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Fighting addiction's death row: British Columbia Supreme Court Justice Ian Pitfield shows a measure of… Small, Dan Oct 28, 2008

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ralssBioMed CentHarm Reduction JournalOpen AcceCommentaryFighting addiction's death row: British Columbia Supreme Court Justice Ian Pitfield shows a measure of legal courageDan Small1,2,3Address: 1Department of Medicine, University of British Columbia, Vancouver, Canada, 2Department of Anthropology, University of British Columbia, Vancouver, Canada and 3PHS Community Services Society, Vancouver, CanadaEmail: Dan Small - dansmall@interchange.ubc.caAbstractThe art in law, like medicine, is in its humanity. Nowhere is the humanity in law more poignant thanin BC Supreme Court Justice Ian Pitfield's recent judgment in the legal case aimed at protectingNorth America's only supervised injection facility (SIF) as a healthcare program: PHS CommunityServices Society versus the Attorney General of Canada. In order to protect the SIF frompoliticization, the PHS Community Services Society, the community organization that establishedand operates the program, along with two people living with addiction and three lawyers workingfor free, pro bono publico, took the federal government of Canada to court. The courtroom strugglethat ensued was akin to a battle between David and Goliath. The judge in the case, Justice Pitfield,ruled in favour of the PHS and gave the Government of Canada one year to bring the ControlledDrugs and Substances Act (CDSA) into compliance with the country's Charter of Rights andFreedoms. If parliament fails to do so, then the CDSA will evaporate from enforceability and lawin June of 2009. Despite the fact that there are roughly twelve million intravenous drug addictionusers in the world today, politics andprejudice oards harm reduction are still a barrier to thewidespread application of the "best medicine" available for serious addicts. Nowhere is this clearerthan in the opposition by conservative Prime Minister Stephen Harper and his faithful servant,federal health minister Tony Clement, towards Vancouver's SIF ("Insite"). The continued angrypoliticization of addiction will only lead to the tragic loss of life, as addicts are condemned to deathfrom infectious diseases (HIV & hepatitis) and preventable overdoses. In light of the establishedfacts in science, medicine and now law, political opposition to life-saving population healthprograms (including SIFs) to address the effects of addiction is a kind of implicit capital punishmentfor the addicted. This commentary examines the socio-political context of the legal case and themajor figures that contributed to it. It reviews Justice Pitfield's ruling, a judgment that has broughtCanada one step closer to putting a stop to addiction's death row where intravenous drug usersare needlessly, for political and ideological reasons alone, forced to face increased risks of deathdue to AIDS, hepatitis and overdose."I am pleading for the future; I am pleading for a timewhen hatred and cruelty will not control the hearts ofunderstanding and faith that all life is worth saving,and that mercy is the highest attribute of man."Published: 28 October 2008Harm Reduction Journal 2008, 5:31 doi:10.1186/1477-7517-5-31Received: 4 August 2008Accepted: 28 October 2008This article is available from: http://www.harmreductionjournal.com/content/5/1/31© 2008 Small; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 16(page number not for citation purposes)men. When we can learn by reason and judgment andClarence Darrow[1]Harm Reduction Journal 2008, 5:31 http://www.harmreductionjournal.com/content/5/1/31Introduction: a measure of legal courageAll heroic figures, and in fact all human beings, areflawed. Perhaps it is this self-evident frailty in all human-ity, readily apparent for all to see in addiction, that scaresus most about injection drug use. Addiction unlocks awindow that glimpses into our own imperfections withblunt truthfulness. The quote opening this commentary isfrom famed American lawyer and orator Clarence Darrowwho provided no exception to the certainty of humanityin his character. Early in his career at the turn of the 20thcentury, a faint shadow was cast over him by the suspi-cions that he may have displayed poor judgment in a caserepresenting labour leaders. As a result, he left corporateand labour law to take up the pursuit of criminal law as adefence attorney. He went on to become one of the great-est orators in legal history with some of his most famousclosing arguments extending to twelve hours in lengthwhile he reviewed law, philosophy and the essence ofhumanity. He had a life long hatred of capital punishmentthat he saw as a kind of cool and calculated murder by thestate. [2] The politicization of responses to addiction, isoften led by anger, hatred and fear rather than science,medicine and compassion. With what modern science hasshown us about harm reduction initiatives like supervisedinjection facilities (SIF) and syringe distribution pro-grams, it is becoming increasingly clear that attempts topolitically block these measures, based on mistaken moraljudgment, is to condemn addicts to a kind of addiction'sdeath row. Justice Pitfield's decision in the matter of PHSCommunity Services Society versus Attorney General ofCanada has further shown us that all life is worth saving[see Additional file 1]. [3]This commentary focuses on a legal case aimed at protect-ing the fundamental right to life, liberty and security ofthe person for people living with addictions by protectingtheir access to North America's only SIF. The SIF, knownas Insite in the community, is a health program located inVancouver, British Columbia aimed at reaching a difficultgroup of people living with active intravenous addictionsin a healthcare setting in order to help reduce HIV/AIDSand Hepatitis by curbing syringe sharing and to preventfatal drug overdoses with clinical supervision. To date,over 1,000,000 injections have been supervised at the SIF,injections that might otherwise have occurred in publicspaces in unsupervised and dangerous circumstanceswhere overdoses could have occurred without emergencyinterventions and dangerous injection practices couldhave taken place. [4] There have been hundreds of over-dose events at the facility, many of which, had theyoccurred in unsafe and unsupervised settings would havesurely resulted in death. While the precise number ofdeaths averted by Insite can never be known, as it wouldthe facility has prevented as many as 12 overdose deathsper year since it opened. [5]Thesecalculationspoint to the possibility that over fiftyfa-tal overdoseshave been prevented by Vancouver's SIFsince the opening of program. These estimates, of course,do not include the lives that would have been saved bypreventing infectious diseasesincluding HIV and HCV.Regardless of the exact number, if even one death couldhave been prevented, it would be enough.While Canada had shown strong political leadership inopening the SIF as a health program in September of2003, the program became the subject of political intru-sion in February of 2006 when a minority conservativegovernment came into power under Prime MinisterStephen Harper. [4] Of course, the issue of a comprehen-sive approach to addiction, that includes harm reduction,doesn't have to be a partisan political issue. Several may-ors, of different parties in Vancouver, have supported andsupport Vancouver's SIF including, Gordon Campbell,Mike Harcourt, Philip Owen, Larry Campbell and SamSullivan. Medical and scientific evidence demonstratingthe efficacy of Insite has been collected through an inde-pendent review by a team of physicians and scientists. Theresults of their evaluation have been published in overthirty peer reviewed research papers published in interna-tionally recognized academic journals.The results of this independent evaluation indicate thatthe program has reduced unsafe injection practices, publicdisorder, overdose deaths and HIV/Hepatitis whileincreasing uptake of addiction services and detox andkeeping people with extremely compromised health aliveto, perhaps, be on the threshold of a successful life oneday. [4].In the face of increasing danger that Prime MinisterStephen Harper and federal Health Minister Tony Clem-ent would not extend a permit for Insite under the Con-trolled Drugs and Substances Act for Insite past 30 June2008, the community organization that operates the pro-gram, the PHS Community Services Society (PHS), feltcompelled to try to protect this life-saving programthrough the courts. As a result, legal case was brought for-ward by a community organization, two people livingwith active addictions and three lawyers working for free(pro bono publico).Essentially, the case against the Government of Canadafollowed two streams of argument. The first related tointer-jurisdictional issues:Page 2 of 16(page number not for citation purposes)be an unethical and forbidden experiment, it appears that (1) In the Constitution of Canada, there is a clear divisionof powers between the Federal and Provincial Govern-Harm Reduction Journal 2008, 5:31 http://www.harmreductionjournal.com/content/5/1/31ment. The PHS made the argument that regulating the SIFoperates within the jurisdiction of the Province of BC andthat, as such, interference from the Federal Government isinappropriate.The second pertained to the first part of Canada's Consti-tution, the Canadian Charter of Rights and Freedoms (theCharter). The critical area of the Charter for Insite is foundin section 7:(2) Section 7 of the Charter states that: "Everyone has theright to life, liberty and security of the person and the rightnot to be deprived thereof except in accordance with theprinciples of fundamental justice.". [6] (p. 4) The PHSargued that if the Health Minister were to use the Control-led Drugs and Substances Act (CDSA) to close Insite, thenthis action would wrongly jeopardize the life chances ofpeople with addictions by denying them access to criticalhealthcare.How, then, do we measure heroism in poignant historicalmoments? Surely, the flaws and frailties of humanity donot turn strong social conscience into fiction? Nowhere isthis more evident than in the courageous decision of Brit-ish Columbia Chief Justice Ian Pitfield on the matter ofInsite. In his landmark decision, Judge Pitfield showed ameasure of legal courage that is certain to shape Canadain terms of our understanding of addiction as a healthcareissue in the years to come.Government of CanadaThe Attorney General of Canada hired a formidable legaladversary, John Hunter, Q.C. of Hunter Litigation Cham-bers as their lead counsel. At the time of his appointmentas lead counsel, he was the president of the Law Society ofBritish Columbia. [7] He has represented the AttorneyGeneral on numerous occasions:"K.L.B. v. v. British Columbia, (Supreme Court of Can-ada; 2003) client: Attorney General of British Colum-bia issue: Crown liability under principles of vicariousliability or non-delegable duty of care for foster parentabuse.Tremblay v. Attorney General of British Columbia, (BritishColumbia Court of Appeal; 2002) client: AttorneyGeneral of British Columbia issue: Whether a Cabinetorder dismissing the board of the Legal Services Soci-ety was valid.Soowahlie Band v. Canada, (Federal Court of Appeal;2001) client: Attorney General of Canada issue:Whether Canada should be enjoined from transferringHuman Rights Institute of Canada et al v. Canada (Attor-ney General), (British Columbia Supreme Court andFederal Court Trial Division; 1999) client: AttorneyGeneral of Canada issue: Whether an injunctionshould be granted to restrain the completion of anexpropriation of land by the Federal government.Luuxhon v. Canada, (British Columbia Supreme Court;1998) client: Attorney General of Canada issue:Whether Canada has a legally enforceable obligationto conduct treaty negotiations with First Nations ingood faith."[8]Mr. Hunter specializes in aboriginal law and has repre-sented government clients in opposition to various abo-riginal groups (e.g. Musqueam Indian Band, HaidaNation, Soowahlie Band and Luuxhon First Nation). [8]He also specializes in forestry litigation. He has repre-sented private sector forestry clients including companiesWeyerhaeuser Company Limited and MacMillan Bloedel.Mr. Hunter made a significant acknowledgment early inthe case. He rose, during a presentation by one of the PHSlawyers, Mr. Arvay, to make the point that the Govern-ment of Canada agrees that addiction is an illness. Thisrecognition proved to be a crucial entry into the legalrecord.Heroes figures in the legal establishment of addiction as a healthcare matterThere were many important figures in this legal case thathelped to further establish addiction as a matter for theChief of Medicine rather than the Chief of Police. All ofthem showed courage and took social risks by participat-ing in this legal case. There was tremendous courage in thethree lawyers, who took on the cause of Insite. There wascourage shown by provincial and municipal bureaucratswho entered their testimony into the record. The federalbureaucracy, sadly, testified on behalf of the AttorneyGeneral of Canada and, as such, defended the position ofthe Prime Minister and Health Minister, and stood againstthe provincial bureaucrats from the Vancouver CoastalHealth Authority (VCH) and the City of Vancouver. Thefederal bureaucracy also dispatched legal and administra-tive staff to assist with, observe and report back on thecase. During the trial, a staff lawyer for the Department ofJustice assisted Hunter Litigation Chambers by using herpersonal data assistant to look up and then communicatekey facts to Mr. Hunter during the proceedings. There wascourage shown from the scientists who evaluate Insite, inproviding scientific evidence about the role of Insite as acomprehensive response to addition. There was courageshown from the community organization that establishedPage 3 of 16(page number not for citation purposes)land claimed by the Sto:lo Nation to third parties. Insite. But most of all, there was courage shown by twopeople living with addiction, wounded witnesses, whoHarm Reduction Journal 2008, 5:31 http://www.harmreductionjournal.com/content/5/1/31opened up their lives and shared their stories of sufferingwith the court. The stories of these important contributorsto the case will be examined in turn.Vancouver Coastal Health authorityRepresenting the VCH, and the Province of British Colum-bia (the Province), Ms. Heather Hay provided testimonythat enshrined the responsibility of the local healthauthority as the institution responsible for addressing thepublic problem of addiction and its epidemiological after-math. Not all problems, of course, are "public problems".A public problem is one for which a public institution for-mally takes responsibility for addressing and for whichpublic resources are dedicated. [9] When an issue, such asan epidemic of addiction, is socially transformed into apublic problem, then it also becomes the responsibility ofpublic institutions, such as the VCH, to discover andimplement a solution. Some social phenomena are trans-formed into public problems requiring institutionalaction and resources while others are not. For instance,universal healthcare, homelessness, psychiatric disorders,road racing, childhood poverty, the environment anddrunken driving have not in the past been consideredpublic problems, whereas today, in Canada, they areexpected to be the focus of government officials and pub-licly funded bodies.The construction of addiction as a public problemdemanding a public health response began as a result ofthree key factors in the late 1990s: rising overdose deaths,and the gradual shift in community organizations toattempt to reach increasingly vulnerable populationsincluding injection drug users and a pandemic of addic-tion accounts for one-third of the HIV infections outsidethe sub-Saharan world. [10] These factors provided thehealthcare context for the establishment of the SIF. Addic-tion was further transformed into a public problemthrough the establishment of the Vancouver Agreement in2000 where all three levels of government officially tookon the responsibility to address injection drug use and itsconsequences. [11]Ms. Hay's written testimony and submissions broughttogether a number of important documents and facts per-taining to the epidemic of addiction in Vancouver. Thedocuments in her submission included the momentous1994 Report of the of the Task Force into Illicit Narcotic Over-dose Deaths in British Columbia [see Additional file 2] [12]chaired by Chief Coroner Vince Cain, the influential 1996report Health Impact of Injection Drug Use and HIV in Van-couver [see Additional file 3] [13] by Dr. Elizabeth Whynotby Vancouver's Chief Medical Health Officer Dr. JohnBlatherwick and the landmark 1998 report HIV, Hepatitis,Officer Dr. John S. Millar outlining the need for harmreduction approaches. Ms. Hay also entered into therecord the recognition by Vancouver Richmond HealthBoard (predecessor to Vancouver Coastal Health) in the1997 that injection drug use and its consequences (spreadof infectious disease and overdose deaths) had become anepidemic. This evidence indicated the early identificationof addiction as an epidemic, by Dr. John Blatherwick, theChief Medical Health Officer of the Vancouver RichmondHealth Board (predecessor to the VCH), and adopted as aBoard Resolution in September 1997 [15] provided sub-stantiation of the planning that went into the establish-ment of harm reduction initiatives in the community.Originally trained as a nurse before pursuing graduatestudies, Ms. Hay worked in the acute care sector beforebecoming the Director for Addictions, HIV/AIDS andAboriginal Health Services for the VCH. Ms. Hay hasalways maintained a connection to the front-line duringher vocational life as indicated by the fact that during hervisits to Insite people from the community that rely on thefacility warmly greet her. Ms. Hay's testimony crystallizedthe official view that the VCH recognizes the SIF as animportant part of its fundamental responsibility to pro-vide and lead healthcare delivery. As her signature driedand her affidavit was sworn in, she had made a sacredcommitment, on behalf of the Province of BC, to a vulner-able group of citizens: those living with active addictionsand their families.Medical expert for the Vancouver Coastal HealthDr. David Marsh, the physician lead for addiction medi-cine at the VCH, also provided evidence on behalf ofInsite. He is medical supervisor of the program. He alsoserves as the VCH Medical Director for Addiction, HIV/AIDS and Aboriginal Health Services. He is the DivisionHead of Addiction Medicine in the Department of Familyand Community Medicine at Providence Health Care (St.Paul's Hospital) and the Leader of Addiction Research atthe Centre for Health Evaluation and Outcome Sciences(CHEOS).Dr. Marsh holds specialist certificates from the Canadian,American and International Societies of Addiction Medi-cine. He is a Clinical Associate Professor, jointlyappointed, in the the Department of Health Care and Epi-demiology in the Faculty of Medicine at the University ofBritish Columbia where he teaches addiction medicineand conducts research into innovative addiction treat-ments including medically managed heroin treatment. Atthe time of his testimony, he was the immediate past Pres-ident of the Canadian Society for Addiction Medicine,Page 4 of 16(page number not for citation purposes)and Injection Drug Use in British Columbia: Pay Now or PayLater [see Additional file 4] [14] by Provincial Healthhaving served as President between October 2003 andOctober 2006.Harm Reduction Journal 2008, 5:31 http://www.harmreductionjournal.com/content/5/1/31Dr. Marsh reviewed the standard definitions of addictionas a chronic disease according to the Canadian Society ofAddiction Medicine and American Psychiatric Associationas delineated in the Diagnostic and Statistical Manual. Hisevidence outlined the usage characteristics at Insiteincluding the fact that over 1,000,000 supervised injec-tion had occurred in the facility and that roughly 60% ofthe injections were opioids and 40% were stimulants. Healso provided an overview of the bio-chemical effects ofheroin, cocaine and methamphetamine as well as inher-ited, psychological and social variables influencing addic-tion. He also presented a description of drug overdose andintoxication along with the appropriate interventions.The City of VancouverThe City of Vancouver was represented by testimony fromDonald MacPherson, Drug Policy Coordinator. His rootsreach back to the Downtown Eastside, where Insite islocated. Before he became the first and present Drug Pol-icy Coordinator, Mr. MacPherson had been the Directorof the local community centre and had served on theboard of directors of the PHS Community Services Society(the community organization that initiated and operatesthe SIF).MacPherson (2001) is the author of the influential policydocument: Framework for Action: A Four-Pillar Approach toDrug Problems in Vancouver [see Additional file 5] [16].This document was drafted in the late 1990's, adopted bythe City of Vancouver Council in 2001 under the leader-ship of Mayor Philip Owen and provides an analyticaltool for bringing diverse approaches together to worktowards common goals. The Framework incorporates fourbroad streams of understanding and action with respect toaddiction: Prevention, Treatment, Enforcement and HarmReduction.Of course, as this is an analytical framework for increasingdialogue and cooperation, the four pillars overlap andconverge with one another. There is, by example, harmreduction within policing such as the Vancouver PoliceDepartment's Policy 11.04 that provides the possibilityfor police to avoid attending illicit drug overdoses in orderto reduce fatal overdoses that might occur due to fear ofprosecution. [17-20] Similarly, state police officers in thedistricts of Espanola and Santa Fe in New Mexico alsoemploy harm reduction and are trained to administernaloxone (trade named Narcan) in order to save lives byreversing opiate overdoses. [21] Moreover, harm reduc-tion measures such as syringe distribution and supervisedinjection facilities play a prevention role with respect toHCV and HIV. Further, some prevention programs con-tain elements of harm reduction by providing practicalThe Framework for Action brought different actorstogether and engendered a spirit of cooperation thathelped Insite to commence with the support of a broadbase of support. While many traditional drug policy doc-uments contain only three elements: prevention, treat-ment and enforcement, a kind of "three-legged dog", theCity of Vancouver's policy framework was a proud depar-ture amongst cities in North America. As the author of thisdocument, MacPherson put his pen to paper for anotherimportant cause with regard to the societal treatment ofaddiction. He entered evidence on behalf of the City ofVancouver and, in so doing, made a further commitmentfrom the City and the municipal level of government tothe core principle that addition is a healthcare matter anda public problem requiring healthcare innovations suchas Insite.The scientific communityThe Centre of Excellence in HIV/AIDS (CFE) provided evi-dence regarding the scientific evaluation of the SIF. Whenthe SIF was initiated, the CFE was chosen to evaluate theproject. Four scientists and clinicians led the evaluationteam: Dr. Julio Montaner, Dr. Thomas Kerr, Dr. EvanWood and Dr. Mark Tyndall. Drs. Montaner, Kerr andWood provided expert evidence in the case.There have been a small number of detractors that haveattacked the CFE's role in evaluating Insite. These detrac-tors have, as a rule, been associated with or paid bynational police organizations. In their condemnation ofInsite, they have tried to imply that the reporting of posi-tive scientific results associated with Insite by the evalua-tion scientists along with their support for thepreservation of Insite indicates a loss of objectivity. Forexample, Canada's national police force, the Royal Cana-dian Mounted Police, has stated publicly that they are "yetto see an arms-length report of the evaluation of the facil-ity" and that they have not seen "research that we can haveconfidence in"[23]. The force has remarked that "untilsuch time as we can have arms-length report by an inde-pendent person or group to show us how well or howeffective that site is, then we're not in a position to supportit-period". [23]The RCMP also appeared to engage consultants to per-form additional reviews of SIFS and hired academics withknown bias against harm reduction approaches to addic-tion to provide public criticism of Insite. These attempts,by the national police force, to publicly and covertlyundermine a healthcare program and the work of a com-munity agency were met with extensive criticism from thecommunity and the media. [24,25] The possibility thatthe national police force may have clandestinely fundedPage 5 of 16(page number not for citation purposes)advise about a spectrum of drug use ranging from activeaddiction to safer, managed use and abstinence. [22]anti-Insite research is especially concerning. [26] Ulti-mately, these activities led to a letter of apology from theHarm Reduction Journal 2008, 5:31 http://www.harmreductionjournal.com/content/5/1/31Deputy Commissioner of the national police force. [27]An internal RCMP review of the circumstances surround-ing this research activity is underway. Hopefully, thisreview signals a new direction for Canada's nationalpolice force; one that will lead to them being a partner ina comprehensive approach to addiction that embracesevidenced based medicine and a comprehensive approachto addiction. We live in hope that the RCMP will be a part-ner rather than an opponent.Of course, the notion that the CFE research is not "arms-length" is farcical. The CFE has published the results oftheir evaluation in peer-reviewed journals including someof the most respected scientific and medical journals inthe world. To date, they have published thirty peer-reviewed papers on the SIF. [28-57]The peer review stream was chosen precisely in order toprovide the uppermost standard for "arm's length" evalu-ation to ensure the highest quality and objectivity inreviewing the outcomes of the program. Furthermore, toimply a loss of objectivity by the CFE would also requirethat nearly the entire medical and scientific communityhad also lost objectivity. In 2007, 130 leading scientists,physicians and healthcare professionals in Canadaendorsed a commentary published in a national medicaljournal publicly stating that the research evaluation onVancouver's SIF indicated that the healthcare programhad reduced harms associated injection drug use and thatno adverse consequences had resulted. [58] Likewise, theCanadian Medical Association (CMA) has come outstrongly in favour of harm reduction and Insite. In a letterto Canada's largest newspaper, Dr. Brian Day, President ofthe CMA states:"In this matter, the science is clear: Harm reduction isa proven and effective tool. Marginalizing an alreadyvulnerable population and leaving them at evengreater risk of disease and death is bad medicine and,as the polls show, even worse politics. And with theB.C. government's plans to intervene on behalf ofInsite, Canadians should rightly wonder why their taxdollars are going to be financing both sides of thisargument. They also should wonder why the federalgovernment seems to be opposed to safe injectionsites in British Columbia, but is willing to considerthem in Quebec. Clement's public hedging on Que-bec's proposal [for an SIF] is further proof that hisdecision appears to be based on political science andnot the real thing. When it comes to safe injectionsites, Conservatives need to consider the health of allCanadians, not just those who agree with the govern-ment's ideological bias against drug-addictedIn fact, to oppose the scientific data on the subject woulditself appear to be driven by ideology rather than objectiv-ity.If it were a healthcare issue other than addiction, then cli-nicians and researchers calling for the best medicinewouldn't have their objectivity called into question. If, forexample, a group of researchers and physicians were advo-cating for the clinical application of an effective cancertreatment, then surely they wouldn't be accused of some-how crossing a line of objectivity?In fact, I would like to carry this argument one step fur-ther. It is the duty of clinicians performing healthcareresearch to be concerned about clinical application andpublic policy that improves the health in the community.[60] The glorious days of pursuing knowledge just forknowledge sake in healthcare, like examining theoreticalextraction of rainwater from zucchinis, are gone. In myview, part of the responsibility of scientists and cliniciansperforming healthcare research is to employ what theyhave learned from their research in order to improvepatient lives. And that is exactly what the Centre for Excel-lence in HIV/AIDS has done through their research, publicstatements and participation in this legal case. If it closes,people will die from preventable overdoses and HIV infec-tions. It's that simple.Government of Canada and PHS witnessesThe Government of Canada relied on three main wit-nesses: a federal bureaucrat, a retired pharmacist and anaddiction physician with what appeared to be little or noexperience working with the vulnerable and multiply bar-ried population of injection drug users served by the SIF.The addiction physician engaged by Canada was "moreclosely associated with healthcare professionals and air-line pilots, a significantly different group from injectiondrug uses in the DTES". [3] (p. 24). In preparation for histestimony, the physician made a visit to the DowntownEastside in order to obtain a tour of Insite on 19 March2008. The retired professor of pharmacology "did notdepose to any personal knowledge regarding Insite, or toinvolvement in any aspect of its operations" (p. 30). Theemployee of Health Canada provided more general infor-mation about drug policy in Canada. Neither of the twowitnesses on behalf of Canada "deposed any specificobservations about Insite or their individual assessmentof its efficacy". [3] (p. 30). The expert witnesses testifyingon behalf of the PHS, had significant knowledge of theefficacy, evaluation and operation of Insite. They also allhad extensive experience working with marginalizedinjection drug users with multiple barriers to their medi-cal and social tenure. They had all also made noteworthyPage 6 of 16(page number not for citation purposes)patients.". [59] contributions to the research and treatment of addictionand its consequences.Harm Reduction Journal 2008, 5:31 http://www.harmreductionjournal.com/content/5/1/31Dr. Julio Montaner provided evidence from the CFE. He isa practising physician who treats people living with addi-tions and HIV. He is Professor of Medicine at the Univer-sity of British Columbia, Chair of AIDS research at St.Paul's Hospital, Director of the BC Centre in HIV/AIDS,Director of the SPH Immunodeficiency Clinic, NationalCo-Director of the Canadian HIV Trials Network and Pres-ident-Elect of the International AIDS Society. He has pio-neered therapies in the treatment of AIDS and receivedover two-dozen awards for teaching, research and publicservice including the Pasteur Prize and the Clinical Infec-tious Diseases Award. He is the editor or co-editor of adozen scholarly journals. He has written 350 peerreviewed articles. He provided testimony outlining thatthe methods chosen for evaluating the SIF were at thehighest level of scientific enquiry. He also affirmed thatthe program demonstrated clear public health and com-munity benefit by reaching an under-served population.Dr. Evan Wood is a physician and researcher. He holdsaPhD and MD. He has published over 170 peer-reviewedscientific articles and has been the lead author of articleson the SIF published in leading medical journals includ-ing the Lancet, Canadian Medical Association Journal,Journal of the American Medical Association and NewEngland Journal of Medicine. He is a clinical assistant pro-fessor with appointments in the Department of Medicineand Epidemiology at the University of British Columbia.He provided evidence outlining the first three years of theevaluation that generated 22 peer-reviewed publicationson the outcomes of the SIF. He testified that the first threeyears of study revealed a number of key benefits associ-ated with the SIF including: reduced dangerous injectionpractices, reduced public injection and increased uptakeof treatment. Moreover, he revealed that the studies exam-ined potential harms associated with the healthcareproject but no evidence of deleterious impacts was discov-ered. He reviewed a number of studies for which he wasthe principal author in his evidence. [43-45,47-56]Dr. Thomas Kerr first began his work with the injectiondrug using population began at the Dr. Peter Centre forpeople living with AIDS. He holds a PhD in psychologyand behavioural science. He is a co-principal investigatorof the Scientific Evaluation Supervised of SupervisedInjecting (SEOSI) study that focuses on Insite. He haspublished over 150 peer-reviewed scientific articles andhas written articles on the SIF published in leading medi-cal journals including the Lancet, Canadian Medical Asso-ciation Journal, Journal of the American MedicalAssociation and New England Journal of Medicine. He isa clinical assistant professor with appointments in theDepartment of Medicine and Epidemiology at the Univer-which he was the principal author, as part of his evidence.[30-34]International physician specialist in the treatment of injection drug useFrom Canada, Australia looms large on the horizon ofhealthcare as a kind of sister country with regard to inno-vations in addiction treatment. Australia opened a Medi-cally Supervised Injecting Centre (MSIC) in May of 2001,two years before Vancouver opened the first such facilityin North America. A number of Australians have extendedtheir social conscience to assist Canada in developing thebest addiction medicine. In 2000, Tony Trimmingham, afather who tragically lost his son to an overdose, travelledto Vancouver to share his story and help lay the ground-work for the public understanding of addiction as ahealthcare matter. Dr. Alex Wodak, a practising physicianin the realm of addiction medicine, has visited Canada,both before and after the establishment of Insite, numer-ous times in order to acquaint himself with the publicproblem of addiction in Vancouver. He graciously agreedto provide extensive expert evidence in the case pro bonopublico. There are only two supervised injection facilitiesoutside of Europe (in Australia and Canada) and Dr.Wodak's testimony further strengthened the special bondbetween our two countries in addressing the pandemic ofaddiction using humane and evidenced based initiatives.Dr. Wodak is a physician and specialist in internal medi-cine who has specialized in the treatment of alcohol anddrug addiction for over 30 years. He has been the Directorof the Alcohol and Drug Service at St. Vincent's Hospitalin Darlinghurst, Australia since 1982. He has published239 peer-reviewed papers examining the health risks andtreatment of injection drug use. His testimony outlinedthree deadly health conditions associated with injectiondrug use: overdoses, local infections (bacterial abscesses,endocarditus, brain abscess) and infectious disease (HIV,hepatitis C, B, bacterial, fungal and parasitic infections).He provided an opinion on the scientific research con-cerning harm reduction measures. He also reviewed thescientific literature on the outcomes associated with SIFsand Insite in particular. After review of the studies onInsite in his affidavit, he provided the expert opinion thatthe research conducted was in keeping with existingresearch indicating beneficence without significant nega-tive consequences. He also stated under oath that theresearch performed by the CFE had set the highest stand-ard, in fact, a benchmark, for evaluation and scientific rig-our of supervised injection facilities.The kind country doctor in the inner cityReaching vulnerable populations with medicine in thePage 7 of 16(page number not for citation purposes)sity of British Columbia. He reviewed five key studies, of inner city, with multiple barriers to their healthcare ten-ure, demands an inversion of medical practice. RatherHarm Reduction Journal 2008, 5:31 http://www.harmreductionjournal.com/content/5/1/31than expecting autonomous patients to attend healthcarefacilities, seek out services and advocate for themselves astheir own personal case managers, barriers need to beremoved, healthcare has to be brought to the population.In essence, what is required is a return to the "kind coun-try doctor" of the past that performed "house calls". How-ever, rather than visiting the country homes and farms ofthe patient, the doctor has to visit 100 square foot singleroom occupancy hotels in the inner city. The most chal-lenging population to reach with healthcare, housing andservices are those with active addictions, histories of non-compliance, conflict with the law, multiple health condi-tions (e.g. HIV, HCV) and untreated psychiatric illness(primarily personality related disorders). This populationwill not, as a rule, travel great distances to obtain health-care. They do not have automobiles or telephones. Forthem, travelling from Vancouver's DTES to the main hos-pital is like travelling from London to Edinburgh. Further,many have severe health problems that limit their mobil-ity.We cannot expect this population to come to healthcare;healthcare has to go to them.Providing medical care to this population, the social lep-ers of today [60,61], is not like fighting for market sharebetween multinational corporations. There is, in contrast,little competition to provide healthcare to this vulnerablegroup. It requires a special commitment and a special phy-sician. Dr. Gabor Mate is one of these special physiciansand he has been treating this population of social lepersfrom within the Portland Hotel in Vancouver's Down-town Eastside for a decade. He provided evidence as apractising physician, working with the most difficult totreat patient group imaginable, often neglected, turnedaway and forgotten by mainstream physicians, in theinner city. A large portion of this group is dually diag-nosed: suffering from active addiction and personalityrelated psychiatric illness and, as a result, are sadly not eli-gible for mainstream mental health services. His testi-mony provided an illustration, based on extensive "on theground" medical experience, of how innovative health-care has to be fitted to this patient population rather thanexpecting this patient population to fit to pre-existingnotions of healthcare.A community organization: PHS community services societyMany thousands of low-income residents in the Down-town Eastside (DTES) of Vancouver typically live in 80 to140 square foot hotel rooms where they share a singlebathroom and kitchen with dozens of other tenants. Thecommunity organization that developed and operatesin an old "single room" hotel (SRO) in the DTES 1993called the Portland Hotel. The philosophy and practice ofthe organization traces its roots back to that early andongoing experience in providing supported housing topeople with multiple barriers to their social and medicaltenure (many of whom were active injection drug users).Much of the constituency of the downtown eastside hotelshas changed in the last twenty years. As of June 2007,there were 4,992 private SRO units in the Downtown East-side and surrounding communities of Chinatown, Gas-town and Strathcona representing 83 per cent of the 5,985private SROs throughout the entire downtown core ofVancouver. [62] Including private SROs, non-profit hous-ing, there are a total of 11,131 housing units in the area.This population is no longer simply reflected by an imageof unemployed or low-income individuals on a fixedincome. Rather, today, many of the individuals whoinhabit this often-demonized district of Vancouver haveare more aptly described in terms of the challenges theyface as the "hard to house", "hard to treat", "hard to reach"or "housing first" population. They live with multiplehealth and social barriers such as:• Serious and persistent active drug use• Poverty• Survival street involvement (e.g. survival sex trade)• Malnutrition• Chronic medical problems• A history of non-compliance• Untreated psychiatric illness (including personalityrelated disorders)• HIV and AIDS related illness• Increased incidence of Hepatitis A, B, C• Conflict with the law• Lower levels of education• High incidence of childhood trauma and adverse lifeevents• High degree of multiple diagnoses (e.g. active addiction,mental illness, hepatitis and HIV/AIDS)Page 8 of 16(page number not for citation purposes)Insite is the PHS Community Services Society (formerlythe Portland Hotel Society; PHS). The organization began• Traumatic residential school experiencesHarm Reduction Journal 2008, 5:31 http://www.harmreductionjournal.com/content/5/1/31• Stigmatization• Denial of housing• Denial of healthcare services• Denial of support servicesThe PHS has learned, from experience, that the challengesencountered with this group are amenable to interventionif services are offered in a low-threshold (without barriers)and tenant-centred manner. In addition, the needs of thisgroup have to be addressed by an adequate level ofresources that respond to the following challenges:• Many do not have a family doctor (healthcare exclusion)• Many individuals do not have personal identification(ID is an important symbol of personhood)• Many require help with completing their taxes• Many require help filling out forms• Many report major components of their diet missing(malnutrition)• Many require help with obtaining supported and afford-able housing (multiple evictions and housing exclusion)• Many do not have the basic necessities of life: clothing,bedding, furniture or cooking utensils• Many do not have a bank account (financial exclusion)• Many are not able to be compliant to excessive rules,policies and proceduresInsite fits into a range of PHS programs including: finan-cial services, a Drug Users Resource Centre, adentalclinic,two medical clinics, an art gallery, a grocery store, a com-munity based antibiotic program and a range of employ-ment and social enterprises. The supported housing stockof the PHS encompasses approximately 1000 unitsincluding operational projectsas well as those underdevelopment. Through its services, the PHS reachesapproximately 10,000 vulnerable individuals who arehomeless or at risk of homelessness each year and comesinto contact with almost every person who lives in an SROin the DTES community. It is precisely the "hardest toreach", "hardest to treat" and "hardest to house" groupthat the PHS aims to reach with low-threshold programslike Insite: vulnerable individuals who have limited or nopreventing this group from being further neglected, for-gotten and pushed into the shadows of society.Attorneys for the vulnerable and forgottenMonique Pongrecic-Speier, a partner in the firm SchroederSpeier, has been the lawyer of record for the PHS for anumber of years. She is an award winning lawyer [63] andhas been involved in a number of socially conscious legalrealms including the protection of workers'. [64] andhuman rights. [65,66] throughout her career. Early on, aspolitical events threatened the fate of Insite unfolded, shewas quick to make the commitment to defend this impor-tant part of BC's healthcare system pro bono publico. Shecompiled and reviewed the majority of the initial evi-dence for the case, in the form of interviews, affidavits,official documents, comprised of thousands of pages,which she prepared for the legal team. She argued theinter-jurisdictional component of the case.F. Andrew (Drew) Schroeder, also partner in the firmSchroeder Speier, is a former Rhodes scholar who hasbeen involved in many high profile cases including abreakthrough victory in the BC Supreme Court for injuredworkers. [67,68]. He also represented 49 descendents ofDoukhobors who were separated, as children, from theirfamilies for years at a time. [69] He is considered to be oneof the best lawyers representing workers rights in Canada.[70] In his role in the case, he argued the early part of thecase and carried the team through the initial administra-tive sections of the case with regard to whether the casecould be heard as a summary trial (relying on written doc-uments) or as a full trial (relying on live witness testi-mony).Joseph Arvay, Q.C., is an award winning lawyer, highlyrecognized for his social conscience, who has, accordingto the Canadian Bar Association, has "litigated manyground-breaking constitutional law cases" in Canada.[71] Mr. Arvay has been described by the President of theInternational Commission of Jurists, Madam JusticeMichele Rivet, as "one of Canada's most tireless civil rightsand human rights lawyers". [72] He has acted on behalf ofgays and lesbians, BC Civil Liberty Association, FirstNations, women involved in the sex trade, the disabled,laid-off mill workers and 400 Crown Prosecutors againstthe Province of British Columbia. [73] He has defendedsame sex marriage, academic freedom, Aboriginal fishingrights, and collective bargaining by unions as a rightunder the Canadian Constitution. He has fought againstwarrantless searches, high voltage power lines, affronts tofreedom of speech and the privatization of healthcare.Some of his most famous cases include representation ofthe rights to free speech for a gay and lesbian bookstore,Page 9 of 16(page number not for citation purposes)other healthcare options. The decision of the PHS tolaunch the legal case to protect the SIF was an attempt atthe protection of same sex-spousal benefits and the pro-tection of the constitutional rights to collective bargainingHarm Reduction Journal 2008, 5:31 http://www.harmreductionjournal.com/content/5/1/31for workers in government contracts, a case that he tookall the way to the Supreme Court of Canada and won. Heled the case on the Charter arguments regarding the rightsto life, liberty and security of the person for people livingwith addictions who need Insite.Two people living with addictionAddiction doesn't really happen in courtrooms; it hap-pens in the lifeworld of everyday humans and their fami-lies. Knee-deep in personal and familial sorrow, peoplewith addictions are often on the edge of psychosocial sur-vival. To venture from the edge of existence in the innercity where Insite is located to the courtroom showed thegreatest measure of personal courage in this legal case.When the lawyer finished each interview, told with pain-ful honesty by wounded witnesses, an almost unbearablesadness blanketed each affidavit. The Government of Can-ada never contested the credibility or representivity of thetwo people with addictions that provided evidence abouthow they rely on Insite. What greater measure of couragethan to share your personal experience with the healthcareissue of addiction, still deeply stigmatized, in the publicrealm? Many people in the community, especially thosethat rely on Insite for life-saving healthcare, are particu-larly grateful to Dean Wilson and Shelly Tomic for theirtremendous social conscience and courage in sharing theirstories for the betterment of others.The trialOn the first day and the last day of this legal case, peoplewept. The evidence in the case, as summarized in the Jus-tice Pitfield's Reasons for Judgement, provided an depthhistory of the recognition of addiction as an epidemic inVancouver and the government responses to it. [3]During the trial, our legal team began to examine thenotion of addiction as a healthcare matter. The lead law-yer for the Government of Canada rose in immediateresponse and stated for the record that Canada had nointention of disputing that addiction is an illness. Thelegal team for Canada had made a crucial concession:addiction is an illness. Nor could they have done other-wise, with any credibility, given that they had relied onevidence from selected experts in the field of addictionmedicine.The moment seemed historic when I attended the court-room and looked into the eyes of Justice Pitfield. I won-dered at the time, if he, too, felt the presence of anhistorical moment. Did Justice Pitfield know that he wason the verge of legal greatness? When the judgement wasrendered, the answer was clear. Judge Pitfield was everpresent in this case, he had heard every word, read everyIn his Reasons for Judgement, Justice Pitfield notes thatthe Government of Canada and the plaintiffs agreed on acrucial point: "drug addiction is an illness". [3] (p. 20).Furthermore, he concludes that all the evidence put for-ward three incontrovertible facts:1. "Addiction is an illness. One aspect of the illness is thecontinuing need or craving to consume the substance towhich the addiction relates.2. Controlled substances such as heroin or cocaine thatare introduced into the bloodstream by injection do notcause Hepatitis C or HIV/AIDS. Rather, the use of unsani-tary equipment, techniques and procedures for injectionpermits the transmission of those infections, illnesses ordiseases from one individual to another; and3. The risk of morbidity and mortality associated withaddiction and injection is ameliorated by injection in thepresence of qualified health professionals."[3] (p. 33,para. 87)Furthermore, Justice Pitfield concludes, on the basis of theevidence, that the SIF is a healthcare facility:"While users do not use Insite directly to treat addic-tion, they receive services and assistance at Insitewhich reduce the risk of overdose that is a feature oftheir illness, they avoid risk of being infected or ofinfecting others by injection and they gain access tocounselling and consultation that may lead to absti-nence and rehabilitation. All of this is health-care."[3](p. 51, para. 136)He also addresses moral arguments, popular with detrac-tors against harm reduction measures that are sometimes,mistakenly, believed to somehow condone addiction:"Society cannot condone addiction, but in the face ofits presence it cannot fail to manage it, hopefully withultimate success reflected in the cure of the addictedindividual and abstinence". [3](p. 54., para. 144).He takes this notion further to examine the process of con-demnation in addiction while drawing analogy to other,less stigmatized, conditions:"Denial of access to Insite and safe injection for thereason by Canada, amounts to a condemnation of theconsumption that lead to addiction in the first place,while ignoring the resulting illness. While there isnothing to be said in favour of the injection of control-led substances that leads to addiction, there is much toPage 10 of 16(page number not for citation purposes)paper and he understood with clarity the truthfulness ofthis historical moment in law.be said against denying addicts healthcare services thatwill ameliorate the effects of their condition. WhileHarm Reduction Journal 2008, 5:31 http://www.harmreductionjournal.com/content/5/1/31those are not prohibited substances, society neithercondemns the individual who chose to drink orsmoke to excess, nor deprives that individual of arange of healthcare services. Management of the harmin those cases is accepted as a community responsibil-ity. I cannot see any rational or logical reason why theapproach should be different when dealing with nar-cotics, an aspect of which is that the substance thatresulted in the addiction in the first place will invaria-bly be ingested in the short-term, and possibly thelong-term, because of the very nature of the illness.Simply stated, I cannot agree with Canada's submis-sion that an addict must feed his addiction in anunsafe environment when a safe environment thatmay lead to rehabilitation is the alternative" (p. 155–156, para 146).Justice Pitfield infers that the management of harm fromaddiction is a community responsibility. Addiction is,then, a public problem demanding public resources andresponsibility. He goes on to conclude that failure to pro-tect the staff of Insite from criminal prosecution throughthe Controlled Drugs and Substances Act (CDSA) for per-forming their duties in the healthcare program is contraryto the Charter of Rights and Freedoms of Canada (Char-ter) that protect, under section 7, their fundamental rightto life, liberty and security of the person. Even moreimportant than liberty, he asserts, is the threat to life andsecurity of the person of people with active addictions ifInsite were to be arbitrarily closed by the federal ministerof health.Moreover, Justice Pitfield notes that the CDSA, as it per-tains to the SIF, is actually incongruent with the state'sinterest:"In particular, it prohibits the management of addic-tion and its associated risks at Insite...Instead of beingrationally connected to a reasonable apprehension ofharm, the blanket prohibition contributes to the veryharm it seeks to prevent. It is inconsistent with thestate's interest in fostering individual and communityhealth, and preventing death and disease." (page 56–57, para. 152)In his reasons for judgment, he also provides critique ofthe unencumbered and blanket power over the programby the federal Minister of Health and his failure to exam-ine the SIF in relation to the public interest:"The unfettered nature of the discretion to exempt isapparent in this case. Following a detailed assessmentof medical and social need, the Health Authoritygranted the exemption was 'necessiity for a scientificpurpose'. No reference was made to necessity for amedical purpose. No reference was made to necessityin the pubic interest, which, in the context of theDTES, was the over-riding concern." (p58, para 155).He emphasizes that the CDSA cannot take precedenceover the Charter rights of users who rely on Insite. As such,he pronounced that sections 4(1) and 5(1) CDSA asapplied to Insite "are inconsistent with s. 7 of the Charter,and have no force and effect."[3] (p. 58, para. 158)Furthermore, Justice Ian Pitfield makes the observationthat the injection of drugs by marginalized people withmultiple barriers to their social and medical tenure is notrecreational:"Residents of the DTES who are addicted to heroin,cocaine and other controlled substances are notengaged in recreation. Their addiction is an illness fre-quently, if not invariably, accompanied by seriousinfections and the real risk of overdose that compro-mise their physical health and health of other mem-bers of the public. I do not assign or apportion blame,but I conclude that their situation results from a com-plicated combination of personal, governmental andlegal factors: a mixture of genetic, psychological, soci-ological and familial problems; the inability, despiteserious and prolonged efforts, of municipal, provin-cial and federal governments, as well as numerousnon-profit organizations, to provide meaningful andeffective support and solutions; and the failure of thecriminal law to prevent the trafficking of controlledsubstances in the DTES as evidenced by the continuingproblem of addiction in the area."[3] (p. 33–34, para.89)His analysis reaches far beyond the simple process ofblaming addicts for their condition towards a more com-plicated understanding of addiction and the factors thataffect it. The Judgement of Justice Pitfield has shown theway to develop kindness in human civilization, as itshould pertain to those struggling with addiction, a littlefurther.The tables are turnedIn the end, Justice Pitfield provided the Government ofCanada with one-year, ending 30 June 2009, duringwhich time the CDSA must be brought into compliancewith the Charter otherwise the law will become constitu-tionally invalid. During that one year period, he grantedthe "users and staff at Insite, acting in conformity with theoperating protocol now in effect, a constitutional exemp-Page 11 of 16(page number not for citation purposes)applied for an exemption that would permit Insite tooperate. The heading under which the Ministertion from the application of ss. 4(1) and 5(1) of theCDSA."[3] (p.59, para. 159)Harm Reduction Journal 2008, 5:31 http://www.harmreductionjournal.com/content/5/1/31Until the completion of this legal case, the PHS, the VCHand the Province of British Columbia had to apply for aSection 56 exemption, for scientific purposes, from theCDSA. As such, those that rely on the program and thestaff who serve them had been constantly subject to thepolitical whims of the Prime Minister and his health min-ister to determine the fate of this crucial healthcare pro-gram. With the Pitfield decision, instead of waiting withtheir hearts in their hands for the outcome of the cabinetdiscussions of Harper and Clement, it is now the federalgovernment that has a tight timeline looming over itshead. If the parliament does not bring the CDSA intocompliance with the Charter by 30 June 2009, then theauthority of act evaporates.We are now standing on the legal shoulders of Justice IanPitfield. As it stands, then, the VCH and PHS has a perma-nent exemption to operate Insite. What is required now isa permanent removal of the SIF from the ControlledDrugs and Substances Actso that recurrent politicizationof serious addiction through this federal act can be elimi-nated. That is, of course, unless the conservative federalgovernment can set the clock back by having Mr. Pitfield'sdecision overturned by the BC Court of Appeal in April2009.Back to DarrowI opened this commentary with a reference to Americanlawyer Clarence Darrow, famous for legal fight for free-dom of speech and his defence of the damned. His workis relevant to the present case in three respects. Firstly, hisincredible dedication to defending the poor, the damnedand the unpopular is particularly relevant here. Defendingpeople with active addictions, who are still deeply stigma-tized, is not an automatically popular legal cause. Thedecision to defend this group of citizens has to be, bysocial necessity, done out of principle. Monique Pon-gracic-Speier, Drew Schroeder and Joseph Arvay showedremarkable legal conscience in taking up the case of peo-ple with addictions, like modern day lepers. [60,61].The second connection to Darrow is the fact that defend-ing the vulnerable and socially damned is not financiallyrewarding. It seems that some of the most important legalstruggles, by virtue of their stigmatization, must be donefor free. It is estimated that between thirty and fifty percent of the people represented by Clarence Darrow didnot have the financial means to pay any fee whatsoever.[2] The lawyers defending Insite in this case did so with-out payment. In fact, all the lawyers and expert witnessesin defence of Insite gave their time and testimony for free.For that, we are in debt for the generous contribution thatthey all made to the public good.However, it was Darrow's tireless work against capitalpunishment that I draw the most important connection.The final link to Darrow pertains to capital punishment,state sanctioned and committed killing, an anachronisticand murderous act by the nation. Ignoring the scientificand medical evidence with regard to harm reductionmeasures, such as SIFs and syringe distribution programs,which are designed to address key epidemiological aspectsof the pandemic of addiction, is to allow the State to unre-servedly condemn addicts to death by preventable causes.Fatal drug overdose is not like some healthcare challenges,like cancer, for which there are no known cures. There is acure for fatal drug overdoses; they can be prevented wheninjections are medically supervised. Deadly HIV and hep-atitis infections can be curbed by initiatives that reducedeadly syringe sharing. Closing the door on harm reduc-tion measures is to condemn addicts to an epidemiologi-cal death row. This state condemnation, like capitalpunishment, is something that is even more calculatedthan murder:"I have always hated capital punishment. To me, itseems a cruel, brutal, useless barbarism. The killing ofan individual by another always shows real or fanciedexcuse or reason. The cause, however poor, wasenough to induce the act. But the killing of an individ-ual by the State is deliberate, and is done without per-sonal grievance or feeling. It is the outcome of longpre-meditated hatred. It does not happen suddenly,without warning, without time for the emotions tocool and subside, but a day is fixed a long time ahead,and the victim is kept in continued prolonged tortureup to the moment of execution". [2] (pp. 49–50)Clarence Darrow was relentless in his pursuit of theimmortal goal of kindness towards all persons, includingthe most vulnerable and weak in our midst. The Judge-ment by Justice Pitfield is reminiscent of that goal. Withwhat we know in science, medicine and now law, staterefusal to accept injection facilities and other harm reduc-tion measures such as Insite as part of a comprehensiveapproach to addiction is, plainly, a form of implicit capi-tal punishment of the addicted by means of fatal over-dose, hepatitis and AIDS. Perhaps, with this Judgement ofJustice Pitfield, we are at the beginning of the end of thedeadly fervour that accounts for addiction's death row anddrives political anger towards addicts.The hard-hearted appeal: where do we go from here?Two days after the decision by Justice Pitfield on 27 May2008, federal health minister Tony Clement announcedthat he would direct the federal justice minister to attemptPage 12 of 16(page number not for citation purposes)to have Justice Pitfield's landmark decision overturned bythe BC Court of Appeal. BC Supreme Court decision. [74]Harm Reduction Journal 2008, 5:31 http://www.harmreductionjournal.com/content/5/1/31He then launched a full offensive attack on Insite. In theparliamentary committee on healthcare on 29 May 2008,he attempted to undermine the scientists who have evalu-ated Insite:"On the question of science, let me assure you I'veread many of the studies that have been published onInsite. These studies have the weight of publication, aswell as some articulate proponents who insist theirpositions are the correct one. Many of the studies areby the same authors who, quite frankly, plow theirground with regularity and righteousness. Indeed,while in our free society scientists are at liberty tobecome advocates for their position, I've noticed thatthe line between scientific views and advocacy issometimes hard to find as the issue on Insite is devel-oped". [75] (pp. 30–31)Clement declares to the Parliamentary Committee thatone of the activities performed by Insite is to "facilitateinjection drug use". [75] (p. 48). As someone that wasintricately involved in the development and implementa-tion of Insite, I can say with conviction that nothing couldbe further from the truth. I have known people, person-ally, to die of fatal overdoses or AIDS and neither I noranyone who is involved in the operation of Insite pro-mote, facilitate or glamorize injection drug use in any wayconceivable. This program facilitates life in a healthcarefacility as an alternative to a lonely death in an ugly alley-way. In fact, no one in their right mind, and certainly notpeople living with addictions or the people that lovethem, would want to facilitate drug use. Minister Clementthen rejects the decision of Justice Pitfield and calls intothe question the very notion of the SIF as healthcare:"In my opinion, supervised injection is not medicine;it does not heal the person addicted to drugs. Each andevery injection, along with the heroin and cocaineinjected, harms the person. Injection not only causesphysical harm, it also deepens and prolongs the addic-tion.". [75] (p. 36)In a letter to the Globe and Mail on 5 June 2008, heattacked physician Gabor Mate, who testified in supportof Insite, calling him hypocritical:"A more apt analogy of what Insite, Vancouver's safe-injection facility, does would be a doctor holding acigarette to make sure a smoker doesn't' burn his lips,or watching a woman with cardiac problems eat fattyFrench fries to ensure she swallows them properly.Given that doctors are ethically bound to do no harm,the idea of one doctor or a community of doctorsfrom drug addiction in Canada would automaticallybe referred to a treatment program based on absti-nence; no addicted doctor would be referred to asupervised injection site and told: 'Keep injecting untilyou are ready for treatment"'. [76]It seems impossible for someone to have made these com-ments that had actually read Justice Pitfield's judgementin its entirety and understood it. So, then, the federalhealth minister appears to draw similarity between savingthe life of person from a fatal drug overdose in an SIF towatching a person with a cardiac condition eat Frenchfries. Perhaps, if he had not had his power to close Insitetaken away by Justice Pitfield, he could have closed thefacility happily and then explained this parallel to amother who has just lost her daughter to a preventableoverdose? If there were, in fact, a hypothetical physicianliving in the systemic refugee camp of the DTES in Van-couver who was addicted to injecting heroin, then, in con-trast to the Minister's lofty ruminations, we woulddefinitely grant them access to Insite to keep them fromdying in an alleyway. And, as a result, Insite would serveas a doorway into treatment and healthcare for the physi-cian.The futureWithin 48 hours of Justice Pitfield's decision, federalHealth Minister Tony Clement reacted by announcingthat Canada would attempt to have Mr. Justice Pitfield'sdecision overturned by the BC Court of Appeal. The legalteam for Insite received official notice of the Canada's aimto have the decision on 3 June 2008. Accordingly, the PHSlegal team provided notice of Cross Appeal on 12 June2008. In taking only 48 hours to weigh up the complexdecision of Justice Pitfield, what does this political deci-sion reveal about the analysis performed byPrime Minis-ter Harper and health minister Clement regarding themedical, scientific and, now, the legal wisdom regardingSIFs?The federal conservatives appeared to be attempting tousedemagogy regarding addiction to garner political sup-port when a pamphlet was mailed out in August of 2008using free postage privileges for members of parliament.The pamphlet featured a picture of a needle in a play-ground with a swing and children playing in the back-ground. The documentstated, "junkies and drug pushersdon't belong near children and families. They should bein rehab or behind bars." [see Additional File 6]. A formalcomplaint from opposition Members of Parliamentensued on the grounds that rights to free postage for fed-eral politicians in Canada does not allow requests for re-election. [77] The Conservative pamphlet asked recipientsPage 13 of 16(page number not for citation purposes)advocating for activities that cause harm is disturbing.It is also hypocritical, given that a doctor sufferingto fill out a ballot and send it back to Ottawa to the atten-tion of a conservative Member of Parliament (who is Co-Harm Reduction Journal 2008, 5:31 http://www.harmreductionjournal.com/content/5/1/31Chair of the Canada-United States Inter-ParliamentaryGroup) using free postage.It appears from their decision to attempt to overturn thefindings of the BC Supreme Court that the Prime MinisterHarper and health minister are once again going to use theresources of the federal government to attempt to standagainst science, medicine and law in their attempt to pre-vent the medical supervision of deadly injections. It ishard to understand what reasoning might account forsuch a cold decision.In sharp contrast, the Premier of the province of BritishColumbia, Gordon Campbell has shown remarkableleadership, along with his health minister George Abbottand attorney general Wally Oppall (former BC SupremeCourt Judge), in funding and protecting Insite as part ofthe continuum of healthcare for vulnerable populationsin the province. Moreover, the Attorney General of BritishColumbia has now officially entered the next stage of thelegal case by exercising the right of the Province of BC tobe a party to the appeal. In fact, a second ministry of theProvince, the Vancouver Coastal Health Authority, havealso signalled their intention to enter the legal case todefend the SIF.It is now time for the conservative government of Canada,under the leadership of Prime Minister Stephen Harper, todo the right thing and to bring the CDSA into compliancewith the Charter. Justice Pitfield has given them one yearto do so. Only a few months are left. While the clock tickson the CDSA, Prime Minister Harper and federal healthminister Clement are missing an important historicopportunity to rise to the challenge of Justice Pitfield.They could be political heroes in the story by showingleadership by joining scientists, physicians and popula-tion health experts in moving the country with a compre-hensive approach to injection drug use. Prime MinisterHarper and health minister Clementcould work togetherwith the other parties in the parliament, in a non-partisanspirit, to remove SIFs from the CDSA. In so doing, theywouldrepresent the will of the vast majority of Canadiansand demonstrate our country'shealthy respectfor scien-tific, medical, legal and humanistic approaches to thepandemic of addiction.For now, we are, sadly, going to back to court in the springof 2008. Once again, the PHS, the two people living withaddiction and three lawyers have been thrust into a legalgale originating from our nation's capital. The federal gov-ernment's determination to overturn the rights of Insite tooperate appears to be driven by stubborn ideology. Thecommunity is forced, once again, to fight for life-savingthat has been provided by Justice Pitfield. Even as thePrime Minister and federal health ministeronce again dis-patch the resources of the federal government against Van-couver's SIF, we still live in hope for a humane andevidence based approach to addiction for the children oftomorrow. We are hopeful, for the wounded addicts thatrely on Insite, that we will one day reach a kinder andmore humane destination where the rights to liberty, free-dom and security of the person for people living withaddiction are a part of fundamental justice. Thank youJustice Pitfield for giving us hope to see beyond addic-tion's death row:"Who hopes for only for what they see before them?For hope that is seen is not hope at all".Paul to the Romans 8Additional materialAdditional file 1The Honourable Mr. Justice Pitfield Reasons for Judgment: PHS Com-munity Services Society v. Attorney General of Canada, 2008 BCSC 661. The legal judgment pertaining to North America's only SIF.Click here for file[http://www.biomedcentral.com/content/supplementary/1477-7517-5-31-S1.pdf]Additional file 2Report of the Task Force into illicit narcotic overdose deaths in British Columbia . The results of a provincial task force examining fatal over-doses due to injection drug use.Click here for file[http://www.biomedcentral.com/content/supplementary/1477-7517-5-31-S2.pdf]Additional file 3Health impact of injection drug use and HIV in Vancouver. A report on the epidemic of injection drug use in the Vancouver area commissioned for the local health authority.Click here for file[http://www.biomedcentral.com/content/supplementary/1477-7517-5-31-S3.pdf]Additional file 4HIV, Hepatitis, and injection drug use in British Columbia: pay now or pay later? A report on the population health impacts of injection drug user by British Columbia's Chief Medical Health Officer.Click here for file[http://www.biomedcentral.com/content/supplementary/1477-7517-5-31-S4.pdf]Additional file 5Framework for action. This is the drug policy document for City of Van-couver.Click here for filePage 14 of 16(page number not for citation purposes)healthcare for people with addictions and their families.But, at least, we are trimming our sails to the legal wind[http://www.biomedcentral.com/content/supplementary/1477-7517-5-31-S5.pdf]Harm Reduction Journal 2008, 5:31 http://www.harmreductionjournal.com/content/5/1/31References1. Closing Argument in The State of Illinois v. Nathan Leopold& Richard Loeb Delivered by Clarence Darrow 22 April[http://www.law.umkc.edu/faculty/projects/ftrials/leoploeb/darrowclosing.html]2. Jensen RJ: Clarence Darrow: The Creation of an American Myth NewYork: Greenwood Press; 1992. 3. Pitfield THMJ: PHS Community Services Society v. AttorneyGeneral of Canada, 2008 BCSC 661.  The Supreme Court ofBritish Columbia; 2008. 4. Small D: Amazing grace: Vancouver's supervised injectionfacility granted six-month lease on life.  Harm Reduction Journal2008, 5:1-6.5. Milloy M-JS, Kerr T, Tyndall M, Montaner J, Wood E: EstimatedDrug Overdose Deaths Averted by North America's FirstMedically-Supervised Safer Injection Facility.  PLoS ONE 2008,3:e3351-e3351.6. The Constitution Act, 1982.  Canada 1982.7. Wong S: On the front cover: John J.L. Hunter, Q.C. (Law Soci-ety of British Columbia president (Testimonial).  In The Advo-cate Volume 66. Law Society of British Columbia; 2008:13-18. 8. John J.L. Hunter, Q.C.: Representative Cases   [http://www.litigationchambers.com/lawyers/john_hunter.htm]9. Gusfield JR: The Culture of Public Problems: Drinking-Driving and the Sym-bolic Order Chicago: University of Chicago Press; 1981. 10. Csete J, Wolfe D: Closed to Reason: The International Narcot-ics Control Board and HIV/AIDS.  Canadian HIV/AIDS LegalNetwork International Harm Reduction Development Program(IHRD) Open Society Institute (OSI); 2007:1-32. 11. Agreement V: Vancouver Agreement: 2000–2005 progressand highlights.  Vancouver: Vancouver Agreement; 2008. 12. Cain JV: Report of the Task Force into Illicit Narcotic Over-dose Deaths in British Columbia.  Office of the Chief Coroner:Ministry of the Attorney General; 1994. 13. Whynot E: Health Impact of Injection Drug Use and HIV inVancouver.  1996.14. Millar JS: HIV, Hepatitis, and Injection Drug Use in BritishColumbia: Pay Now or Pay Later?  Victoria: Office of the Provin-cial Health Officer; 1998. 15. Benoit C, Carroll D, Lawr L, Chaudhry M: Marginalized Voices inthe Downtwon Eastside: Aboriginal Women Speak AboutTheir Experiences.  York University; 2001. 16. MacPherson D: A Framework for Action: A Four-PillarApproach to Drug Problems in Vancouver.  Vancouver: City ofVancouver; 2001:1-90. 17. Vancouver Police Department Policy 11.04 Guidelines forPolice Attending Illicity Drug Overdoses.  .18. Victorial Police Drug and Alcohol Strategy Unit: What isHarm Minimisation   [http://www.police.vic.gov.au/content.asp?Document_ID=5059]19. Fowler G, Allsop S, Melville D, Wilkinson C: Drug harm minimi-zation education for police in Australia. A collaborativereport by the National Centre for Education and Training onAddiction.  Queensland: Queensland Police Service Edith CowanUniversity; 1999. 20. Small D: Two cultures passing in the night.  International Journalof Drug Policy 2005, 16:221-222.21. Safety NMDoP: State Police Officers Trained in use of Narcan.Safety NMDoP ed. Santa Fe: New Mexico Department of Public23. Howell M: RCMP question safe injection site research.  In Van-couver Courier Vancouver: CanWest MediaWorks Publications Inc;2006. 24. Mason G: Insite revelation proves RCMP needs watching.  InGlobe and Mail Toronto: CTV globe media; 2008. 25. Picard A: Hatred for safe-injection sites is irrational: The facil-ities will not cure drug abuse but they're integral to strate-gies for prevention and rehabilitation.  In Globe and MailToronto: CTV globe media; 2008. 26. RCMP secretly funded anti-Insite research   [http://www.pivotlegal.org/pdfs/RCMPsecretlyfundedreserch-documents.pdf]27. RCMP Letter to the BC Centre of Excellence in HIV/AIDS[http://bc.rcmp.ca/ViewPage.action?siteNodeId=39&contentId=6672&languageId=1]28. DeBeck K, Wood E, Zhang R, Tyndall M, Montaner J, Kerr T: Policeand public health partnerships: Evidence from the evaluationof Vancouver's supervised injection facility.  Substance AbuseTreatent, Prevention and Policy 2008, 3:1-5.29. Fairburn N, Small W, Shannon K, Wood E, Kerr T: Women's Expe-riences in North America's First Medically Supervised SaferInjection Facility.  Social Science and Medicine Forthcoming .30. Kerr T, Kimber J, DeBeck K, Wood E: The Role of Safer InjectionFacilities in the Response to HIV/AIDS Among InjectionDrug Users.  Current HIV/AIDS Reports 2007, 4:158-164.31. Kerr T, Small W, Moore D, Wood E: A Micro-EnvironmentalIntervention to Reduce Harms Associated with Drug-Related Overdose: Evidence from the Evaluation of Vancou-ver's Safer Injection Facility.  International Journal of Drug Policy2007, 18:37-45.32. Kerr T, Stoltz J, Tyndall M, Li K, Zhang R, Montaner J, Wood E:Impact of a Medically Supervised Safer Injection Facility onCommunity Drug Use Patterns: A Before and After Study.British Medical Journal 2006, 332:220-222.33. Kerr T, Tyndall MW, Lai C, Montaner JSG, Wood E: Drug-RelatedOverdoses Within A Medically Supervised Safer InjectionFacility.  International Journal of Drug Policy 2006, 17:436-441.34. Kerr T, Tyndall MW, Lai C, Montaner JSG, Wood E: Circumstancesof First Injection Among Illicit Drug Users Accessing a Med-ically Supervised Safer Injecting Facility.  American Journal ofPublic Health 2007, 97:1228-1220.35. Kerr T, Tyndall MW, Li K, Montaner JS, Wood E: Safer InjectingFacility Use and Syringe Sharing Among Injection DrugUsers.  Lancet 2005, 366:316-318.36. Kerr T, Wood E, Small D, Palepu A, Tyndall MW: Potential Use ofSafer Injecting Facilities Among Injection Drug Users in Van-couver's Downtown Eastside.  CMAJ 2003, 169(8):759-763.37. McKnight I, Maas B, Wood E, Tyndall MW, Small W, Lai C, MontanerJSG, Kerr T: Factors Associated with Public Injecting AmongUsers of Vancouver's Supervised Injection Facility.  AmericanJournal of Drug and Alcohol Abuse 2007, 33:319-325.38. Milloy MJ, Wood E, Small W, Tyndall M, Lai C, Montaner J, Kerr T:Incarceration experiences in a cohort of active injection drugusers.  Drug and Alcohol Review 2008:1-7.39. Petrar S, Kerr T, Tyndall MW, Zhang R, McKnight B, Montaner JSG,Wood E: Injection Drug Users' Perceptions Regarding Use ofa Medically Supervised Safer Injecting Facility.  Addictive Behav-iors 2007, 32:1088-1093.40. Stoltz JA, Wood E, Small W: Changes in Injecting PracticesAssociated with the Use of a Medically Supervised InjectionFacility.  J Public Health (Oxf) 2007, 29(1):35-39.41. Tyndall MW, Kerr T, Zhang R, King E, Montaner JG, Wood E:Attendance, Drug Use Patterns, and Referrals Made FromNorth America's First Supervised Injection Facility.  DrugAlcohol Depend 2006, 83(3):193-198.42. Tyndall MW, Wood E, Zhang R, Lai C, Montaner JS, Kerr T: HIVSero-prevalence Among Participants at a Supervised Injec-tion Facility in Vancouver, Canada: Implications for Preven-tion, Care and Treatment.  Harm Reduction Journal 2006, 3:.43. Wood E, Kerr T, Buchner C, Marsh D, Montaner JS, Tyndall MW:Methodology for Evaluating Insite: Canada's First MedicallySupervised Safer Injection Facility for Injection Drug Users.Harm Reduction Journal 2004, 1:1-5.44. Wood E, Kerr T, Montaner JS, Strathdee S, Kerr T, Wodak A, SpittalP, Hankins C, Schechter MT, Tyndall M: Rationale For EvaluatingAdditional file 6Junkies and drug pushers don't belong near children and families. This is a pamphlet mailed out compliments of Rob Merrifield, Member of Parliament, in August of 2008.Click here for file[http://www.biomedcentral.com/content/supplementary/1477-7517-5-31-S6.pdf]Page 15 of 16(page number not for citation purposes)Safety; 2004. 22. Education Programs   [http://www.youthco.org/cms/page1113.cfm]North America's First Medically Supervised Injecting Facil-ity.  Lancet Infectious Diseases 2004, 4:301-306.Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central Harm Reduction Journal 2008, 5:31 http://www.harmreductionjournal.com/content/5/1/3145. Wood E, Kerr T, Small W, Li K, Marsh D, Montaner JS, Tyndall MW:Changes In Public Order After The Opening of a MedicallySupervised Safer Injection Facility for Injection Drug Users.Canadian Medical Association Journal 2004, 171:731-734.46. Wood E, Kerr T, Stoltz J, Qui Z, Zhang R, Montaner JSG, TyndallMW: Prevalence and correlates of hepatitis C among users ofNorth America's first medically supervised safer injectionfacility.  Public Health 2005, 119:1111-1115.47. Wood E, Kerr T, Tyndall MW, Montaner JSG: The Canadian gov-ernment's treatment of scientific process and evidence:Inside the evaluation of North America's first supervisedinjecting facility.  Int J Drug Policy 2008, 19(3):220-225.48. Wood E, Montaner JS, Kerr T: Reflection and Reaction: Illicitdrug addiction, infection disease spread, and the need for anevidence-based response.  Lancet 2008, 8:142-143.49. Wood E, Tyndall MW, Lai C, Montaner JSG, Kerr T: Impact of aMedically Supervised Safer Injecting Facility on Drug Deal-ing and Other Drug-Related Crime.  Substance Abuse Treatment,Prevention and Policy 2006, 1:1-4.50. Wood E, Tyndall MW, Li K, Lloyd-Smith E, Small W, Montaner JSG,Kerr T: Do Supervised Injecting Facilities Attract Higher-RiskInjection Drug Users?  American Journal of Preventive Medicine 2005,29:126-130.51. Wood E, Tyndall MW, Montaner JS, Kerr T: Summary of findingsfrom the evaluation of a pilot medically supervised injectingfacility.  Canadian Medical Association Journal 2006, 175:1399-1404.52. Wood E, Tyndall MW, Qui Z, Zhang R, Montaner JS, Kerr T: ServiceUptake and Characteristics of Injection Drug Users UtilizingNorth America's First Medically Supervised Safer InjectionFacility.  American Journal of Public Health 2006, 96:770-773.53. Wood E, Tyndall MW, Stoltz J, Small W, Lloyd-Smith E, Zhang R,Montaner JSG, Kerr T: Factors Associated with Syringe SharingAmong Users of a Medically Supervised Injecting Facility.American Journal of Infectious Diseases 2005, 1:50-54.54. Wood E, Tyndall MW, Stoltz J, Small W, Zhang R, O'Connell J, Mon-taner JSG, Kerr T: Safer Injecting Education for HIV Preven-tion Within a Medically Supervised Safer Injecting Facility.International Journal of Drug Policy 2005, 16:281-284.55. Wood E, Tyndall MW, Zhang R, Stoltz J, Lai C, Montaner JSG, KerrT: Attendance at Supervised Injecting Facilities and Use ofDetoxification Services.  New England Journal of Medicine 2006,354:2512-2514.56. Wood E, Tyndall MW, Zhang R, Montaner JS, Kerr T: Rate ofdetoxification service use and its impact among a cohort ofsupervised injection facility users.  Addiction 2007, 102:916-919.57. Wood RA, Wood E, Lai C, Tyndall MW, Montaner JSG, Kerr T:Nurse-delivered safer injection education among a cohort ofinjection drug users: Evidence from the evaluation of Van-couver's supervised injection facility.  Int J Drug Policy 2008,19(3):183-188.58. Hwang SW: Science and ideology.  Open Medicine 2007, 1:E99-101.59. Day B: Ottawa's bad prescription on addiction.  In The TorontoStar Toronto: Toronto Star Press Centre; 2008. 60. Small D, Drucker E: Policy makers ignoring science and scien-tists ignoring policy: the medical ethical challenges of herointreatment.  Harm Reduction Journal 2006, 3:1-14.61. Small D: Fools rush in where angels fear to tread: Playing Godwith Vancouver's Supervised Injection Facility in the politicalborderland.  International Journal of Drug Policy 2007, 18:18-26.62. Vancouver Co: 2007 Survey of Low-Income Housing in theDowntown Core.  Group HCCS ed.: City of Vancouver; 2007. 63. Dispute Resolution Award in LawStudies   [http://cfcj-fcjc.org/clearinghouse/drpapers-en.php]64. Lupick T: Olympics on way means workers need to know theirrights.  In Georgia Straight Vancouver: Georgia Straight; 2007. 65. Mason B: Law Worth Losing Sleep Over: The finer points oflaw are no longer moot to Monique Pongracic-Speier.  In UBCReports, May 10 edition Volume 47. Vancouver: University of BritishColumbia; 2001. 66. Mexico: Patterns in Human Rights Abuses   [http://www.lrwc.org/pub1.php]67. Anonymous: Drew Schroeder Rhodes Scholar.  In The MartletVolume 9. Victoria: University of Victoria; 1969:5. 68. McManus T: 20,000 people could be impacted by decision:est could range from $15 to $20 million.  In Burnaby Now Burn-aby: Vannet Newspapers; 2007. 69. Doukhobor children suing B.C. for settlement   [http://www.cbc.ca/canada/story/2002/02/25/doukhobor_bc020225.html]70. Post N: Best lawyers: labour and employment.  In Financial PostVolume 2008. Canwest Publishing; 2006. 71. Joseph Arvay, Q.C., Receives CBA'S SOGIC Ally Award[http://www.cba.org/CBA/news/2000_releases/00-08-21_ally_award.aspx]72. Joseph Arvay, Q.C. Wins Tarnopolsky Human Rights Award[http://www.cba.org/CBA/news/2000_releases/00-08-21_tarnopolsky_award.aspx]73. News Archive   [http://www.arvayfinlay.com/news.htm]74. Galloway G: Clement seeks appeal of Insite decision.  In Globeand Mail Toronto: CTV globe media; 2008. 75. Canada Go: Standing Committee on Health: Transcript ofMeeting Thursday, May 29, 2008.  Health SCo ed. Ottawa: Gov-ernment of Canada; 2008. 76. Clement T: Do no harm, right?  In Globe and Mail Globe and Mail:CTV Globe Media Publishing; 2008. 77. Shore R: MPs launch formal complaint over Conservative fly-ers: Rules forbid using free postage to send out campaignmaterial.  In Vancouver Sun Vancouver: Canwest Global; 2008:A-19. yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 16 of 16(page number not for citation purposes)Schroeder estimates about 20,000 people could be affectedby the court's decision and the funds to be paid out for inter-

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