The magic of morality: scientifically determined human values

Ethics and morality are often regarded as beyond the reach of scientific inquiry. But certain values appear to be shared by all humans as species-typical adaptations. This article is based on a presentation to the 2011 NZ Skeptics conference in Christchurch.

It was a pleasure to speak at the annual New Zealand Skeptics conference last year and hear from people representing a rich variety of scientific disciplines and other community organisations. A special thank-you to everyone who travelled from outside of Canterbury to support us following the recent earthquakes. I’m sure your lives are richer for visiting what is left of our city and sharing a few mild aftershocks with us! We enjoyed the morale boost from the weekend of friendly visitors, thoughtful presentations, light-hearted poetry, feasting and court theatre jesters, and the general atmosphere of proactive prosociality.

Relating to all these matters in the broadest possible sense, I discussed the subject of morality and morale. The theme of the conference was ‘building on solid science’, and I suggested that human wellbeing might be built upon a body of six core values. While my talk and this article are insufficient to address the topic fairly, I think a useful introduction can still be made, while avoiding an approach that would be either too complex or simplistic. I also mentioned the matter of priority – there may be many things that are important, but if everything is important, then nothing is important. Here I am aiming for what is most important.

I welcome questions, criticisms, assistance, and general sceptical inquiry of the points I make. Working as a clinical psychologist in a hospital injury and trauma service following the earthquakes, I cannot guarantee I will have time to respond individually to such feedback, but I will read it all and please know that I sincerely appreciate it.

What is Morality?

Morality is a subject that addresses big questions of existence. Who am I? Why am I here? What should I do? With varying degrees of awareness, everyone learns answers to such questions through processes of imitation, instruction, and inference. The answers take the form of moral models, which are ideas about human nature and right and wrong. Such models are explicit (acted upon with reflection), or implicit (acted upon without reflection), and impact the wellbeing of humanity’s billions on a daily basis.

Historically, considerable scepticism about moral models has been evident. “Those who promise us paradise on earth never roduced anything but a hell,” stated our own Professor Sir Karl Popper, summarising prior efforts of a utopian character. However, within many academic disciplines there has been an even stronger statement, a Humean consensus that science must concern itself with answering descriptive ”is’ or ‘fact’ questions, rather than prescriptive ‘ought’ or ‘value’ questions. This has been accepted as a truism by many, with attempts at scientifically based moral or value reasoning criticised as ‘scientism’ or the ‘naturalistic fallacy’, with dire predictions.

Challenges to these charges of scientism have arisen in recent years (Baschetti, 2007; Brinkmann, 2009; Kristjansson, 2010(, perhaps most influentially and eloquently from the philosopher and neuroscientist Sam Harris, in his 2010 book The Moral Landscape. In his book, Harris attacks moral relativism with a perceptive argument for scientific moral realism. As Harris explains, every single scientific ‘is’ statement ultimately rests upon implicit ‘ought’ statements – “all the way down” (p 203).

What logic can prove logic itself? What if you don’t value logic or empiricism? In such a case you destroy all of science, not just moral claims. 2+2=4, but only if you value mathematics. If people do not share such values there may sometimes be no way to convince them. However, there is also no need for the rest of us to take their arguments seriously either – any more than we need to convince everyone that physics or medicine can be helpful before we use it to improve at least our own wellbeing. Harris also argues that moral claims are universally claims about the wellbeing of conscious creatures (real or imagined), an area increasingly well illuminated by neuroscience and other sciences of the mind. In reality there is no choice but to go from ‘is’ to ‘ought’ and science offers the safest path to action, due to the collaborative scepticism and empiricism of scientific peer review process. These points and more are elaborated upon in his book, and I recommend reading it to examine the case in persuasive detail.

Ultimate, Universal, Unavoidable

The Moral Landscape argues that a science of human wellbeing is possible, based upon neuroscience and other sciences of the mind. Indeed, this is the very field of clinical psychology, broadly defined. Given evidence emerging and converging from the scientific literature, I would like to advance further and suggest that human wellbeing may be associated with six core moral values that are ultimate, universal, andunavoidable. I will briefly summarise and explain what I mean by this.

I use the word ultimate in the sense of evolutionary origins (Scott-Phillips et al, 2011) and values coded at the level of the genotype (Yamagata et al, 2006) that develop through processes of epigenesis (feedback effects of culture/environment upon genetic expression). Simply put, social organisms including humans must develop systems to (1) perceive patterns in their environment: (2) allocate time between competing needs: (3) regulate social relationships: (4) value inclusive fitness: (5) defend against threat: and (6) maximise all of these abilities within homeostatic limits. Certain system organisations tend toward Nash equilibrium or evolutionarily stable strategies, that outcompete other strategies. In other words, these values may not only be how life is, but how life must be, for reasons ultimately reducible to the laws of chemistry, physics and mathematics. Historically, evolutionary modelling using game theory simulations has been a prominent scientific tool in exploring the nature of such systems, for example in the domain of social relationships (Axelrod & Hamilton, 1981).

Six values also appear to be universally shared by humans as species-typical adaptations, as suggested by psycholexical and cross-cultural research. Psycholexical theory posits that because languages evolved, they are likely to contain words for patterns in the world (including patterns of valued personality) that are important to human wellbeing.

Across world languages, the thousands of words for describing personality appear to cluster in six main domains (Lee & Ashton, 2008). Additionally, across world ethical codes, philosophies and religions, six core values seem to be shared. They apply across the literature traditions of Confucianism, Taoism, Buddhism, Hinduism, Athenian philosophy, Judaism, Christianity, Islam, and also seem integral to oral traditions ranging from the Masai of the African savannah, to the Inughuit of Arctic environs (Dahlsgaard, et al, 2005). Specific expression of these varies, as do a range of non-shared values. However, the cross-cultural nature of these six core values refutes claims of moral exclusivity by any one tradition, and given the thriving of societies lacking the non-shared values, these appear less generally important and perhaps even obfuscating or detrimental in some cases (Paul, 2009).

Six values also seem unavoidable, in the sense that people must develop them to at least a minimum degree to survive, and to a higher degree to thrive. Failure leads to high levels of dependence or institutionalisation – ranging from requirements for supported living arrangements, to psychiatric hospitalisation or prison. For example, low levels of intelligence characterise intellectual disability and dementia, and low levels of altruism characterise psychopathy. Conversely, high-level development of such values aides flourishing – enhanced wellbeing via autonomy, social connection and competence. These patterns of negatively and positively developed characteristics are the focus of psychiatry and clinical or applied psychology.

I.T.E.A.C.H.

I have used the mnemonic I.T.E.A.C.H. to summarise six values, each letter representing a value word. An important caution is that this word set is only one possibility from hundreds of potential words across the six domains (Ashton et al, 2004). It is selected for memetic reasons, including being easy to remember, descriptive and prescriptive – and with the star for associations with light and enlightenment, bright and magical things, aspiration and inspiration, and matching the embodied metaphors of our intuitive folk psychology (Blackmore, 1999; Seitz, 2005; Winne & Nesbit, 2010). You probably have your own meaning attached to these words, but that meaning is not what I mean, or at least not only. Instead they refer to diverse but related phenomena across physical, biological, psychological and sociological levels of knowledge (Henriques, 2003), with consilience or ‘unity of knowledge’ as an aim (Wilson, 1998). “Words are only tools for our use” as the biologist Richard Dawkins has said (Dawkins, 2006). Nonetheless we must choose some words to use and these seem adequate. Choose your own if you prefer.

To briefly summarise these values then, Intelligence might be parsimoniously defined as pattern recognition, with some other words that cluster in this psycholexical domain being knowledgeable, perceptive, educated, curious. Temperance refers to the ability to temporally sequence actions adaptively, with some other words in this domain being conscientious, self-disciplined, organised, systematic. Equality refers to the ability to maintain mutualistic or non-zero-sum social relationships, with some other words in this domain being just, fair, honest, humble. Altruism refers to helping, with some other words in this domain being kind, warm, generous, compassionate. Courage refers to the ability to tolerate distress, with some other words in this domain being resilient, tough, intrepid, and brave. Lastly, Holism may refer to the ability to integrate the other five virtues, transcend prior limitations, and connect as part of a larger socio-cultural, and even evolutionary and cosmological perspective. I suspect other words in this domain reflect the frequent social context or status of such endeavours, with words such as extroverted, vivacious, inspiring, and spirited.

Building a Stronger Culture

The Moral Landscape argues that we should build morality upon solid science. In this article I have provided a brief glimpse of how, suggesting attendance to six core values. Development of such values is associated with increased wellbeing and decreased physical and mental health problems, as demonstrated by many randomised placebo controlled clinical trials (the scientific gold standard) of psychological interventions. The evidence is good enough to begin applying scientific approaches to wellbeing on a larger cultural scale than is currently the case (Henriques, 2005; Seligman, 2011). Data collected on the way can be used to adjust and amend approaches, via evolutionary processes of cultural variation, selection and retention. This is temperate scientific progress, rather than hotly impulsive or coldly compulsive dogma.

At the conference I was asked about development of these values, and about the role of the golden rule (“consider yourself and treat others accordingly”, as stated by Confucius for example) – widely known as a culturally universal endorsement of altruism. As suggested by its position in the star, altruism is central to the development of other values through valuing the wellbeing of self and others. Mammalian brains do not self-assemble like those of many reptiles, but rely upon nurturance to reach their full potential (Hrdy, 2009). Altruism has ultimate origins in evolutionary processes such as kin selection (Hamilton, 1964) and (together with equality) reciprocal altruism (Trivers, 1971). Parallel to this, skeptical inquiry is a process fostering the accurate pattern recognition that characterises intelligence. Yet, as I said at the conference, altruism alone is as useless as a body without head or limbs, incapable of seeing wisely or acting effectively – and intelligence alone is as a head detached from body and limbs, potentially lost in autistic pattern seeking or psychopathy. And even head (I) and heart (A) are lame, without arming methodically for action (T), standing as two to exceed the power of one (E), stepping forward despite distress (C), and reaching forever higher to transcend what has gone before (H). Simplified even further – head and heart, standing together, standing strong, and reaching out to help.

We aim to build our most important cultural institutions upon solid science rather than superficial superstition. Our challenge is to speak comprehensively but comprehensibly and reach as many people as possible. At the conference, chemist Michael Edmonds spoke of our chemical origins in the heart of stars as “starstuff”, and biologist Alison Campbell of our biological origins in the great evolutionary tree of life. In this manner an evolutionary cosmology to which we all belong is now introduced at new entrant level in our schools, providing fertile ground for sustaining knowledge to grow.

In terms of physics we are matter and energy, creating and destroying, yet neither created nor destroyed. Awareness emerging, submerging and re-emerging, evolving as it is revolving. As a psychologist, I am aware that to grow starstuff into flourishing form, human genes need memetic light. Symbolic linguistic devices such as these words, the “Bright-Star” above or Humanist symbol below, are examples of memes that might aid the teaching of scientifically based morality and brighter prospects for individual and collective wellbeing.

“When will you attain this joy?
It will begin when you think for yourself,

When you truly take responsibility for your own life,

When you join the fellowship of all who have stood up as free individuals and said,

‘We are of the company of those who seek the true and the right, and live accordingly;

‘In our human world, in the short time we each have,

‘We see our duty to make and find something good for ourselves and our companions in the human predicament.’

Let us help one another, therefore; let us build the city together,

Where the best future might inhabit, and the true promise of humanity be realised at last.”

The Good Book 9:4-11(Grayling, 2011).

References

Ashton, M.C., Lee, K., & Goldberg, L.R.(2004).Journal of Personality and Social Psychology, 87(5), 707-721.

Axelrod, R., & Hamilton, W.D.(1981).Science, 211,1390-1396.

Baschetti, R.(2007).Medical Hypotheses, 68, 4-8.

Blackmore, S.(1999).The Meme Machine.Oxford: Oxford University Press.

Brinkmann, S.(2009).New Ideas in Psychology, 27, 1-17.

Dahlsgaard, K., Peterson, C., & Seligman, M.E.P.(2005).Review of General Psychology, 9(3), 203-213.

Dawkins, R.(2006).The Selfish Gene (30th Anniversary ed.).Oxford: Oxford University Press.

Grayling, A.C.(2011).The Good Book: A secular bible.London: Bloomsbury.

Hamilton, W.D.(1964).Journal of Theoretical Biology, 7,1-52.

Harris, S.(2010).The Moral Landscape: How science can determine human values.New York: Free Press.

Henriques, G.(2003).Review of General Psychology 7(2), 150-182.

Henriques, G.R.(2005).Journal of Clinical Psychology, 61,121-139.

Hrdy, S.B.(2009).Mothers and Others: The evolutionary origins of mutual understanding.Cambridge, MA: Belknap/Harvard.

Kristjansson, K.(2010).Review of General Psychology, 14v4), 296-310.

Lee, K., & Ashton, M.C.(2008).Journal of Personality, 76(5), 1001-1054.

Paul, G.(2009).Evolutionary Psychology, 7(3), 398-441

Scott-Phillips, T.C., Dickins, T.E., & West, S.A.(2011).Perspectives on Psychological Science, 6(1),38-47.

Seitz, J.A.(2005).New Ideas in Psychology, 23,74-95.

Seligman, M.E.P.(2011).Flourish: A visionary new understanding of happiness and wellbeing.New York: Free Press.

Trivers, R.l.(1971).Quarterly Review of Biology, 46,35-57.

Wilson, E.O.(1998).Consilience: The unity of knowledge.New York: Random House.

Winne, P.H., & Nesbit, J.C.(2010).Annual Review of Psychology, 61, 653-678.

Yamagata, S., Suzuki, A., Ando, J., Ono, Y., Kijima, N., Yoshimura, K., et al.(2006).Journal of Personality and Social Psychology, 90, 987-998.

Confessions of a New Age Skeptic

How should a skeptic relate to those who have other belief systems?

What does a skeptic and atheist do when they are part of a broader group that is quite loose on empirical evidence and critical thinking? A lot of us experience this to some degree, but I’ve wrestled with my engagement with a particular group I’m fond of for the last 20 years.

Convergence: Beyond 2000 (previously, “Towards 2000”) is an annual camping event that takes place in North Canterbury over the New Year break. Its tag line is: “Gathering every year for a co-creative festival celebrating nature, spirituality, love, and healing”. The event is alcohol and drug-free, has good facilities, and includes about 350 people.

Convergence is a place where the cultural norm is one of suspension of disbelief. All of the typical energy healing models are practised and taught there in workshop context by volunteer facilitators. Reiki, guru aspirants, channelers, tarot card readers, Mayan calendar adherents, fairy lovers, tantric energy, The Secret, massage healers … well, where do you stop?

I found myself coming along to the events first in 1992. I’d migrated from Canada and my flatmate and all his friends, who were a playful, friendly bunch, went every year and I was drawn into it. I was still coming out of 12 years of study and work as a mechanical engineer installing computer systems into paper mills and was quite happy to regress into a less linear approach to my perception of life and how to live it.

My first year I was quite guarded, being aware that there are people out there that attempt to get people away to events “just-like-this” with the aim of drawing them into some sect or other. All the warmth, playfulness and affection that seemed to be happening was pretty overwhelming and I felt I stuck out like a sore thumb. Fortunately, it wasn’t a sect, and I wasn’t pressured to be “one of us”, and I was generally engaged with at a warm, receptive level.

At Convergence in the first few years I remember often feeling discomfort while the friend I might be walking or talking with would leap joyfully into the arms of someone they knew from previous events. It took a lot of self-reassurance to stick with it, and in time I found myself being outrageously affectionate as well, and carrying that forward into my life. I’ve made a lot of friends at Convergence, and found my last two partners there as well (having a child with both of them). So, there have been a lot of good times inside my relationship with the group.

My other exposures to “hooey” weren’t disturbing. I’d lived already for a few years on a hippy commune near Motueka where I’d seen any number of loose approaches to life. In a way, it made me feel more sane being around people that I was genuinely very fond of but that obviously had one or two screws loose and rattling around.

This Xmas, having recently turned 50 and after having gobbled up the the Skeptics Guide to the Universe (and other skeptic podcasts) I joined the ranks of the NZ Skeptics. I’ve finally come to the conclusion that I’m an atheist, a humanist, and I’m going to share that when it is relevant.

It’s still a learning experience for me. When do I say something? If a friend talks about the great course in acupuncture that they are in their final year of do I say what I believe? No, I haven’t, not often. But I do wonder the cost in not saying something. Did we lose an opportunity for intimacy? Did I miss giving them a test to their chosen life path, possibly sparing them some wasted years of hand-waving healing modalities? I’m still not clear on that one, being new to this.

“What’s the harm” is a classic response. I’ve reflected on my hippy years and now realise there was harm. The anti-vax/DIY home-birthing (without adequate support) crowd had three kids that are still paying the price. I’ve supported the deaf community as a social worker and found that there are years during which a lot of them go through milestone birthdays (anti-vax again). I’ve had my kids treated with bogus, outwardly professional therapies (waste of cash and time).

This year, when I went to Convergence I found the issue of my personal beliefs much more emotionally charged. I told quite a few people that I met that I had ‘come out’ as a skeptic. In saying this, I found others that shared my feelings.

Encouraged by my gathering support, in front of the whole crowd I ‘testified’ as an atheist/critical thinker and offered a workshop on the issue. The crowd barked with laughter and good will as I did it humorously. It turned out the others I’d spoken to prior to the meeting had initiated a workshop already!

In the workshop people spoke about the fear of diverging from the group norm, and holding their tongue while others spoke about their wild unfounded beliefs. They mentioned the discomfort of “having to” participate in opening rituals (blessing to the four directions…yadda yadda). And not knowing others that felt the same. We agreed that our general perspective was a healthy one for the fesitival, and one to be openly celebrated.

Next year we’ll open with a workshop for sceptics. It’s a beautiful event, and the acceptance is big enough to include critical thinking. And who knows, we may make us a few converts!
www.convergence.net.nz/wordpress/

Truth is the daughter of time, and not of authority: Aspects of the Cartwright Affair

The ‘Unfortunate Experiment’ at National Women’s Hospital has entered the national folklore as a notorious case of medical misconduct. But there is still disagreement about what actually happened.

It is 22 years since the Cartwright Inquiry published its findings. Arguments about the whole affair persist, with repeated public support from those who say it was a valuable and proper exposure of damaging improprieties by the medical profession, and from those who say that the inquiry and the events which led to it are based on an erroneous interpretation of a scientific paper, and selective evidence gathering at the Inquiry.

If indeed an error has been made, then the vilification of the medical people involved, which has occurred and which still goes on, must be redressed.

I want to consider two aspects of this affair, and if the evidence shows a miscarriage of justice, to offer reasons as to why this might have happened.

I shall:

  • consider the contention that an unethical experiment was performed at National Women’s Hospital (NWH) by Professor Green and his associates, and whether or not the Inquiry made a fair and just assessment of the current (1988) internationally accepted management of carcinoma-in-situ of the cervix (CIN3);
  • discuss what factors in our scientific literary world might be contributing to error.
  • describe unwelcome aspects of our human behaviour which allow an issue of this magnitude to survive in our society, unresolved for 22 years, and how writers have described these for many centuries. I have chosen as my title a quotation from Aulus Gellius in his Attic Nights, written in c.150 CE to emphasise the long-standing nature of the problem.

It is important to have a clear outline of the sequence of events over time at NWH and here is a timeline for reference:

1966: Green proposed to the NWH Medical Committee that CIN3 should be managed by cone biopsy if indicated and regular review. This was in response to considerable doubt worldwide about the natural history of the condition, for which many advocated hysterectomy. The committee agreed.

1973: Editorial in the British Medical Journal, “Uncertainties of Cervical Cytology.”1

1974: Article in New Zealand Medical Journal (NZMJ) by Green showing evidence that “The proportion progressing to invasion must be small.”2

1975: The NWH Medical Committee reviewed the management protocol and agreed it should continue.

1982: Professor Green retired.

1984: “The Invasive Potential of Carcinoma-in-situ of the cervix” was published.3 This was the paper on which Sandra Coney and Phillida Bunkle based their Metro article.

1985: A letter to the NZMJ by Skrabanek and Jamieson was critical of a national cervical screening programme for CIN3 as a detection and treatment method for carcinoma of the cervix (14 August).

1986: A letter from David Skegg was published in the NZMJ supporting a cervical screening programme. “The case for the effectiveness of screening does not rest on the unfortunate experiment at NWH in which women with abnormal smears were treated conservatively and a proportion have developed invasive cancer” (22 January).

1987: “An Unfortunate Experiment at National Women’s” appeared in the June issue of an Auckland magazine,Metro. Within 10 days the Minister of Health (Michael Bassett) has announced the inquiry, and that it was to be chaired by Sylvia Cartwright.

1987/1988: The inquiry sat, and published its report in 1988.

1988: A book, An Unfortunate Experiment, by Sandra Coney was published.

1990: Jan Corbett, a journalist, wrote an article in the July issue of Metro reviewing the errors in the Coney and Bunkle paper, and the way in which the data in the 1984 paper had been distorted.

2008: A conference was held to commemorate the Cartwright Inquiry. A number of papers including Charlotte Paul (a medical adviser to the inquiry), and Sandra Coney, were presented endorsing the inquiry findings.

2009: A book, A History of the ‘Unfortunate Experiment’ at National Women’s Hospital, by Linda Bryder, a professional historian, was published.

2009: A book, The Cartwright Papers, published by participants in the 2008 conference, and now including a vehement criticism of Linda Bryder and of her book.

2010: The NZMJ publishes a letter from Dr Helen Overton, “In defence of Linda Bryder’s Book.”4

The 1984 paper

“The Invasive Potential of Carcinoma-in-situ of the Cervix” was written by two gynaecologists from NWH (McIndoe and Jones), a pathologist from NWH (McLean) and a statistician (Mullins).

I have read this carefully, and made a summary of its contents. It described the follow-up data for 948 women with carcinoma-in-situ of the cervix. The women were followed for five-28 years by repeated smears and observation according to the 1966 proposal, unless they showed evidence for spreading cancer. The women were seen at three, six, and 12 months after presentation, and yearly after that. The women’s records showed that at 24 months after presentation, 131 continued to have an abnormal smear. (Of course, the other 817 had normal smears, or had had removal of the cervix by hysterectomy or other treatment.) There was no difference in age or parity between those in either group.

The division into the two groups was made retrospectively by the authors on the evidence for the presence or absence of an abnormal smear at 24 months.

They compared the outcomes in the two groups in terms of the development of invasive cancer (22.1 percent in the group with positive smears at 24 months, 1.5 percent in the larger group). They also compared the number of deaths in each group at the end of the observation period (June 1983). Four women who had had normal smears at 24 months had died (0.5 percent) and eight women had died who had had abnormal smears at 24 months (6 percent).

Treatment

There was no withholding of treatment in that group with the persistently abnormal smears – see Table 1.

Initial treatment Eventual treatment
Total hysterectomy Cone biopsy or amputation Total hysterectomy Cone biopsy or amputation
Group 1 (n=817) 217 (26.6%) 576 (70.9%)
Group 2 (n=131) 33 (25.2%) 88 (67.2%) 62 (47.3%) 166 (126.7%)

Table 1. Initial and eventual treatment of patients with normal smears, or who had cervixes removed by hysterectomy or other treatment (Group 1), and of patients with persistent abnormal smears (Group 2). Percentages exceeding 100 percent reflect the need for two cervical procedures in some women.
The authors said in the paper’s discussion, “the almost universal acceptance of the malign potential of this lesion has made prospective investigation into the natural progression of CIS ethically impossible”. That would require an experiment where women had no treatment. This is quite clearly not the case in this reported series.

It is clear that in this report of the management of CIS there is no evidence of withholding of treatment, nor of an experiment.

Three years after this paper was published, it was used by Sandra Coney and Phillida Bunkle as evidence for gross wrongdoing by the medical staff at NWH. Here is what they wrote:

“The study divided the women into two groups – 817 who had normal smears after treatment by conventional techniques, and a second group of 131 women who continued to produce persistently abnormal smears. This group is called in the study the conservative treatment group. Some had only biopsies to establish the presence of disease and no further treatment.”

Later in the article the authors refer to “group two women who had little or no treatment”.

This paper in a popular magazine was used by the Cartwright Inquiry as some of the evidence which led to its conclusions.

In 1990, Liggins said, “The famous 1984 article which emanated from the National Women’s Hospital and on which the Metro article which stimulated the cervical cancer inquiry was based, was misinterpreted by the authors of the Metro article and by the judge”.5

Was the management of cervical carcinoma-in-situ unethical?

This is the second aspect of the Cartwright affair that I wish to examine. In June 2010 the statement was made that “treatment with curative intent was withheld in an unethical study” at NWH from 1965 to 1974.6

It is important to make clear what we understand by ‘ethical’, ‘unethical’ and ‘conventional’, or we shall be reduced to the state of the Looking-Glass world: “‘When I use a word,’ Humpty Dumpty said in a rather scornful tone, ‘it means just what I choose it to mean – neither more nor less.'”7

Ethical: “In accordance with principles of conduct that are considered correct, especially those of a given profession or group”. (Collins Concise Dictionary, 1988.)

Unethical: Not in accordance with these principles.

Conventional: Relating to convention or general agreement. (OED)

Convention is a general agreement or consent. (OED)

Was the protocol for the management of CIN3 by Prof Green and his colleagues at NWH an unethical experiment? If he had proposed to divide the women as they presented into two groups, one of which was treated and the other not, then that would have been unethical. Although uncertainty existed as to what proportion of women with an abnormal cervical smear developed an invasive cancer, it was agreed that an abnormal smear meant that the woman was more likely to develop cancer than if she had a normal smear.

His protocol did not deny women treatment.

There was widespread international uncertainty as to the best form of management. If Prof Green had withheld an acknowledged proven treatment that was agreed to by the majority of workers in the field, and replaced it with an unproven treatment, then that would indeed have been unethical.

He didn’t do that.

During 1966-1984 there was no international agreed conventional treatment for this condition. As Iain Chalmers of the James Lind Library in Oxford points out, 8 Linda Bryder in her book has made a thorough review of the contemporary medical literature on this subject which makes it clear that there was no worldwide, generally accepted treatment of CIN3. The evidence called by the Cartwright Inquiry did not reflect the lack of an international consensus. It was indicative of only one aspect of the issue. It has all the attributes of ‘cherry-picking’.

The accusation that Green and his colleagues behaved unethically in these matters is not sustainable. Unless his detractors can show that there was a single international conventional treatment which he ignored, then repeated accusations of “unethical behaviour” are wrong. These accusations continue to be made, as recently as 1 June, 2010.6

Why do manifestly false beliefs persist over time?

There are features of our human behaviour which are conducive to the persistence of untruths, and they include a desire for uniformity in the interest of the maintenance of a coherent and more easily managed society.

Once a decision has been made, it is easier for all of us to go along with it, and not to ‘rock the boat’.

There have been trenchant criticisms of the Cartwright affair and its outcomes, often met with strident objections and not much logic. To accuse the whistle blower of “intransigence and arrogance” rather than meet the questions fairly is shameful.

Another feature of the last 22 years is the increasing number of papers published in the medical literature which on close examination are of poor quality. An example of this is the paper published on 1 June, 2010.

This was published as an abstract online. The authors include a medical adviser to the Cartwright Inquiry, a medical witness at the inquiry, and one of the authors of the 1984 paper. There is the old accusation that “treatment with curative intent was withheld in an unethical clinical study of the natural history of CIS at NWH in the years 1965-1974.” But in the results it is stated that 51 percent of these women had treatment with curative intent! The group treated with the diagnosis made in 1975-1976 had curative intent treatment in 85 percent. Prof Green retired in 1982; his proposal for the management of carcinoma in situ was approved in 1966.

Treatment with curative intent was not defined in the abstract.

The results include P values of 0.0005 for the significance of differences between groups, for a difference which defines the grouping.

The number of new patients in the year 1975-1976 was half that in each of the two previous decades. There is no explanation for this in the abstract. This group was not included in the comparison of risk for cancer of the cervix or vaginal vault. There is no explanation for this.

The medical science literature shares with all scientific paper publishing a current deterioration in standards. This contributes to the persistence of error. This issue has been recently addressed in an editorial in The European Journal of Clinical Investigation.9

“Why would scientists publish junk? Apparently the current system does not penalise its publication. Conversely, it rewards productivity.
Nowadays, some authors have been co-authoring more than 100 papers annually. Some of these researchers only published three or four papers per year until their mid-forties and fifties. Then suddenly they developed this agonising writing incontinence.”

Another factor in our society which feeds our appetite for orthodoxy is the popular press. Truth is often submerged in the sensational. An example of this occurred in the NZ Herald on 1 June, when their health reporter wrote a report of the on-line article6 with the headline:

“Otago research backs cancer inquiry findings: Unfortunate experiment at National Women’s not imagined, says report”

There followed 40 column centimetres supporting the headline, including two which stated: “The cancer death rate differences between the periods and sub-groups are not significantly different”. This information is not included in the on-line published paper. The reporter’s statement is not correct in his summary of the report. In addition he cites information which suggests he has access to the complete (as yet unpublished on June 1st) paper.

The television ‘press’ included that morning an interview with Charlotte Paul, one of the authors, and that evening, an interview with Clare Matheson, the woman named as ‘Ruth’ in the original Metro article. There was no reference to the valid criticisms of the Cartwright affair which have been made over the years.

It is not my case that the medical profession to which I belong is without fault, and I accept that since 1988 more attention has been paid by doctors to issues such as informed consent. But the means, by this miscarriage of justice, do not justify the ends.

Our human desire not to alter our beliefs in the face of contrary evidence, the willingness of the popular press not to disturb established ‘truth’, the current deterioration in the standards of the world medical press, and an unquestioning respect for ‘authority’ are factors recognisably active in the persistence of the myths surrounding the Cartwright affair. These behaviours are not new, and their effects on the emergence of truth have been recognised for centuries. Francis Bacon (1561-1626) in his Axioms wrote, in number 46:

“The human understanding when it has once adopted an opinion (either as being the received opinion, or as being agreeable to itself) draws all things else to support and agree with it. And though here be a greater number and weight of instances to be found on the other side, yet these it either neglects and despises, or else by some distinction sets aside and rejects; in order that by this great and pernicious predetermination the authority of its former conclusions may remain inviolate.”

References

  1. Editorial. 1974: BMJ, 5891, 561-2.
  2. Green, GH. 1974: NZMJ 80, 279-287.
  3. McIndoe, WA; McLean, MA; Jones, RW; Mullins, PR. 1984: Obstetrics and Gynecology 64, 451-458.
  4. Overton, H. 2010: NZMJ 123, 95-96.
  5. Liggins, CC. 1991: Australia and New Zealand J. Surgery 61, 169-172.
  6. McCredie, MRE; Paul, C; Sharples KJ; Baranyai, J; Medley, G; Skegg, DCG; Jones, RW. 2010: Australia and New Zealand J Obstetrics and Gynaecology, ‘earlyview’ on-line 1 June.
  7. Carroll, L. 1871: Through the Looking-Glass. Chapter 6.
  8. Chalmers, I. 2010: NZMJ Letters to the Editor. 30 July.
  9. Editorial. 2010: European J Clinical Investigation 40(4), 285-7.

History denied is history repeated

Today, gonorrhoea infections in young girls are taken as certain evidence of sexual abuse. Yet there is an extensive but now-forgotten literature showing that this is not necessarily the case. This article is based on a presentation to the NZ Skeptics 2008 conference in Hamilton, September 26-28.

In 2006 I was asked for my forensic opinion in a case involving a 13 month old Pacific Island girl, Lana,* found to have a gonorrhoeal infection of her vagina and vaginal lips. Her 19-year-old mother and 20-year-old father had also tested positive for gonorrhoea. Her father had acquired this infection through having an affair when Lana was aged 10 months. Both parents had noticed they had a discharge but had not sought treatment, but when Lana developed symptoms they took her to their GP. Once gonorrhoea was diagnosed, it was immediately decided that either her mother or her father must have sexually abused her and she was taken into foster care.

The parents denied any abuse. They lived in an extended family household, shared a room, bed, and towels, sometimes bathed together, and the mother would use her sarong as a nappy when she ran out of disposables. They accepted that they must have been the source of Lana’s infection, but denied any sexual contact and said that she must have acquired the infection through contamination. They were battling in the Family Court to get their daughter back. The doctors for Child Youth and Family (CYF) insisted that gonorrhoea can only be transmitted by “mucous membrane to mucous membrane” and that gonorrhoea infection in a child under the age of puberty (ruling out vertical transmission when a newborn baby acquires the infection at delivery from the birth canal of an infected mother) is considered diagnostic of sexual abuse.

I was therefore asked by the parents’ lawyer whether gonorrhoea can be transmitted non-sexually in pre-pubertal children after the newborn period. In my opinion gonorrhoea was exclusively a sexually transmitted disease. Experts in the field, both in New Zealand (such as Auckland paediatrician Patrick Kelly) and internationally (for example Margaret Hammerschlag and Nancy Kellogg in the USA) say that gonorrhoea in a child, other than a newborn, is presumptive evidence of sexual abuse.

Various international guidelines indicate that gonorrhoea in pre-pubertal children is nearly always a sexually transmitted disease, although the possibility on non-sexual transmission is not conclusively excluded. In the US Committee on Child Abuse & Neglect (American Association of Paediatricians, 2005), gonorrhoea is said to be diagnostic of sexual abuse “if not perinatally acquired and rare nonsexual vertical transmission is excluded” and a positive culture for Neisseria gonorrhoeae makes “the diagnosis of sexual abuse a near medical certainty”. The UK National guideline for the management of suspected sexually transmitted infections in children and young people (2003) states that “The bulk of evidence strongly suggests that gonorrhoea in young people over one year is sexually transmitted and the isolation of a gonococcal infection is highly suggestive of sexual abuse”.

Certainly there is no doubt that children as well as adults can and do contract gonorrhoea from sexual contact and sexual abuse. I agreed to conduct a systematic literature review to establish whether there is evidence on the possible non-sexual transmission of N. gonorrhoeae in children after the neonatal period. After some months, having accessed and read several hundred papers, it was apparent that there is overwhelming evidence of thousands of reported instances of possible, probable and definite non-sexual transmission of gonorrhoea.

Results of the literature review

The bacteria which causes this infection, N. gonorrhoeae, will grow at temperatures between 25 and 39 degrees Celsius, It is killed by heat (five minutes at 55 degrees) and dies quickly if dried, but thrives in warm humid conditions. It grows on the mucous membranes of the body and hence can infect the mouth, throat, conjunctiva of the eyes, the urethra, anal canal and cervix. Pre-pubertal girls (but not adult women) are susceptible to infection of the vagina and vaginal lips (vulvovaginitis). The mucous membrane of a young girl’s vagina is more delicate than that of an adolescent or adult because of lack of oestrogen and it has a neutral pH which renders it an excellent culture medium for the bacteria.

Survival on inanimate objects

Studies have been conducted where various objects are contaminated with the organism and then attempts made to culture it after periods of time. It has been recovered and grown from a variety of surfaces including paper, swabs, fabric, rubber, wood, glass and condom after a number of hours, and has been grown from infected bathwater after 24 hours. It can live in pus on towels and other fabric for hours or days. Studies of toilet seats have found that these are unlikely to be sources of infection. Gonorrhoea was not grown in a study of random swabs of public toilet seats. When seats were inoculated with the bacteria, it died within 10 minutes if dried, although it could be grown from pus on the seat after two to three hours.

People are at greater risk from contaminated toilet paper rather than toilet seats. There is one case study of an eight-year-old Australian girl who travelled for 72 hours on a plane from Russia to Sydney. The toilets were very dirty and the girl, instructed by her mother, wiped the seat with toilet paper before using it. A few days after arriving in Australia she developed a gonococcal infection. Despite extensive questioning she remained adamant that she had never been subjected to any sexual contact and it was presumed that she had probably contracted the infection from self-inoculation, wiping herself with contaminated fingers.

Accidental transmissions

The literature contains a number of examples of accidental transmission. The three-year-old son of a laboratory technician was left in the car while his mother shopped, ate infected chocolate agar from a culture plate and subsequently developed gonorrhoea of the throat. Laboratory technicians have developed cases of infected eyes (conjunctivitis) from being struck in the eye with the strap of an infected face mask, and from accidentally spraying their face and eyes with infected fluid. There is an unusual cultural practice of Filipinos using their own urine as an eyewash, and a case series is reported of 13 men with genital gonorrhoea who inadvertently gave themselves gonorrhoeal infection in their eyes. Another case of indirect transmission is of a soldier immobilised in bed for many weeks with fractured legs who acquired urethral gonorrhoea from sharing a urinal bottle with an infected patient in the next bed. An even more bizarre case is one of a sea captain acquiring gonorrhoea from using an inflatable sex doll belonging to the chief engineer who had contracted the infection in a previous port.

Epidemics of conjunctivitis

Large-scale epidemics of gonorrhoeal infections, largely affecting the eyes, are reported in communities where there are overcrowded conditions in substandard housing, insufficient water supply with poor sanitation, inadequate hygiene and a high fly density. Such epidemics are prevalent in parts of rural Africa and outback Australia. For example in 1988 an epidemic involving over 9000 cases over an eight-month period was reported in a district in Ethiopia. Most of those infected were children aged under five years, with no concurrent genital outbreak in the adult population. Similar epidemics of gonococcal conjunctivitis have been reported in Aboriginal communities in outback Australia throughout the 1980s and 1990s. Those affected are predominantly children, most under five years of age. A prospective study of 432 cases in one epidemic in 1991 found that risk factors for infection were being aged under five years and having unwashed hands and faces. Although not definitively demonstrated, it appears likely that flies act as vectors of the disease in these African and Australian outbreaks.

Epidemics of gonorrhoea in children’s hospitals and orphanages

What my review uncovered through successive hand-searching of the references of various papers was a large body of academic literature published between the 1880s and 1920s. I found case reports of over 40 epidemics of gonorrhoea in institutions throughout Europe and the United States involving thousands of children. While the original case may have been sexually transmitted, once a young girl with gonorrhoea was admitted into a children’s hospital or orphanage, this infection would spread rapidly through the inmates. Because no antibiotics were available for treatment, these infections had a huge impact and were the subject of intense international discussion.

The most common site of infection was vaginal in prepubertal girls, but children also developed infections in the eyes, rectum, and joints. In cases of serious infections some children died. In 1883 after an infected girl was admitted into a Budapest hospital, 25 girls developed vulvovaginitis and a nurse contracted conjunctivitis. The infection was thought to be transmitted via contaminated bedding, instruments and bandages. In one case in Posen (now in Poland), 236 little girls developed the infection from sharing a public bath. In 1896 after an infected child was admitted into a New York City orphanage, 65 girls developed vulvovaginitis with some progressing to peritonitis. In this case the disease was spread by common bathing of 20 to 30 children in a tub. A boy also developed an infected eye from a towel. A 1927 epidemic in a Philadelphia hospital involved 67 babies in same ward. The initial case was likely a vertical transmission from birth but the infection was probably spread by the use of a rectal thermometer leading to the babies developing vulvovaginitis, rectal infection and arthritis.

For most of these cases there can be no doubt that the infective organism was gonorrhoea. Neisseria gonorrhoeae is a gram-negative diplococcal (‘double rod’ shaped) bacterium. It was diagnosed microscopically by seeing the bacteria inside cells from gram-stained smears of secretions and also by culture of the bacteria on selective media wiped with infected swabs. There are many other species of Neisseria as well as N. gonorrhoeae (for example, N. lactimica, N. cinera, N. meningitides) which may be present normally in the mouths and throats of adults and children. However these do not cause infections such as vulvovaginitis. The combination of the vaginal symptoms plus identification by both gram stain and culture realistically means there is no other organism that could have been responsible for these outbreaks.

The only means of control of these epidemics was identification and prevention of the source of transmission. Strict isolation strategies were introduced. In some institutions girls underwent vaginal cultures and were refused admission if they were found positive with gonorrhoea. In other cases, infected children were kept isolated with separate rooms and separate nurses. Strategies documented in the literature to curb outbreaks include no sharing of clothes, wash cloths, towels or bathwater. Infected children were provided with individualised thermometers, nursing bottles and combs. Nappies were sterilised or made of light muslin and then destroyed. Strict attention to hand-washing in caregivers, especially nurses, was introduced and in one institution an epidemic was finally brought under control by nurses wearing rubber gloves to change nappies.

Household transmission

There are a number of cases reported in the literature of clusters of gonorrhoea infection (vulvovaginal, urethral and conjunctival) occurring in over-crowded living conditions where there are many family members in small crowded dwellings. In these circumstances there is often sharing of bedding, towels and under-clothes, and lack of available water for personal and laundry washing. Case reports come from all over the world from countries such as Nigeria, Malaysia and Alaska. There is a British report of an eight-month-old boy who presumably developed gonococcal conjunctivitis from the towel of 21-year-old infected female lodger, and two preschool children similarly contracted eye infections from towels used by infected parents.

In household cases often it will not be possible to determine whether transmission has been sexual or non-sexual. However in these circumstances, especially where there is no disclosure of sexual abuse by the children, nor any sign of trauma on examination, some cases are likely to have resulted from contamination rather than sexual abuse.

What happened to Lana

Lana was 13 months old when she was taken into foster care. Her mother was pregnant at this time. Two months later her parents separated for a month in an attempt for Lana to be returned to her mother, but the doctors involved were adamant that either her mother or her father had sexually abused her and therefore she was safe with neither. A month later the couple reunited. When Lana was aged 18 months her brother was born. CYF had been considering uplifting him at birth but they decided to allow the parents to keep their boy. Lana was cared for in a number of different foster homes.

By the time the case was heard by the Family Court, she was aged two years six months. I wrote a report on the possibility of both sexual and non-sexual transmission, and provided the doctor for CYF with photocopies of all the papers in my review. However she stated that

Mothers and fathers can abuse children and there has had to have been transmission from and to mucous membranes

Furthermore:

It does not help that Dr Goodyear-Smith is suggesting that accidental contamination is possible when there is no scientific evidence in the literature that has ever confirmed this possibility

She dismissed all literature prior to 1980 as unreliable, and considered that the institutional cases were either all cases of unrecognised sexual abuse, or alternatively were caused by an organism other than gonorrhoea. She said that the vagina was a different “immunological compartment” to the conjunctiva (hence you could have non-sexual transmission in the eyes but not the vagina), and persisted with the orthodox view that gonorrhoea in a child beyond the newborn age is sexually transmitted.

The judgement was reserved for another two months, and was released when Lana was aged two years eight months. The judge accepted the orthodox view, decided that it was more likely than not that Lana’s infection had been sexually transmitted, could not determine whether it was her mother or her father who had abused her, expressed concern at her parents’ steadfast and united denial of sexual abuse, considered that there was a grave risk that Lana was likely to be sexually harmed if she was returned home and therefore made a declaration that the little girl was in need of care and protection as a ward of the state.

An Australian case

I was involved in a similar case in Australia where a father, who had transmitted gonorrhoea to his young daughter, was similarly accused of sexual assault. He had been acquitted in the criminal court but the social services would not allow him to have any contact with his wife and daughter. They were fighting to be reunited as a family and the case finally reached the Appeal Court in March 2008. I attended a conference of expert witnesses in Australia, where myself, an Australian pathologist, two Australian sexual health physicians and an American paediatrician spent a day with an independent mediator to discuss the possibilities of non-sexual transmission. The three Australians and myself were in agreement that non-sexual transmission could occur, and in our opinion was the likely cause of the child’s infection in this case. The paediatrician was adamant that non-sexual transmission was not possible. The case was heard in the Appeal Court over the next few days and resulted in the judgement being in favour of the opinion of myself and my Australian colleagues.

International controversy

British Medical Journal

Having conducted this comprehensive systematic review, I considered it important for this information to be disseminated professionally in the peer-reviewed academic literature. I submitted my paper for consideration to the British Medical Journal (BMJ). Their review process took considerably longer than usual. I later learnt that this was because of debates by the journal editors on whether to consider it for review, and then difficulty finding someone to review it. Eventually it received one of the best reviews I have had. The reviewer wrote:

“The paper tries to redress some balance to this emotive area and uses evidence to show that each case of infection should be judged on individual merit … the paper is important and should be accepted for publication.”

Despite this review, the BMJ editors then rejected the paper because:

“We can find no evidence that the guidelines (or anyone really) would suggest that a mere finding of this sort would merit removal of a child from its family as suggested in the intro to this piece. All authorities in the UK would say that it is just one piece of evidence to be added to others.”

Journal of Forensic and Legal Medicine

I subsequently, in 2007, published my review in a peer-reviewed forensic medical journal, the Journal of Forensic and Legal Medicine, (JFLM). I also presented my review at the Faculty of Forensic and Legal Medicine, Royal College of Physicians Conference in Torquay, England in 2007 to a responsive audience. My paper solicited a long and scathing Letter to the Editor by Nancy Kellogg, author of the USA guidelines (Committee on Child Abuse and Neglect. Clinical Report: the evaluation of sexual abuse in children, published in the journal Paediatrics in 2005). Kellogg described my review as “One person’s speculative journey into her belief that non-sexual transmission is not rare” claiming “She provides neither evidence nor a systematic review.” She suggested that the numerous institutional cases were either all cases of sexual abuse or alternatively were due to an organism other than gonorrhoea. She wrote:

” It is totally baffling why case reports met the criteria for this ”systematic review,” yet randomized controlled trials, comparing, for example, the gonorrhea rates of children who were sexually abused to children who were not, were excluded.”

Kellogg’s letter was published with my rebuttal. I responded that hers was a strawman argument, because fortunately gonococcal infection in prepubertal children is a rare event, by whichever means it has been acquired. Mine is in fact a rigorous systematic review, meeting all the required criteria, and the reason why no randomised controlled trials were included were because none exist, and would of course be unethical to conduct.

NZLawyer

An article about my review was published in the NZ Lawyer 12 October, 2007). NZ members of DSAC (Doctors for Sexual Abuse Care) Drs Janet Say and Patrick Kelly wrote a Letter to the Editor the following month, claiming that mine was not a systematic review, that the outbreaks in institutions were caused by non-gonococcal organisms, that the outbreaks in institutions were caused by sexual abuse, that “The eye (anatomically, immunologically, and physiologically) is different from the genitalia” and that I had not conducted a forensic sexual abuse examination in 20 years.

Again I had right of reply and had the opportunity to explain how the review was systematically conducted, and why the papers reviewed involved cases where the diagnosis of gonorrhoea in institutions was not in doubt.

The physical signs of child sexual abuse

The Royal College of Paediatrics and Child Health (RCPCH) was conducting a major revision of their child sexual abuse guidelines, and colleagues of mine in the Faculty of Forensic and Legal Medicine, Royal College of Physicians, sent them my review to include in their chapter on sexually transmitted diseases. The physical signs of child sexual abuse: An evidence-based review and guidance for best practice was published in March 2008. Despite receiving my review, this book persisted with the message that gonorrhoea in children after the newborn period indicates sexual abuse. They wrote:

“sexual abuse is the most likely mode of transmission in pubertal and prepubertal children with gonorrhoea”

and:

“In a recent systematic review, Goodyear (2007) considered the evidence for non-sexual transmission of gonorrhoea in children after the neonatal period. This review did not have the rigorous criteria used in this evidence-based guidance concerning the certainty of diagnosis/exclusion of abuse and included conjunctival infections”.

At the book launch the leading authors of this chapter, Drs Karen Rogstad and Amanda Thomas, said that there was no evidence of children acquiring gonorrhoea from non-sexual means. The full audiotape of the proceedings was posted on the RCPCH website. When asked about my review Dr Rogstad said that it was a very dangerous paper developed by someone producing papers to support an incongruous belief and that it was a harmful editorial that had not been peer-reviewed.

My subsequent complaint to the RCPCH has resulted in their removal of the audio-taped recording of the book launch from their website, and an apology that my work was not “a non-peer reviewed editorial”, but has made no concessions regarding the possibility of non-sexual transmission in children. What I asked for but did not receive was a page insert into the book (in those volumes not yet sold) explaining the importance of considering both non-sexual and sexual transmission when gonorrhoea is found in children, looking at it case-by-case for possibility of both sexual contact and accidental contamination, with reference to my review plus Kellogg’s letter and my reply. I also requested that this statement be posted on the RCPCH website at www.rcpch.ac.uk/Research/CE/RCPCH-guidelines where the book is promoted.

Does it matter?

While Drs Kellogg, Rogstad, Thomas, Kelly and others have made disparaging remarks about me and erroneously criticised and discredited my work, I am well used to such attacks which in themselves have little impact on me. However, The physical signs of child sexual abuse is a guidance published by the RCPCH which purports to promote best practice based on an evidence review. This potentially is a highly influential publication in the English-speaking world.

It is my presumption that my review is considered as “dangerous” because it was perceived that it might assist guilty men be acquitted, and children returned into unsafe homes. My view is that in the absence of any supporting evidence or suspicion of sexual abuse, the presence of gonorrhoea alone may not be adequate evidence to convict beyond reasonable doubt, nor even to remove a child from its family on the balance of probability that the child has been sexually abused. While I do not want guilty men to go free nor children returned to abusive situations, nor do I want innocent men convicted and non-abused children losing their families.

This has very significant medicolegal ramifications. In most instances where children are diagnosed with N. gonorrhoeae there has been no disclosure of child sexual abuse. Clearly the possibility of abuse must be immediately and seriously entertained and investigated. However forensic physicians and paediatricians using The physical signs of child sexual abuse as their guideline will be unaware that non-sexual (indirect or fomite) transmission may be the mode of infection in some children, and that this possibility must also be considered on a case-by-case basis.

Furthermore, doctors including myself who put forward the possibility of non-sexual transmission in particular cases in the courtroom, are likely to be presented with statements from The physical signs of child sexual abuse which will be used to discredit or override my review. These guidelines may serve to misinform some of those involved in the care of children and young people.

Apart for the cases in which I have been involved, it is clear that in New Zealand at least, if gonorrhoea is found in a pre-pubertal child beyond the newborn age sexual abuse is presumed a “medical certainty”. In 11 years there were 14 cases seen at the Auckland children’s hospital (Kelly P. 2002: NZ Med J 2002;115(1163). All were taken to their GP with genital symptoms and abuse was not suspected until the gonorrhoea was detected, but all cases were deemed sexual abuse. The identity of the perpetrator was deduced ‘based on who was in contact with child during incubation period’. The outcome of these cases were convictions of suspected abusers, children taken into care and families fleeing the country. It is not possible to know if at least some of these cases were the result of accidental transmission, because this possibility was not considered. It is not known how many cases are occurring in the UK and elsewhere where children are found to be positive for gonorrhoea and sexual abuse is automatically assumed.

Clearly it is difficult to determine whether transmission has been sexual or non-sexual. In the past, cases of sexual abuse may have been missed. The current thinking is that gonorrhoea is definitive evidence of sexual abuse or contact, yet there is conclusive evidence that accidental contamination may occur on occasions. It is my recommendation that all such cases must be taken seriously and considered on case-by-case basis. Missing sexual abuse has serious social and legal consequences, but removing children from their parents on wrongful assumptions can be equally damaging. Doctors and lawyers should be cognisant of the large body of literature demonstrating both sexual and non-sexual means of transmission of gonorrhoea in children.

Hokum Locum

Now that Terri Schiavo has been allowed to die peacefully there is an opportunity to reflect on the matter free from the hysteria and religious arguments advanced as an excuse to maintain her in a vegetative state. When discussing the ethics of the situation with a local surgeon he commented that the main problem was that the feeding tube should never have been inserted in the first place. A feeding tube is surgically inserted into the stomach through a hole in the abdominal wall. Once such medical interventions have been made it is very hard to reverse them. In this case the debate appears to have been hijacked by Catholic pressure groups.

Continue reading

Prayer – Not so effective after all

A widely publicised trial which appeared to show prayer was effective in enhancing fertility now appears to have been fraudulent.

In 2001 an extraordinary paper, from the highly regarded Columbia University Medical Center, New York, appeared in the also highly regarded Journal of Reproductive Medicine. About 100 women in South Korea who were undergoing in vitro fertilisation treatment were divided into two groups; half had their photographs prayed over anonymously by persons in the US, the other half were not so prayed over. Astoundingly, the conception rate in the “prayed for” group was twice that in the “not prayed for” group. The work was hard to fault from internal evidence, as it had apparently been done using all the procedures of a modern clinical trial, and it became widely quoted as firm evidence for the efficacy of prayer. Publicity was aided by a press release from the university.

This intrigued Dr Bruce Flamm, clinical professor of obstetrics and gynecology at California University. The scandalous nature of his findings is described in a recent Skeptical Inquirer. He wrote to the three authors and the journal editor, asking, as one would of a colleague in the same field, for access to the raw data of the experiments. Over a period of some years repeated similar inquiries have elicited no answer, not even an acknowledgment, from either journal or authors. Such behaviour is not only unusual and discourteous, it is also unethical, and inviting of suspicion.

Complications

In his article, Dr Flamm first comments on the unnecessary complication of the praying arrangements. Not only were the Korean women prayed for, but the Americans who were praying for them had their prayers “fortified” by themselves being prayed for by another group. And yet a third tier of prayers was added, praying that the prayers of the middle tier would be answered. The paper offered no reasons for this complexity, which would seem to introduce unnecessary confusion into the trial. Some prayers asked that “God’s will be done”, so, in the absence of knowledge of what God’s will is, any result is a “success”. How much prayer was offered, and whether the prayer and the prayed-for acknowledge the same God, were not enquired into.

The Korean women were quite unaware of all this praying, and the university had later to admit it was wrong not to have obtained informed consent. The university had initially described one man (Lobo) as lead author, but when Dr Flamm did get a reply from the vice-chancellor, this person was said to have not known of the work until well after it was done, and had had a merely editorial role in the paper. Another author had recently left the university, while the third has a long criminal history, and is now in jail for fraud. This man, Daniel Wirth, has also a history of publishing reports of “healing” in several papers in obscure paranormal journals.

Why a respectable journal was conned into publishing such a bizarre paper remains a mystery, because the editor refuses to communicate with Dr Flamm, or media inquirers. Despite the criticisms of Dr Flamm and others, the journal kept this paper on its website until a few months ago. Were the claims made in this paper true, they would represent possibly the greatest discovery of all time. That the journal was so incredibly sloppy in its editing, and so obdurate in retracting the paper, is highly damaging to its reputation, and suggests the editor is blinded by his religion.

Another miracle paper

Reading Dr Flamms critique, I am reminded of the now notorious homeopathy claim of Benveniste et al published in Nature. Some useful comparisons can be made. In 1988, as in 2001, reports containing claims of events that should not have occurred according to current scientific understanding, arrived in the respective editorial offices. We are told that the question of publishing Benveniste’s was fiercely argued at Nature, and printed, most unusually, with an explanatory note. As far as is known, the other paper, from workers at the Columbia University Medical Center, had a smooth ride editorially, and was printed without comment.

Nature received a flood of letters to the editor, and several critical of the paper and of the editor for publishing it were printed. Whether anything similar happened at JRM was never admitted. Dr Flamm’s repeated requests for information and discussion were never acknowledged.

Benveniste’s extraordinary claims led the Nature editor to an extraordinary action; he sent a team of investigators to Benveniste’s laboratory in Paris to observe what was done “at the bench”. The flaws in technique thus revealed destroyed Benveniste’s claims. The team’s findings, when published in Nature, caused the authorities to close Benveniste’s laboratory, and almost ended his scientific career. The Columbia University Medical Center appears unmoved and unchanged in the face of Dr Flamm’s criticisms, and two of the three authors of the “Prayer” paper are pursuing their careers apparently unhindered.

L’Affaire Benveniste is now well in the past. Science is still, as before, opposed to homeopathy, and Nature retains its position at the top of the heap of scientific journals. On the contrary, thanks to Columbia University Medical Center and the Journal of Reproductive Medicine, the issue of the efficacy of prayer remains to clog the stream of medical thinking and inhibits progress. And what researcher who values his reputation and the standards of his work will now wish to offer papers to the JRM?

Published with acknowledgment to, and approval of, Skeptical Inquirer, Buffalo, NY,USA.

Credence is Beyond Belief

The Break Free tour will be coming soon to a city near you. The week-long tour of lectures and book selling will start in Christchurch at the end of November and proceed to Wellington, Taupo, Hamilton and Auckland. The person who will head the tour is Phillip Day, who supposedly is “an award-winning author, health researcher and world-class speaker.”

Day may be a good speaker. He certainly has had enough practice, since his tours regularly take him from his base in Britain to several countries. He has been in New Zealand before. Day also runs websites that sell books by himself and a few associates. But what awards he has won or research he has conducted is unclear. What he says is not worth hearing and often is dangerous.

Phillip Day says and writes a lot about many things. He leads Credence, which claims to be “an independent research organisation dedicated to reporting contentious issues that may harm the public. [Their] goal is to report properly annotated and verified information of tremendous benefit to humanity.”

Day also runs the Campaign for Truth in Medicine (CTM) and the Campaign for Truth in Europe (CTE). He manages a website called Eclub to publicize these efforts.

Day’s CTE hates the European Union and denounces Britain’s “own conniving politicians” for permitting “the destruction of Britain by giving their consent to be ruled by an unelected, unaccountable European autocracy dominated by Germany and France.” The EU wants to hijack the success of British athletes, Day complains, by making them compete under the European flag at future Olympics. While such political views may be merely quirky, they offer a glimpse of a mindset gripped by conspiracies.

Day accuses the British government of conducting “a programme of coercion and terrorism against the British farming industry” because it slaughtered animals during the recent foot-and-mouth crisis. According to Day, the disease is no worse than a bad cold for an animal, is not caused by a virus, and can be cured by good housing, bedding and food. The reality of the so-called outbreak, he says, is the British government’s criminal and treasonous decision to rid an independent Britain of its livestock industry in order to promote a European federalist agenda.

Doctors top Phillip Day’s list of people who harm the public. He sees a “slaughter of the citizenry.” He quotes approvingly an alternative therapist who charges, “The most dangerous place on planet Earth is the hospital – next is the doctor’s office – followed closely by the dentist’s office.” Although he lacks a suitable qualification, Day knows better than doctors. His tour promises to show audiences how to “BREAK FREE from cancer, addiction, and depression.” Sadly, Day also quotes Dr Bill Reeder, an alternative therapist who offers questionable chelation therapy near Hamilton, who says he will be “directing all my cancer patients to your site.”

Perhaps the most dangerous misinformation Phillip Day spreads concerns cancer. He condemns prescription drugs, radiation and chemotherapy. He says mammographies do not detect cancer – they cause it. Police officers supposedly get testicular cancer by sitting in their squad cars with a speed gun in their lap. Day insists cancer is a deficiency disease. He recommends apricot seeds/laetrile/Amygdalin/vitamin B-17 as a cure for cancer, praising the work of Ernst Krebs. In fact, Krebs and laetrile long have been discredited. Ernst T Krebs, Jr never earned a graduate degree. Starting in the 1950s, he and his father sold quack “cures” for major diseases, especially cancer. Krebs spent time in jail. Laetrile, sometimes called amygdalin or vitamin B-17 (it is not a vitamin), has been rigorously tested in the US by the National Cancer Institute and the Food and Drug Administration. The tests showed it to be medically useless. It even contains cyanide and has killed people. It is now illegal to sell laetrile in the US. In the mind of Phillip Day, laetrile is outlawed only to protect “the multi-billion dollar, world-wide cancer industry.”

Day says there is no HIV virus – the “highly poisonous Aids medications” are part of a “calculated and inhumane population control agenda which has been sanctioned at the highest political levels.” He praises South African President Thabo Mbeki’s bizarre views on Aids, which have led the South African government to refuse medication to people with HIV. Tragically, the World Health Organisation says Aids is the biggest cause of death in South Africa.

Also dangerous is Phillip Day’s insistence that children do not need any vaccinations. Good food, water and love supposedly are sufficient.

Yes, the Break Free tour is coming to New Zealand. People who value evidence, critical thinking and reason may want to attend – to witness a bad example.
Dr Raymond Richards is a Senior Lecturer in History and American Studies at Waikato University . He can be reached at [email protected]

Forum

Ancient Celtic New Zealand – More Reasons Not To Believe

In connection with David Riddell’s article about “Ancient Celtic New Zealand” (Skeptic, Winter 2004) your readers may be interested in my more detailed examination of the twaddle in Martin Doutré’s book in two articles published in the Auckland Astronomical Society Journal last year.

In these I analysed the garbled astronomy and contrived mathematics with some rigour. I did my own survey of the Maunganui Bluff site on the ground, identifying clear examples of misrepresentation and deception, leaving me in no doubt that the Waitapu “stone observatory” and “survey network” are pure invention. More recently I have found other examples of deception on Doutré’s website. No doubt this is not deliberate deception – I’m sure these people believe their own fabrications – but it is dangerous because many gullible people are sucked in by it.

This grossly misleading material is widely available in bookshops, libraries and websites, giving it an air of respectability. But there is no widely available corpus of published work to counter it. May I suggest that NZCSICOP find some way to commission investigators to research, publish and disseminate definitive books to expose and correct these deceptions case by case. We are dealing here with a growing trend. Crackpots are exploiting modern information and publishing technology, and freedom-of-speech principles, to spread fabrication posing as fact. We cherish freedom of speech ourselves, so we can’t suppress this material, and it won’t go away if we ignore it. Our only option is to match it punch-for-punch.

My articles are:

  • An Ancient Megalithic Observatory Near Dargaville? I Don’t Think So! AAS Journal, July 2003.
  • Secret Astronomical Number Codes? Bunkum! AAS Journal, August 2003.
  • These can be read at the Auckland Astronomical Society website (www.astronomy.org.nz). On the home page select Journal, then select the issue.

Bill Keir
Hokianga

Greenhouse Effect: What would it take?

In this magazine, and at conferences, a number of skeptics seem to have classified the belief in anthropogenic climate change as nonsense, together with spoon-bending and astrology. I wonder if the opposition to a radical new scientific idea is not just a symptom of conservatism – resistance to change – as demonstrated by the historical reluctance of scientists to accept other iconoclastic beliefs such as tectonic plate movement or quantum theory. If so, this is a desirable characteristic (in moderation), because science has progressed only by slow, cautious steps.

Regrettably, the debate has remained at the level of vikings and grapevines, rather than (say) discussion as to whether increasing cloud cover constitutes a negative or a positive feedback loop. Remember that the theory of the enhanced Greenhouse Effect was well established long before any warming was actually observed (in the 1990s). I first became aware of it in 1970, but Sven Arrhenius published a paper on it back in 1896.

The letter is an open challenge to all Greenhouse skeptics, including Vincent Gray, Chris de Freitas, Owen McShane, Denis Dutton and Jim Ring. What empirical evidence would it require, over and above that which has been published in the first, second and third IPCC reports, for these people to publicly declare in these pages that they were wrong? I assume that (being good scientists) skeptics would be quite willing to change their beliefs when confronted with compelling evidence. That being the case, there would be no loss of face if that eventuality should arise. What would it take?
Piers Maclaren

Moral Values

Vincent Gray asks which combination of moral values I support. My values are irrelevant to the topic of this discussion, which concerns the efforts by Bruce Taylor to find a consensus on environmental policy. Gray leaves us in little doubt as to his own values – like the Model T Ford, they come in one colour only! He doesn’t believe in consensus; in fact he opposes any environmental policy other than the continuing insanity of placing scientific “progress” before any other consideration. I am, it seems, “one of the few people who believes what comes out of the Pentagon”. Well, not exactly. Others include the ex-CEO of the UK Met Office and the Chief scientist at the World Bank. The Pentagon warns of chaos as global warming continues. I am also “a sucker for disaster scenarios” because I quoted from a report in Nature which estimated that a quarter of all species will become extinct by 2050. His scorn is misplaced. I never suggested that global warming would be the sole cause of this. The shift in climate zones is too rapid for ecosystems to make corresponding shifts in location. He quotes from an unnamed reference which estimates three to five extinctions per year. This was indeed worth citing in more detail, since the best estimates of the “background” extinction rate are much higher than this!

His references to Darwinism and to evolution derive from Herbert Spencer’s 19th century concept of Social Darwinism, which was an attempt to apply Darwinist ideas to politics. The fallacy is, of course, that “survival of the fittest” in a socioeconomic context has nothing to do with biological fitness. Over a century later, Gray perpetuates this fallacy. Like it or not, Homo “sapiens” is part of nature, and not separate from it.

Finally, environmentalism does not “fundamentally oppose modern technology, such as GE and nuclear energy”. It does, however, advise the proper use of the precautionary principle.
Alan P Ryan
Kaiapoi

Personal Restraint

It is good to see Forum getting letters but the tone of some recent ones is disturbing. It should be possible to challenge somebody’s views without resorting to personal attack; a little more politeness would help. In the last issue Vincent Gray found it necessary to defend his moral values; this should not be necessary.

I am not asking for editorial censorship, just personal restraint. Argue the case, do not attack the person, such attacks are somewhat self defeating. I may well believe that my intellectual opponents are blithering idiots but saying so in print merely gets them sympathy.
Jim Ring
Nelson

Forum

Moral Values

I am finding it difficult to respond to Alan P Ryan’s diatribe (Skeptic Autumn 2004) as it borders on the incoherent and self-contradictory. I wonder if it will help if I summarise my views on moral values, about which he seems confused.

Moral values vary between individuals, groups, societies, nations, and time periods. They consist of a complex mixture of conventional wisdom, prejudice, religious dogma, superstition and fantasy, plus a dose of community spirit, experience, facts, evidence, common sense, and scientific and technical knowledge. The question is, which particular combination does Mr Ryan support, and what proportion of it emphasises the earlier items?

Genocide, murder of unbelievers, opponents and minorities; discrimination against women, homosexuals and “inferior” races, and slavery exploitation and oppression of the weak figured large in the “moral values” of many of our ancestors, and these precepts are unfortunately still widespread. They were often successful, on a Darwinian basis, in securing survival of dominant groups or nations.

If we wish to promote world peace, human rights, freedom of thought and expression, democratic institutions and equality before the law, we have to state our views plainly, and we have to give reasons why such values are consistent with human survival and progress.

Science and technology have a major influence on moral values. Copernicus, Newton and Darwin caused profound changes in moral behaviour, as did the factory system, electricity, the motor car, the computer and the contraceptive pill.

Attempts are made to impose, or promote moral values. Those emanating from ancient books, such as the Bible, or the Koran, are not always as rigid as they pretend to be. Christians no longer burn heretics or witches, although some feel justified in assassinating legally authorised abortion doctors. Most Muslims disapprove of stoning rape victims or cutting off the hands of thieves. Gandhi was killed because he advocated tolerance for Muslims and the abolition of Hindu castes. Skeptics and atheists have a responsibility to promote humanist values, free from ancient dogma.

There is one unfailing recipe for extinction: a resistance to change.This principle can be found as a factor in the downfall of all the great empires of the past. It is perhaps a matter of faith in the future, that if we are to survive we must find means of preventing wars and other violent behaviour, encourage individual and social development, freedom of conscience and criticism, and the embracing of new ideas and technology.

Mr Ryan is a sucker for disaster scenarios. The “Species Extinction” scam was based on the absurd assumption that climate is the only influence on biological success. Estimates of “extinctions” are notoriously unreliable. A recent estimate I have seen has been unable to justify more than three to five per year. Also, Ryan must be one of the few people who can believe what comes out of the Pentagon.

Vincent Gray, Wellington

Medical Principles

It may be time to expand the principles of the Hippocratic Oath

First do no harm. That’s the major principle of the doctor’s Hippocratic Oath. For the most part, the public are well-served by that principle and by our medical community. It’s a principle which any health professional should follow as a matter of course. But I think they could do with an addition to “First do no harm” — how about “Second, do some good&quot.

I’m not convinced, though, that that would have been enough to help the unfortunate patients of Dr Richard Gorringe, the Hamilton GP recently struck off the register after being found guilty of disgraceful conduct. His combination of unorthodox practices appeared to pass neither principle for a number of his patients, and he was found to have caused them “unnecessary suffering”.

Perhaps the most disturbing aspect of this case was the comment from the Medical Practitioners Disciplinary Tribunal that:

“Dr Gorringe’s belief in the accuracy of his diagnoses and in the efficacy of his unusual treatments is such that the tribunal can have no confidence that, were he to continue in practice, his patients would be properly advised of their nature and limitations so as to permit informed choice.”

Patient advocates have fought long and hard to get informed choice enshrined as an important principle in medical practice, so it’s worrying to hear that Mr Gorringe intends to continue to offer medical advice and treatment, albeit as a naturopath.

Given the tribunal’s caveat, one wonders how informed his next patients will be as to the principles guiding his treatments. And what protection or redress, if any, there will be for future patients who find themselves undergoing “unnecessary suffering”.

These are not questions solely for the Gorringe case, however, but ones we all need to consider. After all, we have a Ministerial Advisory Committee for Complementary and Alternative Health currently examining what modalities are to be integrated into the New Zealand health system, and what regulations, if any, this new and lucrative health market is to operate under. The committee has defined complementary and alternative medicine (CAM) to include “all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and wellbeing.”

I guess this extremely loose definition is understandable, given that five of the eight committee members are self-identified CAM practitioners, with business interests in iridology, naturopathy, natural medicines, traditional Chinese medicine, acupuncture, aromatherapy, massage therapy, counselling, sclerology, osteopathy, homeopathy, anthroposophy and culturally defined health sectors.

However, such an all-encompassing, self-serving definition doesn’t help the patient trying to decide if a recommended practice is safe and effective, and it’s a bad look for the CAM industry as a whole. Two CAM practitioners who were members of the White House Commission on CAM Policy, were honest enough to warn that:

“Generic recommendations neither serve the public interest nor protect the public health because they fail to distinguish between approaches, practices and products for which there is some scientific evidence and those that either stretch the realm of logic or are demonstrably unsafe.”

And while it’s said more Kiwis are turning to alternatives, they also want reassurance that not only are such practices safe, but that they will really work. According to the New Zealand Family Physician journal, 71 per cent of New Zealand patients surveyed wanted regulation of complementary medicine to be on a par with orthodox medicine.

The distinction, of course, is an artificial one. As Marcia Angell, editor of the New England Journal of Medicine, says, there is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work.

Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. Everyone would welcome cures for cancer, eczema, multiple sclerosis, arthritis, whatever their origin, so long as they do no harm and, as an equally important requirement, actually do some good.

But if the modality involved has no basic grounding in reality, then it doesn’t matter how many doctors take it up, how many products are sold, how well integrated it is in our hospitals, it won’t do any good and, as demonstrated, can do a great deal of harm — physical, emotional and economic.

Any health practitioner, whether registered doctor or naturopath, who refuses to acknowledge this, is guilty of disgraceful conduct. You don’t need a professional board to tell you that, just simple ethical principles.

Medical Evidence

In the second of a two-part series, Jim Ring looks at what evidence means to different people

Scientific evidence is often difficult to interpret, in medicine in particular. ‘An Unfortunate Experiment’ was the title given to the treatment for some women after screening for cervical cancer. In this case science was considered by the legal profession and apparently found wanting. The doctor involved was castigated and publicly humiliated for experimenting on humans. But no real experiments were ever done; it appeared he did not understand scientific methodology. Neither did the journalists and legal people involved. The point is that no proper controls were used so it was very poor science.

Were the women disadvantaged? It is difficult to tell, but many were certainly outraged. It generally escaped notice that the surgeon was responding to public pressure for less radical surgery and that a group of patients involved seem to have had on average a slightly better outcome than the norm.

One of the most unfortunate ideas that came out of the long legal case was the emphasis on privacy for the individuals involved which implied their records should not be available for medical study. There is a difference between privacy and anonymity. It is very important to explain to those involved in medical procedures that for medicine to progress it is essential to collect data. Women appeared on TV complaining bitterly that they had been used in an experiment without their consent. But all good medicine is experimental.

We are not much closer to determining whether mass screening for cervical cancer does improve the chances for the screened population and now we have another scandal in New Zealand. Public expectation of screening programs is far in excess of what they can deliver. Efforts to sue Dr Bottrill, and compensation claims from ACC, seem to imply that patients think a false negative reading is necessarily medical error. Women have appeared on TV claiming their lives have been devastated because they had a false negative. Surely this is wrong; they are rightly upset but this is because further tests show a medical problem. Of course some who died might have been saved if an early intervention had resulted from a correct positive reading; however this does not seem to be the main thrust of their complaint.

False Negatives vs False Positives

It is possible to reduce the number of false negative readings at the expense of an increase in the number of false positives. This may seem desirable but there is a cost. In Britain large numbers of women in a screening project reacted very badly to finding they might have a ‘pre-malignant’ condition. This included some members of the medical profession. There is a clear indication that patients were not well informed before screening.

Patients involved in any medical procedure are supposedly asked for their ‘informed consent’. It seems now obvious that ‘informed consent’ is largely lacking during mass screening for both cervical and breast cancer. Several of those involved in the public hearing are surprised to find that screening is less than 100 per cent accurate. All mass screening procedures are likely to have a high error rate as they are designed to be rapid, cheap and simple; leading to more precise testing if there is a positive result. Is a large and expensive inquiry, using legal methods, a suitable way of investigating scientific questions?

Cervical cancer, unlike breast cancer, is strongly correlated with environmental factors. The former is very rare in the general population with a relatively high incidence in a certain sector. However it is politically incorrect to target the high-risk population for screening because the risk correlation is with such factors as poverty, poor hygiene and sexual promiscuity.

A recent case of a gynaecologist accused of misconduct raises some interesting issues. The unfortunate patient would seem to be outside the high-risk group for cervical cancer, thus an assumption may have been made that the correct diagnosis was very unlikely. But no physical vaginal examination was made. Feminist literature once strongly criticised the medical profession for over-use of this procedure, which one writer described as ‘legalised rape’. It would be interesting to know the rate at which this procedure is used today compared with, say, 30 years ago. Is the medical profession responding to crusades in a way that disadvantages patients?

Objections to trials

Medical ethicists – now a profession – have objected to various drug trials saying it is unethical to provide some patients with a placebo that will not improve their condition. This is in effect a claim to certain knowledge – that the drug being trialed is the ideal treatment. Patients receiving a placebo are not disadvantaged when the new drug may do more harm than good. We can sympathise with terminally ill patients who know that they will die in the absence of treatment and where anything seems a better bet than a placebo. But it is essential that drugs be properly tested before being used routinely.

Experiments have even been done in surgery. In 1959 patients were randomly assigned, but all prepared for surgery and the chest cavity opened. Only then did the surgeon open an envelope and follow the instruction; either to perform the procedure or immediately close the chest. Although some ethicists have objected (one stated that such surgery would never take place in the UK), a double-blind study of brain surgery was recently done in the US. Not only did it pass an ethics committee but patients welcomed the chance to take part even though it involved drilling the skulls of both real and placebo patients. In this case there was considerable improvement in those under 60 who had the real operation.

This indicates people may be willing to give consent to risky experiments providing they are given good information.

Most evidence in medicine comes not from experiments but from epidemiology. This requires the collection of huge amounts of data and sometimes produces conflicting results. Two populations, which differ only in the factor under investigation, should be matched and this is difficult to achieve. Recently, in a world-wide study, doubt has been cast on the efficacy of breast-cancer screening. New analysis purports to show that when populations are matched correctly, the screened population has no better chance of survival than an unscreened population.

Demands for safety

Some demand that all medical procedures should be ‘safe’, though curiously this is not required of alternative medicine. Suppose a new drug has fatal consequences for one patient in 100,000. It is quite likely that this will not be discovered during testing. Should such a tiny risk preclude the use of a drug that gives significant benefits to the vast majority of patients? New medicines are introduced when they show a clear advantage over a placebo. When very large numbers are involved in a study it is possible for a drug to show a significant advantage, yet not be worth introducing. Significance is a technical term and it is possible to find an advantage of only 0.1% is ‘significant’, though it may not be worth taking such a product.

It was this confusion that bedevilled early experiments on ESP. Rhine in America and Soal in England recorded the success of subjects guessing unseen cards. The experimenters wrongly assumed controls were unnecessary; instead they compared guesses with a theoretical chance result. A few subjects scored correct guesses at slightly more than chance and because huge numbers of guesses were involved, statistical tests showed these results had ‘significance’. That is, there was a huge probability that the guesses were not simply ‘lucky’.

Enthusiasts then made the enormous leap to say that because the guesses were not due to chance they must be due to a previously undiscovered human faculty, extra-sensory perception or ESP. Disinterested observers, not just skeptics, should have concluded that other explanations, such as poor experimental design, badly recorded results, fatigue, or just plain cheating were more likely. A great deal of time, money and effort was spent pursuing this will-o’-the-wisp.