Pope's prophylactic priorities

Number of new HIV infections worldwide since Pope's statement on condoms 1 month ago: 200,000.

Number of these due to male prostitution, for which Pope approves condoms as "a first step towards moralisation": overwelming minority.

Catholic hospital may lose status over 'abortion' to save mother's life

From Medical News Today via RDFS

Bishop Thomas Olmsted sounds like a chap with his priorities in the right order. In response to a case of fetal termination to save a mothers life, Olmstead states that CHW's "actions communicate to me that [the hospital does] not respect my authority to authentically teach and interpret moral law in this diocese."

I previously blogged on this case here.

Biblical medicine #1: How to be cleansed from leprosy

An occasional series on medical nonsense in the bible (I've met a couple of colleagues who are biblical literalists, both of them seemingly excellent docs but thankfully neither infectious diseases specialists).

(thanks to irreligion.org for the Leviticus reference).

The cleansing ritual is necessary to "make atonement for him that is to be cleansed because of his uncleanness". I wonder how many religious doctors, guided by the bible or its even wackier interpretations such as Christian Science, see their patients' illnesses as consequence of sin.

Cleansing ritual from leprosy:

Get two birds. Kill one. Dip the live bird in the blood of the dead one. Sprinkle the blood on the leper seven times, and then let the blood-soaked bird fly away. Next find a lamb and kill it. Wipe some of its blood on the patient’s right ear, thumb, and big toe. Sprinkle seven times with oil and wipe some of the oil on his right ear, thumb and big toe. Repeat. Finally find another pair of birds. Kill one and dip the live bird in the dead bird’s blood. Wipe some blood on the patient’s right ear, thumb, and big toe. Sprinkle the house with blood 7 times.
– Leviticus 14:2-52

Tolerating the intolerant? Bigoted views not apparently bigoted if they’re held by persons of faith

George Carey, the former Archbishop of Canterbury, has been taking time out from the House of Lords, where he and 26 other 'Lords Spiritual' enjoy governing power on the basis of their faith, to argue that we discriminate against people of faith (saywha?). Not withstanding this paradox (or the somewhat questionable record of Christian tolerance as indexed by such trifling historical episodes as The Crusades or The Inquisition), he was at the Intelligence Squared debate where the motion "Stop bashing Christians! Britain is becoming an anti-Christian country" was defeated by 378 to 216 with 48 undecided.

More worrying for doctors is his association with the Spirituality Special Interest Group of the Royal College of Psychiatrists, which held a session entitled ‘Intolerant Secularisation'.* In the chair was the psychiatrist Chris Cook, who believes that mental disorder can be caused by demonic possession. Though psychiatrists are the least religious of doctors, this group has an agenda is to allow doctors to bring their faith into the workplace (with the inevitable foisting of evangelism upon patients) without fear of reprisal that has rightly greeted nurses who offer to pray with patients, evangelical NHS employees refusing to tuck crosses into their shirts, and relationship therapists who refuse to counsel homosexuals.

(Source: Matt cartoon, Daily Telgraph UK)

Lord Carey's argument appears to be that we should tolerate discrimination by religious organisations because it's not really bigotry if it's faith-based; far from being your common-or-garden homophobia, Lord Carey's desire to see homosexuals denied rights that the rest of us take for granted is far more high-minded, you see. His testimony (roundly criticised by a rather bemused Court of Appeal) in the case of the sacked relatonship therapist speaks for itself:

The comparison of a Christian, in effect, with a 'bigot' (ie a person with an irrational dislike to homosexuals) begs further questions...In my view, the highest development of human spirituality is acceptance of Christ as saviour and adherence to Christian values. This cannot be seen by the Courts of this land as comparable to the base and ignorant behaviour [of homophobes]. My heart is in anguish at the spiritual state of this country.

As is mine, Lord Carey, as is mine. And not least because of illogical and nonsensical arguments like this perpetrated by supposed role models for people of faith. How much more irrational can dislike of homosexuals be, if it's based upon freely chosen subscription to iron age ancestral dogma?

-----------------------------------------------
*To give the Spirituality group their due, they did have a dissenting speaker, Prof. Rob Poole, on their programme who argued that faith in the workplace clearly violates important professional boundaries in direct contravention of General Medical Council guidelines. They declined to let me speak on intolerant secularisation as a 'Just War' - my abstract is below - but I received a very polite note from Chris Cook quite reasonably pointing out that the agenda had already been drawn up. The title and text of my abstract submitted to the meeting was as follows:

Intolerance of Intolerance: A Just War.
Religious communities portray predominantly secular society and its healthcare system as being intolerant of their beliefs and right to express them through practices at work. Recent cases, for example, have addressed whether Christians should be allowed to refuse public and private services as diverse as sex therapy and accommodation to homosexual persons whose sexual orientation conflicts with their faith. I argue here that such practices are themselves intolerant, and that a fortiori they therefore have no right to be tolerated by the wider community which sees intolerance as a social ill. In the same way that 'Just war' principles sanction proportional aggression towards actual or threatened military action from aggressive states, intolerance is a reasonable (and possibly imperative) societal reaction towards intolerance. The reaction (such as increasing

secularisation) of society (and its healthcare system) to intolerant religious beliefs and practices cannot thus be referred to as intolerant, in the same way as a proportional and legally sanctioned military response towards an aggressor cannot itself be described as 'aggression'. Dr. Ed Mitchell has begun his CT1 psychiatry training this year. His medical degree was from Oxford University. He has an undergraduate degree in experimental psychology also from Oxford, and Masters and PhD degree from Cambridge University in criminology. He has been a Fulbright visiting research fellow in with the Program in Psychiatry and Law at Harvard University.

Vatican + doctors = bad medicine

Shady goings on at the Vatican with the canonisation of Mary MacKillop. Two cases of remission from cancer and TADA!!!!! a new saint!!!. This nonsense is lent ostensible gravitas by the commission of doctors. The Medical Committee of the Congregation for the Causes of Saints is responsible for establishing whether a genuine medical miracle has occurred (quick recovery from a laminectomy in the case of Cardinal Newman's beatification). Now, all studies thus done have shown no benefit from intercessory prayer. Thus, any doctor who testifies on any Vatican medical committee ignores evidence and invokes a supernatural explanation. That's not being a doctor, that's bearing witness. They might as well ask anyone with a belief in supernaturalism. If a doctor is giving evidence about something to which his training is irrelevant, then a committee of ice-cream salesmen could do as good a job.

Most of these miraculous justifications state that at least one doctor said "the patient would never walk again", or "had 6 months to live". No doctor I've ever known has never had the confidence in their skills to make a definite prognosis like that (and I've known some pretty confident consultants). That's the way doctors break bad news in Hollywood films and bad daytime TV dramas. Patients might unfortunately hear it that way, and people anxious to prove a miracle might make it up, but doctors don't say it. Doctors say things like "his spinal cord is almost completely severed at T7-T8 level. It's extremely unlikely he'll ever get sufficient motor function back to be independent of a wheelchair". Or "On average, people with small-cell lung cancer survive 6 months". Prognostication is something EVERY doctor has doubts about his ability to perform, as each one knows several patients who defy the odds (whether they pray to Mother McKinnon or not). I've seen diabetic patients whose blood sugars should have killed them years ago. I contact their GP, not the Vatican.

Adele Horin (thanks Pharyngula) has another splendid angle on the whole affair here.

At the time Mary MacKillop answered the prayers of a woman dying of leukaemia, there was a lot of static in the air. In China 43 million people were dying of starvation in one of the world's worst famines. Thirty years later in the 1990s, when MacKillop answered the prayers of a woman dying of lung cancer, 3.8 million were dying in the Congo wars, 800,000 in the Rwanda genocide, a quarter of a million in the Yugoslav wars.

Very good of MacKillop's ghost to hear and answer the prayers of two Australians amongst such carnage.

VP of Center for Intelligent Design in Glasgow is a consultant colorectal surgeon!

David Galloway is a consultant colorectal surgeon working at Gartnavel General Hospital and Western Infirmary, Glasgow. He is also vice-president of the new Centre for Intelligent Design in Glasgow. Yep - a surgeon holding office in an organisation that gets into all sorts of difficulties with evolutionary concepts such as development of bacterial resistance to antibiotics.

A member of the Lennox Evangelical Church, Dumbarton, his medical career has not been visibly hitherto encumbered by the cognitive dissonance involved in reconciling Eve's creation from Adam's rib (or Mary's virginity) with his scientific training. Indeed, he is current vice president of the Royal College of Physicians and Surgeons of Glasgow. I would think that august institution is particularly proud of his new affiliation and its rather unsubtle attempt to get intelligent design teaching into schools north of the border (thankfully, down here the government has clarified its position on that sort of nonsense). However, the centre's leaders have rather given the game away by talking about their fundamentalist Christian beliefs rather than the supposedly scientific basis of ID. Oopsy.

Francis Collins betrays the rational basis of his profession

With a distinguished research career, and having directed the National Center for Human Genome Research and latterly the National Institutes for Health, Francis Collins is one of the most accomplished and important doctors of his generation. But that doesn't make him a good example to other doctors.



Collins is an evangelical Christian, but he's not a bigot else I doubt if Christopher Hitchens would have suffered his friendship for long. Of greater concern is that Collins has written in the Washington Post about how he's praying for Hitchens ('Praying for my friend Christopher Hitchens'). Praying for someone who believes his legacy will be to have "made a stand for those who are trying to hold reason and science against superstition", and who has requested people do not pray for him seems pretty disrespectful (that is, after all, why most Christians are participating in the 'Pray for Christopher Hitchens' day). But doing it without a shred of dignity by putting one's piety on display for the purposes of self-promotion in the pages of a national newspaper is doubly so.

In any case, Collins is the sort of apologist who finds no clash between science and religion, believing that his god is outside the normal universal terms of reference and therefore impervious to scientific investigation. (Jerry Coyne begs to differ here). In other words, so as not to fall foul of the 'God of The Gaps' (the gaps eventually yielding to scientific investigation and thus progressively squeezing the hiding places for the irrationality of faith), by a sleight of hand he's invented in his own mind a chasm rather than a gap. But to ensure that even this chasm can't be bridged by science, he's importantly declared that this chasm has only one side. And to think that Thomas Aquinas went to all that bother with natural theology.

I've alluded to various psychological research that shows how of the cognitive biases that allow intelligent doctors to believe nonsense, but it is astonishing what otherwise reasonable people can do in the service of their beliefs. Collins' acheivements cannot excuse the poor example he sets for the medical and clinical science. Don't worry about an evidence-base if it doesn't suit your purposes. Just make something up. Preferenably something that other people can't call you on.

And whilst you're there, why not take the opportunity to do a bit of proselytising by writing about it in the Washington Post?

Royal College of Psychiatrists spirituality group chairman thinks Demons can cause mental disorder

In 1976, two Bavarian priests were convicted of negligent homicide in the case of 23-year-old Anneliese Michel, an epileptic who died after her treatment was discontinued in favor of exorcism.

It's nice to know that such potential is still alive and well in the UK. I previously blogged about an article appearing on the Christian Medical Fellowship's website advocating that doctors should consider demonic possession as a differential diagnosis in mental disorder. It was picked up on by Iain Brassington at the excellent Journal of Medical Ethics blog.

At the time I didn't realise that the author held office. The article was written by Prof. Chris Cook, who is now the Chairman of The Royal College of Psychiatrists' Spirituality and Psychiatry Special Interest Group. He's a consultant psychiatrist who still works for Tees, Esk & Wear Valleys NHS Foundation Trust. Is it only mental disorder, or are other disorders caused by demons, such as hypertension or diabetes? It's one thing when society stigmatises mentally disordered persons, but quite another when members of the medical profession do so.

http://www.dur.ac.uk/theology.religion/staff/?username=dth0ccc
http://www.rcpsych.ac.uk/rollofhonour/specialinterestgroups/spirituality/aboutus/executivecommittee.aspx

Hospital chaplains facing the axe

The National Secular Society has an article on swingeing cuts facing hospital chaplaincies.

The chaplains have always attempted to justify themselves by saying they provide an important source of spiritual comfort to the religious (of all denominations) and non-religious alike. The notion that those of other religions benefit from the pastoral services of Christian chaplains is of course nonsense, a bit like saying that the provision of free petrol benefits those with diesel cars (or, in the case of atheists, no car at all). Try to imagine Christians utilising pastoral services provided by Scientologists (and proposing that these services are paid for by taxpayers!). Those sharing the beliefs of the chaplain are privileged by this spending.

And what a lot of spending it is. Many people I talk to are amazed that hospital chaplains are funded by the NHS. In 2009, figures obtained under freedom of information requests revealed the total annual cost of chaplaincy services to the NHS in Great Britain to be upward of £35million.

The Unite union for healthcare workers is investigating whether chaplains are being targeted 'disproportionately' as in Nottingham, where four out of five chaplains have been cut. If the alternative is to cut doctors and nurses, whose services are needed by everyone in hospital irrespective of creed, I think this could be a case of most people agreeing where the axe should fall in the NHS.

Now, that defence department spending review: shall we cut Trident or army chaplains? (actually...I...er...best not get started).

70 children dead from religious opposition to vaccination

As if the children of that country have't got enough problems, Pharyngula notes that a measles outbreak in Zimbabwe has killed at least seventy children over the last two weeks. The outbreaks are mainly in apostolic religious sects which combine Christian Fundamentalism with traditional African religious practices, with children being treated with holy water and prayer. They are strictly opposed to vaccination. But I suppose at least they can claim poor education, a country ravaged by poverty and corruption, and colonial religious indoctrination. Unlike other supernaturalists such as the adult model Jenny McCarthy, the actor Jim Carrey, or sundry Christian Science sects who hold similar beliefs with similarly tragic consequences.

Religious doctors more likely to flout professional guidelines on end of life care

A study finds that doctors who are religious are less likely to discuss options about end-of-life care than non-religious doctors (specifically, options relating to deep sedation and withdrawal of treatment that may be expected or partly intended to end life). These findings, reported in all the major media yesterday, suggest that religious doctors break GMC guidance (the UK General Medical Council) which states that end-of-life care issues such as withdrawal of feeding, 'do not resusitate' orders, and treatment decisions that may hasten death should be discussed with patients who have a terminal illness at the earliest appropriate opportunity.

Darwin used to extol the virtues of writing down any and every thought that might refute one's favoured hypotheses, and consider them at length. The results of this study agree with how I think religious doctors are likely to think and act. So, in case I am blindly accepting empirical data with preconceived notions, let's try to consider if the papers conclusions could be wrong: that it's possible that religious physicians are NOT more likely to break GMC guidance on end of life care. Possible methodological flaws that make this more likely include:

1) The doctors to whom the questionnaires were sent are not representative of their profession, or faiths.
2) The doctors who returned questionnaires represent a biased sample.
3) The doctors who returned questionnaires incorrectly recalled (or deliberately mis-stated) how they handled the cases of their last patient who died.

The paper, by Prof. Clive Seale at London University and published in The Journal of Medical Ethics, considers each of these possibilities. With regards to 1), the sample of doctors was selected to include disproportionate numbers of palliative care specialists, geratologists, and neurologists, whom are involved in complex end-of-life cases (e.g. in the case of neurologists, multiple sclerosis, motor neurone disease). The sample is thus biased, but biased in order to better elicit a good answer to the question in hand. With regards to 2), 42.1% of the 373 doctors sent questionnaires replied, and the proportion was as high as 67.3% for the palliative care specialists. This seems a relatively decent response rate for a postal survey to busy professionals. Furthermore, the author presents data to show that responders were not significantly different in attitudes from non-responders (whose attitudes were elicited by follow-up in another study).

3) is likely to be a far more valid criticism of the study, but it is also a problem with any attitudinal/self-report study. Although the questionnaire was anonymous, if I were a devotee of a religion which held as a core tenet that life should be preserved at all cost (even if the patient's suffering is increased as a result of my belief), I would certainly want to report that I never consider treatment that might shorten patients' lives (in case my deity took note of my response). And if I were an atheist doctor, I might want to show my support for the doctrine of double effect by answering that I consider terminal sedation a great way to avoid unnecessary suffering, even (but no because) it hastens death (the study also found that non-religious doctors are approximately twice as likely to report having taken treatment decisions that might be expected or partly intended to hasten death).

The British Medical Association said in response to the study: "Decisions about end-of-life care need to be taken on the basis of an assessment of the individual patient's circumstances - incorporating discussions with the patient and close family members where possible and appropriate. The religious beliefs of doctors should not be allowed to influence objective, patient-centred decision-making. End-of-life decisions must always be made in the best interests of patients."

Likewise, Dr Ann McPherson, the Oxford academic, GP, and patron of the charity 'Dignity in Dying' added that "The fact that some doctors are not discussing possible options at the end of life with their patients on account of their religious beliefs is deeply troubling". And, in spite of being an argumentum ad verecundiam, as a recipient of a CBE for her lifetime campaigning for patient choice, as well as being a terminally ill patient herself, Dr. McPherson's views might be thought somewhat more weighty than the author of this blog.

Unfortunately for those such as Dr. McPherson who believe that patients have a right to be involved in decision-making about their treatment, where ethical guidelines clash with religious beliefs, doctors appear to prefer the codes of their ancestral belief systems instead of the latest GMC guidelines. Whilst quality of end-of-life care is ranked higher in Britain than any other country, the moral of the story is, as soon as you are diagnosed as terminally ill, ask whether your doctor is religious. Or get a tattoo.

Summer holidays: Peak time for female genital mutilation of UK schoolgirls

According to this Guardian report and video (warning: shocking images), up to 2000 British schoolgirls will be taken abroad to undergo female genital mutilation this summer. Summer holidays are the peak time as the girls have to have their legs bound together for several weeks afterwards.

Like any 12-year-old, Jamelia was excited at the prospect of a plane journey and a long summer holiday in the sun. An avid reader, she had filled her suitcases with books and was reading Harry Potter and the Prisoner of Azkaban when her mother came for her. "She said, 'You know it's going to be today?' I didn't know exactly what it would entail but I knew something was going to be cut. I was made to believe it was genuinely part of our religion."

Perhaps it's insensitive of me to criticise this practice, and it's about time I became a convert to ethical anti-universalism.

More religious healing (child abuse) in Oregon

Viewing pictures of victims of acts of questionable morality (and even use of the word 'victim') increases the likelihood of making emotive rather than rational judgements of the culpability of the actors/perpetrators. However, an Oregonian op-ed, about an 8 month girl whose parents preferred Christ's healing power to that of doctors, shows the astonishing effects of faith in the form of a huge haemangioma that may cause the girl to lose sight in the affected eye (image from Clackamas County Sheriff's Office and linked from oregonlive.com).

Perhaps the only way such treatment could not be labelled child abuse is a distinction between acts and omissions. As Jonathan Glover (whose tidy desk policy speaks to his philosophical credentials) states:

...in certain contexts, failure to perform an act, with certain foreseen bad consequences of that failure, is morally less bad than to perform a different act which has the identical foreseen bad consequences. It is worse to kill someone than to let them die. (Glover, J. Causing Death and Saving Lives. 1977. Penguin. p.93).

The doctrine of distinction between acts and omissions is often invoked, for example, to explain why we are less morally culpable for the death of a child in Africa through failure to give to charity than we are for deliberately running over a child in our country. In such cases the remoteness of cause/effect is frequently invoked to explain our moral hunch that the latter is grossly more culpable than the former. However, if my child has crawled into the path of my car as I reverse, and I am fully aware of that, then I am no less liable for resultant injury than ifI intentionally place the child there just before backing the car out. There is no remoteness of cause and effect to invoke the acts/omissions distinction of crawling versus being placed there, just as no distinction can be made in the Oregon cases of blinding a child versus letting the child go blind through failure to seek medical help.

However, the courts in Orgeon continue to protect parents who, for faith reasons, do not seek medical treatment for their children. According to the state medical office, more than 20 childen of parents who belong to the same church as the girl pictured above have died of treatable illnesses. My suspicion is that the courts think little of leniency to those of faith (not unlike Cherie Blair showing clemency to a man who broke another's jaw in a fight, simply because he was a man of faith; AC Grayling's take on the matter here). Whilst it is always reprehensible for religious persons to be treated more leniently by the criminal justice system than the non-religious, it's particularly ironic to adopt such a position when faith itself is the cause of the criminality! Maybe photos such as that above can help combat such misplaced tolerance towards the results of 'faith', no matter how emotive they may be.

Genital mutilation of boys in Oxford for religious reasons

A research paper in the Journal of Public Health finds that 13 of 32 genital mutilations ('circumcisions') carried out for religious reasons on teenage boys by the Oxford Islamic community led to complications, including infections, urethral scarring and severe bleeding.

For these reasons, the NHS is urged to conduct mutilation under controlled circumstances, by well trained doctors in sterile conditions (rather than in the library of a faith school as some of these coerced and botched operations were performed).

Perhaps other health endangering practices of religion would benefit from controlled medical supervision. Female genital cutting, by which 8000 clitoridectomies, labial excisions or vaginal inibulations conducted throughout the world everyDAY (WHO report) should perhaps be conducted by doctors rather than by untrained mutilators who generally do not use sterile technique or anaesthetic. Stonings would no doubt be more humane if conducted under general anesthetic or at least victim sedation; medical checks on the child bride victims of public floggings (caution: link contains graphic violence) for running away from their husbands would certainly help safety of such events. As it's in the news, would not the Srebrenica massacre (perpetrated by Christians against Muslims for the VERY REASON that they were Muslims) have been far more palatable if 7000 lethal injections had been used instead of the far less clinical method of tearing up bodies with machine guns?

Benefits to the person (an 8 year old boy not having to be held down whilst his penis is mutilated under local anaesthetic which is a method of anaesthesia suitable only for Jewish newborn circumcision) whilst admittedly persuasive, are far outweighed by upholding the principle and practice of a faith-blind socialised health service that does not conspire to give respectibility to inherently unrespectable practices and ideas. That health services should assist in genital mutilation, or indeed assist in or mitigate the perpetration of any religious atrocity, is a notion as obscene as the acts themselves.

Religiousness and teen pregnancy rate linked

This paper finds that US states with greater levels of conservative religious beliefs have a higher teen birth rate. The statistical significance of this relationship survives controlling for mean income (more religious states tend to have lower mean income), and, of course controlling for abortion rates (if states with higher religiosity have lower abortion rates then higher teen birth birth rates would not necessarily be a surprise). Here is the graph (Mississippi is on the top right!)
 

The authors state "One possible explanation for this relationship is that teens in more religious communities may be less likely to use contraception". For example:

Rosenbaum compared adolescents who reported taking a virginity pledge with a matched sample of nonpledgers [12]. Among the matching variables was pre-pledge religiosity and attitudes toward sex and birth control. Pledgers did not differ from nonpledgers in lifetime sexual partners and age of first sex, but pledgers were less likely to have used birth control and condoms in the past year and at last sex.

So much for sex education which promotes abstinence as a viable form of contraception. And how astonishing that international aid organisations like Catholic Relief Services still see abstinence education as a key weapon in their fight against HIV/AIDS.

Another case of illogical beliefs resulting in very logical (and tragic) outcomes.

The foetus cannot feel pain before 24 weeks

The peer-reviewed working party report by the Royal College of Obstetrics and Gynaecologists is here. The findings of the committee hinge on the following evidence:

1) That the foetus is not conscious by that time, being kept in a state of "a continuous sleep-like unconsciousness or sedation".

2) That the neural connections allowing the experience of pain (by relay of neural signals to the cortex) are not sufficiently developed.

Recently, UK parliamentarians (including the Prime Minister, David Cameron) have begun making noises about possible downwards review of the 24 week limit. This follows bills introduced by various US states to limit late term abortions on the basis of the putative ability of foetuses to feel pain, most notably that of Nebraska which has decreased the upper limit to 20 weeks. Another 29 states have bills scheduled for the 2010-2011 legislative seasons. Of course, none of those bills will now pass if the lawmakers are interested in scientific evidence (and, of course, the separation between church and state means that the lawmakers will most certainly not be considering any religious views!).

I had calling from God to be a doctor, says GP who admits to shortening patients' lives

Dr. Howard Martin, age 75, has admitted he shortened the lives of "scores" of patients by administering large doses of opiate drugs (morphine/diamorphine), to enable them to die at home. He did this out of "Christian compassion":

"I don't believe I've killed any patients. I believe I've made them comfortable in their hour of need. But I am deemed to be arrogant because I used my discretion. They want to extrapolate that to say I'm choosing to kill people. It's not like that. The patients are about to die and I want to make sure they are comfortable. How can a so-called caring society not understand that? How can I be reckless with someone who is about to die?"

Dr. Martin is no doubt correct that there are serious problems with end of life care in the UK and that there is frequently a dissonance between public opinion and criminal law regarding voluntary euthanasia. However, he has also admitted that in two cases he hastened patients deaths without their permission. Professor Steve Field, chairman of the Royal College of General Practitioners, said:

"I'm horrified that the doctor seemed to indicate in the interview that he actually hastened the death of two patients without their consent - I'm speechless."

It is perhaps unsurprising that the GMC panel found that he had an "autocratic attitude" and believed he was always right.

“On Judgment Day I will have to answer to God, and my answer will be this: that I did my best for my patients.”

Dr. Martin's frequent religious references seem to indicate that there is a link between his faith and his medical care (or lack thereof, depending on viewpoint). As considered in a previous post, to make decisions using texts that exalt the stories of a group of iron-age shepherds (instead of using a process of rational and exhaustive ethical decision-making) is a recipe for poor decisions in which the patient comes second to the decision-maker's desire for supernatural approval.

For these reasons, and in spite of the importance of the topic and need for its careful reform, I find it difficult to imagine a worse medically-trained ambassador for end of life care issues than Dr. Martin.

OK, maybe one.

Justice John Paul Stevens — The Practice of Medicine and the Rule of Law

New England Journal of Medicine (free full text article) marks the retirement of Supreme Court Justice John Paul Stephens and his record of defending medicine against interference by government and other groups, including matters of abortion and assisted suicide:

Although it’s not a thought that has leapt to the minds of commentators, U.S. Supreme Court Justice John Paul Stevens will be missed by physicians and patients. Stevens believes that the Constitution prohibits government from interfering in personal decision making, including medical decisions that belong in the hands of physicians and their patients, not politicians and regulators; it was for this reason that he was Justice Harry Blackmun’s staunchest ally in upholding the Roe v. Wade abortion-rights decision.

What can be expected of his successor, Elena Kagan, here: Kagan Memos On Abortion Limits, Religious Rights

Christian Medical Fellowship and demonic possession of the mentally disordered

In these supposedly enlightened times, the Christian Medical Fellowship is publishing on its website material that would prove perfectly acceptable to the persecutors who wrote the malleus maleficarum five hundred years ago. The CMF presumably endorses the content of the essay, which considers that much psychiatric disorder might be a consequence of demonic possession (you read that right).

The following are quotes from this (not even pseudo-academic) bunk:

Demon Possession and Mental Illness (by Chris Cook)

For example, if people can become depressed because they are bereaved, or because of physical illness, why should they not also become depressed because of demonic interference in their lives?

...a psychiatric assessment may sometimes assist the non-medical minister to avoid attributing a primary psychological disturbance to demonic activity.

It would seem reasonable to argue that demon possession may be an aetiological factor in some cases of mental illness, but it may also be an aetiological factor in some non-psychiatric conditions, and in other cases it may be encountered in the absence of psychiatric or medical disorder.

As Christians in psychiatry, then, we have an important responsibility...The New Testament tells us that Jesus has commissioned us to ' drive out demons' (Mk 16:17), and we must be ready to respond to this commission if and when we are called to do so.

The astonishing thing is that at least one Christian psychiatrist, in an article buried amongst the Catholic rantings of the New Oxford Review, gives credence to such nonsense. In the article he gives undue prominence to his impressive list of qualifications. I want to write at greater length about doctors who hold religious beliefs, but lets concentrate on one matter at hand: how do such apparently intelligent believe such astonishing guff?

In  in Michael Shermer's excellent Why People Believe Weird Things (TED lecture here) he devotes a chapter to "Why SMART people believe weird things". Shermer examines beliefs in UFOs, intelligent design, resurrection and psychic phenomena by a roll-call of biochemistry professors, famous cosmologists, and those with multiple PhDs from leading universities. His conclusion? That smart people are good at proposing and defending ideas; when their thought processes go awry, they are even better than the rest of us at engaging in the cognitive biases and perturbations of reasoning that are necessary to accommodate weird beliefs. Their odd beliefs take root and endure for the same reasons as their host was thought to be smart in the first place.

That doesn't, of course, excuse the Christian Medical Fellowship from publishing material likely to stigmatise mentally disordered individuals who already face an uphill battle to dispel the multitude of public misconceptions about their condition.

Nun excommunicated for allowing abortion

Various sources are reporting the excommunication of Sister Margaret McBride for allowing a fetus to be aborted which, if the termination had not taken place, would almost certainly have resulted in the deaths of both the mother and the fetus. Bishop Thomas J. Olmstead, after finding out about the abortion, ordered the excommuncation of Sister McBride, every Catholic involved with the decision and the procedure, and indeed the patient herself.

In decrying the doctrine of double effect (for which, ironically, we owe a debt to Catholic theology), Rev. John Ehrich, the medical ethics director for the Diocese of Phoenix stated: "She consented in the murder of an unborn child...There are some situations where the mother may in fact die along with her child. But — and this is the Catholic perspective — you can't do evil to bring about good. The end does not justify the means."

The notion of a medical ethics director abiding not by principles of medical ethics, but by substituting (or overlaying) his or her system informed by faith, is against all tradition of medicine as an activity designed to better the lot of the ill, rather than to better the lot of the decision-maker or his church. Decision-making in medical ethics should shun 'absolute' (deontological) approaches and instead adopt frameworks that help guide the clinician or other agent to the best possible outcome for the particular case being considered by incorporating a wide range of moral considerations. Such a system is exemplified by the decision-making approach from the University of British Colombia detailed here (PDF), or the 'Ethox structured approach' from the Ethox Centre at the University of Oxford, which I reproduce below:

Compare the principalist and reflective decision-making process depicted here which includes elements such as 'Does this option respect the persons involved', with the deontological approach used by Rev. John Ehrich in the case of Sister McBride. His ethics come from the Ethical and Religious Directives for Catholic Health Care Services, Fourth Edition, which states, for example:

Directive 36: Compassionate and understanding care should be given to a person who is the victim of sexual assault...It is not permissible, however, to initiate or to recommend treatments that have as their purpose or direct effect the removal, destruction, or interference with the implantation of a fertilized ovum.

The difference between the two methods of decision-making, the Ethox approach designed to produce the best outcome for the patient, and the Catholic approach which will frequently have the opposite effect, is so stark as to negate the latter as a system of medical ethics; it is instead dogma, which should not be tolerated by medicine.

But let us submit ourselves to dogma for a moment. We glance at Directive 47 of the above document:

Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.

In light of such provision, the justice administered to Sister McBride appears rather summary and in stark contrast to the leniency shown to the paedophilic actions of thousands of priests.

Society for the Protection of Unborn Children: Incompetent or deceitful?

The cryptically named Society for the Protection of Unborn Children (can children be unborn?) has put out a press release in response to the announcement by Marie Stopes International that they will be running a TV campaign to raise awareness of abortion services.

The SPUC release states "Abortion is in English law a criminal offence. Advertising of a criminal offence is not permitted". According to SPUC, the NHS and several hundred thousand health professionals (including myself) were mistaken in our belief that abortion was legal under the 1967 Abortion Act.

So SPUC's statement is either: 

1) A genuine mistake on the part of SPUC. Are they thinking about the The Offenses Against the Person Act, 1861, s.58 under which procuring or supplying abortion was an offence? Is it possible that a group (one of whose expressed aims is "To examine existing or proposed laws, legislation or regulations relating to abortion") are so incompetent as to be one hundred and fifty years out of date in their research? (the act they seem to think is still operating also mandates life imprisonment for homosexuality). 

or:

2) A deliberate and grotesque attempt to mislead women at a vulnerable point in their lives.

I direct SPUC to the wording of the 1967 abortion act and presume that a further press release will follow shortly, admitting either 1) their incompetence; or 2) their willful deceit.

Faith healing and medical obligation

Because of their religious beliefs, Jeffrey and Marci Beagley of Oregon allowed their 16 year old son die rather than take him to a doctor. His urinary tract obstruction could have been treated easily, but instead he died an unfathomably painful death from heart failure secondary to kidney failure. In March 2010 his parents received 16 months in prison for negligent homicide.

According to The Oregonian, Neil Beagley was taken to the home of his grandmother, Norma Louise Beagley, where more than 60 Followers of Christ Church members held a faith-healing session that included anointing the boy with oil, 'laying on of hands' and praying for a cure (not best evidence treatments subjected to Cochrane review).

The Christian Science Church, who shun medical treatment due to their belief that disease is an illusion caused by sin, had successfully lobbied Oregon legislators to introduce a 'spiritual defense law' which protected parents who 'treated' their children with prayer rather than medicine from charges of first or second degree homicide. However, following a series of deaths, laws were passed in 1999 which required faith healing parents of ill children to seek medical help or risk prosecution.

A US-wide study estimated that 172 children died between 1975 and 1995 due to parental rejection of medical care on religious grounds, not including 78 deaths reported in Oregon from 1955-98 or 12 reported in Idaho from 1980-98 that were probably due to the faith healing practices of the Church of which the Beagleys were members (Seth Asser & Rita Swan, Child Fatalities From Religion-motivated Medical Neglect, 101 Pediatrics 625, 626-629, Apr. 1998).

One of the authors of this study, Rita Swan, writes in a courageous article in The Humanist:

My husband Douglas and I were devout, lifelong Christian Scientists until 1977 when we lost our only son Matthew as a result of our religious beliefs regarding medical care. It's hard for most people to understand this. It's hard for many to grasp how parents could watch a beloved child suffer, yet not call a doctor.

Now, faith-healing is clearly a belief which endangers a child (or adult, for that matter) when it comes to preventing and treating disease, and parents are thus rightly prosecuted for the deaths of their children (though, in many states, they cannot be prosecuted for neglect causing serious injury - there is a faith-based get-out clause due to successful lobbying by the Christian Science church).

Attempting to put aside the moral outrage engendered by parents letting their child's eye tumour become as large as his head, so that he could only get around by supporting his head on the walls (leaving bloody stains from tumour haemorrhage), let us consider a further matter: if people are culpable for injurious effects of their beliefs, then should they be held culpable for death or injury due to other, non-faith-based, beliefs?

The most interesting of these would be anti-vaccination beliefs (particularly anti-MMR, as espoused, for example, by the actor Jim Carrey) leading to measles outbreaks and child deaths. It is difficult to see how rejection of child vaccination differs from faith-healing in terms of parental culpability for injury or death of a child. A parent has a legal responsibility to look after their child's welfare. If they fail to do so, and a child dies or is injured because of it, it matters not whether the neglect resulted from beliefs that are based on 'religous faith'. Should similarly preposterous beliefs rejecting all available evidence for vaccine safety should also qualify?

Oklahoma abortion laws: physicians doing harm

The recently enacted Oklahoma abortion laws have been delayed for 45 days whilst the state prepares its defence to a legal challenge. A quick recap on the substance of these laws:

Law 1) Before an abortion, the woman must have an ultrasound in which the monitor must be turned towards her so she can see the fetus, and the physician must describe the condition of the heart, limbs, and fetal organs. No exceptions for rape/incest victims.

Law 2) Any woman who has a disabled baby may not sue her physician who withheld information as to fetal deformity, even if that physician withheld the information to prevent the woman from having an abortion.

There are myriad arguments against these positions, which cannot be dealt with here. I simply wish to address the ethical implications for physicians complying with these laws, in relation of the four principles of medical ethics outlined by Beauchamp & Childress in 'Principles of Medical Ethics' (1979). These are 'non-maleficence', 'beneficence', 'respect for autonomy', and 'justice'.

Law 1) violates the principles of 'first do no harm' (non-maleficence) and 'do good' ('beneficence') if the description or visual image causes distress to the woman, as these are not required for discharging the physician's clinical duty. This indeed seems to be the case; Jennifer Mondino, a staff attorney for the Center for Reproductive Rights (who filed the suit against the enactment of the laws), stated “We have been in touch with our clients and they are telling us stories of having women break down into tears hearing the description of the ultrasound”. The law also violates the principle of 'respect for patient autonomy' if the woman does not wish for such information to be revealed.

Law 2) violates principle of 'respect for patient autonomy' as witholding information (or, indeed lying) limits options available to the patient (e.g. choosing to abort a deformed fetus), preparing her life to look after a disabled child etc. Also violates the principle of 'justice' as the physician's actions may bring a potentially unwanted child into the world who will likely be a heavy consumer of scare medical and social resources.

Counterarguments to these violations of standard ethical frameworks will likely appeal to ethical duties to 'potential persons' i.e. the fetus overriding those of the woman. These are dealt with well by Francesca Minerva at the Oxford Practical Ethics blog.

Physicians clearly have an obligation to obey the law, but they also have a duty to uphold the ethical principles of their profession. When a law clashes with those principles, it's a fairly good barometer that the law itself is ethically flawed, or designed to serve the concerns of a particular group of people or lobby whom are unlikely to find themselves falling under that law's ambit.

Update: Satire can pinpoint ethical unease with great precision. The Onion news network: New Law Requires Women To Name Baby, Paint Nursery Before Getting Abortion.

General Pharmaceutical council & conscientious objection

Though the first of the seven principles of pharmacist professionalism published by the GPhC is "To make patients your first concern", the GPhC's draft standards allow pharmacists to refuse to hand over items that they find distasteful to their beliefs such as emergency contraception. This 'conscience clause' sounds to me as though the first concern is the pharmacist, not the patient.

As this article from the BBC details, a pharmacist refused to hand over the contraceptive pill to a woman, who was told to come back the next day when a member of staff who did not have such objections would be available.

Similar goings on in the US; in 2004 a rape victim was refused emergency contraception in Denton, Texas by 3 pharmacists, who refused to dispense the prescription due to their religious beliefs. In 2005 a Milwaukee pharmacist berated a woman with a prescription for EC shouting “You’re a murderer! I will not help you kill this baby. I will not have the blood on my hands.” In the US, the legislative situation is complicated; conscience clauses are endorsed or forbidden by local state law or alternatively by pharmacy boards, and these laws/codes may apply either to the pharmacy or indvidual pharmacists. Three states have passed laws mandating pharmacies to fill valid prescriptions (with a further state - Illinois - legislating that pharmacies must dispense birth control pills if stocked); a further three have pharmacy board statements requiring pharmacists to dispense valid prescriptions (source: Guttmacher Institute and National Women’s Law Center, 2008).

Back in the UK, the GPhC's draft standards state "3.4 Make sure that if your religious or moral beliefs prevent you from providing a service, you tell the relevant people or authorities and refer patients and the public to other providers".

The draft standards are available at http://www.pharmacyregulation.org/imagesandvideos/gphcstandardsconsultationfullsetoffourstandards2417.pdf

A consultation exercise is running on the draft standards until 28th May 2010 at http://www.pharmacyregulation.org/getinvolved/consultations/standards/fullconsultation/index.aspx

The council should be urged to remove the 'conscience clause' which essentially gives pharmacists the arbitrary right not to dispense medication that has been legally prescribed by a doctor. Whilst conscience clauses may be acceptable in certain situations e.g. a pacifist stance upon conscription to the army, pharmacists are not conscripted. As LaFollette and LaFollette state in an excellent article in The Journal of Medical Ethics (J Med Ethics 2007 33: 249-254):

Some medical professionals want to follow their private consciences without having to sacrifice their livelihood. We understand that. However, since their actions standardly affect others, often profoundly, we should not straightforwardly let them act on that conscience, especially since in their roles they uniquely satisfy some public needs. We should not recognise—nor should medical professionals claim—an unqualified right of conscience.

(Thanks to Epsilon Clue for this one: The Washington Post reports on a 'pro-life' pharmacy which recently closed down due to a lack of customers).

Medical miracle - Man survives without food or water 'for decades'

I wish my first post wasn’t such a distraction from more serious happenings in India, such as religious backing for ‘honor killings’, but it looks like we got ourselves an all-singin'-all-dancin' medical miracle right here, splashed across all the news wires.

Prahlad Jani is an 83 year old Indian ‘yogi’ being examined in a hospital in Ahmedabad to uncover how he has apparently survived without food or water ‘for decades’. Mr. Jani describes himself as a Jain ‘breatharian’ who can sustain life on ‘spiritual life force alone’. During the six days he has been monitored (apparently around the clock, with cameras overseeing his every move), he has not passed urine or stool (ethical aside for doctors: how long to do you let your patient’s urine output to be zero without a fluid challenge? Six days?).

Now the Scottish philosopher and resolute deathbed atheist David Hume seemed to have a pretty robust position on miracles (see ‘An Enquiry concerning Human Understanding’ published in 1748). He rather reasonably defined a miracle as "a transgression of a law of nature by a particular volition of the Deity, or by the interposition of some invisible agent." As reports of miracles generally come to us from the testimony of others, a miracle can only be said to have occurred if the probability of the miracle was higher than the probability of these people being mistaken, or the probability that they wanted to please others with their testimony, or the probability of them being outright liars (the apparition of the ‘Virgin Mary’ at Fatima in Portugal, to three shepherd children, comes to mind). Since a miracle is by definition a violation of the laws of nature, the probability of which is so diminishingly small (else it would not be termed a miracle!), miracles do not in fact occur as the odds of human senses having been fallible, or of others’ desire to deceive us, are always higher than ‘diminishingly small’.

Of course, we are all familiar with stories of patients with severe spinal injuries who walked again to the amazement of his doctors, or even the cancer patient who was given days to live and is now completely clear of any cancer as proven by scans and blood tests. Many of these turn out to be false, but many other such amazing recoveries undoubtedly occur*

Such recoveries are, unfortunately (or fortunately?), not miracles, but errors of prognosis. Medicine is partially art, based on science of course, but it relies most immediately on probabilistic science rather than upon inviolable laws like those found in physics. Medicine does not generally establish for itself sufficiently rigid parameters that we could say ‘if X occurred, then that would go against medical science to the extent that it would be a miracle’. Even if someone grew back an amputated limb, which of course has never happened (and might I cheekily interject Emile Zola’s remark upon visiting Lourdes: “I see lots of crutches but no wooden legs”), we would have a (major) challenge for embryology and our fledgling knowledge of adult stem cells. Here medicine differs from cosmology or physics: if I were to witness the rising of two suns tomorrow, and had no reason to think my senses deranged, then I would have to concede that a miracle.

However, Mr. Jani’s condition is not scarcely a medical one. As he doesn’t take in any energy through food (but expends energy through movement and presumably generates some heat and noise); his continuing existence is in violation of the physical laws of thermodynamics. Such a violation would count as a miracle for me (and, I believe, Hume), if we knew enough about the conditions under which Mr. Jani was being observed, and could rule out bias or fraud. So, we need a peer reviewed paper, reporting a suitable study period (I recall IRA hunger strikers, who took water, would usually die after about 2 months), access to original monitoring footage for anyone who wishes to verify the data, and statements of conflict of interest of the team involved. This is standard practice for a medical case study.

Until that occurs (and I doubt very much it will), there can, disappointingly, be no miracle of the fasting holy man.

*(and can be claimed, whether true or false, by the Vatican for the purposes of the canonisation process, who now engage with ‘expert’ medical witnesses).