The natural origins of morality

The Moral Landscape: How Science can Determine Human Values. Sam Harris. 2010. Free Press, New York. ISBN 978-1-4391-7121-9 Reviewed by Martin Wallace.

If faith is belief without evidence, then it is not open to scientific enquiry by a weighing of evidence. This attitude was supported and promulgated by Stephen Jay Gould. He claimed that there are “non-overlapping magisteria” of science and religion (NOMA).

However, what if it could be shown that there are events in the world of human brain physiology which can account for such “religious” activity as a sense of moral values?

This question is discussed brilliantly in this new book by Sam Harris. He says: “Questions about values are questions about the well-being of conscious creatures.” A sense of well-being is dependant in sentient beings like us on cerebral events and is therefore open to scientific investigation.

Well-being is engendered for example, by happiness, kindness, and compassion. Harris is a neuroscientist and has studied brain function by magnetic resonance imaging while subjects consider propositions. He has shown that the same part of the brain is active when considering scientific suggestions as when considering moral or religious precepts. The process of belief is the same, irrespective of content.

The part of the brain involved is that where activity can be seen with the placebo effect.

Harris makes interesting comments about the damaging effects of religion and politics on our sense of well-being. Given his past writing, we can expect some acerbic comments:

” For nearly a century the moral relativism of science has given faith-based religion-that great engine of ignorance and bigotry-a nearly uncontested claim to being the only universal framework for moral wisdom.”

He dismisses “cultural relativism” as a creation of academics. Well-being is shared by all members of all human cultures given the same conducive surroundings, as is our shared physiology.

He also is very firm about “scientific relativism” and the inhibitory effect it has had on human well-being. There can be no such thing as Christian physics or Muslim algebra!

The text of this book is accompanied by an expansion of the arguments in extensive Notes which are listed in the Index. There is also an extensive list of references.

This book answers the question my mother put to me 60 years ago. “It is all very well to talk about your lack of belief in religion, but what will you put in its place?”

Dealing with wingnuts – which way to turn?

It’s not a hopeless cause to engage with proponents of the irrational – but some ways of doing this are more effective than others. This article is based on a presentation to the 2010 NZ Skeptics conference.

There has never been a time in history when the public understanding of science and rational thinking has been so important. Science has revealed new challenges for humankind, such as climate change and depletion of resources, while new technologies are often accompanied by ethical and social implications that need to be carefully considered. In response to these challenges science communicators spend more time trying to carefully explain science and related issues to the public. However, these efforts to make science more understandable are being confounded by ‘wingnuts’ who use misinformation to confuse public understanding of science.

The term wingnuts has been used by a number of people to describe those who propagate misinformation for a variety of reasons. In his book Wingnuts’ how the lunatic fringe is hijacking America, John Avlon describes a wingnut as “someone on the far-right wing or far-left wing of the political spectrum – the professional partisans and the unhinged activists, the hardcore haters and the paranoid conspiracy theorists.” This is probably a fair summation of the groups that skeptics often confront. Specific examples include Jenny McCarthy for her misinformed and vehement opposition to vaccines, Suzanne Somers for her advocacy of dodgy and dangerous “natural” therapies, Peter Duesberg with his HIV denialism, and Christopher Monckton for his use of misinformation in opposing global warming.

With wingnuts attacking many areas of science and undermining attempts to educate the public, the question has to be asked – How should we deal with these purveyors of irrationality? Some skeptics advocate an aggressive counterattack – personally attacking the wingnuts, in the same way that they have attacked science and science communicators. Others suggest a purely educational and rational approach, relying on the ideal that the truth will win out in the end. For myself, I see the first approach as dangerous in that it muddies the waters – one only has to look at the mess that has resulted in the climate change debate. Personal attacks from both sides of the debate – accusations of conspiracy, impropriety, etc – have confused the public and risk having climate change dismissed as ‘too hard’ to deal with. On the other hand, taking a purely rational approach overlooks the fact that human behaviour is not always rational and prone to being swayed by emotive arguments.

In trying to sort out the best way for me to respond to wingnuts I have developed a list of 10 rules as a guide.

1) Know what you are talking about

Many wingnuts are well versed in their area of ‘expertise’. Debating them without adequate knowledge of the subject as well as an understanding of the typical wingnut ploys is risky. It is worth noting, however, that when exchanging views with a wingnut via blog comments this does give one the opportunity to do research between exchanges.

2) Use precise, simple and neutral language

It is easy to be misunderstood, especially via written language. So, one should keep the language as precise and simple as possible. A choice of neutral language helps maintain a calm exchange of ideas. Emotive language can readily escalate an exchange of ideas into an irrational argument. We have over 600,000 words in the English language to choose from, so why not take some care in deciding how we explain things to others.

3) Respond to rudeness in a calm manner

Some people, including skeptics, see debating ideas as an opportunity to insult others. In my opinion, snide remarks, personal attacks and swearing detract from any rational exchange and serve to both escalate any exchange of thoughts into irrationality as well as hardening the views on both sides of the debate.

When confronted with rudeness, I try to focus on repeating factual information. There is also value in pointing out the rude behaviour. This can be done in an assertive, non-threatening way by making comments about the wingnut’s behaviour and not about them personally. For example by saying “I find it offensive, when you claim that scientists are shills for big pharma” followed by a list of supporting facts, instead of “you are a rude and obnoxious #$@&”. Most people will accept criticism of their behaviour far more readily than what they feel is a personal attack, particularly when the person making the comment ‘owns’ the effect of the behaviour.

It is also worth remembering that it is difficult for someone to continue being rude if you do not reply in kind. If you can maintain being polite to someone who is being rude, in most cases the rudeness will dissipate and one can return to a calm exchange of ideas.

4) Remember – wingnuts are people too

No one is completely rational. We all have our own biases which may result in irrational behaviour. Whether it is a result of our environment or our biology, many of us engage in irrational behaviour without even recognising it. So while we may often assume that a wingnut is being purposely irrational, it is usually the case that they consider their actions to be completely rational. In his book Why we Believe, Michael Shermer describes such behaviour as “intellectual attribution bias” – where those with opposing views typically consider their own actions as being rationally motivated, whereas they see those of their opponents as more emotionally driven.

A simple rule to remember – challenge the ideas, not the person.

5) Ask questions … and listen to the answers

When someone appears to express a view counter to what we believe it is easy to respond by bombarding them with counter arguments. However, this will not only put them on the defensive, it also relies on the fact that you have understood their point of view correctly (see point 7, below). If one takes the time to explore their beliefs further by asking questions, it not only gives you time to assess the extent of their beliefs, if done in a friendly manner it helps establish rapport, allowing for a more rational exchange of ideas. If we leap into an argument with a limited understanding of the other person’s position we can find ourselves trying to convince them of something they already agree with.

6) Leave your ego at the door

In my experience once you start taking comments personally, rationality goes out the window. There are times when the comments of some wingnuts make me furious. At such times the best option is to take time to calm down before responding.

“Science is the search for truth – it is not a game in which one tries to beat his opponent, to do harm to others.” – Linus Pauling

7) Expect misunderstandings

No matter how carefully we think we have phrased something, those hearing or reading them will often misunderstand at least part of what we have said. So one always needs to be ready to rephrase. In order to clarify what we are saying a number of techniques can be used:

a) Counter anecdotes with anecdotes. Follow up by explaining this is why anecdotes are not particularly good as evidence.

b) Use analogies to explain difficult concepts.

c) Apologise when you make a mistake. While some may view apologising as a loss of face, it can actually establish a better rapport. It is far more honest and trust-inspiring than trying to cover up or justify a mistake you have made. There is nothing wrong with acknowledging that we all make mistakes.

d) Acknowledge points of agreement. In any argument there are often points that both parties agree on. If we can identify these up front and acknowledge them, it not only makes it easier to explore the points of difference, it again establishes some rapport by saying “look, there are some points on which we can agree.”

8) Don’t make the same mistakes we criticise them for

There is nothing more frustrating than seeing other ‘skeptics’ debate a wingnut by erecting their own strawmen, using ad hominem attacks or other irrational arguments. An experienced wingnut will quickly turn these mistakes to his or her own advantage. It always pays to carefully think through all of your own arguments before using them.

9) Be persistent and don’t expect to change their views overnight

Most wingnuts have spent years developing and reinforcing their positions. Some probably have the psychological equivalent of Fort Knox built around their ideological positions.

So if we can’t easily change their minds, what is the point in debating with them?

Debates with wingnuts seldom take place in a vacuum. Whether they are arguing their point via a letter to the editor, on a blog or amongst a group of friends or workmates, there is always an audience. If their points go unchallenged some of the audience will be swayed by their arguments. So challenging the arguments of a wingnut is less about changing their point of view, and more about educating any audience they have about the flaws and fallacies of their argument. One should aim to win over any such audience with superior knowledge, civility and by pointing out how your position benefits them.

10) Learn more about persuasion

Many skeptics have a great respect for facts and rational debate. However, when it comes to making decisions human beings tend to be more readily swayed by their emotions. Psychologists have spent decades researching how people make decisions. Such research has been embraced and effectively used by marketers and salespeople to get us to buy things we don’t need or want. If the Journal of Marketing Research refer to books like Robert Cialdini’s Influence: the Psychology of Persuasion as “the most important book written in the last 10 years” then perhaps we should also be reading it, not only to help us work out appropriate ways to better present a skeptical viewpoint, but to also immunise us against some of the less scrupulous methods of persuasion.

Some persuasive techniques directly applicable to debating with wingnuts include”

a) Appealing to self interest. Everyone naturally looks at how anything benefits themselves. So when we advocate for vaccination use, rejection of dangerous or ineffective ‘alternative medicines’ and other wingnut ideas we need to focus on the benefits of our positions.

b) Creativity. In a world where we are bombarded with many demands for our attention, the creative ideas stand out. One only has to consider the incredible amounts of money companies spend on novel advertising campaigns to understand this.

c) Repetition. Many wingnuts rely on the idea that if you repeat a lie often enough it will be believed. If this is the case, then surely if you repeat the truth often enough it will also be believed.
d) Soundbites. Many science communicators are now recognising the value of sound bites – short memorable statements outlining key points. Most people are more likely to remember sound bites than the long and complex (albeit more accurate( explanations preferred by many scientists.
e) Be positive. It has been demonstrated that most people remember positive messages more accurately. Thus is it more effective to say that “vaccines save millions of lives each year” as opposed to “vaccines are not dangerous.” Over time, a negative message can become confused and may be remembered instead as “vaccines are dangerous.”

A good example of clever use of such techniques was the 10:23 campaign in January 2010 to educate the public about homeopathy. The public ‘overdose’ on homeopathic remedies by skeptics was a creative way to draw the attention of the media and the public to the irrationality of homeopathy. Clever sound bites such as :ten dollars for a teaspoon of water: were not only memorable but focused on financial self interest. The event also caused several homeopaths or homeopathic organisations to state outright that they don’t know how homeopathy works, a remarkable and useful soundbite (for skeptics( in itself.

Conclusion

This 10-point list outlines my own approach to wingnuts. Others may have different, possibly even contrary rules. I believe it is important that we, as skeptics, share and discuss these ideas rationally and with the view of what will best encourage better and more rational thinking by the general public.

Whether you agree with all of my rules or not, there is hopefully one thing we can agree on. We cannot afford to ignore the wingnuts.

“All that is necessary for the triumph of evil is that good men do nothing.” – Edmund Burke

“We have to create the future or others will do it for us.” – Susan Ivanova, character, Babylon 5 TV series.

Even Psychics Can Only Be Medium

Englishwoman Doris Stokes was a medium – by which I don’t mean her dress size was between small and large. She claimed she spoke to people “on the other side,” to use the euphemistic jargon of the darkened drawing room. She was a sort of cosmic Telecom operator, only I suspect her charges were a good deal higher than 99c a minute plus GST.

I use the past tense because Doris herself has moved on into the spirit world with which she had so long claimed to communicate. Nothing has been heard from her since she died, which I think is pretty contemptuous of her fellow media (the plural of medium(.

Doris became world famous and made a lot of money travelling around linking people up with restless ghosts, using what often sounded like an old country-town party-line system. You could never be quite sure who would answer the call or whether some celestial storm had brought the line down.

Doris Stokes was a professional name. She was born Marilyn Dashing in London but her first manager pointed out that if she wanted to make money bringing messages back from the other side to suckers on Earth, most of the clients would be ordinary and wouldn’t trust anyone who looked and sounded smart or had intellectual pretensions. So Doris changed her name, burned her grammar school diploma, threw away her tight skirts and blouses and bought half a dozen cardies and several strings of paste pearls.
… I remember some years ago when Doris was in New Zealand promoting a book, a radio interviewer asked her if anyone on the other side had described in detail for her what heaven was really like. Doris shocked me to the very soul by verbally painting a setting and ambience almost exactly identical to an inner suburb of Christchurch on a fine Sunday morning. I was gripped by a deep spiritual crisis, wondering if trying to be a good bloke was worth it after all.
Originally published in NZ Skeptic 19, March 1991.

Irrationality waxes once again

There are times when the world seems to run along quietly from day to day, with very little happening. Then there are times like these. There are the ongoing aftershocks in Christchurch, many of them big enough in their own right to qualify as major quakes at any other time. There was the far larger earthquake in Japan, with its ensuing slow-motion nuclear disaster. There are wars and revolutions across the Middle East and North Africa which seem set to transform the politics of those regions. Millennial anxieties are on the rise once more.

It’s only to be expected at such times that irrationality should flourish. When natural disasters strike at random, many have a desperate need to seek some kind of pattern, or cause. Hence the attention given to Ken Ring’s claim to have used phases of the moon and solar activity to predict the Christchurch quakes – if the experts can’t say when earthquakes will strike (though the general pattern of aftershocks has actually followed GNS’s forecasts quite well) then there is a niche for those who claim they can. Many skeptical bloggers (eg Peter Griffin, Matthew Dentith, Alison Campbell, Darcy Cowan and particularly the Silly Beliefs team) have dealt with Ring’s claims; we add our five cents’ worth later in this issue.

Meanwhile in the US, many commenters on internet forums are putting the Japan earthquake down to karma for Pearl Harbour. Also in that country self-proclaimed prophet Harold Camping is raising quite a stir with his calculation that the Rapture will occur on May 21 this year – 19 months before the 2012 buffs’ choice for the Big Day. Camping says of the current upheavals: “There are still people that God has to save, and he uses them to get them to cry out for his mercy.”

There’s not much sign of that happening yet in Christchurch, where the citizens are more intent on helping themselves and each other, rather than seeking divine assistance. Slowly the city is getting back on its feet, despite ongoing tremors; life is returning. A small sign of that is that the NZ Skeptics annual conference will once again be held there, from 26 to 28 August. Register with the form mailed out with this issue, or do it on-line at www.skeptics.org.nz

Christchurch always seems to have had more than its share of Skeptics, many of whom have been seriously affected by the quakes. It will be good for us to get together once again, to share the strength of our usually far-flung community.

Ones for the history books

In the aftermath of the Christchurch earthquakes, Ken Ring’s predictions were widely, though often inaccurately, reported. David Riddell looks at Ring’s writings, and compares them with actual events.

Of the many stories coming out of the Christchurch earthquake, the claims and counter-claims surrounding long-range weather forecaster Ken Ring’s alleged quake predictions gained a surprising amount of media coverage.

Ring claims earthquakes are more likely to occur at times of New and Full Moons, with solar activity also playing a part in triggering tremors. The basic idea of tidal forces setting off quakes is not unreasonable, but has been thoroughly investigated by seismologists and found to be invalid. The forces involved are just too weak to have an effect, and there is no correlation between the timing of quakes and the position of the moon.

Skeptics should have no trouble recognising the perceived link between Ring’s predictions and actual events as a case of subjective validation, sometimes referred to as the Barnum Effect. Humans are terribly good at detecting correlations between events, even where there is no direct linkage. Ring predicted many things, most of which did not eventuate. He missed other, major events. Those who were predisposed to believe him remembered the times his predictions bore a resemblance to later occurrences (in fact often misremembering the prediction as more accurate than it was), while forgetting the misses.

Ken Ring’s website (www.predictweather.com) records his predictions, so it is a fairly straightforward process to check what he actually said, rather than relying on media reports. Here, then, is a timeline of events over the past few months, with edited highlights from Ring’s writings.

September 4, 4.35am: a 7.1 magnitude earthquake strikes Canterbury, 40km west of Christchurch.

7 September: Ring states: ” …the next full moon [24 September] may present as an earthquake potential time … for New Zealand only N Cant/Marl may be in the zone.” Although: ” … nothing would eventuate if the 24 Sept tremors occur about 100kms down.” He continues: ” … a potential for earthquakes on the evening of the 1st” . And: ” Next year, the morning of 20 March 2011 sees the South island again in a big earthquake risk … As that date coincides with lunar equinox this will probably be an east/west faultline event this time, and therefore should be more confined to a narrower band of latitude. The only east/west fault lines in NZ are in Marlborough and N Canterbury. All factors should come together for a moon-shot straight through the centre of the earth and targeting NZ. The time will be just before noon. It could be another for the history books.”

24 September: With magnitude 4+ aftershocks striking the Canterbury region at a rate of more than one per day (18 between September 16 and September 30), Ring claims a 4.6 aftershock near Rolleston as confirmation of the above prediction for this date.

27 September: Ring says the moon’s position on September 30 indicates a “potent time” for earthquakes. “And that will cover 1-3 Oct. If we get whales coming ashore somewhere around our coastline we can assume quakes near to NZ. Then we have 6-8 October which is when the moon is in new moon…”

7 October: >Ring begins to withdraw from the 20 March 2011 prediction, while playing down the possibility of another large quake for Christchurch: ” …it is again more likely than not that a significant shake may affect the South Island in March next year… We have not said an earthquake is certain on 20 March 2011, but there is potential for possible activity on an E/W fault line around the time and likely to be in the upper half of the South Island… But I don’t think we should live our lives in fear – we have to accept sometime that earthquake damage has always been a reality living in NZ and Christchurch got its turn recently. No doubt somewhere else will cop it next time. Yet we can observe in hindsight that the Napier earthquake didn’t come back to buzz Napier, nor have the Murchison and the Edgecumbe shakes returned to the same place. In fact we can confidently say quite the opposite, like the measles once you have had it you probably won’t get it again in your lifetime. So on the basis of historical probability, next March Christchurch might well be one of the safest places.”

Ring also predicts the Hokitika Wildfoods Festival will be hit by extreme weather: ” Gale westerlies and much rain is expected…”

12 October: ” …the next lot [of quakes] expected around the 13th.”

18 October: Ring repeats: ” I would still not consider that another massive earthquake is certain, in fact I think it’s more likely not to be the case in Christchurch.” Then he hedges: ” For another disastrous event, Christchurch may or may not be in the firing line again; it could be Wellington or anywhere, and it may not even happen.”

20 October: ” … on the 27th, if there are cluster-shakes … they may be less close to Christchurch … these aftershocks will end soon for Christchurch, probably around the end of November.”

27 October: ” After tomorrow, the 28th, once the northern declination has passed, the numbers of shakes should decrease again, but should return with some of higher magnitude in the first week of November.“ (Emphasis in original.)

13 November: ” … it is reasonable to relax and asume that another devastating shake is unlikely to repeat anytime soon, despite a seismology-department knee-jerk reaction that a 6+ mag. earthquake aftershock could be arriving in the district at any time.”

22 November: ” There is no reason to suppose any aftershocks of significance will occur until [solar] flares climb again…”

26 December: Christchurch is rattled by a series of strong aftershocks, up to 4.9.

26 December: Ring writes: ” Today is the perigee, … Perigees bring earthquakes” (Emphasis in original.)

27 December: ” … the Christchurch shake is not part of some lasting new development, reaffirming that the activity of the past couple of days has probably been just remnants of general global disturbance due to the recent lunar eclipse. The main hits seem to have been to Vanuatu and Japan, and possibly NZ copped something because we share similar longitude. In a day or so things should be back to normal.”

14 February: ” [the] area of the sun that corresponds to NZ is again seeing some activation. The window of 15-25 February should be potent for all types of tidal action, not only kingtides but cyclone development and ground movement. The 18th may be especially prone. The possible earthquake risk areas are N/S faults until after 16 February, then E/W faults until 23rd. The moon will be full on the 18th and in perigee on the 19th. This perigee will be the fifth closest for the year. The 15th will be nodal for the moon. On the 20th the moon crosses the equator heading south. Strong winds and swells may arrive around 22nd to NZ shorelines. … For an earthquake to occur many factors have to come together, but sun activity, full moon and perigee are arguably the most potent, and they are all starting to chime now. Over the next 10 days a 7+ earthquake somewhere is very likely. This could also be a time for auroras in the northern hemisphere and in the southern tip of NZ. It may also be a time for whale strandings because of increases in underwater earthquakes. The 7+ is sure to be somewhere in the ” Ring of Fire” , where 80% of all major earthquakes seem to occur, and NZ is at the lower left of this Ring. The range of risk may be within 500kms of the Alpine Fault.” Note that this prediction does not mention Christchurch.

22 February: Christchurch is struck by a destructive 6.3 aftershock. Several claim it as confirmation of Ring’s 14 February prediction.

11 March: A magnitude 9.0 earthquake strikes northern Japan. The moon is a week away from full, and mid-way between apogee and perigee, one of the safest times for earthquakes by Ring’s prediction method.

12 March: The Hokitika Wildfoods Festival goes ahead in warm, sunny weather.

20 March: As thousands flee the city in advance of Ring’s predicted “one for the history books“, a lunch to mark the occasion is held at the Sign of the Kiwi on the Port Hills. Journalist Sean Plunket is master of ceremonies, with MP Nick Smith and several Skeptics in attendance. The largest of the aftershocks, still occurring daily in the city, comes at 9.47pm, with a magnitude of 5.1. Some claim this confirms Ring’s prediction.
Photo credit: New Zealand Defence Force

Opening a Dore?

A learning difficulties programme that claims to re-train the cerebellum makes some impressive claims which don’t stand close scrutiny.

DORE is an organisation that claims to treat learning difficulties without drugs. Their programmes supposedly

“… tackle the root cause of learning difficulties by improving the efficiency of the cerebellum – the brain’s ‘skill development centre’ – and the part of the brain now understood to play a significant role in learning, coordination, emotional control and motor skills.”

Recently the company held a series of information sessions to coincide with the opening of a new Dore centre in Lower Hutt, to go with their existing centres in Auckland and Christchurch. I attended a session to see what it was all about.

As we entered the room, video testimonials were playing, showing parents and their children claiming dramatic results for a range of learning disabilities and conditions, such as Asperger’s syndrome. An information pack was handed out, which included newspaper clippings and another testimonial. It claimed that Dore gets to the “core of learning difficulties”, “actively improves ability to learn”, is drug-free, based on scientific principles, is personally tailored and is not a “quick fix” or “soft option”. A FAQ stated that people who successfully complete the programme did the exercises accurately and consistently and if improvements don’t occur this is mainly because people are not sticking to the routine.

A video introduced Wynford Dore, who stated his daughter had learning problems, for which he searched for a solution. Then a mother and her son related how the son had dyslexia and behavioural problems at school which the mother was only made aware of after a few years when a teacher spoke to her. The child was already on a three-year programme with SPELD when the family discovered Dore; they followed this programme for a year concurrently with SPELD. They claimed significant improvement about three months after starting Dore.

The presentation went on to claim that approximately 16 percent of the New Zealand population had learning difficulties, with only four percent diagnosed; these were said to affect one in six New Zealanders. It was difficult to locate comparative figures, but SPELD estimates that seven percent of children have a specific learning disability, which would equate to about 50,000 school children.

The Dore programme claimed to assist with dyslexia, ADD/ADHD, dyspraxia (motor skills) and Asperger’s syndrome, and is targeted at people aged seven and over. The presenter briefly went over the typical feelings of those struggling with learning difficulties, and described how they thought these conditions manifest – as a multitude of literacy, numeracy, memory, attention, coordination, social and emotional problems. This was all claimed to be due to an inefficient cerebellum. Dore, they said, addresses underlying causes rather than symptoms (where have I heard that before I wonder?).

The conditions treated all allegedly have a physiological basis and nothing to do with other factors. Figures were presented, said to be from the Otago University longitudinal study and purporting to show that dyslexics were significantly disadvantaged compared with peers (with the consequent implication that treatment would help prevent this disadvantage).

Dyslexic students were more likely to leave school with no qualifications, much less likely to have a Bachelors degree, and none achieved Masters/Doctorate levels. Average income was more than $10,000 less than their peers. However, there was no word on whether this lack of achievement could be generalised to all people suffering dyslexia, given the long time period of the study and the considerable changes in educational services over that time.

In a further video presentation a Dr Sara Chamberlain claimed the cerebellum governs the automatic performance of simple tasks, and that this facility can be enhanced through exercise. We then heard about Dore’s assessment process. Following an initial phone consultation, prospective clients fill out a questionnaire, and there are a variety of tests and a medical assessment. Posture and ocular-motor skills are tested, and then dyslexia is screened for, apparently using a standard tool. Other conditions such as ADD/ADHD are assessed using the DSM-IV manual; the whole initial appointment takes three to four hours. The programme, it appears, is not suitable for everyone. Clients then have 1.5-hour interviews at three-monthly intervals and on completion of the course.

It was claimed that many scientific papers link the cerebellum with learning, attention, etc; these can be found on their website. They say they have done research themselves and written papers, and will provide details on request. They mentioned ongoing studies into ADHD at Ohio State University and by another US office; the Ohio State University testing appears to be a pilot study, but I couldn’t find any references to the other. A testimonial was introduced from a Dr Edward Hallowell, presented as an expert in ADD and ADHD. When I checked on this later, he appears to be involved with the Dore programme and would hardly be an unbiased commenter.

We were presented with figures from self-evaluation claiming to show 86.5 percent of children and 88.5 percent of adults showed progress in literacy and numeracy after taking the Dore programme. For coordination the respective figures were 81 percent and 75.4 percent, and for social skills 78.1 percent and 72.6 percent. The exercise programme was claimed to be individualised, unlike other programmes like ‘Brain Gym’ that aren’t (for more information on Brain Gym see Ben Goldacre’s Bad Science blog(.

The regime

The exercises take 10 minutes twice daily, with a mandatory four-hour break between; they have 400 exercises and 16 levels that could be completed. These involve such things as using a wobble board, or an exercise ball, or throwing and catching mini bean bags. Again, the cerebellum was claimed to be receiving, processing and automating sensory information from somatosensory, visual and vestibular inputs. The cerebral cortex (the thinking part of the brain) is apparently supposed to integrate all of this but with the conditions Dore say they treat, it is claimed the cerebellum isn’t working with the cerebral cortex.

The idea that defects in the cerebellum cause learning difficulties would seem to be a classic case of correlation not necessarily equating with causation. As noted by Oxford University psychologist Dorothy Bishop in her 2007 paper “Curing dyslexia and ADHD by training motor co-ordination: Miracle or myth?”, cause and effect would seem to be not so simple as presented at the session.

“The notion that the cerebellum might be implicated in some children’s learning difficulties is not unreasonable: both post-mortem and imaging studies have reported cerebellar abnormalities. Furthermore, some studies have reported behavioural deficits involving balance and automatisation of motor skills in a subset of people with dyslexia, consistent with a cerebellar deficit hypothesis. However, it is premature to conclude that abnormal cerebellar development is the cause of dyslexia, rather than an associated feature. Many people with dyslexia do not show any evidence of motor or balance problems. Furthermore, the cerebellum is a plastic structure which can be modified by training, raising the possibility that cerebellar abnormalities might be a consequence of limited experience in hand-writing in those with poor literacy.”

The programme used to use a book, but is now web-based. Exercises are carried out and then “marked” according to their criteria. They stressed that compliance was key, along with parental support. Times for completion vary, but are usually 12-14 months, with a weaning process at the end of the programme where the exercises are gradually wound down. The course is expensive, costing almost $5,400 or a little less for a one-off payment. They did say that they gave three “sponsored” places per month, but didn’t describe what exactly this entailed, outside of mentioning that it was for low income families and that children with a medical diagnosis could apply for a disability allowance through WINZ which could be used to access their programme.

A few questions

During question time, they were asked how they could be sure the child in the video testimonial had improved because of Dore and not the other programme he was on. The answer was fudged: they said they didn’t diagnose but looked for “sensory processing problems” and it was those they treated, which then enabled the person to learn. In other words, if there was improvement, it was Dore, not any other intervention specifically targeted at helping the person learn to overcome their disability and learn to read.

Another questioner asked why it was so costly given that the programme is mostly self-directed. They equivocated, talking about staffing costs, the website, and having support available. They said that braces cost much more and that that is basically cosmetic, when their programme “benefited a person for life” so was worth the investment. Yet another question was about the doctors – why wouldn’t they use paediatricians and other suitably qualified professionals? They stated that for their purposes, the level of medical expertise was sufficient.

Dore has obviously learned from experience following actions taken by overseas advertising standards authorities, and no longer make claims of “100 percent cure” and “miracle cure” for the conditions they claim to treat. In fact they seemed to be reasonably realistic in introducing caveats such as “it doesn’t work for everyone”. Despite this, they still claim to be proven to help overcome learning difficulties even though the evidence base is weak to non-existent. Although they make many claims to be “scientific” and have an extensive list of papers on their website, when the UK Advertising Standards Authority considered a complaint against Dynevor, Dore’s parent company, they assessed the studies submitted in support as poor, lacking control groups, and not supporting the treatment claims made:

“The ASA noted Dynevor’s interpretation of the ad. We considered, however, in the absence of any qualifying text to the contrary, that consumers were likely to understand the claim “Need help with Dyslexia, ADHD, Dyspraxia or Asperger’s?” to mean that the DORE programme could help treat the named conditions. We also considered that we would need to see robust, scientific evidence to support the claim. We noted that the two studies provided by Dynevor assessed the effect of the exercise-based DORE programme on children with reading difficulties and children and adults with ADHD respectively…

“… As neither the first nor second study referred to Asperger’s syndrome and only two participants in the first study had dyspraxia, we considered that the evidence was inadequate to support claims to treat those conditions. With regards to dyslexia and ADHD, we did not consider that the studies were sufficiently robust to support the treatment claims for those conditions, and we therefore concluded that the claim was misleading…”

The average person would have trouble verifying claims about the role of the cerebellum and the ability of an exercise programme to improve function. If it really was that easy everyone would be using Dore’s exercises. Their claim that dyslexia, dyspraxia, ADD/ADHD and Asperger’s syndrome have one cause, one cure, is insufficient. The conditions they claim to treat are disparate and cause and effect is not established. There was little discussion of how cerebellar function or dysfunction is assessed, or of the relevance of their testing of such things as eye tracking, and no discussion at all of how the exercises impact on the cerebellum or how outcomes are measured. Bishop says:

“The gaping hole in the rationale for the Dore Programme is a lack of evidence that training on motor-coordination can have any influence on higher-level skills mediated by the cerebellum. If training eye-hand co-ordination, motor skill and balance caused generalized cerebellar development, then one should find a low rate of dyslexia and ADHD in children who are good at skateboarding, gymnastics or juggling. Yet several of the celebrity endorsements of the Dore programme come from professional sportspeople.”

There is little real involvement from the company once the programme has commenced, with only a few appointments to follow up after the initial assessment. Many who join the programme don’t apparently have a formal diagnosis of the conditions Dore claims to treat, and they won’t get that from the company, as they state they don’t diagnose anything other than the alleged cerebellar problems.

It’s not surprising that some would see benefits though – the commitment and parental support required to do the programme would alone benefit some children. Then there is regression to the mean, the Hawthorne effect (subjects modify an aspect of their behaviour being experimentally measured simply in response to being studied) and natural improvements with growing maturity. On retesting later, there may appear to be improvements due to the client having done the test before and being aware of what is required. Many would concurrently use other services such as reading recovery, and Dore themselves recommend that if the child has spare time, that it is spent practising reading and writing. That extra practice reading could be extremely beneficial.

The high cost of the programme is concerning, especially when they acknowledge that not everyone will benefit. Despite this, they had parents travelling from the Wellington region to undertake assessments in Auckland – hence the opening of an office in the region. There may also be a financial risk to participants; Dore UK and Australia have both failed, leaving clients out of pocket. In New Zealand Dore was placed in liquidation in 2009 and the Companies Office states: “This Company currently has Liquidators, Receivers or Voluntary Administrators appointed” with the liquidators due to report again in May 2011.

Resistance to science

Alison Campbell reviews a study of why so many struggle with scientific concepts.

One of the topics that comes up for discussion with my Sciblogs colleagues is the issue of ‘resistance to science’ – the tendency to prefer alternative explanations for various phenomena over science-based explanations for the same observations. It’s a topic that has interested me for ages, as teaching any subject requires you to be aware of students’ existing concepts about it, and coming up with ways to work with their misconceptions. So I was interested to read a review paper by Paul Bloom and Deena Weisberg, looking at just this question.

Bloom and Weisberg conclude there are two key reasons why people can be resistant to particular ideas in science. One is that we all have “common-sense intuitions” about how the world works, and when scientific explanations conflict with these, often it’s the science that loses out. The other lies with the source(s) of the information you receive. They suggest that “some resistance to scientific ideas is a human universal” – one that begins in childhood and which relates to both what students know and how they learn.

Before they ever encounter science as a subject, children have developed their own understandings about how the world works. This means they may be more resistant to an idea if it’s an abstract concept and not one that they have experienced – or can experience – on the personal level. Bloom and Weisberg cite research showing that the knowledge that objects are solid, don’t vanish just because they’re out of sight, fall if you drop them, and don’t move unless you push them, is developed when we are very young children. And we develop similar understandings about how people operate (eg, that we’re autonomous beings whose actions are influenced by our goals) equally early.

Unfortunately for science educators, these understandings can become so ingrained that if they clash with scientific understandings, those particular science facts can be very hard to learn. It’s not a lack of knowledge, but the fact that students have “alternative conceptual frameworks for understanding [these] phenomena” that can make it difficult to move them to a more scientific viewpoint. The authors give an example based on the common-sense understanding that an unsupported object will fall down – for many young children, this can result in difficulty seeing the world as a sphere, because people on the ‘downwards’ side should just fall right off. This idea can persist until the age of eight or nine.

And it seems that psychology also affects how receptive people are to scientific explanations. When you’re four, you tend to view things “in terms of design and purpose”, which means (among other things) that young children will provide and accept creationist explanations about life’s origins and diversity. Plus there’s dualism: “the belief that the mind is fundamentally different from the brain”, which leads to claims that the brain is responsible for “deliberative mental work” but not for emotional, imaginative, or basic everyday actions. This in turn can mean that adults can be very resistant to the idea that the things that make us who and what we are can emerge from basic physical processes. And that shapes how we react to topics such as abortion and stem cell research.

In other words, those who resist the scientific view on given phenomena do so because the latter is counterintuitive, although this doesn’t really explain the fact that there are cultural differences in willingness to accept scientific explanations. For example, about 40 percent of US citizens accept the theory of evolution – below every country surveyed with the exception of Turkey (Miller et al. 2006). Part of the problem seems to lie with the nature of ‘common knowlege’: if everyone regularly and consistently uses such concepts, children will pick them up and internalise them (believing in the existence of electricity, for example, even though it’s something they’ve never seen). For other concepts, the source of information is important. Take evolution again: parents may say one thing about evolution, and teachers, another. Who do you believe? It seems, according to Bloom and Weisberg, that it all depends on how much you trust the source.

The authors conclude:

“These developmental data suggest that resistance to science will arise in children when scientific claims clash with early emerging, intuitive expectations. This resistance will persist through adulthood if the scientific claims are contested within a society, and it will be especially strong if there is a nonscientific alternative that is rooted in common sense and championed by people who are thought of as reliable and trustworthy.”

Yet we live in a society where ‘ alternative’ explanations are routinely presented by media in a desire to present ‘ balance’ where there isn’ t any, or indeed, without any attempt at balance at all. And the internet makes it even easier to present non-scientific views of the world in an accessible, authoritative and reasonable way. As science communicators and educators, my colleagues and I really are up against it, and I would say there’s a need for Bloom and Weisberg’s findings to be much more widely read.

Bloom, P; Weisberg, DS (2007): Childhood origins of adult resistance to science. Science 316 (5827), 996-7.
Miller, JD; Scott, EC; Okamoto, S 2006: Public acceptance of evolution. Science 313: 765 – 766.

Orthodoxy? – Revisiting the Cartwright Report (Part 2)

NZ Skeptic issues 96, 97 and 98 contained articles presenting different viewpoints on the ‘Unfortunate Experiment’ at National Women’s Hospital and its aftermath. Wellington registered nurse and NZ Skeptics treasurer Michelle Coffey continues the discussion in this web-only special.

When I wrote my original article (NZ Skeptic 97), it was written with the intention that it could stand alone as a more thorough discussion of the findings of the Cartwright Report and later research. This was because there were a number of important issues raised as a result of the report which have been almost lost in the debate, many of them systemic ones. While I’m sure that readers interested enough can source the relevant material and judge for themselves, in Skeptic 98, Linda Bryder has responded and the statements made merit a response to clarify several points. I referenced the Bryder’s book for a complete review of the topic, but did not address it in the original article as while it does deal with aspects of the ‘Unfortunate Experiment’ the book ultimately fails to provide any complete assessment of the matter due to the book omitting to investigate key figures such as McIndoe or dealing with the health care system (in particular it’s politics) as opposed to social movements.

1. “There was no medical certainty about the proportion of cases of CIS…”

None of the references support the contention that there was no medical certainty about the proportion of CIS cases that would advance to invasion, and in any case proportion of cases isn’t the point – it’s whether CIS was considered to be a precursor of invasive cancer. This appears to be the case. In the Cartwright Report1 (p23) a compilation of studies was introduced into evidence giving figures that indicate over time, a significant proportion would progress to invasion.

The 1976 Editorial2 cited is discussing screening and states “The report faces up to the problems which still cause fierce controversy – those of the natural progression and regression of early lesions, the discrepancy between total [CIS] cases and the combined number of number of clinical invasive cases, and the incidence and mortality rates.” The Walden Report3 it is referring to states unequivocally that “The significance of [CIS] as a precursor of invasive disease has been recognised for more than 3 decades. Several series of patients, followed for months or years, have demonstrated progression from [CIS] to invasive disease at rates ranging from 25 to 70%.” The issue of where earlier dysplastic changes fit appears to be where any “controversy” laid rather than the concept of progression from pre-invasive lesion to invasion. The report placed these earlier changes a decade or so prior to invasive disease as a precursor state stating “the concept that progressive degrees of cervical dysplasia are part of the natural history of neoplastic disease of the cervix now seems firm.” This is relevant to developing a screening programme given that there is a window of many years in which the condition could be detected and treated. Ostor4 in his statement “The ultimate fate of patients with CIN is the most controversial issue facing investigators interested in cervical neoplasia.” is discussing similar issues to that discussed in the Walden report which is relevant in terms of assessing the relevance of findings and being able to predict the behaviour of these ‘atypias’. Most studies ended at the point of CIS. Ostor looked at not only progression to invasion but the likelihood of regression, persistence and progression to CIN3 (11% in the case of CIN1) with the conclusion that the probability of invasion increases with severity of dysplasia, but there is potential for regression which reflects on therapy.

One man’s dysplasia is another man’s carcinoma #40;notably without insertions to influence the reader to place a particular meaning on it) is a statement that crops up frequently. One issue is the correlation between cytology and histological confirmation, while this wasn’t perfect it was generally agreed that smears could reliably indicate an existing lesion. Histological confirmation was required, but there could be a lack of agreement between pathologists and laboratories on the histological criteria meaning that the precise differentiation between dysplasia and CIS varied. These uncertainties don’t seem to have impacted on the confidence of pathologists regarding screening for cervical malignancies and grading of a lesion was seen by surgical pathologists as more a statement of probability of progression which had limited applicability in clinical management as noted in Löwy’s history5. The precise definition didn’t matter as much as understanding that it was the same disease that was being managed. This is nothing other than a fairly typical debate as biology and medicine rarely, if ever, give certainties.

1. ” Coffey cites 1958 ” official policy… to show this.”

It’s important to note for clarity that there could be variation in policies in other areas but what is more critical in this case was policy at NWH, the hospital where Green practised which set the standard of care. Policies at NWH evolved over a period of time. In 1955 the formation of a cancer team to which all cases of carcinoma of the cervix were to be referred to for treatment was unanimously supported. Over the next ten years, policies regarding the diagnosis and treatment of CIS and invasive cancer were regularly reviewed. This wasn’t just agreed to at a meeting of “…only nine senior consultants…”the decision was made a formal meeting of the Hospital Medical Committee, with a majority which indicates that the committee was happy with the level of evidence for the policy. The clear majority and evolving policy don’t seem to fit too well with the narrative that there was considerable medical uncertainty and controversy about CIS and its progression.

2. “Professor Barbara Heslop explained this more appropriately…”

Heslop’s6 article is one to which I referred to in writing my article as I found some aspects of it informative. However, it is based in the opinions of the author so it’s unsafe to use this article to make certain statements about Green. Heslop considers that Green was doing research but seeks to place this in context stating “Herb Green aimed to ‘prove’ his hypothesis by carefully observing that dysplasia did not lead to cancer…Unfortunately, the proposed methodology was equally appropriate for showing dysplasia did lead to cancer. Paradoxically, and I am sure unintentionally, he ended up demonstrating…more convincingly than had been done before, the transition of dysplasia to cancer.” It was demonstrable that Green considered his work as a study initiated to test a theory and his 1974 paper said (p65) “This…represents the nearest approach yet to the classical method of deciding such an issue as the change or not of a disease from one state to another – the randomised controlled trial. It has not been randomised and it is not well controlled but it has at least been prospective…”

While Baker may have had the presumption that the therapeutic relationship would predominate, little suggests this happening in the case of Green. Whether he knew about such things as falsifiability, Green set out to prove his ‘dormant cancer’ idea despite indications early on that following such patients was unsafe (such as three cases of invasive disease in patients followed with positive cytology occurring by 1969). If the therapeutic relationship was predominant, those cases should have prompted reconsideration of the hypothesis; instead they were reclassified and removed from the study.

3. The 1966 management protocol was to “extend” conservative treatment…”

What seems to be being said here is that under 35 doesn’t mean that, but that it means older patients can be included as well. It should mean what it says as this was a safeguard intended to protect patients which Green then breached. When aging occurs, physiological changes mean it is more difficult to view areas of abnormality and Green and his colleagues were aware of this and the additional risks. The report (p37) stated “As a woman gets older, the squamocolumnar junction is more likely to lie in the endocervical canal and therefore be invisible to the colposcopist.” This means that it can’t be determined whether lesions extending further are suspicious and it was impossible to get a sample without a cone biopsy. Older women were more likely to have unsuspected invasive carcinoma. The use of words like treat is misleading as the intention was not to extend conservative treatment, but to monitor women with positive cytology to fulfil the aim of the proposal. As an example the proposal stipulated punch biopsies and used the word treat and treated (p 21 “four have been treated by punch biopsy alone.”) however this was regarded as a diagnostic procedure. The only way a punch biopsy could be a ‘treatment’ is if somehow by accident or design, the biopsy managed to obliterate a small lesion.

4. “Coffey presents this as a negative outcome, as if it was unnecessary outcome for the women.”

It was. There is a difference between ongoing monitoring which often can be done at primary care level and repeated attendances at a hospital over many years for multiple tests and interventions. Patient 4M (p44) was first admitted in 1970 with abnormal smears. In between 1970 and 1983 she had 38 appointments and six biopsies (wedge, ring, cone, surface) were performed with two occasions being histologically incomplete. A review of patient notes (p42) showed many women had more than one cone biopsy and in some cases up to six. Testimony showed that doing this more than twice was not considered unless under exceptional circumstances and doing this procedure could have effects such as stenosis or haemorrhage and make later evaluation difficult. Bonham testified that this was a dangerous practice and with the third or fourth conisation, it was probably a greater risk than hysterectomy.

Nothing in medicine is benign, and there are obligations to treat patients ethically. This includes minimising as far as possible unnecessary medical procedures as there are a number of risks entailed every time intervention is made. In a condition as treatable as CIS that could have been simply excised that means that over a period of time many women had a number of procedures that were unnecessary and posed excess risk to them that still left them with positive cytology resulting in risk of progression with its own complications. The associated disruption, pain and discomfort of these multiple interventions shouldn’t be trivialised.

5. Regarding the infant vaginal swabs, a press release by Judge Cartwright’s counsel stated “Mothers were told of the tests.”

Any kind of consent would have sufficed. Judge Cartwright stated (p141) “&#8230 there was no provision made to comply with the fundamental requirement that children are not included in research with the consent of their guardians.” This was not a test but a trial and was non-therapeutic research that held no benefit for the infant. Green quickly realised after 200 babies had undergone the procedure that it was a waste of time and lost interest in the study without communicating this to the nursing staff leading to over 2000 babies being subjected to an unnecessary and potentially harmful vaginal vault smear for the purposes of research without the consent of their parent or guardian.

With randomisation of Green’s 1972 “R series” radiotherapy and hysterectomy trial it is difficult to see that it conformed to international practice. Randomisation is aimed at preventing systematic differences between groups and preventing bias but in this case, the selection criteria were made in advance but there was no allocation of patients prior to anaesthesia, grading and decision on surgical treatment so no concealment. Enrolment could have been influenced by biases such as the need to enrol sufficient patients into the study along with the potential for further bias to be added with the use of coin tossing. The patients were not given any opportunity to consent, and were mislead about the treatment decision. Testimony on p170 states “Dr Green and myself and others discussed this question of informing women in the trial about it when it was initiated in 1972. We decided in the end not to tell patients about the trial. We told them they would be examined under anaesthetic when the most appropriate mode of treatment would be decided and then we would proceed accordingly.”

I can contrast this lack of any kind of consent from the parents or “R series” patients with the oral consent obtained by Sir Liley for his intra-uterine infusions where he sufficiently informed the patient of the possible risks and that the treatment was experimental. His case study published in 19637 states “the patient and her husband were an intelligent couple, and the prognosis for the foetus, the possibility and uncertainty of intrauterine transfusion, and the potential hazards to the mother were fully explained to and discussed with them.” This was not the case with Green and his research projects, as no real attempt was made to provide any kind of informed consent.

6. “Despite writing this, Coffey herself makes it clear that the two groups…had nothing to do with the two groups whose records Green analysed.”

This is an assertion and no reason is given as to why you state this. As such, there is nothing there to counter other than to say they had everything to do with those groups. McIndoe et al8 was retrospective while Green’s research was prospective, which made a difference in how the study was conducted but they were measuring the same thing as Green’s 1974 paper (p65) describes: “This series of 750 cases of in situ cervical cancer, and the following of 96 of them with positive cytology for at least two years…” The McIndoe paper was also a comparison of two groups of women, one with normal follow-up cytology and one without and was the final paper that Green never wrote that completed follow-up on the patients that were the subjects of his study. In my discussion, I highlighted the summary in the paper of patients who were included in the punch biopsy special series and that alone should make it clear the relationship between the “special series” and the study. I’m sure if Green could have asserted the same he would have, but couldn’t. The report didn’t rest on this paper alone but reviewed 1200 patient files and 226 were used as exhibits.

7. “Cartwright accepted this as “accurately reflect[ing] the findings of the 1984 McIndoe paper.”

Except Judge Cartwright did not. This is selective quotation that distorts the statements in the report and falls short of what you would expect from an historian whom you would expect to take care to fairly represent the context and statements in documents. The statement is from Ch4 “Expressions of Concern” where the article is addressed as it was the subject of public comment and had prompted the Hospital Board to request an inquiry. This put the article under scrutiny and criticism by some witnesses. Under the title “Was the magazine article accurate?” It is stated that the manuscript was submitted and editorial changes explained but there were some errors in the article that was finally published. This section states:

1.Significant editorial changes: The matter of accuracy was raised firstly by the authors themselves. In her evidence Sandra Coney drew attention to two editing changes which she considered substantially altered the meaning of sentences in the magazine article.

a. “Twelve of the total number of women had died from invasive cancer as had four, or 0.5%, of the group-one women, and eight, or 6% of the group-two women who had limited or no treatment.”

In the original manuscript the authors had written: “Twelve of the total number of women died from invasive carcinoma. Four (0.5%) of the Group-one women, and eight (6%) of the Group-two women who had limited or no treatment. Thus women in the limited treatment group were twelve times more likely to die as the fully treated group.”

I accept that the unedited material more accurately reflects the findings of the 1984 McIndoe paper. The edited version is not accurate.

It’s clear when looked in context that the statement was sourced from the original manuscript of the article and those words cannot be attributed to Cartwright. Cartwright is accepting that the original manuscript more accurately reflected the findings of the paper and is being misquoted to say something else. It is of note that in Bryder9 p33 that this statement is used to say “Cartwright too suggested differential treatment. In her report she quoted Coney and Bunkle’s statement that: ‘Twelve of the total number of women died from invasive carcinoma… [etc]” Cartwright accepted that this accurately reflected the findings of the 1984 McIndoe paper.” This statement is again used misleading to say something other than what it actually says and is being used inconsistently.

8.“How had they “returned to negative cytology”

McIndoe did not say treatment did not enter the study. The citation in Bryder used to reference this says only “The detailed management of patients is not under consideration in this paper…” The paper looks at the initial management and in some cases more detailed management of patients as Bryder would be aware. Here, it does become evident that there were differences, for instance in group 1 cone biopsies excision was incomplete in 24%, but in group 2, 74% were incomplete with the difference likely to be largely due to management where complete excision is not a necessity. The paper states “…any examination of the natural history of CIS of the cervix must depend on a representative, though incomplete, biopsy specimen on which to base the initial diagnosis. Thereafter, meticulous long-term follow-up of all patients using techniques such as clinical examination, cytology, and colposcopy, and if indicated biopsy, is required.” The paper detailed some limitations, such as small biopsies or possibly trauma eradicating lesions, or inadequate biopsies missing abnormalities. So in answer to that question, it was because initial management in group 1 patients either intentionally or unintentionally was adequate in treating the lesion and restoring them to negative cytology. Of this group only 0.7% had recurrence of CIS. In group 2, follow-up showed continuing positive cytology after initial management either by limited biopsy or incomplete treatment which was ideal for studying the natural history of CIS as set out in the 1966 proposal.

9. “Coffey refers to the 1986 paper…as critical of conservative treatment…”

This paper10 was only briefly mentioned before moving on with discussion of McIndoe et al as there was insufficient space to deal with it in detail. Here long term follow-up of vulvar carcinoma shows that of 31 patients managed by surgical excision, there were 4 recurrences and one developed a vulvar carcinoma 17 years later. 4 women managed only by biopsy progressed to invasion in 2-8 years and one additional patient managed with incomplete excision after a lengthy period of observation progressed to invasion. The paper demonstrated that untreated lesions have significant invasive potential. This approach was an extension of Green’s study of CIS of the cervix, and in this case a biopsy cannot be considered treatment at all. While the authors were advocating conservative treatment this was excision of the lesion not biopsies or incomplete excision.

10.“Would a modern gynaecologist agree with this assessment?”

The relevant sentence is presented as a statement, but it omits a significant portion of the sentence which is “This needs to be explained, as those figures strongly suggest the progression of CIS to invasion when it is and was a totally curable lesion.” Gynaecologists would accept the statement that CIS is a curable lesion which can be readily treated with a variety of local destructive methods with complete removal of the lesion and reversion to negative cytology which then prevents the risk of the lesion progressing. In the quoted statement McIndoe et al is referring to group 1 patients, whose cytology had returned to normal. It states “However, contrary to what would be expected, of the 139 group 1 patients with incomplete excision of the original lesion, only five (3.5%) later developed invasive carcinoma. Thus whether or not the lesion is completely excised does not appear to influence the possibility of invasion occurring subsequently.” In this case it didn’t, the rate of recurrence was unexpectedly small probably due to the initial intervention influencing the condition.

Treatment of a diagnosed lesion is then conflated with cervical cancer at a population level in asking for an explanation of why cervical cancer hasn’t been completely eliminated. In an ideal world this might be possible, but in the real world there are a number of difficulties to be faced in ensuring the entire population at risk is screened and treated if necessary. Green’s conclusion was that screening was not effective, however the conclusion was unjustified. The report discusses this on page 56 and crucially treatment needs to improve the prognosis as if subsequent cases are not adequately treated there is little value in screening in the first place. Also, if screening is done in low risk cases and high risk populations are missed, that means screening will be limited in being able to affect morbidity and mortality. In McIndoe et al, the age-standardised incidence of invasive carcinoma in group 2 was 1141/100,000 compared with 18.2/100,000 in the general population in 1975. This has since dropped considerably.

11. “As stated above, group 1 and group 2 had a similar range of treatments…”

My statements stand on this matter that “this ignores that while many women were treated with various procedures, there was evidence of continuing disease, demonstrating that the intervention was inadequate. This was not followed up, posing a high risk of development of invasive disease.” To prove that CIS is not a premalignant disease necessitated the area is sampled for diagnosis, but done in a way that left the lesion available for further study. In some cases there was no treatment, for instance the punch biopsy series which only used a diagnostic method. The criteria included that “the colpscopically-significant area is large enough not to be completely excised by the diagnostic punch biopsy.” The intention was to leave the lesion as undisturbed as possible. The use of cone biopsy is covered in q 5 and 9 as this could also be diagnostic. Of the hysterectomy series, only 4 out of 25 had the procedure for CIS so the procedure was done but not often specifically for CIS. Either way, women were left with positive cytology which put them at risk.

12. ” The methodology of the 2008 paper has been questioned by Sandercock and Burls…”

I would be embarrassed to cite this letter11 as an example of “questioning”. Every paper is flawed to a degree but this isn’t the right criticism to make. They cite a secondary source and claim this explains what they say is a problem with McIndoe et al – “He points out that, not only were the two group retrospectively divided on the basis of persistent abnormal cytology during follow-up and not prospectively as experimental groups for the comparison of different treatment strategies…” They misread the letter12 which does not appear to state anything regarding type of study and apparently draw from Overton’s misleading statement that “…Green and other senior NWH clinicians endorsed policy changes in dysplasia management. Younger women were to be continuously monitored, by repeat smears, colposcopy, lesser biopsies and appropriate more major surgery if evidence of early cancer.” which omits mention of Green’s role and his published studies. Sandercock and Burls then make an erroneous conclusion that McIndoe’s research should have been prospective and be following different treatments without realising that prospective research had already been done by Green. They cannot have read McIndoe et al despite citing the paper otherwise they would have seen the paper outlined the 1966 proposal. A few minutes reading would have shown the difference in between the statements which if they were honestly critiquing the study they should have checked.

Sandercock and Burls then claim a similar “problem” with McCredie et al even though they are aware it was retrospective. This might be correct to say for prospective studies that ask a question and look forward such as Green’s as this type of study should assess outcomes relative to interventions but retrospective studies are meant to pose a question and then look back. McIndoe et al looked at the question of outcomes for patients with CIS with the patient groups defined by presence of positive or negative cytology which categorised according to the risk they had persistent disease. McCredie13 takes this a step further with the approach being to look at the question of outcomes for patient groups classified by management that was adequate or inadequate. There is no problem with this approach; the problem lies with Sandercock and Burls.

13. “…It should be noted a study on outcomes cannot make such pronouncements…”

It can however tell a story, one that is further strengthened by understanding what the author is trying to achieve. Papers are meant to be considered in the light of all the evidence and that includes context. McCredie et al shows half the cancers in women initially managed with punch/wedge biopsy were diagnosed within 5 years of a finding of CIN3. It can be judged objectively there that merely doing a diagnostic procedure in patients with CIN3 leads to a high risk of developing cancer in a relatively short period of time, while the context shows up much more and shows the unethical nature of the original research which meant they were managed in that manner.

14. “Yet Green’s achievement was to encourage an openness to look at the evidence.”

Which story is it that is being referred to? The one where there is a controversy in medicine? If so, he wasn’t the spirited free-thinker he is being cast as. If it is the one where Green was the controversial one, willing to question modern medicine then the controversy wasn’t in medicine. If he is going to be cast as Galileo type of figure, persecuted for his heresy, the critical point is that Galileo was proven correct. So where are his papers? Even his supporters never present his papers to support their claims. Their resort is to complain about everything else.

Green’s ‘achievement’ was the reverse. On p108 of the report, in an Auckland Star article in 1972 it was reported that “Professor Green asserted that a woman with a positive cervical smear showing what is called [CIS] is no more likely to develop invasive or malignant cancer of the cervix than any other woman of the same age. In other words, in situ cancer is not a forerunner of invasive cancer, and the smear test is over-rated.” There is no shift in attitude over time, despite that over the years, much more would have been studied on the matter and medical practice would have changed. Green’s set views were taught, leading to Registrars and other staff being under the impression that screening for cancer precursors was a waste of time. Apparently he kept an Ogden Nash quotation on his blackboard for many years saying “My mind is made up – don’t confuse me with the facts”. None of this shows any willingness to debate the evidence; on the contrary when faced with evidence of patients with invasive cancer that he had originally diagnosed with CIS though not a trained pathologist, he reclassified them and excluded them from the study. They did not fit, so he changed the evidence to suit his theory. True scepticism is not about holding an idea or defending a position but about being open to the evidence and being willing to examine it and change if necessary. Hitting on the hard edges of scientific debate is a tough experience but it serves no one if the record is distorted to hold an untenable position and legitimate questioning of this is taken to be persecution instead of honestly examining whether the position is, in fact, a correct one to hold.

References

  1. “The Cartwright Report”: http://www.nsu.govt.nz/current-nsu-programmes/3233.asp
  2. “Screening for cervical cancer” 1976: BMJ 659-60
  3. The Walden Report: June 5, 1976: CMA Journal Vol. 114 1003-1012
  4. Ostor, AG 1993: Intern. J. Gyn. Path. 12, 2, 186-92
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