Sunday, 26 June 2011

Radio 4 on male circumcision

Antony Lempert, head of the Secular Medical Forum, spoke on Broadcasting House this morning on Radio 4 (listen right at end of programme). The programme broadcast the cries of a 8 day old infant being circumcised (under anaesthetic).  
A Muslim boy cries as a doctor performs a circumcision on him. Photograph: Stoyan Nenov/Reuters. Picture from detailing the charity Norm-UK who, addressing a conference on the physical and psychological consequences of male circumcision at Keele University, encouraged parents to wait to circumcise their children until they were old enough to give consent.
Over 30,000 male circumcisions are performed in the UK each year (in a ritual ceremony 8 days after birth for children of Jewish parents, and at approximately 7 years of age for children of Muslim parents) with complications ranging from severe bleeding, urethral scarring, infection, and in rare cases, death (see Williams, N & Kapila L. Complications of circumcision British Journal of Surgery Volume 80, Issue 10, pages 1231–1236, October 1993 DOI: 10.1002/bjs.1800801005).

Dr. Lempert spoke on the programme about this study in the BJU International which shows that 'circumcision ablates the most sensitive parts of the penis'; indeed, in circumcised males, the circumcision scar is the most sensitive part left of the penis.

The programme noted that the procedure does not have to be carried out by a doctor, or indeed with any anaesthetic. I blog here about a research paper in the Journal of Public Health which found 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. They were conducted by non-doctors (local religious leaders and others) in the library of a faith school.

The BMA still refuses to tackle this issue. There is going to be a demonstration Monday 27th June 2011 outside the BMA Annual Representatives Meeting who refuse to debate Motion 310 and encourage representatives to choose it as one of five additional motions for debate. Motion 310 asks the BMA to endorse the 2010 position of the Royal Dutch Medical Association which calls non-therapeutic genital surgery on male minors a violation of the boy's rights to autonomy and to physical integrity.

I find our differential attitudes to male circumcision and female genital mutilation peculiar, as if the less severe injury to males somehow makes us ignore the fact we are still cutting a child's genitals. Mutilating the genitals of non-consenting children as a result of their parent's faith is not something with which doctors should collude.

Tuesday, 21 June 2011

Some thoughts on assisted dying and the 'argumentum ad Hitlerum'

The argumentum ad Hitlerum or reductio ad nazium is a form of argument that was given its dog latin appellation in 1953 by the political philosopher Leo Strauss. It is an informal fallacy, suggesting that X is bad because it has been associated with Y, with Y being something Hitler or the third Reich did or espoused. It is easily shown to be a fallacy because X might be playing competitive sport, something which the Nazis promoted as a way of proving the superiority of the Aryan race. It does not follow that playing competitive sport is bad.

The Nazi holocaust began in 1939 with the killing of 6,000 disabled children and 70,000 patients in geriatric and psychiatric institutions. Leo Alexander, a psychiatrist who gave evidence at Nuremberg in 1949 said that ‘its beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the attitude, basic in the euthanasia movement that there is such a thing as a life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans.
Firstly, the killing of disabled children and geriatric/mentally disordered patients is not assisted suicide. It is involuntary euthanasia, more commonly known as murder. Does Leo Alexander’s claim that this extermination was born from the notion that there is such a thing as a life not worthy to be lived make assisted suicide wrong? No, once again, the shift in attitude by physicians that Alexander mentions was not a precursor to assisted suicide. It was a precursor to murder and systematic extermination of classes of persons on an unimaginable scale. 

A Nazi propaganda slide depicting portraits of mentally ill people. From the Holocaust Education and Research Archive Team
Dr. Saunders denies having made the argument in the face of replies to his blogpost. For example, in reply to one post: “Wow, I read this assuming credibility until you likened it to Nazi Germany”, Dr. Saunders states “The article simply lists twenty facts the programme did not tell us about assisted suicide and euthanasia in Europe - of which the 20th is undoubtedly one…what you conclude from it is up to you.” This defence is given short shrift by another commenter on the blog: “Dr Saunders - you definitely have undermined the credibility of your argument by bringing up Nazi Germany… and in response to your assertion that you're factually correct, you could write an endless list of irrelevant facts if you wanted, but that wouldn't make your argument more convincing.” 

This article on the use of the argumentum ad Hitlerum shows how the Nazi card is easily played by implication:
In a debate about the Republican contract, US congressman John Lewis first read out Martin Niemoller's speech about the Nazi takeover ('They came first for the Communists, and I didn't speak up because I wasn't a Communist. Then they came for the Jews…'), then said, with gravity: 'Read the Republican contract. They are coming for the children. They are coming for the poor. They are coming for the sick, the elderly, and the disabled.’
It seems to me that there's something more complex and morally pernicious about the reductio ad nazium than it being a simple fallacy. It attempts to recruit a particular tragedy, in this case the systematic murder of thousands of patients, in (spurious) support of a particular viewpoint. The class of persons so recruited has no voice to indicate whether they object or assent to the viewpoint. As an example, I could say “All religion is bad because of the Catholic abuse scandal” (see Sam Harris here on why he’s tried to steer clear of the abuse scandal). But all religion cannot be bad because of the bad acts of some members of one religious group. By saying this, I would exploit the suffering of thousands of victims of abuse as a smokescreen for a viewpoint that I might hold for reasons totally unrelated to the abuse scandal.

In summary, to object to an issue by invoking the suffering of a group of persons (whose suffering is entirely irrelevant to the point being made and being used a smokescreen for deeper beliefs) seems to me to be a more grievous act than the mere commission of a fallacious argument.

Sunday, 19 June 2011

Health benefits of religious involvement? The flawed evidence quoted by Dr. Peter Saunders and the Christian Medical Fellowship.

Dr. Peter Saunders, advocating that doctors should proselytise to patients in consultations, trotted out on Radio 4 last week the rather exhausted canard that there is a huge evidence base to suggest a positive relationship between religion and health. Dr. Saunders states: “We are talking about in the vicinity of 1,200 research studies and 400 reviews in peer-reviewed medical journals. 81% show a positive correlation between faith and health; 4% a negative correlation and 15% sit on the fence.” This astonishing number of papers was mentioned by Dr. Harold Koenig in his “Handbook of Religion and Health”, and trotted out again in a (no doubt impartial) report by the Christian Medical Fellowship (CMF).

Over a thousand studies? Really? Others don’t see the statistics in quite this way. The researcher Richard Sloan (Professor of Behavioral Medicine at Columbia University Medical Center) analysed 266 papers identified as relevant to religion and health by the healthcare literature database Medline that appeared over the course of one year. However, only 42 of 266 (17%) were relevant to claims about the effects of religious involvement on health.

Sloan continues: “So proponents of a connection between religion and health are technically correct when they write that there are a great many studies on the topic. But they are wrong when they report that the vast majority demonstrate positive relationships between religious involvement and better health. In fact, the vast majority of these studies have nothing whatsoever to do with the health benefits of religious involvement”.

Let’s have a look at some of these papers supposedly demonstrating the effects of religious faith on health. Of 89 studies on cardiovascular health cited by Koenig and the Christian Medical Fellowship report, 33 were studies on denominational differences in health or compared groups whose religiosity was unknown e.g. comparing cholesterol levels in Seventh day Adventists to age-matched New York city residents. Such studies show us nothing about the effect of religious involvement and health. Eleven studies were reviews of other studies, case reports or “mere descriptions of projects”. Three were published only in abstract form and cannot therefore be critically appraised. This leaves 34 of the original 89 papers that Koenig and the CMF claim to be the basis of the relationship between religious involvement and healthcare. Sloan reviewed these and found 30 had serious methodological flaws or were “so misinterpreted or misrepresented that they cannot possibly be used as evidence for an effect of religion on health”. 

That leaves 4 studies out of the original 89. Extrapolating this to the 1200 cited by Dr. Saunders, only in the region of 50 are likely to actually be about the effect of religious involvement in health, and we don’t know whether they show positive or negative effects.

The quality of many of the papers cited is also dubious in the least. In one of the 81% of 'positive' studies cited by Koenig, the CMF, and Dr. Saunders, eight ‘remote healers’ prayed for patients with high blood pressure, who did indeed have a reduction in systolic blood pressure greater than the control group. No patient details are given. The eight remote healers were four “Science of Mind Practitioners”, one was a Presbyterian Institute Minister, another was a Church of Christ Minister, one was “Director of the Seventh Sense Institute” and another was “a gifted individual whose healing abilities have been verified by both doctors and scientists”. Data was presented only for the patients of four healers who “had the highest number of returned patients”. It is a wonder that the authors managed to publish a study that drops patients from its analysis who are likely to have a negative outcome.

Whilst the Christian Medical Fellowship and Dr. Peter Saunders might consider this a study that supports the discussion of religion with patients, I would hope most doctors would look at such studies and consider that proselytising to patients on the basis of such nonsense would be a serious breach of their duty to treat patients on the basis of evidence (not to mention a breach of General Medical Council guidelines).

Sloan R. Blind Faith. New York: St. Martin’s Griffin.
Koenig H, McCullough M, Larson D. Handbook of Religion and Health. New York: OUP.
Bunn A & Randall D. cmf file 44 (2011) - health benefits of Christian faith. Available at