like manner, my comments on the articles that I quoted referred to the efficacy of testing, not its philosophy. As for the article's substance, Somerville states in her reply to me that "6protection of public health is not a valid justification for excluding people with HIV from Canada". Two paragraphs later she states: "Because prospective immigrants with HIV are not per se a threat to public health they are comparable to persons with Huntington's chorea and other inherited conditions (which are also 'transmissible')." Somerville and I, it seems, are on completely different wavelengths, but, then, I have no legal qualifications and, despite her title, she has no medical qualifications. Somerville and her legal colleagues have made AIDS unique, requiring that medical practitioners obtain informed consent to test for it. Ironically these efforts have protected the disease rather than the public. Somerville does not seem to comprehend the difference between inherited transmissibility and infectivity. Protection of the public health does not seem to be a legal consideration. However, people promoting policies that disregard proven physiological principles of epidemic containment will not be considered blameless by succeeding generations, particularly AIDS victims. Sooner or later we will have to return to "John Snow and the handle of the Broad Street pump". James E. Parker, MB 303-2151 McCallum Rd. Abbotsford, BC
[Dr. Somerville responds.] Dr. Parker's logic is difficult to follow. Is he suggesting that the rules on inadmissibility to Canada on health grounds governing immigrants and refugees are different from those governing "the admissibility of HIV-positive people 1182
CAN MED ASSOCJ 1990: 142 (I 1)
to Canada"? If so, he is incorrect. The same sections of the Immigration Act of 1976 govern this matter for both groups. If we are not going to use the results of HIV antibody testing to influence our decisions on inadmissibility to Canada on medical grounds or possibly even to determine this, there is no justification at all for doing this testing on immigrants and refugees. Both legislators and public health physicians must work from an initial presumption. If, as Parker claims, he does not propose "a presumption against allowing the entry of HIV-antibody-positive people", then he must have adopted the opposite presumption (to which, of course, there may be exceptions), that such people should be allowed entry to Canada. In this case he and I are entirely on the same "wavelength", despite our different qualifications. Moreover, when one considers his initial serious disagreement with me, our ability to reach such concordance through correspondence in the pages of CMAJ could be seen as an excellent example of the benefits of transdisciplinary scholarship, which is nowhere more essential than in dealing with the complex issues raised by HIV infection and AIDS. It is a paradox that we have engaged in this form of scholarship when it seems that Parker is opposed in principle to
physicians working with people from outside medicine on what he views as purely medical matters. Parker is correct that the rules governing immigration, as with the rules governing all activities in our society, are "a matter for legislators". But under the provisions of the Immigration Act of 1976, inadmissibility to Canada on medical grounds is not, in day-to-day practice, such a matter. The legislature has delegated the power to decide this to a medical officer of health, provided this judgement is concurred in
by at least one other medical officer of health. It can even be argued that under the provisions of the act the minister of immigration cannot override decisions of medical officers of health in this respect. The word "transmissible" was within quotation marks in my response to indicate its out-of-theordinary use. In particular, this usage indicates that fruitful insights can be gained by comparing our approaches to situations involving on the one hand genetically (vertically) transmissible disease and on the other hand infectiously (horizontally) transmissible disease. Parker apparently did not understand this. The law on informed consent is clear: one must obtain informed consent to all medical interventions, including diagnostic. Interventions relating to AIDS are not, and I agree should not be, unique in this respect. To the event that the diatribe in the last paragraph of Parker's current letter is understandable, the approaches that seem to be espoused are counterproductive to containing the spread of HIV. Consequently, I am left with the strong feeling that I am thankful Parker is not in charge of formulating public policy on AIDS in Canada. Margaret A. Somerville, AM, AuA (Pharm), LLB, DCL Director McGill Centre for Medicine, Ethics and Law Montreal, PQ
Here's something to chew on I n a recent Vista column in CMAJ (1990; 142: 465) Dr. Douglas Waugh addresses the issue of tobacco use in our society. Most of his comments are very true. Tobacco addiction is a serious and difficult problem, and all
of us involved in the field of tobacco abuse have an enormous amount of compassion for those who have not yet been able to quit. Waugh notes that the tone of the arguments against smoking have changed. It is a real pity that he has not taken the time to read these arguments. If he had, he would have seen that the content has also changed. Virtually all of the analysis today concerns how best to prevent children from starting to smoke. The elimination of advertising, the educational campaigns, the encouragement of price increases and the efforts to limit access to tobacco are all specifically designed to discourage smoking among children. Does Waugh disagreee that this is important? I wish Waugh were correct when he says that the battle over smoking is just about over. Children are taking up smoking at distressingly high rates, and this is particularly true for girls. A 1986 study by the Department of National Health and Welfare found that 329 164 Canadians between 15 and 19 years of age were regular smokers. I We are destined to not be free of tobacco-caused disease for at least one more generation. A recent study from the World Health Organization2 has estimated that tobacco will kill 500 million people around the world in the next 25 years and that smoking will be the number one cause of death in the world by the turn of the century. Today 8000 people a day die from smoking-related disease. When today's children reach middle age the figure will be 28 000 a day. The battle is far from over. The contention that the poor tobacco companies are losing money is patently absurd. Tobacco remains the most profitable product available, with a captive market of millions of addicts. These companies will stay alive by
finding new strategies to create child addicts. The notion that each of us has the right to self-destruct is interesting. If another ubiquitous substance - for example, aspartame - were shown conclusively to have killed 35 000 Canadians last year, as tobacco did,3 would Waugh advocate the right of each person to continue to use it if he or she wished? I contend that the government would immediately ban the substance, and the manufacturer would face massive lawsuits. I recommend that Waugh review the data that led to the banning of saccharin and compare it with the data on tobacco. Since more than 5.5 million Canadians remain addicted to tobacco' a total ban would be impractical as well as unkind, but we should all be moving as quickly as possible to eliminate this lethal substance. Let us portray the tobacco companies in their true light, as drug pushers whose survival depends on turning our children into addicts. So there. Mark C. Taylor, MD Nova Scotia representative Physicians for a Smoke-Free Canada PO Box 9530, Stn. A Halifax, NS
tionally inept as a missionary, but I do what I can. So there. Douglas Waugh, MD 183 Marlborough Ave. Ottawa, Ont.
Abortion as mayhem D r. Catherine Ferrier ("CMA's response to
abortion bill" [Can Med Assoc J 1990; 142: 515]) may well have no love of British common law, but the criminalization of abortion in Britain stemmed from the crime of mayhem. Any act that left the victim less able to serve the monarch was mayhem. Thus, removing a man's front teeth left him unable to eat army rations and so unable to serve in the British army. Hence the cockney threat "I'll kick your back [my emphasis] teeth in", which would avoid the crime of mayhem, although it must be difficult to
achieve. Abortion might deprive the monarch of a future British soldier, so it was considered mayhem. Its criminalization had little to do with the sanctity of life. R.H. Boardman, MD Box 1000 Ponoka, Alta.
References 1. Smoking Behaviour of Canadians, 1986 (cat no H39-66/1988E), Dept of Na-
tional Health and Welfare, Ottawa, 1988:28 2. Lopez A, Peto R: Paper presented at 7th World Conference on Tobacco and Health, Perth, Australia, Apr 1-5, 1990 3. The Active Health Report on Alcohol, Tobacco and Marijuana (cat no H39-145/1989E), Dept of National Health and Welfare, Ottawa, 1989: 7
[Dr. Waugh responds.]
A
Dr. Taylor is right: he and I agree on tobacco addiction. The difference between us is that he approaches it with missionary zeal, whereas my style is the lampoon. I cannot help it that I am constitu-
Acute asthma: emergency department management and prospective evaluation of outcome I was disappointed to read the paper by Drs. J. Mark Fitzgerald and Frederick E. Hargreave (Can Med Assoc J 1990; 142: 591-595). The authors offer opinion as fact, with little objective evidence from their own study to support it. Because the portion of the CAN MED ASSOC J 1990: 142(I 1)
1183
[Dr. Somerville responds.] Dr. Parker's logic is difficult to follow. Is he suggesting that the rules on inadmissibility to Canada on health grounds governing immigrants and refugees are different from those governing "the admissibility of HIV-positive people 1182
CAN MED ASSOCJ 1990: 142 (I 1)
to Canada"? If so, he is incorrect. The same sections of the Immigration Act of 1976 govern this matter for both groups. If we are not going to use the results of HIV antibody testing to influence our decisions on inadmissibility to Canada on medical grounds or possibly even to determine this, there is no justification at all for doing this testing on immigrants and refugees. Both legislators and public health physicians must work from an initial presumption. If, as Parker claims, he does not propose "a presumption against allowing the entry of HIV-antibody-positive people", then he must have adopted the opposite presumption (to which, of course, there may be exceptions), that such people should be allowed entry to Canada. In this case he and I are entirely on the same "wavelength", despite our different qualifications. Moreover, when one considers his initial serious disagreement with me, our ability to reach such concordance through correspondence in the pages of CMAJ could be seen as an excellent example of the benefits of transdisciplinary scholarship, which is nowhere more essential than in dealing with the complex issues raised by HIV infection and AIDS. It is a paradox that we have engaged in this form of scholarship when it seems that Parker is opposed in principle to
physicians working with people from outside medicine on what he views as purely medical matters. Parker is correct that the rules governing immigration, as with the rules governing all activities in our society, are "a matter for legislators". But under the provisions of the Immigration Act of 1976, inadmissibility to Canada on medical grounds is not, in day-to-day practice, such a matter. The legislature has delegated the power to decide this to a medical officer of health, provided this judgement is concurred in
by at least one other medical officer of health. It can even be argued that under the provisions of the act the minister of immigration cannot override decisions of medical officers of health in this respect. The word "transmissible" was within quotation marks in my response to indicate its out-of-theordinary use. In particular, this usage indicates that fruitful insights can be gained by comparing our approaches to situations involving on the one hand genetically (vertically) transmissible disease and on the other hand infectiously (horizontally) transmissible disease. Parker apparently did not understand this. The law on informed consent is clear: one must obtain informed consent to all medical interventions, including diagnostic. Interventions relating to AIDS are not, and I agree should not be, unique in this respect. To the event that the diatribe in the last paragraph of Parker's current letter is understandable, the approaches that seem to be espoused are counterproductive to containing the spread of HIV. Consequently, I am left with the strong feeling that I am thankful Parker is not in charge of formulating public policy on AIDS in Canada. Margaret A. Somerville, AM, AuA (Pharm), LLB, DCL Director McGill Centre for Medicine, Ethics and Law Montreal, PQ
Here's something to chew on I n a recent Vista column in CMAJ (1990; 142: 465) Dr. Douglas Waugh addresses the issue of tobacco use in our society. Most of his comments are very true. Tobacco addiction is a serious and difficult problem, and all
of us involved in the field of tobacco abuse have an enormous amount of compassion for those who have not yet been able to quit. Waugh notes that the tone of the arguments against smoking have changed. It is a real pity that he has not taken the time to read these arguments. If he had, he would have seen that the content has also changed. Virtually all of the analysis today concerns how best to prevent children from starting to smoke. The elimination of advertising, the educational campaigns, the encouragement of price increases and the efforts to limit access to tobacco are all specifically designed to discourage smoking among children. Does Waugh disagreee that this is important? I wish Waugh were correct when he says that the battle over smoking is just about over. Children are taking up smoking at distressingly high rates, and this is particularly true for girls. A 1986 study by the Department of National Health and Welfare found that 329 164 Canadians between 15 and 19 years of age were regular smokers. I We are destined to not be free of tobacco-caused disease for at least one more generation. A recent study from the World Health Organization2 has estimated that tobacco will kill 500 million people around the world in the next 25 years and that smoking will be the number one cause of death in the world by the turn of the century. Today 8000 people a day die from smoking-related disease. When today's children reach middle age the figure will be 28 000 a day. The battle is far from over. The contention that the poor tobacco companies are losing money is patently absurd. Tobacco remains the most profitable product available, with a captive market of millions of addicts. These companies will stay alive by
finding new strategies to create child addicts. The notion that each of us has the right to self-destruct is interesting. If another ubiquitous substance - for example, aspartame - were shown conclusively to have killed 35 000 Canadians last year, as tobacco did,3 would Waugh advocate the right of each person to continue to use it if he or she wished? I contend that the government would immediately ban the substance, and the manufacturer would face massive lawsuits. I recommend that Waugh review the data that led to the banning of saccharin and compare it with the data on tobacco. Since more than 5.5 million Canadians remain addicted to tobacco' a total ban would be impractical as well as unkind, but we should all be moving as quickly as possible to eliminate this lethal substance. Let us portray the tobacco companies in their true light, as drug pushers whose survival depends on turning our children into addicts. So there. Mark C. Taylor, MD Nova Scotia representative Physicians for a Smoke-Free Canada PO Box 9530, Stn. A Halifax, NS
tionally inept as a missionary, but I do what I can. So there. Douglas Waugh, MD 183 Marlborough Ave. Ottawa, Ont.
Abortion as mayhem D r. Catherine Ferrier ("CMA's response to
abortion bill" [Can Med Assoc J 1990; 142: 515]) may well have no love of British common law, but the criminalization of abortion in Britain stemmed from the crime of mayhem. Any act that left the victim less able to serve the monarch was mayhem. Thus, removing a man's front teeth left him unable to eat army rations and so unable to serve in the British army. Hence the cockney threat "I'll kick your back [my emphasis] teeth in", which would avoid the crime of mayhem, although it must be difficult to
achieve. Abortion might deprive the monarch of a future British soldier, so it was considered mayhem. Its criminalization had little to do with the sanctity of life. R.H. Boardman, MD Box 1000 Ponoka, Alta.
References 1. Smoking Behaviour of Canadians, 1986 (cat no H39-66/1988E), Dept of Na-
tional Health and Welfare, Ottawa, 1988:28 2. Lopez A, Peto R: Paper presented at 7th World Conference on Tobacco and Health, Perth, Australia, Apr 1-5, 1990 3. The Active Health Report on Alcohol, Tobacco and Marijuana (cat no H39-145/1989E), Dept of National Health and Welfare, Ottawa, 1989: 7
[Dr. Waugh responds.]
A
Dr. Taylor is right: he and I agree on tobacco addiction. The difference between us is that he approaches it with missionary zeal, whereas my style is the lampoon. I cannot help it that I am constitu-
Acute asthma: emergency department management and prospective evaluation of outcome I was disappointed to read the paper by Drs. J. Mark Fitzgerald and Frederick E. Hargreave (Can Med Assoc J 1990; 142: 591-595). The authors offer opinion as fact, with little objective evidence from their own study to support it. Because the portion of the CAN MED ASSOC J 1990: 142(I 1)
1183
