If three-year olds reformed healthcare

For its fall project, Ms. Taylor's pre-school class decided to tackle healthcare reform. According to Ms. Taylor, who has taught the Teddy Bear class of three-year olds for the past 20 years, "Instead of drawing autumn leaves and learning the ABC's, I wanted to try something new this year. And since every American thinks no actual knowledge is necessary to have an opinion on healthcare reform, I thought my three-year olds ought to give it a try."

Ms. Taylor continued, "You might think that three-year olds would have trouble with a topic like this, but they understood it right away. They were especially talented at issue spotting." Consider:

No sooner had the dimensions of the problem been explained than little Michelle Bachman, a pert toddler with adorable brown curls, exclaimed, "My healthcare is the bestest healthcare in the world. Everyone else's healthcare is ugly, ugly, ugly. Only mine is pretty, and it's mine, all mine."

Following up on that theme, Rush, a sturdy little boy who spoke while simultaneously knockiing down the building block castle of another child, declared, "I'm not going to share my healthcare with anyone and no one can make me."

Several children agreed with this sentiment. As little Glen Beck explained, "My mommy says nice boys share, but when I'm holding a toy, it's mine and I'm not gonna share it. The teacher has to pry it from my cold, sticky hands to let anyone else have a chance. I'm not sharing my healthcare, either."

There was a bit of a commotion when Ms. Taylor explained to the class that healthcare isn't free and everyone would need to contribute to making healthcare work. Anne Coulter began to whine, "I don't want to be a helper. I'm tired. Everyone else should help but not me and my friends. We're too busy doing other stuff."

In fact, there was universal agreement on this point. Every child thought that the other children should be helpers, but not them. Being a helper is boring, and that's not fair.

Suddenly Sarah Palin began to cry. "If I share my healthcare with other kids, they'll come to my house and take away my toys and my food. And then they're going to hold playdates without me and plan to kill me."

When Ms. Taylor tried to explain that no one was going to steal her toys and food, and no one would plot her death, Sarah refused to be consoled.

"No, no, no, they will try to kill me. They'll hold special playdates to plan it and I won't be invited. Theyll call them 'death playdates'."

When Ms. Taylor tried to explain that some children had no healthcare at all, Dickie Cheney became defiant. "Tough noogies for them. I'm not going to share and you can't make me."

Maxie Baucus summed it up best:

"I want the prettiest healthcare in the world, and I don't want anyone else to have pretty healtchare. It's not fair if I have to share my pretty healthcare and it's not fair if I have to do anything to earn it."

Ms. Taylor proudly reflected on her students' precociousness. "People often underestimate pre-schoolers" she said. "They think the children are immature, self absorbed and selfish, but I think we've proven them wrong today. They exhibited an understanding of healthcare worthy of any member of the GOP."

Ms. Taylor continued happily:

"We're planning a field trip next week to our Congressman's local town meeting. I'm sure others who oppose healthcare reform will welcome the children's insights."

Supporting Down Syndrome parents from conception right through birth

The fallout from my post Should we lament the disappearance of Down Syndrome? continues to percolate through the blogosphere. What is striking to me is how the reaction seems to be taken directly from the anti-choice agenda.

The whole notion that parents who elect to terminate a DS pregnancy need to be "educated" bears a more than passing resemblance to the approach of pregnancy "crisis" centers that attempt to talk women out of their decision to abort. The idea that women facing a DS pregnancy don't understand their options (as if they don't already know that they could bear the child or give it up for adoption) makes about as much sense as the idea that women seeking abortion don't understand their options.

The idea that women facing a DS pregnancy can only be "educated" by those who have elected to continue the pregnancy is offensive. The claim that women who have not solicited the advice of strangers should be given the contact information for strangers with an agenda is grossly inappropriate. Those parents are in no more need of the advice of strangers than a woman contemplating an abortion is in need of the advice of strangers.

Although those who support "educating" DS parents claim that they are not anti-choice, the resemblance in inescapable. For me, the most telling behavior is the way that parents who have DS children treat those parents who are overwhelmed by DS children. Only a few such women posted among the more than 400 comments, but the response was alarming and illuminating. Those women who vilified in the most crude and cruel fashion.

If parents of DS children were truly interested in supporting the decision to raise a DS child, they would provide the most support to the people in the most need: people struggling to raise a DS child, and faltering under the burden. I did not detect the least bit of compassion for these women; there was only harsh condemnation.

Inadvertantly, through their reaction, parents of DS children revealed their true agenda. It is not to support those who are raising DS children. It is to vilify those who terminate, bully those who might terminate, and cruelly turn away from anyone who won't pretend that raising a DS child is "enriching."

Don't believe everything you think

The most common mistakes of alternative health advocates are mistakes of logic. They assume that what "makes sense" to them is automatically true. Thomas Kida, a professor at the UMass Isenberg School of Management, explains why this assumption is unjustified in his book Don't Believe Everything You Think: The 6 Basic Mistakes We Make in Thinking.

The 6 mistakes are:

Mistake #1: We prefer stories to statistics. Stories are easy to understand; statistics are hard. The problem is that particular stories which may not be representative while statistics, which are merely the aggregation of thousands or millions of stories, offer a realistic assessment of what typically happens. Vaccine rejectionists' striking reliance on anecdotes shows how alternative health advocates embrace this mistake.

Mistake #2: We seek to confirm our opinions, not challenge them. Homebirth advocacy is a perfect example of this mistake. To my knowledge, there is not a single homebirth advocacy website or publication that contains accurate information about homebirth. Nonetheless, homebirth advocates actually think that they have done "research" simply because they read the opinions of others who agree with them. In contrast, they generally make no effort to read websites and publications by those who offer information that does not support predetermined conclusions.

Mistake #3: Lay people often do not understand chance and coincidence. Most people have no idea of incidence of various risks. They grossly overestimate the chances of rare events and grossly underestimate the chances of common events. Homebirth advocates grossly overestimate the chances of death from a labor epidural, while simultaneously dramatically underestimating the chance of death from homebirth, which is more than a thousand times higher.

Mistake #4: Our personal perceptions about what is happening are often wrong. Unfortunately, the level of confidence in our perceptions is often entirely unjustified.

Mistake #5: We tend to oversimplify our thinking. Oversimplification is easy; reality is hard. While some simplification is necessary, particularly for lay people when first learning about complicated concepts, we must always keep in mind that simplification introduces distortions. Simplification is the merely the first step in thinking about complicated issues. It does not lead us to correct conclusions.

Mistake #6: Our memories are often inaccurate. This has actually been studied quite extensively. People tend to alter their memories to create a "narrative" that makes sense to them. Reality is not a narrative, however.

These mistakes are a vestige of the thinking processes that served us well in the hundreds of thousands of years of evolution in the wild. Statistics did not exist, so stories were the best way that we had to understand the world around us. Our perceptions were all we had available to us, and oversimplification is almost always the first step to understanding. In other words, there was a time when reasoning from what "makes sense" was the only thing that we had. Now those methods have been superceded by other, more accurate methods, but some people are still stuck in the past.

The typical homebirth advocate, or the typical vaccine rejectionist, does not know about or does not understand the new, more accurate methods for evaluating the world around us. They revert to more "primitive" forms of reasoning because they literally do not know any better.

This post originally appeared on Homebirth Debate in May 2008

Is illness a choice?

During my years of medical training I learned about the many causes of illness, but evidently that understanding is outmoded. Sophisticated Americans know that illness is a choice. People bring it upon themselves by their own choices. This new understanding is incredibly liberating. No need to feel sorry for people who are sick because it is their own fault. No need to provide healthcare, since poor health is attributed to bad choices. Best of all, no need to worry about getting ill. If illness is a choice, all you have to do to stay healthy is slavishly follow the socially mediated goals for weight and exercise, and nothing bad will ever happen to you.

Unfortunately, illness is not, by and large, amenable to choice. The new understanding of healthcare, what everyone knows to be true, is that diet and exercise are magically protective, that preventive medicine is the only medicine that counts, and that illness is a sign of slovenliness and lack of self-discipline. This new understanding tells us more about the psychological needs of the people who believe it than it tells us about health and disease.

Only a small fraction of illness is caused by lifestyle choices. The leading cause of disease is aging. The wear and tear on the human body inevitably leads to breakdown, whether the breakdown is physical or cognitive. No one chooses to get shingles, suffer from Alzheimer's or to succumb to diseases like the flu that would be far less serious in younger adults.

Infectious diseases, caused by viruses or bacteria, are not amenable to choice, either. Viral or bacterial illness is usually caused by nothing more than being in the wrong place at the wrong time, being exposed to an illness that someone else has. Fortunately, preventive care for infectious diseases is highly effective. It is called vaccination and it saves ten of thousands of American lives each year.

Some diseases are genetic. These include diseases with obvious genetic causes like sick cell anemia or Huntington's Disease, but other diseases like cancer almost certainly have a genetic basis, too. That genetic basis may be a propensity to develop the disease through mechanisms that we do not yet understand. It is likely to turn out that cancer, auto-immune diseases, and even heart disease are mediated by our genes.

It is true that some lifestyle choices behaviors impact the chance of developing illness, in particular smoking, drinking to excess and eating to obesity. Yet it is far from clear that even these behaviors are entirely amenable to choice.

Many of the worst excesses are the result of addiction. People do not make a conscious choice to become alcoholics or drug addicts. Yes, the decision to drink for the first time or to use drugs for the first time is a choice, but being gripped by addiction is not a choice at all. Indeed, there is some evidence that there is a genetic predisposition to addiction. While most people can drink alcohol without any permanent effects, alcoholics have a different reaction, one that leads to an inability to stop drinking.

Even making the choice to engage is a behavior known to be harmful does not mean that one has chosen to become ill. Most people who smoke don't get lung cancer, and many people addicted to tobacco assume that they will avoid that dreadful outcome; they certainly don't choose to get lung cancer.

The bottom line is that there is no evidence that illness is a choice. So why do many people persist in believing that it is a matter of choice?

It's not difficult to understand their rationale. If illness is a choice, then they can choose not to be ill. If illness is a matter of failing to meet socially mediated goals for weight and exercise, staying healthy is easy: just meet those goals by dieting and exercising. In addition there's need to feel sorry for people who are sick because it is their own fault. And there's no need to provide reform the healthcare system, since poor health is attributed to bad choices.

Pretending that illness is a choice minimizes both fear and guilt. Sadly, it is nothing more than wishful thinking.

Is your medication violating your privacy?

According to The Wall Street Journal, Novartis is developing a system that reminds patients to take their medications.

The company is testing inserting tiny microchips into the pills as part of a system that tracks whether patients are taking their meds as prescribed. When patients veer off course, they get a text message reminder.

The technology has significantly improved adherence in a very small group of patients taking the company's blood pressure medicine Diovan ...

The benefits of this technology could be huge. Patient compliance is a very serious issue, and anything that promotes compliance is likely to improve health. But the technology has disturbing implications that we ought to explore before it is widely implemented.

Bioethicist Summer Johnson points out:

...The tiny little microchip inside the medication would monitor one's blood level and when it slips too low it sends a message to the patient saying, "Hey dude, time to take your medication!" It's efficient, simple, and could potentially save your life. No complaints here, right?

Wrong! This invades patient's privacy and a patient's right to be delinquent taking medication and screwing up their dosing. It makes it much more difficult for patients to ignore doses or to say, "If I don't want to take medication, I don't have to" with a microchip inside their body beaming out text messages to a device annoying them all the time. Particularly if that device can send its data to their physician or worse yet to their insurance company reporting them as a non-compliant patient.

Dr. Johnson dismisses these concerns:

But isn't that the point? To motivate patients to be compliant? Personally, I think the more we can do to encourage chronic disease management that actually works and compliance with long-term dosing regimens that work, the better.

If this drug can actually do what it promises, I hope they make more of them.

I am surprised at that response. Didn't we learn in ethics 101 that the ends do not justify the means? Although the goal is admirable, the privacy concerns are real and should not be dismissed out of hand.

The technology could represent a substantial benefit for patients who want help remembering to take their medications. Individuals suffering from complex medical conditions and elderly patients often have difficulty remembering to take medications that they fully intend to take. No doubt those patients would appreciate the reminder, and might also appreciate the fact that their doctor (and family) could be notified if they forget to take a particular medication.

Most of us, though, could buy a simple pillbox alarm if we felt we needed help remembering to take medication. It is not clear if there is any additional benefit to the micro-chip technology and there are substantial privacy concerns.

Taking medication is a personal decision. Although I as a doctor may lament the fact that some patients are non-compliant, should I employ tools to guarantee compliance? Should doctors be receiving minute-by-minute information on patient behavior? Should insurance companies have access to this information? Should they be allowed to terminate coverage if they learn that patients have not taken each and every recommended pill as directed.

Inserting micro-chips into medication is a form of surveillance. And as with any type of surveillance, the argument can be made that you have nothing to worry about if you are not doing anything wrong. Yet the police are not allowed to put cameras into people’s houses to make sure they are behaving behind closed doors. That’s because we value the right to privacy. That right to privacy should extend to medical decisions like whether or not to take blood pressure medication on time, or whether to take it all.

Is Down Syndrome counseling inadequate?

The vociferous response to my post Should we lament the disappearance of Down Syndrome? advocating choice in terminating a Down Syndrome pregnancy alerted me to an organized effort by DS parents to "educate" everyone else. It reminds me of, and shares many characteristics in common with, efforts by pregnancy "crisis centers" to "educate" women experiencing unwanted pregnancies. In both cases, the efforts are rather transparent attempts to get women to change their minds.

The movement was profiled in a 2007 piece in The New York Times.

Convinced that more couples would choose to continue their pregnancies if they better appreciated what it meant to raise a child with Down syndrome, a growing group of parents is seeking to insert their own positive perspectives into a decision often dominated by daunting medical statistics and doctors who feel obligated to describe the difficulties of life with a disabled child.

Their concern is hardly selfless:

A dwindling Down syndrome population, which now stands at about 350,000, could mean less institutional support and reduced funds for medical research. It could also mean a lonelier world for those who remain…

"If all these people terminate babies with Down syndrome, there won't be programs, there won't be acceptance or tolerance," said Tracy Brown, 37, of Seattle, whose 2-year-old son, Maxford, has the condition. "I want opportunities for my son. I don't know if that's right or wrong, but I do."

Interestingly, the vast majority of parents who elect to terminate are not complaining about being "uneducated" either at the time of termination or years later. And certainly no one in the community of DS parents is complaining about the "education" of those who were encouraged to continue the pregnancy. In fact, the only complaint emanating from the community of DS parents appears to be that people who make different decisions must be receiving inadequate education.

The approach, on view in the comments section of my previous DS post, is fairly formulaic:

... [T]he richness of their children’s lives, parent advocates say, is poorly understood. Early medical intervention and new expertise in infant heart surgery stave off many health problems; legally mandated inclusion in public schools has created opportunities for friendship and fostered broader social awareness of the condition.

The effort to "educate" other is remarkably intrusive:

... [P]arents are arranging to meet with local obstetricians, rewriting dated literature and pleading with health care workers to give out their phone numbers along with test results.

The medical community has been unimpressed. They understand that their obligation is to present unbiased information, not to present false hope in an effort to sway their patients' choices.

Genetic counselors, who often give test results to prospective parents, say they need to respect patients who may have already made up their minds to terminate their pregnancy. Suggesting that they read a flyer or spend a day with a family, they say, can unnecessarily complicate what is for many a painful and time-pressured decision...

There is certainly no objective evidence that Down Syndrome counseling is inadequate. There is only the conviction of some DS parents that people who make a different choice are making the wrong choice. Their effort to "educate" other parents is nothing more than an attempt to pressure them, and, as such, it is wrong.

My brain tumor

I first noticed difficulty with my vision in the early spring of 2000. Sitting at Little League Games I often had trouble focusing on the action. Over time I realized that the problem was intermittent double vision.

As the weeks went by, the double vision got worse. My optometrist suggested that adjusting my contact lens prescription; that didn't seem to work. Over time it became apparent to me, despite my vigorous attempts to pretend otherwise, that this was not a problem with my eyes, but almost certainly a problem inside my head. I made an appointment a highly regarded neuro-ophthalmologist, a hospital colleague.

I read up on double vision. There were three principle causes of double vision in otherwise healthy patients: idiopathic, which is the technical term for unknown cause; multiple sclerosis, and, least likely, a brain tumor. I convinced myself that I had idiopathic double vision, distressing because there was not cure, but certainly better than having multiple sclerosis or a brain tumor.

I arrived for my appointment on time. I had to spend an hour and a half in the waiting room because the doctor was "running behind," but, as an obstetrician, I'm hardly in a position to complain about waiting. Finally, the doctor flung open the exam room door and swept into the room.

"I can't see you today," he announced. "My secretary is an idiot. You have double vision and double vision requires an extra long appointment. She booked you for a regular appointment. You’ll have to come back another time when I have more time to see you."

"I don’t think so," I responded. "I'm here now and you can start the exam in the time we have available. If we need more time, I'll make another appointment."

The doctor looked irritated, but after learning I was a colleague of his, he seemed mollified. From that point forward, he was on his very best behavior. Considering how he treated me, I feel very sorry for his patients who are not doctors.

The doctor did a few simple tests, asked me to look up and down, side to side and follow his finger. In less than 5 minutes he announced findings.

"You don't have to come back," he said. "I already know what you have. You have a sixth nerve palsy. The nerve that controls one of the muscles of your eye (the sixth cranial nerve) is not working. You can't move your left eye to the left, that's why you have double vision, and why it happens intermittently. You only get double vision when looking to the left."

"There are three main causes of double vision," he continued. "Idiopathic, but I don't think it's that; multiple sclerosis, but your story is wrong for multiple sclerosis; and brain tumor. You must have a brain tumor. I'm sure of it."

That was it. That was how he broke the diagnosis. I had known about the possibility, of course, but I was stunned nevertheless.

"How are we going to find out whether I really do have a brain tumor?" I asked.
"Oh, you have a brain tumor," he responded emphatically. "We need to get an MRI to find out how big it is and where it is located. I suspect that it's benign, and based on its appearance on the scan, we should be able to confirm that."

He continued, "You can have an MRI on Monday, then you can come back on the following Monday and I'll tell you what it showed."

"Wait a minute," I was beginning to recover from the shock. "What do you mean that I find out the results the following Monday? The radiologist can see the findings during the scan itself. Why can't you get the results from the radiologist by phone on Monday?"

"You know those radiologists," he confided. "They’re all foreigners, Pakistanis, Indians; who can understand what they say? I can't, so I'll just wait for them to write me a letter."

Even in my shocked state, I recognized that it was pointless to try to deal with this doctor. I determined to deal with the radiologists directly.

I told my husband what had happened. I related the doctor's comments about the foreign radiologists. He was appalled by the blatant racism, but then he smiled.

"As it happens, I know those radiologists. I am one of their lawyers. My contact person in the group is Dr. Z, He’s Pakistani, but I have no trouble understanding him. He speaks better English than we do."

My husband called Dr. Z who assured him that he would come down and read my scan after it was done, and tell us the results immediately.

On the day of the scan, as I slid out of the MRI machine, a radiologist approached and stuck out his hand.

"Hi, I'm Dr. Z and I've already looked at your scan. Come out to the computer and I will show you what I found."

He was warm and engaging. He spoke perfect English with a slight British accent. I had no trouble understanding him. I followed him to a large computer screen.
“Good news,” he said, with a smile. "Your brain tumor is benign."

The room started to spin. I asked for a chair and sat down with a thump.

"I can't have a brain tumor," I said stupidly. "My son is having his Bar Mitzvah in two months and now is not a good time."

He looked at me kindly. "I'm not sure what that is, but it doesn't prevent you from having a brain tumor. But look at the scan. The tumor is small and well contained. It looks like a meningioma, a very common type of benign tumor. See how it is pressing on the sixth nerve. That's why you have double vision. Don't worry, though, a neurosurgeon will be able to remove it, and you'll be fine. They typically don't come back."

I wasn't counting on brain surgery, and this did not seem like good news to me. However, when I realized that Dr. Z was genuinely happy to be sharing this news, I understood that he had worried that the scan might have showed something far worse.

Later that afternoon, I got a call from the neuro-ophthalmologist. Dr. Z had informed him that I already knew the results of the scan. I'm not sure why he called since he did not impart any helpful information.

"I've looked at the film," he reported, "and you have a small tumor that is almost certainly benign. It's only a half inch across, but it is located deep inside your brain and pressing on lots of important structures."

Then he added: "I'd hate to be the neurosurgeon doing your case. That sucker is sitting in a lake of blood. The surgery's going to be a mess."

To be continued

This piece originally appeared on Open Salon in October 2008.

Let's have a professional homebirth debate

Homebirth advocates have a fallback position when presented with reams of data that homebirth increases the risk of neonatal death. They declare that the evidence is "conflicting" and that "there's no way we can solve this." But, of course, there are neutral ways to establish the truth, and I'd like to offer them publicly to homebirth advocates.

The following was originally posted on RH Reality Check in response to a piece by Amie Newman entitled What's So Scary About Home Birth? I offer this proposal to her, and if she doesn't accept, to any and all homebirth advocates:

"I'm sure you would agree that American women deserve to know the truth about homebirth. The best way to do that would be to present the information from both sides in a way that everyone could understand and make their own decisions.

I propose that RHRealityCheck sponsor a homebirth debate. I am willing to debate any professional homebirth advocate at any time. I would welcome the opportunity to present my claims side by side with those of homebirth advocates. I am very confident that when women see the actual data, they will realize that professional homebirth advocates have not been completely honest about the safety of homebirth.

Of course, the real problem will be finding a professional homebirth advocate willing to debate. They know what I know and they know that if they are forced to publicly defend their claims, they will be unable to do so. Hence they will do anything possible to avoid a debate.

Last year I was invited to participate in a childbirth conference by the organizers of the conference. They thought that my controversial status in the homebirth community would be an excellent draw. I agreed that I would attend the conference, but with one condition attached. I would only appear in a debate with a professional homebirth advocate, many of whom were already planning to attend.

The conference organizers thought this was a great idea. I warned them that no one would agree, including those who were already planning to attend. Professional homebirth advocates never appear in any forum where they can be challenged by people who are equally knowledgeable. Sure enough, much to the surprise of the organizers, they were turned down by almost everyone. Ultimately they managed to cajole a very prominent homebirth advocate into participating and I made plans to attend the conference. Then, predictably, the homebirth advocate announced that he had changed his mind and would not participate. I did not attend the conference.

I'm hoping that you could be more persuasive, but I am not optimistic. Professional homebirth advocates are afraid of me, and anyone else who has command of the data and scientific literature. They cannot afford to appear in any type of debate because their claims would be eviscerated in short order.

Second, since it is highly unlikely that any professional homebirth advocate would participate in a debate, I offer an alternative way of settling the controversy. Let's hire a professional statistician to analyze the data and present his or her findings to the public. We could find a mutually agreeable statistician who has no previous connection to the homebirth issue. I am so confident about the results that I am willing to pay for the analysis by any mutually agreed upon professional statistician.

We may not be able to solve the controversy by arguing with each other, but you, in your role as a professional journalist, are capable of presenting a public analysis of the evidence, either by sponsoring a debate or by agreeing to publish the results of an independent statistical analysis.

Check with the executive staff of RH Reality Check and see what they think. It seems like the perfect forum. RH Reality Check is committed to providing women with accurate information on reproductive health topics. This is a chance to inform the public and get lots of publicity and traffic as a result. And, as I said, I'd even be willing to pay for it."

Should we lament the disappearance of Down Syndrome?

Is Down Syndrome disappearing? Is that a bad thing? Brian Skotko asks these provocative questions in a recent article in the journal Archives of Childhood Diseases, With new prenatal testing, will babies with Down syndrome slowly disappear?.

The proportion of children born with Down Syndrome is declining rapidly. That's not because the incidence of Down Syndrome is declining. The cause is the dramatic increase in prenatal testing and the high abortion rate for Down Syndrome babies. As Skotko explains:

...[W]omen are waiting longer to have children. Because advanced maternal age is associated with increased chances of having a child with DS, the birth incidence of DS would have been expected to climb. However, the worldwide birth incidence of DS has actually decreased from what it could have been ... For example, in the U.S., there would have been a 34% increase in the number of babies born with DS between 1989–2005, absent prenatal testing. Instead, there were 15% fewer babies born, representing a 49% decrease between the expected and observed rates.

Down Syndrome is a chromosomal anomaly with a straightforward cause. Human beings have 23 pairs of chromosomes for a total of 46. Individuals with Down Syndrome have an extra chromosome for a total of 47. Chromosomes pairs are numbered and Down Syndrome is the result of an extra chromosome 21. The extra chromosome leads to effects of varying severity throughout the body. Down Syndrome individuals have mental retardation, distinctive facial features, low muscle tone and medical problems such as congenital heart defects.

A major genetic defect like an extra chromosome is relatively easy to diagnose by amniocentesis. More recently, we have developed less invasive methods of screening for Down Syndrome such as the triple test or quadruple test. Further improvements in prenatal testing are on the horizon. Skotko wonders if improved testing will further decrease the proportion of Down Syndrome children:

...Several factors suggest so. First, the new tests will be offered in the first trimester ... Consequently, women will be able to receive a DS diagnosis and make a decision about the continuation of their pregnancies in private... Second, the new tests are noninvasive, carrying no risk to the fetus ...

Thirdly, in countries like the U.K., where women are only offered CVS or amniocentesis if their screening test is deemed "high risk," the new tests would afford everyone an opportunity to know definitively if their fetus has DS … Lastly, the new tests are projected to cost less than amniocenteses ...

Stotko, who has a sister with Down Syndrome, laments these advances, under the dramatic heading "our genetic future."

While DS might be the first genetic condition that can be definitively diagnosed in the first trimester on a population basis, others will undoubtedly follow… ACOG issued an opinion opposing obstetric practices that perform terminations based on fetal sex alone. Barring work-up for sex-limited genetic conditions, sex selection could be interpreted as "condoning sexist values" and creating a "climate in which sex discrimination can more easily flourish." By contrast, in its support for DS prenatal screening, has ACOG endorsed a climate in which disability discrimination could more easily flourish?

Skotko has strong feelings on the subject, dramatically concluding

...Parents who have children with Down syndrome have already found much richness in life with an extra chromosome. Now is the time for the rest of us to discuss the ethics of our genetic futures.

Richness? The use of that term is patronizing to both parents and to people with Down Syndrome. It is patronizing to parents because it implies that the lifelong burden of caring for a disabled child should be perceived as "enriching." It is patronizing to people with Down Syndrome by suggesting that their primary value is to enrich the lives of others.

Interestingly, Skotko pays very little attention to the myriad of genetic diseases for which testing and termination are also available. He does not advocate the "richness" of life with a child who has a terminal neurologic condition like Tay-Sachs, or the "richness" of life with a child who has similar but more serious chromosomal abnormalities like Edward's Syndrome (extra chromosome 18) or Patau's Syndrome (extra chromosome 13). Evidently these disorders are not "enriching" enough to justify his concern.

Skotko is right to raise these issues, but he is wrong to substitute his judgment for the parents who face these decisions. Raising a child with a serious genetic anomaly is a major burden, one that never ends and one that often gets harder as the years go by. It should be up to those parents to make the decision, and they should be entitled to the most advanced and least invasive technology with which to do so.

The dangers of evidence based medicine

On the face of it, it sounds like an idea that everyone can love, patients, doctors and insurers. I'm talking about "evidence based medicine," the idea that treatment decisions should be determined solely by the scientific evidence. In practice, though, evidence based medicine can harm or even kill patients. That's because the evidence may be conflicting and various third parties like drug companies and insurers may have undue influence in determining what qualifies as the "evidence" in evidence based medicine.

The recent findings about diabetes and tight control serve as a stark reminder of the drawbacks of evidence based medicine. Good control of blood sugar levels in adult onset diabetics improves long-term health outcomes. Therefore, it seemed reasonable to assume that tight control (very strict control of blood sugar levels) would provide even better outcomes. When drawing up the guidelines for management of adult onset diabetes, the National Committee for Quality Assurance deemed tight control to be the evidence based treatment guideline.

A recent large-scale study of tight control showed that, contrary to assumptions, tight control actually increased the death rate for adult onset diabetics. In fact, the results were so dramatic that the study was ended early to prevent harm to any other patients. This unexpected finding prompted a deeper look at how the standard had been promulgated and the story is not pretty.

First, it quickly became apparent that the guideline for tight control was approved over the protests of many diabetes experts. They had cautioned that the evidence for tight control was lacking and that the difficulties of maintaining tight control often led to unexpected side effects, poorer compliance, and poorer outcomes.

Second, there was a third party that would benefit from a guideline for tighter control, whether that guideline helped or harmed patients. That party was the pharmaceutical companies that sold insulin, the cornerstone of blood sugar control. Tighter control automatically means using more insulin than less rigorous control. A guideline insisting on tight control would immediately and dramatically benefit drug companies.

Third, the National Committee for Quality Assurance, a supposedly impartial organization that sets the standards used by insurers to determine whether a treatment qualifies for payment, had received money from the drug industry. Indeed, last year the NCQA received approximately $3 million from drug companies, fully 10% of its revenue.

This story is a cautionary tale about the dangers of evidence based medicine. In theory, evidence based medicine is the ideal. In practice, the evidence is often unclear, or leads to the need for personalized recommendations in place of a universal standard. Since the evidence is often unclear, third parties like drug companies and insurers may have motives for promoting one view of the evidence over another and can exert undue influence over supposedly impartial organizations that set the evidence based standards.

This does not mean that we shouldn't use evidence in determining care. It just means that we need to be sensitive to the fact that the evidence for specific treatment recommendations in specific cases is often lacking or conflicting. Sometimes there really is no evidence based standard and we shouldn't try to create one simply to fill the gap.

Moreover, acknowledging that the evidence is lacking or conflicting minimizes the chance that the standard will be influenced by third parties. When a treatment standard is set, there are often third party winners and losers like device manufacturers and drug companies. A specific standard may represents millions of dollars in profit or loss, and it is only to be expected that the winners and losers will try to influence the choice of standard.

Finally, the entities that promulgated evidence based standards must be thoroughly insulated from the influence of third parties. Those organizations must be prohibited from taking money from companies who stand to benefit or lose based on the standards.

Evidence should always guide treatment decisions, but evidence based medicine often doesn't reflect the evidence accurately, leading to injury or even death of patients.

Natural vision advocates protest requirement for glasses while driving

Natural vision advocates are planning rallies at DMV (Department of Motor Vehicle) offices around the country today. They are protesting what they believe to be the coercive tactics of the DMV in mandating vision correction for drivers with less than perfect vision. Simply put, anyone applying for a license must submit to a vision test, and anyone who has been diagnosed with nearsightedness must wear glasses or contacts while driving. Members of the group Vision Junkies United think that is wrong.

According to their spokesperson Mr. Jayden Kayden Hayden:

Human eyes are designed by nature to see perfectly. Are we really supposed to believe that 25% if the population needs vision correction? That's simply laughable. We wouldn't be here if nearsightedness were so common. We would have died out long ago.

Ms. I. C. Yu, the president of Vision Junkies United, explains the ten point manifesto prepared by her organization:

Eyeglasses and contacts are unnatural. Nature never intended human beings to have vision correction.

Relying on natural vision instead of giving in to glasses is empowering. Anyone can drive safely wearing glasses. It is a true achievement to drive safely without them.

The requirement for a vision test is absurd. All you have to do to drive it to see; it is hardly necessary to test every single person for vision impairment.

We need to trust vision. It's time for us to reject the notion that human eyes are broken and need to be "fixed" by artificial means.

People should rely on their intuition about vision. If they believe that it is safer to drive without glasses, then they should drive without glasses.

Vision affirmations lead to better outcomes. Drivers should continually remind themselves, "I can see the car in front of me" and that will naturally improve their ability to see.

The decision to wear glasses is a choice. The DMV has no right to interfere with individuals' right to make their own choice about whether they will wear glasses or contacts while driving, or even whether they will submit to the vision test when renewing their license.

Vision junkies are far more educated on the topic of vision than others. Most people behave like sheep when told that they need glasses for vision correction. They just go out and buy them, without ever questioning whether they are truly necessary.

There's no scientific evidence that driving with glasses is safer than driving without. No one has even bothered to study it. Those in authority simply assumed that correcting nearsightedness is safer.

No one should underestimate the influence of "Big Glasses." The vision industry is a multi-billion dollar industry. No one profits by declaring that you have perfect vision. Eyeglass manufacturers, contact lens manufacturers, optometrists and opticians only profit if you need vision correct. Is it any wonder that so many people are told they need glasses?

According to Ms. Yu, the American people need to "take back vision" from those who have tried to intimidate us into believing that our eyes are broken. We should stop giving in to the perceived need to actually see the road and return to our natural roots. We must learn to see the way nature intended, without glasses and without contacts, and we will surely feel empowered as a result.

Fundamentalism, science and mob rule

It's not enough for Christian Fundamentalists to keep their own compatriots ignorant of science; now they want you to be ignorant, too. And they are bringing their traditional technique, mob rule, to a movie theater near you.

The producers of a widely acclaimed British film about Charles Darwin's life have revealed that they cannot find an American distributor for the film because it is "too controversial." Not the substance of the film Creation; that's true and that, of course, is the problem. The movie reveals that Charles Darwin could not reconcile his scientific discoveries with the Bible, and like millions of people since, was forced to conclude that the religion he was taught is directly contradicted by scientific discoveries.

In many ways this movie represents a more critical challenge than the scientific facts of evolution. Religious fundamentalists fear evolution, but for a very specific reason. If evolution is true than the Bible is not, and Fundamentalists will not, cannot, acknowledge that.

If this conflict sounds familiar, that's because it is. As I wrote in When it comes to science, religion is always wrong:

The "debate" over evolution is almost an exact recapitulation of the "debate" over Galileo's demonstration that the sun is at the center of the solar system, not the earth. The Bible had located the earth as the center of the entire universe, to literally represent the role of man as the center of God's concern. When it became apparent that the earth wasn't even the central planet in our little solar system, religious authorities felt compelled to prevent anyone from learning the truth.

If it became widely known that the Bible was wrong about something as straightforward as the location of the earth within the universe, then it might be wrong about anything. Church leaders reacted as conservatives often do; they attempted to suppress knowledge...

What is particularly frightening for Fundamentalists about this movie is that it focuses specifically irreconcilable aspects of science and the Bible. Darwin was not irreligious. He was a religious man who could not reconcile the tenets of his faith with the scientific discoveries he had made.

What's especially frightening for the rest of us about the Fundamentalist reaction is that it is no longer enough for them to make sure that their compatriots, and especially their children, never hear the scientific truth. They are exerting their political power to make sure the rest of us don't hear the truth.

Fundamentalists could easily avoid the film, and they could ensure that their children do not see the film. They don't want anyone to see the film and they plan to exert political and economic leverage to punish anyone who makes it possible for others to see the film.

Don't get me wrong. They are well within their political rights to speak out against anything they want to speak out against. Nonetheless, it is chilling when any group tries to exert political power to suppress the truth.

As I have written before, over the last two millennia, religion has opposed science on many different occasions. And every time religion has opposed science, regardless of the topic, religion has been spectacularly wrong, every single time. Evolution is no different. Religion has never vanquished science and it isn’t about to start now.

Religious efforts to suppress scientific facts are harmful to society. Those efforts make our children ignorant and prevent progress. They make us the laughingstock of the world. Most countries are trying to solve contemporary problems. Americans are still fighting about issues that were definitively settled 200 years ago.

Hopefully, Americans who care about the truth will step forward and bring the movie to this country. It is up to us to resist the public promotion of ignorance.

Grocery industry says soup kitchen option is unfair competition

Officials of the American grocery industry have announced that they are preparing a two pronged attack against soup kitchens for the poor. They plan an advertising campaign to alert the public of the dangers of soup kitchens, and a lobbying effort in Congress.

A spokesman for the grocery industry, I. M. Greedy, declares:

"Americans are compassionate people and on the face of it, a soup kitchen is a compassionate attempt to help the poor. Dig a little deeper, though, and you'll find that the soup kitchen option is both unfair competition and will hurt all Americans."

The grocery industry is concerned, first and foremost, that the soup kitchen option represents unfair competition. As Greedy explains:

"We have to make a profit, but soup kitchens do not. Therefore they can charge less for their soup.

Let's be honest here. When poor people are given a choice between buying their soup in the grocery store or heading to the soup kitchen, they'll pick the soup kitchen every time. The only way we could make the grocery store more attractive is to lower the price of soup and that is unfair."

Greedy emphasizes that they are not the only ones who will be harmed. Though the government insists that the soup kitchen option will be just one among many options for obtaining soup (citing the continuing availability of soup in grocery stores, restaurants and food courts, the industry is convinced it is only a matter of time before everyone is forced to get their soup in soup kitchens.

According to Greedy:

"Sure, they say that you will still be able to choose where to get your soup. That’s what they want you to believe. The reality is that it is only a matter of time before the government bans soup in grocery stores, restaurants and other places, forcing everyone who wants soup to get it from a soup kitchen."

The grocery industry believes that the worst thing about the soup kitchen option, from the point of view of the general public, is that it takes away choice. Rather than selecting any soup from the grocery store shelves, consumers who select the soup kitchen option will be restricted to eating only the soup available that day.

Greedy says:

"Americans are not going to tolerate any situation in which they are deprived of choice. You go to a soup kitchen, and can you choose your favorite soup, the one that you have loved for years? No, you cannot. At the soup kitchen you are forced to accept whatever they are offering. Suppose it's chicken soup and you don't like chicken soup? Too bad."

The grocery industry also plans an extensive lobbying effort on Capitol Hill. They have already contributed millions to the re-election campaigns of several Senators and Congressmen. One of those Congressmen has introduced legislation to ban soup kitchens.

Greedy explains:

"We in the grocery industry are gratified that several Senators and Congressmen already understand what it is at stake here. That's not enough, though. We want to meet with even more Senators and Congressmen to impress upon them the unfairness of the soup plan option. American is a great nation because it won't countenance socialism. And what are soup kitchens but a socialist attempt to benefit the poor at the expense of the rich? Real Americans refuse to accept schemes that redistribute money from those, like grocers, who work for a living, to the undeserving poor."

Mr. Greedy is optimistic about the eventual outcome.

"Once Americans understand what is at stake here: government forcing people to get their soup through soup kitchens; government restricting people’s choice of soup; government stifling honest American competition; they will reject the soup kitchen option."

Mr. Greedy is modest:

"I don’t think that Americans will ever realize that the grocery industry, through a successful advertising and lobbying effort, will have protected them from the harms that would occur if the soup kitchen option were allowed. That’s okay. We in the grocery industry are content to let people believe that they thought of opposing the soup kitchen option instead of being incited to do so by a relentless barrage of fear mongering."

Mr. Greedy smiles:

"We don't need the public to thank us. Banning the soup kitchen option will be thanks enough."

Cesarean section as a narcissistic injury

Narcissistic injury is a term from psychoanalysis. A narcissist in psychoanalytic theory is different from our colloquial use of the word. Rather than being a person who is obsessed with herself, a narcissist is a person who suffers a deep sense of inferiority and masks it by projecting an air of grandiosity and excessive self regard. A narcissistic injury occurs when reality threatens the narcissist's carefully constructed facade of perfection.

In reading the work of homebirth and natural childbirth advocates, I am repeatedly struck by the assumption that a not having an uncomplicated vaginal birth is viewed as an imperfection. Hence the use of words like "failed" and "broken", the insistence on comparing birth to competitive sports, and the use of goofy birth "affirmations" that are all variants of "I can do it."

I suspect that some homebirth and natural childbirth advocates experience a C-section as a narcissistic injury. A narcissistic injury is not simply an imperfection. It is an imperfection that threatens the narcissist's protections against feelings of inferiority.

For example, many people need vision correction, but the overwhelming majority are able to accept that their eyes are not perfect without viewing it as a fundamental deficiency. Similarly, many women have C-sections and view the surgery as nothing more than one of many acceptable ways to have a baby. In contrast, a small proportion of women have such a fragile sense of self, and have constructed such elaborate defenses to protect against these feelings, that a C-section is experienced as a "failure," a sign of being "broken," and an insupportable assault on a very fragile sense of self-regard.

Experiencing C-section as a narcissistic injury can explain many confusing aspects of homebirth and natural childbirth advocacy, particularly among advocates who have already had a C-section. The refusal to see a doctor (with some women even refusing to see a midwife) can be explained as the inevitable result of regarding even the possibility of pregnancy complications as personal criticism, combined with the inability to tolerate criticism of any kind.

It can also explain the seemingly inexplicable reactions to the death of a baby at homebirth. Reacting to a baby's death by being "proud" of oneself for having a vaginal birth is extremely bizarre. However, it makes sense if the mother's overriding preoccupation is to preserve her narcissistic mask of perfection and keep feelings of inferiority at bay.

The real problem, then, for women who view C-section as "failure" is not the C-section, but the outlook of the women themselves. C-section is experienced as a narcissistic injury, not because it really is an injury, but because women with carefully constructed defenses that keep feelings of inferiority at bay feel those defenses threatened by the lack of perfection.

I don't expect homebirth and natural childbirth advocates to acknowledge this. Narcissists are notorious for their lack of introspection and their insistence on blaming everything on everyone else. They could never acknowledge that the source of their distress comes from within; they are compelled to externalize it to others who are supposedly criticizing them or disrespecting them.

This piece originally appeared on Homebirth Debate in November 2008.

At least you had a great birth experience

Homebirth and natural childbirth advocates are incensed that anyone might think a healthy baby is compensation for a less than ideal birth "experience."

The piece by Kathy at Woman to Woman Childbirth Education, At least you have a healthy baby, is typical of the genre bemoaning C-sections and other life saving methods of modern obstetrics.

Many women, on telling stories of how they felt abused or traumatized during birth — or some other negative feeling, like having failed as a woman after having a C-section, or something — have their feelings dismissed with, "at least you have a healthy baby..." [I]t only makes her feel worse, because then she has the added guilt of not being able to "just be happy" that her baby is healthy. Certainly she is happy that her baby is healthy… but can she not also be sad that it came at the cost of severe bodily trauma?

I especially like the picture of the "mutilated" apple. That apple was torn apart and left ruined just to get at the seeds.

Certainly, not every woman who had a C-section is going to feel this way ... otherwise there would be at least 31.7% of women last year who were as traumatized in body and spirit as this apple was brutalized ...

So, the next time you hear someone process her negative birth experience, and you’re tempted to say, "At least you have a healthy baby," remember the picture of the mutilated apple, bite your tongue, and if you can’t think of anything else, just say, "I'm so sorry."

Is a healthy baby merely a "silver lining" after a C-section? Let's do a little thought experiment and consider the converse. Imagine a courtroom during a malpractice trial, a trail that alleges that an obstetrician did not perform a C-section in time to save a baby's life. The mother is on the stand and being questioned by the doctor's lawyer:

Yes, Mrs. Smith, your baby is dead, but at least you had a great birth experience. You didn't have surgery; you didn't have an epidural; the baby was born vaginally and put immediately on your chest for bonding. Sure the baby was dead, but consider the experience.

And look at the picture of this mutilated and brutalized apple. Is this what you would have preferred? Dr. Jones has saved you from a psychic wound that would never have healed. You ought to be grateful.

People would be horrified by the lawyer's complete lack of perspective. The health of the baby and the quality of the "experience" are not remotely comparable, and it is absurd, and even cruel, to suggest they are.

Similarly, the idea that a healthy baby is merely a "silver lining" after C-section is indicative of the complete loss of perspective on the part of homebirth and natural childbirth advocates. The picture of the "brutalized" apple is particularly telling. The implication is that physical perfection is critical, and a surgical incision leaves a woman mutilated and incapable of healing.

There is another, deeper implication that is both unexamined and unjustified. The implication of the picture is that the removal of the seeds could have and should have occurred without changing the apple. The reality in nature is far worse that the "brutalization" of the apple. In nature, the apple must desiccate and die in order for the seeds to live.

The reality of childbirth in nature is far more brutal than a C-section. In nature, the mother often dies while the baby lives. Or the baby must die in order for the mother to expel it and live. Thousands of women and millions of babies around the world die each year for lack of C-sections.

A live baby is not the "silver lining" of a C-section. It is the entire purpose of pregnancy and childbirth.

Wealthy women have more orgasms

They say blondes have more fun, but they're wrong. According to recent scientific research, wealthy women do, or, more accurately, partners of wealthy men.

Researchers Pollet and Nettle of the Centre for Behavior and Evolution at Newcastle University have reached that conclusion after surveying more than 1500 women. Their study, Partner wealth predicts self-reported orgasm frequency in a sample of Chinese women, was published in the Journal Evolution and Human Behavior. As the authors explain:

The frequency of orgasm has been found to be an important component of sexual satisfaction, which in turn is a predictor of relationship satisfaction, for Chinese women. In American women, age and religiosity are negative predictors of orgasm frequency, and the frequency of masturbatory orgasms but not orgasms with a partner increases with increasing education…

The authors found:

In a large representative sample of the Chinese population, we found evidence that women's self-reported orgasm frequency increases with the income of their partner. The effect of partner income is not an artifact of female age, educational attainment, happiness, health, relationship duration, regional differences, and differences between partners in educational attainment and wealth.

The following graph makes that clear.



It is difficult to tell if the authors complicated regression models actually show a correlation, and, as we know, a correlation does not mean causation. Nonetheless, the results are more than a fun fact. The study is meant to contribute to an ongoing investigation of the evolutionary purpose of female orgasm.

Evolutionists have taken opposing positions on the function of female orgasm. On one hand, it has been seen as a functionless by-product of the ejaculatory response in males. An alternative view is that women's capacity for orgasm is an adaptation that serves to discriminate between males on the basis of their quality, leading to either enhanced conception probability or selective emotional bonding with high-quality sires...

The findings of this study appear to confirm the adaptive origins of female orgasm. In other words, better lovers make better fathers.

This paper is hardly definitive, but it is a good faith attempt to investigate the origins of female orgasm. Rather than being a neurologic relic of male orgasm, female orgasm may serve an important evolutionary function.

It may also explain a preference for wealthy men that extends across all cultures. Wealthy men may be perceived as not only better able to provide for children, but more pleasurable as partners for conceiving children.

Are chastity belts liberating?

Hard on the heels of the Katie Roiphe contretemps, the feminist world is being roiled by another conflict. Two prominent feminists are arguing over the meaning of the Islamic practice of veiling women. As Tracy Clark-Flory of Salon explains:

[Naomi Wolf] recounts ... the time she spent with women in "typical Muslim households." She observes, "It is not that Islam suppresses sexuality, but that it embodies a strongly developed sense of its appropriate channelling -- toward marriage, the bonds that sustain family life, and the attachment that secures a home." ...

Then, Wolf turns to the inevitable comparison with Western styles of dress. Many of the Muslim women she spoke with said that revealing get-ups cause men to stare at and objectify them. Wearing a headscarf or chador, however, leads people to "relate to me as an individual, not an object," they told her…

Feminist Phyllis Chesler vehemently disagrees:

Chesler is horrified by Wolf's argument and doesn't pull any punches in a blog response titled "The Burqa: Ultimate Feminist Choice?" ...

She goes on to contend that "most Muslim girls and women are not given a choice about wearing the chador, burqa, abaya, niqab, jilbab, or hijab (headscarf), and those who resist are beaten, threatened with death, arrested, caned or lashed, jailed, or honor murdered by their own families" and asks whether Wolf is so "thoroughly unfamiliar with the news coming out of Afghanistan, Pakistan, Iran, Saudi Arabia, and Sudan on these very subjects." ...

I'm with Chesler on this one. Wolf's argument is touching in its naivite, absurd in its reasoning, and vile in its implications, implications that Wolf fails to understand. The burqua is just the Islamic iteration of the solution to a very serious problem. Other iterations include female genital mutilation and chastity belts. The serious problem? Cuckolding, of course.

In animals where fathers have a substantial role in raising young (that includes humans), the possibility always exists that the father will exert himself on behalf of offspring that are not his own. That is an evolutionary dead end, and many animal behaviors have evolved to prevent cuckolding. Human beings have taken it further by creating cultural methods of prohibiting cuckolding.

Men want to be absolutely certain that the children borne to their wives are their children, and they will go to extraordinary lengths to do so. Hence the emphasis in all cultures on virginity for women and absolute sexual fidelity among married women with no analogue for men in either case. The punishment for deviation is fierce, ranging from shunning, to stoning, to death. Since men are typically stronger, they have been able to enforce their will on this point.

Cultural constraints are not nearly enough, and men have taken steps physical steps to ensure female sexual continence. These physical steps include chastity belts, precluding sexual intercourse, and female genital mutilation, making intercourse painful and destroying the possibility of female orgasm. Physical efforts to ensure female sexual continence extend to hiding women so that they cannot be the objects of male desire. They may be literally hidden, as in harems, or figuratively hidden behind garments meant to rob them of any sexual allure.

In the most fundamental sense, the burqa is an instrument for controlling female sexuality. In this, it is no different from a chastity belt or a clitoridectomy. It exists for one and only purpose: to ensure that men are not cuckolded.

Wolf's naivite on this point is stunning. The burqa, chador, etc. have nothing to do with preventing objectification of women. They exist precisely because women are viewed only as objects, objects owned by men. The burqa, the chasity belt and clitoridectomy are all ways in which men keep their property off limits to other men, nothing more.

Yes, in countries like the US or those of Western Europe, women can adopt the burqa as their own choice, just as they are free to don chastity belts if they choose. That, however, does not change the purpose of the burqa, nor does it change the fact that most women who wear it, like the women who wore chastity belts, and the women who endure clitoridectomy, are forced to do so.

The burqa is an instrument of sexual control. Women may don it willingly, and they have every right to do so. However, no one should be so foolish as to pretend it is a sign of liberation.

Can doctors trust patients?

Yes, you read that right. Doctors often wonder if they can trust their patients.

Most patients want a trusting relationship with their doctor and they assume that the only issue is whether the doctor is trustworthy. However, a lot of the problems in the contemporary doctor-patient relationship stem from the fact that doctors cannot be sure they should believe their patients. Patients insist that they are educated, that they want to manage their care and that they want treatment plan A. Yet when treatment plan A does not work out, they are unhappy with the doctor. He or she should have explained it better or been more aggressive or refused to go along with their plan.

Don't believe me? Here's an excerpt article by a professional journalist detailing her years of infertility treatment, Not giving up hope for a biological baby:

My first doctor in Santa Monica, Calif., was thoughtful and attentive, with an Ed Harris sort of look and a kindly, if somewhat passive, approach. The fertility practice he was part of had wonderful nurses, a sleek, minimalist aesthetic and a reputation for a celebrity clientele.

My second doctor was in Arizona, a blowhard with pictures of his success stories (i.e., babies) insensitively plastered on the walls of his tacky Southwest-décor office. (Please don’t make infertile women look at photos of other people's kids, I wanted to scream.) After keeping me waiting for 45 minutes, his first words on hearing my history with the L.A. doc were that I should have done a single round of IVF instead of the seven inseminations — I would have been more likely to get pregnant, he said. Very helpful, I thought, since I can’t actually turn back time. I disliked him immediately.

But who do I think was the better doctor for me? Probably Dr. Arizona. The truth is, in retrospect, I should have had a doctor who was much more aggressive. Though I had no history of any sort of physical problem, I believe I should have started drugs much sooner, and my L.A. doctor should have tried to make a case for IVF rather than simply swallow my (admittedly defiant) declarative that I would not do anything high-tech...

I said I'd never do IVF. Never. That was when I was 37, when it wasn't so much that I had hope as that I had no doubt that this would work. It wasn't even a question in my mind...

So the patient ignored the advice of her doctor and told him that she would not follow his recommendation ever, under any circumstances. Instead she asked for, and received, the treatment that she wanted.

She was wrong. Now she knows that, but her doctor knew that at the time. In retrospect, does she blame herself? No, her doctor should have been "much more aggressive" and he should have argued with her rather than "swallow" her clear, unambiguous refusal to accept his treatment plan. At no point does it occur to Ms. Parch that this is her fault and that she bears sole responsibility for what happened.

These situations happen quite often. Patients make demands or refuse treatments because they believe that they are "educated" about their options and they are in the best position to decide what is most likely to work. Now just imagine the same situation playing out with a baby's life at stake. The doctor recommends a C-section or an induction and the patient refuses. Should the doctor just accept that refusal? What happens when the baby is harmed or dies? Typically what happens is that the patient blames the doctor in exactly the same way that this journalist blames her doctor. She refuses to accept responsibility for the results of the decision that she made.

Patients complain that doctors do not respect their decisions, but how can you respect a decision if the patient refuses to take responsibility for it?

Big Placebo says Medicine never cures anything

Kudos to Lindsay Beyerstein of Majikthise for coining a new phrase "Big Placebo." Big Placebo is the alternative health counterpart to Big Pharma. Both are special interest groups designed to promote their products, whether they are worthy of promotion or not. There is one big difference between them: Big Pharma makes products that usually work (though not always, and sometimes not safely). Big Placebo hawks books and products that never work.

Big Placebo is unsatisfied with the $40 billion it takes in every year on treatments that don't even work. They’re aiming for a much larger piece of the healthcare pie and to do so they are criticizing modern medicine. I have previously written about the disingenuous efforts to focus attention on preventing diseases in the "worried well" as opposed to curing diseases of the poor and medically underserved.

To hear Big Placebo tell it, virtually all illness can be prevented and anyone who gets sick deserves it because of poor lifestyle choices. If only that were so. Unfortunately, most illness and disease is caused by factors beyond people’s control, including infectious agents, genetic defects and inherited predispositions.

Another axiom in the Big Placebo armamentarium is the notion that contemporary American Medicine cures nothing and merely "manages" diseases. According to "Dr." John Neustadt (naturopathic doctor) writing in the Huffington Post:

The current system teaches disease management and symptom suppression, which is insufficient to meet our healthcare needs. A reformed system needs a new paradigm that stresses health promotion and treatments that attempt to correct the underlying causes of disease.

Dr. Andrew Weill, of Weil Lifestyles LLC, licensing Weil Nutritional Supplements (vitamins and supplements), Dr. Andrew Weil for Origins (skin-care products), Pet Promise (premium pet food), Dr. Andrew Weil for Tea (premium teas), Lucini Italia Organics(organic extra virgin olive oil and whole, peeled tomatoes), Weil by Nature's Path (organic cereals and nutrition bars), Weil for Vital Choice, Weil Baby™ (baby feeding systems), Weil by Vita Foods, and Orthaheel™, claims:

By no stretch of the imagination does mainstream American "health care" move us closer to this vision of robust, resilient health. It is a fiscally unsustainable, technology-centric, symptom-focused disease-management system.

To hear them tell it, American medicine cures nothing. It simply manages disease and suppresses symptoms. It is a measure of the astounding success of the American medical system that anyone could listen to that drivel and not fall to the floor laughing hysterically. American medicine cures so much disease, involving so many people, so reliably and so often that everyone takes it for granted.

Evidently American Medicine doesn't cure anything except ... tuberculosis, pneumonia, bacterial meningitis, gonorrhea, any bacterial illness you care to name. American medicine routinely cures previously deadly conditions like appendicitis, ectopic pregnancies and obstetric hemorrhage. Better yet, it can completely prevent many viral and bacterial scourges through vaccination. It's not a coincidence that American lifespan has increased from 48 years to 77.7 years in slightly more than a century. Much of what routinely killed Americans is now routinely cured.

In fact, cure is so routine that these illnesses rarely enter American consciousness. No one worries about dying from tertiary syphilis, diphtheria or rheumatic heart disease. Those diseases are routinely prevented or cured in their early stages.

And "disease management" is hardly a deficiency, either. Some diseases cannot yet be cured. Until the day that a cure is discovered, we manage those diseases. Juvenile (type I) diabetes was uniformly fatal until the discovery of insulin. Insulin doesn't cure diabetics; it merely allows them to live an addition 50 years or more. Instead of dying in childhood, type I diabetics routinely live to have and enjoy grandchildren. Such "disease management" is worthy of praise, not the contempt that Big Placebo attempts to heap on it.

Can we do better? Of course we can, particularly in the areas of diseases caused by smoking and alcohol abuse. However, that's a far cry from claiming that American Medicine doesn't cure disease. That cynical and disingenuous claim should be understood for what it is, Big Placebo's attempt to line its own pockets. Alternative health purveyors and practitioners are charlatans and quacks ... and liars, to boot.

Lessons from Canadian and Dutch homebirth studies: Don't trust birth, trust obstetrics

American homebirth advocates continue to celebrate the recent publication of homebirth studies from Canada and the Netherlands. Evidently, they have failed to grasp the central lesson of both studies: homebirth can only be safe when practiced by highly educated, highly trained midwives under rigorously controlled conditions. Since this is in direct opposition to the philosophy of American homebirth, it is not clear what advocates are celebrating.

Reading the Canadian and Dutch studies makes it clear that Canadian and Dutch midwives don't "trust birth." There is none of the prattle traditionally associated with American homebirth. No babbling about how birth "is not a disease"; that women's bodies are "designed" for birth; that babies are "not library books," due on a certain day.

In fact, the fundamental premise is exactly opposite: birth is inherently dangerous and great care must be taken to prevent, diagnose and manage complications. Practitioners must adhere to the tenets of modern obstetrics. Consistent with that premise, both countries mandate rigorous education and training of midwives. Midwifery is a university degree; midwives are trained for both hospital and home; and significant education and training is devoted to handling complications. No one pretends that homebirth midwives are "experts in normal birth," as if such a thing were even possible. There is no such thing as a homebirth midwife. All midwives attend births in the hospital and at home.

In contrast, American homebirth midwives are grossly undereducated and undertrained. The CPM designation (certified professional midwife) is a post high school certificate program, not a college degree. Most courses are not eligible for transfer college credit because they are foolish: homeopathy, flower essences, gem energy, etc. There is no training in managing complications because there is no hospital training. Clinical training is nothing more than an apprenticeship to an older midwife.

Keeping with the premise that childbirth is inherently dangerous, both Canada and the Netherlands have strict criteria for homebirth eligibility. Virtually anything that raises the risk of potential complications results in disqualification for homebirth: no breech, no twins, no postdates, no pre-existing conditions or conditions arising during pregnancy. These are not considered variations of normal; they are recognized as abnormal and treated accordingly.

American homebirth midwives, in contrast, like to pretend that virtually anything that happens naturally is normal. Postdates pregnancy? That happens naturally, so the baby must "know" when to be born. Labor stalled at 7 cm for 5 hours? No problem, just keep waiting for labor to naturally pick up. American homebirth midwives routinely ignore due date, blood pressure, glucose tolerance, colonization with group B strep, virtually that occurs naturally during pregnancy.

The dismal mortality statistics of American homebirth midwives reflect their poor understanding of childbirth. Homebirth with American homebirth midwives has approximately triple the neonatal mortality rate of homebirth in Canada or the Netherlands. Homebirth with American homebirth midwives has almost triple the neonatal mortality rate for low risk hospital birth in the US.

Both the Canadian and Dutch studies have methodological problems that raise questions about their conclusions. The Canadian study has an unusual way of calculating perinatal mortality, and the Dutch study points out that homebirth is as safe as hospital birth in the Netherlands without addressing the fact that the homebirth population is much lower risk than the hospital population. Nonetheless, the neonatal death rates for homebirth in both studies is dramatically lower than for homebirth with an American homebirth midwife.

Homebirth with an American homebirth midwife can never be safe unless the midwives are held to a higher standard. Their level of education and training must be brought up to the same level as midwives in every other first world country. Homebirth must be subjected to the same eligibility requirements as in other first world countries. Unless standards are raised, babies will continue to die unnecessarily at births attended by American homebirth midwives.

New Canadian study is bad news for American homebirth midwives

American homebirth advocates are celebrating a new Canadian study of homebirth. I suspect that they don't realize that it's not good news for them. Indeed, the study shows that homebirth with an American direct entry midwife has more than triple the death rate of homebirth with a Canadian midwife.

First, a little background on the study, Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. The lead author is Patricia Janssen who published a similar study in 2002 and then was forced to publicly retract the conclusion that homebirth is safe because the homebirth group had two perinatal deaths and the hospital group had none.

Dr. Janssen presented a much more careful and rigorous study this time. The study population was drawn from all births in British Columbia from 2000-2004. Patients were divided into three groups, homebirth, hospital birth with a midwife and hospital birth with a doctor. Risk levels were matched by excluding anyone from either hospital group if they would not meet the eligibility criteria for homebirth. The key finding:

The rate of perinatal death per 1000 births was very low and comparable in all 3 groups: it was 0.35 (95% confidence interval [CI] 0.00–1.03) among the planned home births, 0.57 (95% CI 0.00–1.43) among the planned hospital births attended by a midwife and 0.64 (95% CI 0.00–1.56) among the planned hospital births attended by a physician. There were no deaths between 8 and 28 days of life.

These results are good news for Canadian homebirth advocates, demonstrating that homebirth in Canada is as safe as hospital birth. However, the results are very bad news for American homebirth advocates. They throw into sharp relief the dangers of homebirth in the US.



The death rates for hospital births in Canada are comparable to the death rates for American hospital births in 2003-2004. However, the homebirth death rate for American midwives is more than triple the homebirth death rate for Canadian midwives.

There are two reasons for this.

1. American homebirth midwives have less education and training than Canadian midwives. Canadian midwives attend both hospital and homebirths, and therefore have extensive education and training in the recognition and treatment of complications. They receive comparable training to American certified nurse midwives.

2. There are strict eligibility requirements for homebirth in Canada. You can't have a homebirth simply because you want one. You must be very low risk because anything else is considered too dangerous.

The new Janssen study has many strengths, but it has one glaring weakness. It fails to provide the nature and circumstances of the deaths in each group. Since there were only 7 deaths in the entire study, it is an inexplicable omission. That is especially relevant since the authors chose an unusual measure of mortality. Rather than using neonatal mortality (birth to 28 days) or perinatal mortality (from 28 weeks of pregnancy to 28 days of life), they used deaths from 20 weeks of pregnancy to 7 days of life.

It is widely recognized that stillbirths prior to 28 weeks have nothing to do with obstetric care. Therefore, the decision to include stillbirths from 20-28 weeks raises the possibility that the authors chose to include such stillbirths to make the numbers from the hospital group look poor by comparison to the homebirth group. Unless and until the authors are forthcoming about the circumstances of the deaths, we need to reserve judgment about what the study really shows. If the early stillbirths are removed, the study may actually show that homebirth in Canada is not as safe as hospital birth.

addendum: CMAJ has published my letter about the paper. It can be found here