inclusion. 🧵
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Simply updating the definition of 'fully vaccinated' to 3 doses and reporting that only 47.26% of Canadians are fully vaccinated would be an effective means of increasing uptake. Such low-hanging fruit.
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The main takeaway from Dr. Moore attending a party unmasked after urging Ontarians to mask indoors isn't that the man is hypocritical, it's that this undercuts the force of his recommendation and in turn threatens the public's health.
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"We can't continue to live in fear." Except, people don't advocate for public health measures out of fear. They do so because they see a path to improving people's health and reducing inequities - you know, the mission of public health.
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"Why is the science different
@WesternU
?"
In fact, booster doses are mandated at Harvard, Yale, Penn, Columbia, Brown, Dartmouth, NYU, Stanford, etc., etc., and in some cases have been since the beginning of 2022.
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Personal risk assessments are inadequate for communicable diseases because you're both a potential victim of the disease AND a potential vector of transmission. Risk assessments should consider the risks you face but also the risks you pose to others.
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To be clear: it's certainly possible to make a sound ethical argument against vaccine mandates (even though I think more persuasive arguments can be made to support them). This just isn't it, & we should treat claims supported by appeals to "authority in ethics" with suspicion.
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2/ Equity demands inclusion. Making masks optional risks excluding people who rely on those around them to mask to protect their health/loved ones' health.
(Retorts that mask mandates risk excluding those who prefer not to mask ignore that these risks are clearly asymmetrical.)
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The strength of a position in ethics comes from the support provided via reasons & arguments, not that it's uttered by an ethicist. And her reasons used to support her position are distorted by falsehoods & concern areas about which she has no apparent expertise🧵
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Ethicists aren't necessarily known for taking clear-cut positions. But the fact that we can't easily access free or low-cost rapid tests 21 months into a pandemic? That's wrong.
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4/ That's why there's an especially compelling reason to be inclusive in non-discretionary settings (e.g., classrooms, health care, work, public transport, etc.). Where people have no choice but to be in such settings, we should make those settings as safe as possible for *all*.
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7/ This isn't unusual. We ban nuts and peanuts in schools even though there are many other places kids can and will be exposed to nuts and peanuts. The ban has no effect outside the school walls, but it makes *schools* safer, and, hence, more inclusive, and that's the point.
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People didn't wear masks prior to 2020 and so are keen to ditch them & other measures for a "sense of normalcy." But "normal" pre-2020 also included no COVID illness & death. So, it seems we're abandoning any semblance of normalcy in the latter to achieve normalcy in the former.
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(Though, I would never call myself an 'authority on ethics'. My views on what are right & wrong are not 'authoritative'. Rather, I have *expertise* in, eg, ethical reasoning, ethical dimensions of public health issues. Not: "I'm an ethicist, whatever I say is right".) 2/3
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Waiting until there are no more pediatric ICU beds in the province to introduce *preventive* measures is a failure of public health.
Will Doug Ford and Kieran Moore change their stance on masking? Experts say it’s time.
As hospitals struggle with triple threat of COVID, influenza and RSV, a growing chorus of voices say the moment has arrived.
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5/ This is the reason it remains coherent to require masks in university classrooms, for instance, even though students can and will do many other things that don't require masks (e.g., go the bar). It ensures the places *all* students *must* go are as safe as can be.
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Stop framing public health as rewards & punishments. The unvaccinated aren't 'punished' when they're denied access to concerts & theatres any more than restaurants are 'punished' when they're shut down for failing health inspections. It's about keeping people safe & healthy.
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"Given the educational cost of healthy children missing school, we understand and respect your decision to send your kids to school with measles."
Because there's no way sending your kids to school with measles could lead to children missing school...
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"It is usually recommended that individuals without history of prior [measles] infection or vaccination stay home for up to 21 days."
"With that being said, you do you."
#BREAKING
:
#Florida
@FLSurgeonGen
sends letter to parents re:
#measles
outbreak at
#Weston
’s
@ManateeBayElem
. “DOH is deferring to parents…to make decisions about school attendance. This recommendation may change as epidemiological investigations continue.”
@WPLGLocal10
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@DFisman
@amandalhu
When lifting public health measures to 'align with society' reveals just how ugly society can be.
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6/ In fact, because some students will do many other things that don't require masks, mask mandates become even more important in the few settings that require those students and others (especially students at high risk of severe outcomes) to study or work closely together.
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8/ N.B.: One-way masking is capable of reducing risk for the wearer (). But we know masks work best to prevent the spread of SARS-CoV-2 when everyone wears one ( ). Hence, universal masking will tend to be more inclusive.
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3/ In other words, a mask mandate might find its justification in the fact that it helps to protect those 'in the room'/'on the plane'/etc., and specifically those who are at greatest risk, irrespective of whether this impacts broader population-level transmission dynamics.
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"If you notice any of the above symptoms, do not abruptly visit your health care provider without contacting them in advance. But it's your call if you'd like to send your kid to school."
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Court dismisses application against
@WesternU
. "I do not accept the Policy will “force” members of the university community to disclose their personal information...The choice is the individual’s to make. Each choice comes with its own consequences. That is the nature of choices"
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Take it from a public health ethicist: the vision of public health to help the most vulnerable is grounded in aspirations of social justice, not "doing the greatest good for the greatest number."
@EpiEllie
@AndrewMakeTweet
@j_g_allen
Public health is about doing the greatest good for the greatest number. Continuing to shut down schools and harm the economy won’t help the most vulnerable. We need better treatments for the immunocompromised, while we also recognize that good health is not just absence of covid.
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"Inevitable" means "cannot be avoided." Surely, then, it'd be a mistake to say "getting COVID is inevitable" while dispensing with the very measures known to help us avoid it.
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The fact that any Canadians are inadvertently getting an older formulation of the COVID vaccine when they intended (laudably) to get the updated XBB vaccine is such an unforced error. Beyond regulatory curiosities it shows how abysmal messaging about the updated vaccine has been.
Canada has made Covid-19 vaccines convoluted. In the US, FDA de-authorized OG + bivalent versions, we have yet to do so. We will be seeing many reports of incorrect vaccines being administered.
There also aren't clear guidelines re: primary doses with XBB for those above age 5.
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Right-handed people make up a majority of covid deaths.
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Let me get this straight. Mandatory vaccination is coercive and an unjustified infringement on rights, but mandatory pregnancy is just fine?
#RoeVWade
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9/ N.B.: To be clear, justifications of mask mandates should *begin* with an analysis of their impact on population-level transmission dynamics and/or inclusion. A full justification will of course require a more comprehensive analysis involving other considerations. /thread
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My mask protects you, your mask protects me.
Prematurely removing mask mandates while instructing those at risk to keep wearing them is akin to saying we do not have collective responsibilities to protect those at risk. In fact, it says we're okay with increasing their risk.
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Evidently, public health is now incapable of even endorsing "stay home when sick."
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Really not looking forward to people pointing to plateauing or decreasing case counts as evidence of progress against Omicron, arguing in turn that public health measures ought to be eased, despite knowing full well that eligibility for testing has been significantly restricted.
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@WesternU
has announced that it's implementing a
#COVID19
vaccination policy for all students, staff, & faculty on campus. Prudent & smart. As a public health ethicist, I thought I'd address some frequently raised concerns about vaccination policies and
#vaccinationmandates
1/13
#COVID19
Update: All
#WesternU
,
@kingsatwestern
,
@huronatwestern
,
@BresciaUC
students, staff and faculty who plan to be on campus this fall will be required to demonstrate proof of vaccination.
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Discrimination means wrongfully imposed disadvantageous treatment, not simply differential treatment. While people were treated differently based on vaxx status, this wasn't wrongfully imposed because vaxx status is not immutable + it helped to ensure rights to health and safety.
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@ptullochott
@MGirash
@WesternU
Even though it's attractive, I think we need less 'us vs them' & more 'we're in this together, let's act like it & each do our part to prevent avoidable suffering & deaths'. I am of course not convinced this tack will get us anywhere, but it seems we need more of this these days.
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We endlessly scrutinize whether mask mandates "work" but don't seem to care that merely recommending them does not.
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If choice 1 (to work in healthcare) requires that you make choice 2 (to get vaccinated), but you don't *have* to make choice 1 (to work in healthcare), then you aren't being *forced* to make choice 2 (to get vaccinated). Choosing whether to meet employment conditions = your call.
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How is it that the next several weeks & months are so uncertain but at the same time so predictable? Make no mistake: the prospect of school closures, overwhelmed hospitals, & delayed care are a result of policy failures. An ethical imperative exists to *prevent* these outcomes.
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@nilikm
@TheAgenda
I at least liked that you were given the opportunity to carefully explain to the viewers why - and you did an excellent job doing so. 🙌
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A new vax requirement for a job you already have is an issue of labour law & contracts, not informed consent. Employment conditions can change, like when new health/safety measures are needed because of a pandemic. Again, choosing whether to meet those new conditions = your call.
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👇This is public health. Unfortunately, we have been led to believe 'living with COVID' means removing public health measures until none are remaining, rather than introducing structural interventions that protect us as we go about our daily lives.
“Like fluoridation of drinking water to prevent tooth decay & road & vehicle design improvements to increase road safety, structural interventions that reduce the concentration of SARS-CoV-2 particles in the air can protect ⬆️people w ⬇️ individual effort”
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This is why it would be more accurate to revise
#ChoiceNotUnemployment
to be
#ChoiceAboutUnemployment
. Choosing not to accept reasonable employment conditions is just that: a choice.
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Just because something is a "personal choice" doesn't mean there aren't "right choices" and "wrong choices." Even if people aren't required to do something, this doesn't mean their choices cannot be ethically objectionable or that we can't say there's a choice they "should" make.
After Ontario’s top doctor urged indoor masking to slow the spread of respiratory viruses, Health Minister Sylvia Jones said it’s a “personal choice” and rejected calls for mass advertising campaigns on wearing masks and getting flu and COVID-19 vaccines.
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Note the unambiguous language of
@WHO
's COVID Technical Lead and Director of Epidemic and Pandemic Preparedness and Prevention:
COVID is still a pandemic.
Important thread ⬇️
Long🧵
#COVID19
and where we are. I’m worried.
We are entering the 5th year of the pandemic and we are certainly in a different phase. This phase is marked by an evolving virus (with the XBB and BA.2 sublineages circulating and JN.1 becoming dominant).
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Whereas assessing & acting on the risks you face comes down to your personal risk tolerance, assessing & acting on the risks you pose to others comes down to things like empathy, compassion, moral imagination, and a commitment to justice. The latter appear to be in short supply.
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Despite all the interest in learning lessons for the *next* pandemic, it seems there's little interest in learning anything for the current one. IMO, the best indicator of whether we've learned any lessons for future pandemics is whether we're willing to put them into action now.
“Emergency departments in Italian hospitals are in chaos and on the verge of collapse” says this
@euronews
article - with respiratory infections in the elderly a major factor.
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"It's a personal choice whether to act collectively" is not how collective action works.
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It's crucial the public understand that recent COVID policy decisions have been made not because they're evidence-based, prudent, or good for their health, but because our govs have been backed into a corner due to poor planning, policy failures & consequent limited alternatives.
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As we tally lessons from COVID, it's attractive to think the lesson here is that "SARSCoV2 is airborne."
But the real lesson is that we cannot afford to ignore a threat unless and until an *entire paradigm shift* occurs in a scientific community affirming that threat.
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My 2024 resolution is to work out more - work out my immune system, that is! From what I gather, I need to expose myself as much as possible to COVID, flu, RSV, polio, measles, etc. No pain, no gain! Can't believe I haven't been prioritizing my health all these years.
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We successfully normalized these expectations for sexually transmitted infections - no, you can't forgo a condom just because *you* are personally comfortable with the risk. All parties must take responsibility. Why is this so hard to comprehend for other communicable diseases?
Agreed but there is a reciprocal right to not be exposed to your comfort with risk
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Excited to share the news that I was granted tenure and promoted to Associate Professor
@WesternU
. A great way to end 2023, a year where I also became a Western Research Chair in Public Health Ethics and was awarded the
@westernuFHS
Teaching Award of Excellence. 🎉🎉👇👇
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Should we call policies "good" because they "align with society"?
"One major reason this is an error is that it virtually ensures the moral status quo. If the way things are exhaust our sense of the way things ought to be, we will never strive for moral and ethical improvement."
As of October 1, all measures at the border will be dropped, including the mandates for masks.
I would still encourage folks to stay up to date with vaccines and consider masking based on individual risk.
But this aligns with society. Good.
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And that choice is not rendered 'involuntary' because it is 'coerced'. Coercion is "a threat that makes a certain choice irresistible" (). 'Irresistible' means that only one reasonable course of action remains open - it isn't about *disliking* your choices.
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Important lessons of the COVID pandemic are ironically missed when we do post-mortems on a pandemic that's still a pandemic.
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Ponesse says she's 'just asking questions' re: ethics & vaccines. But as a fellow ethics prof
@WesternU
who served on Ontario's Vaccine Task Force, led Ontario's ethics framework for vaxx distribution + WHO's brief on ethics & vaccine mandates, she hasn't asked me any. Telling.🧵
‘I wouldn’t pass her in my ethics class’: Medical ethicist pans London professor who spoke against vaccine mandates at PPC rally
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Thrilled to be named a
@CIHR_IRSC
Applied Public Health Chair in Applied Ethics in Health Emergencies. Over the next 6 years, I'll be partnering with public health decision-makers to conduct research that will enhance 'ethical preparedness' for future public health threats.
💡 A challenging world requires innovative thinkers.
That’s why the Government of Canada is investing in 12 new Applied Public Health Chairs, mid-career researchers committed to improving health and health equity.
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When decision-makers ease or remove public health measures as soon as it's evident a wave has peaked, it suggests they think waves operate like a hurricane that comes & goes, not that we play an active role in shaping them, in shaping their decline.
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Universities: "We'd like to see more research aiming to learn lessons from the pandemic."
Researchers: "We've learned we have a tendency to drop measures prematurely."
Universities: "Great stuff. BTW, we've decided to drop measures prematurely."
While universities *have* masking but are dropping them in a few days.
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'Instead of “What should we have done differently?” I say, “What can we do differently today?”'
'There’s a lot of complacency at the individual level, and more concerning to me is that at the government level.'
Wearing a mask? "A no-brainer."
“We’re still in a pandemic,” says a lead COVID official with the World Health Organization
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In which I argue 1) the shift to 'personal responsibility' represents a retreat from "we're all in this together", 2) pandemic fatigue doesn't nullify ethical obligations to protect public health & reduce inequities, 3) mandates can be ethically justified, but the details matter.
The provincial government is taking a "back to normal" approach to COVID-19 this fall, leaving it up to institutions to decide their own restrictions.
@spaikin
spoke with
@nilikm
,
@strauss_matt
&
@maxwellsmith
about masks and vaccination mandates.
#onpoli
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For a forceful argument as to why pandemic fatigue and other practical challenges do not nullify our ethical obligations to protect public health and reduce inequities, see
@prof_goldberg
's excellent analysis here:
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#VaccinePassports
are a measure intended to facilitate societal & economic reopening while still trying to reduce community transmission & avoid lockdown. They should be seen not as "imposing restrictions on the unvaccinated" but rather "easing restrictions for the vaccinated"🧵
I can confirm what
@brianlilley
and
@ColinDMello
have reported: Proof of vaccination will be required in Ontario as of Sept. 22 for indoor restaurants, gyms, theatres, concerts- not patios or retail - vax receipt/govt ID to start followed by an app expected later in Oct.
#onpoli
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"Living with the virus" = pandemic privilege.
In a context of inequities in access to tests, vaccines & therapies, inequities in infections, hospitalizations & deaths, & inadequate paid sick leave & other social supports, it's only the privileged who can 'live' with the virus.
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Perhaps we need to revise the precautionary principle to be even clearer:
"When an activity raises threats of harm to the environment or human health, precautionary measures should be taken even if the scientific nature of the threat has yet to become dogma."
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At what point do we simply replace the entire public health apparatus with an alarm?
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Pleased to share that our updated
@WHO
policy brief on the ethics of mandatory vaccination for COVID-19 has now been published and can be found here:
@upshur_ross
@JoWolffBSG
@Thaliaarawi
@AnantBhan
@ZekeEmanuel
@fadenethx
@CalvinWLHo
@MohgaKamalYanni
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As a member of Ontario's COVID-19 Bioethics Table, adding my voice to those of my colleagues. Enhanced police powers are likely to disproportionately harm Black, Indigenous, and other marginalized populations.
Adding my voice to this as another member of the Ontario COVID-19 Bioethics Table. This is not an evidence-based, proportionate, reasonable response that uses the least restrictive measures. And the burden of these measures will be born disproportionately by racialized people.
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@XxDeadboy
Like when we had no community transmission of influenza in Canada during the 2020-2021 flu season due to the measures taken for COVID? When normally we experience ~3,500 deaths in a flu season?
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A 'public health' that is resigned to simply meeting people where they're at is redundant.
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An it's important to acknowledge that "normal" to some in this context will mean "greater risk" for others.
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Homecoming
@WesternU
starts in 10 days. Given the institution's sordid history with fake homecoming (FOCO) & the events of last week, the university must go above & beyond to prevent COVID transmission & sexual violence on & off campus. We cannot simply admonish after the fact.
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Perhaps not the most equitable idea to use financial penalties when there's a socioeconomic gradient in vaccine uptake.
Quebec Premier Francois Legault says the province will start charging people who refuse a COVID-19 vaccination an additional fee for health care. He says the exact amount hasn’t yet been decided. He says the charge wont apply to people with valid medical exemptions
#cdnpoli
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Fatal flaw: the result of personal risk/benefit calculations for interventions that impact other people is mediated by how much one cares about other people (i.e., how to weight risks/benefits to others vs. risks/benefits to oneself).
Masking up is a risk/benefit calculation. If you’re young, healthy, up-to-date on your vaccinations and you're not worried about long Covid, it may be reasonable to unmask. But if you're medically vulnerable or around people who are, or worried, you might want to adjust. 2/
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@FourWinns298
"We will not prohibit people from smoking on planes or indoors. It turns out people LOVE to smoke. This aligns with society. Good."
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To put this in overtly ethical language (which I think is important to do): we should not accept 15,000 deaths a week from COVID if it is within our power to make that number lower without thereby sacrificing anything of comparable moral importance.
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Would've preferred a greater focus on prevention (not only recommending masking when health systems are impacted - let's prevent this!) + source control and taking steps to protect the most vulnerable (not only recommending masking for the high risk - we can reduce their risk!)
NEW - I talk to Dr. Moore about the new COVID update shot that is rolling out, why he’s not more visible in promoting it, and what he’s expecting out of the new variant. My full, unedited interview.
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"Masking as a disability accommodation in health care settings should be recognized as part of physicians’ ethical obligations."
I would also support a general principle (which applies outside health care settings) that is equity-promoting: see a mask, wear a mask.
What can be done when providers refuse to mask to accommodate immunocompromised patients
@Mical_Raz
@DrZackaryBerger
& I suggest interventions involving regulatory bodies in a new piece
@JAMAHealthForum
. W references to
@KatAMacfarlane
's work.
#CripTheVote
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Vaxx policies/mandates do not force anyone to be vaccinated. It's erroneous to call this a forced medical intervention or to reference Nuremberg. Informed consent is still required and people can still choose to not be vaccinated. There are simply consequences to one's choice. /2
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When confronted with stories like this we should feel compelled to find areas in our lives where we could make sacrifices to lessen the heavy burden experienced by the most vulnerable & least advantaged. The reality? Tonight's Raptors game proceeds with a capacity of 10,000 ppl.
Ontario stops visits, social trips for long-term care residents as
#Omicron
spreads via
@globeandmail
@NeglectedNo
#COVID19
#onpoli
#eldercare
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'Learning to live with the virus' is code for 'choosing to ignore the virus'. If people were actually interested in 'learning' to live with the virus, they'd be figuring out a path to normality that's compatible with the well-being of society's most vulnerable & least advantaged.
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Those who are 'loath' to using mandates argue we should first use every tool at our disposal before making something compulsory. And yet, we're doing virtually nothing to increase masking. Make quality masks available, full court press on education + communication, etc. But nope.
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Great. But the view from critical care alone should not dictate priorities for public health. Imagine if public health "moved on" from preventing and mitigating population health threats simply because they didn't overwhelm or immediately show up in ICUs?
I personally have NOT taken care of a ventilated covid pt since January. The landscape has changed. This is why many of us have been saying it’s safe to move on.
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Public health is what we, as a society, do *collectively* to assure the conditions in which people can be healthy.
Yet, governments are systematically removing collective measures related to the pandemic. Is there no longer a role for public health in this public health crisis?
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Is there significant SARS-CoV-2 in the community? Yes.
Do masks reduce the risk of spreading SARS-CoV-2? Yes.
That's kinda all you need to know.
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In fact, as
@DiegoSilvaPhD
,
@upshur_ross
, & I have argued, public health will sometimes perpetuate or worsen the struggles of the least advantaged & most vulnerable due to misunderstanding & uncritically aligning its goals with utilitarianism.
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