American Academy of Pediatrics not so
scientific:
Circumcision policy marred by financial
self-interest and the distortions of faith
Before we start making assumptions about
the objectivity of the policy on non-therapeutic circumcision recently issued
by the American Academy of pediatrics, we should bear in mind that doctors who
stand to make money from the routine performance of an operation are not the
best people to make a judgement as to its necessity; and that doctors are not
necessarily as scientifically expert as they would like us to think.
On the first problem, the playwright
Bernard Shaw pointed out long ago that doctors who both advised on whether a
procedure was necessary and stood to pocket the fee for performing it faced a
conflict of interest that must raise doubts as to the recommendation. As the
lawyers ask, Cui bono?
It is not the fault of
our doctors that the medical service of the community, as at present provided
for, is a murderous absurdity. That any sane nation, having observed that you
could provide for the supply of bread by giving bakers a pecuniary interest in
baking for you, should go on to give a surgeon a pecuniary interest in cutting
off your leg, is enough to make one despair of political humanity. But that is
precisely what we have done. And the more appalling the mutilation, the more
the mutilator is paid. He who corrects the ingrowing toe-nail receives a few
shillings: he who cuts your inside out receives hundreds of guineas, except
when he does it to a poor person for practice.
Scandalized voices
murmur that these operations are necessary. They may be. It may also be
necessary to hang a man or pull down a house. But we take good care not to make
the hangman and the housebreaker the judges of that. If we did, no man’s neck
would be safe and no man’s house stable. But we do make the doctor the judge,
and fine him anything from sixpence to several hundred guineas if he decides in
our favour. I cannot knock my shins severely without forcing on some surgeon
the difficult question, “Could I not make a better use of a pocketful of
guineas than this man is making of his leg? Could he not write as well—or even
better—on one leg than on two? … The leg may mortify—it is always safer to
operate—he will be well in a fortnight—artificial legs are now so well made
that they are really better than natural ones—evolution is towards motors and
leglessness, etc., etc., etc.”
(Preface to The Doctor’s Dilemma, 1911)
Similar remarks about the foreskin being
superfluous, or even that men are better off without it, are regularly made by
doctors who make a steady income from performing circumcision procedures,
mostly on non-consenting infants and boys. Cui bono? (Who benefits?) indeed.
How scientific is the AAP?
The scientific literacy of American Academy
of Pediatrics is also open to question. They are part of a society in which
nearly 80% of the population reject scientific biology in favour of various
forms of creationism. A Gallup poll taken last June found that 78% of Americans
believed that god had played a role in human evolution (or creation), and 46%
believed that god created humans in their present form. Astonishingly, no fewer
than 25% of people with post-graduate degrees believed this, and 46% of college
graduates. Only 29% of post-graduate degree holders believed that “humans
evolved, God had no part in process”, but this was double the proportion for
all other educational categories (college graduate, some college and high
school or less).
On top of this rejection of scientific
biology, a disturbingly high proportion of Americans believe in visits and
abductions by aliens, but that “the authorities” cover them up; that the
September 11 terrorist attacks were a White House conspiracy; that the 1969
moon landing was faked in a movie studio; and that hurricanes are sent by the
deity to punish whatever practice the speaker happens to disapprove of. No
doubt we shall soon hear such explanations for the damage recently wrought by
Sandy.
As Shaw remarked, we should not assume that
doctors are pure-minded men of science:
I
presume nobody will question the existence of widely spread popular delusion
that every doctor is a titan of science. It is escaped only in the very small
class which understands by science something more than conjuring with retorts
and spirit lamps, magnets and microscopes, and discovering magical cures for
disease. To a sufficiently ignorant man every captain of a trading schooner is
a Galileo, every organ-grinder a Beethoven, every piano-tuner a Hemholtz, every
Old Bailey barrister a Solon, every Seven Dials pigeon dealer a Darwin, every
scrivener a Shakespeare, every locomotive engine a miracle, and its driver no
less wonderful than George Stephenson.
As
a matter of fact, the rank and file of doctors are no more scientific than
their tailors; or, if you prefer to put it the reverse way, their tailors are
no less scientific than they. Doctoring is an art, not a science: any layman
who is interested in science sufficiently to take in one of the scientific
journals and follow the literature of the scientific movement, knows more about
it than those doctors (probably a large majority) who are not interested in it,
and practise only to earn their bread. Doctoring is not even the art of keeping
people in health (no doctor seems able to advise you what to eat any better
than his grandmother or the nearest quack): it is the art of curing illnesses.
It does happen exceptionally that a practising doctor makes a contribution to
science (my play describes a very notable one); but it happens much oftener
that he draws disastrous conclusions from his clinical experience because he
has no conception of scientific method, and believes, like any rustic, that the
handling of evidence and statistics needs no expertness.
As
an example of this Shaw cited the tendency for Victorian doctors to claim
credit for the achievements of sanitary engineering and, in the process, made a
prophetic comment on the recent obsession with blaming the foreskin for the
African HIV epidemic:
Now
let us suppose that in the early nineteenth century somebody had come forward
with a theory that typhus fever always begins in the top joint of the little
finger; and that if this joint be amputated immediately after birth, typhus
fever will disappear. Had such a suggestion been adopted, the theory would have
been triumphantly confirmed; for as a matter of fact, typhus fever has
disappeared [thanks to greater domestic cleanliness]. The vaccination controversy is full of such
contentions. So is the controversy as to the docking of horses’ tails and the
cropping of dogs’ ears. So is the less widely known controversy as to
circumcision and the declaring certain kinds of flesh unclean by the Jews.
Faith (i.e. religiosity) trumps scientific
medicine
The United States is one of the most
fervently religious countries in the world (on a par with Iran or Italy), and
it is stretching credibility to suppose that the members of the AAP
circumcision policy task force are unaffected by this mood. According to the
International Social Survey Programme 2008: Religion III database, 80% of the
American population identify as Christian, and only 16% have “no religion” – a
dramatic contrast with Australia, on 52% and 45% respectively. Indeed, a
prominent member of and spokesman for the AAP circumcision policy, Douglas
Diekema, is on record as giving greater weight to the faith of parents than to
the health and welfare of their children. He was a supporter of the AAP’s
short-lived policy on female genital mutilation issued in 2010, endorsing
“mild” forms of female circumcision, as a mark of respect for the cultures that
traditionally perform such rituals. What is more, in 2010 a boy’s parents were
charged with manslaughter after their son died from a urinary tract blockage;
they had refused to seek medical treatment for him and insisted on relying on
faith healing. At their trial Dr Diekema appeared for the parents as a defence
witness.
Another member of the AAP circumcision task
force,
Dr Andrew Freedman, claimed that the new policy was based on medical evidence
as to circumcision having minor health benefits, but admitted that he circumcised his
own son on the kitchen table “for religious, not medical reasons. I did it
because I had 3,000 years of ancestors looking over my shoulder.” Presumably he
would still have done it even if there had been no evidence of circumcision
having “health benefits”’ or even if there were evidence of its being harmful
and risky.
Even those who insist that their support
for routine (and preferably compulsory) circumcision of male infants is based
entirely on science can exhibit an astounding degree of credulity. In his little
pro-circumcision booklet, Australia’s own Brian Morris writes:
“The Bible records
that Abraham circumcised himself at age 99, along with his 13 year-old son
Ishmael. Not long afterwards his wife Sarah, after many barren years, became
pregnant and bore Isaac. Weiss speculates that Abraham had a foreskin problem,
possibly exacerbated by the desert environment, and that this problem
interfered with his sexual activity. The difficulties were solved by having a
circumcision.” (For Circumcision, p.
60, citing G.N. Weiss, “Prophylactic neonatal surgery and infectious diseases”, Pediatric
Infectious Diseases Journal 16, 1997: 727-34).
It is surprising to
see a molecular biologist who never tires of parading his scientific
credentials treating the Old Testament as though it was literal history. As for
Weiss’s effusion, you would need to go back to Victorian times (a text such as
Remondino’s History of Circumcision)
to find a so bizarre a collection of fabulous stories, unsubstantiated
assertions and wild non-sequitors. To quote such a farrago as an authority
suggests a chronic inability to distinguish scientific evidence from religious
myth.
This inability is widespread in the United
States, where (according to a Gallup poll of 8 July 2011), 30% of the
population accept the literal truth of the Bible as the actual word of God, 49%
regard it as the inspired word, and only 17% regard it as a book of fables and
legends. It is a pity that the poll did not distinguish between the Old and New
Testaments, as it may well be that some of the biblical literalists accept the
truth of the crucifixion but not of the stories about Abraham and the ancient
Israelites. Most fundamentalist Christians, however, turn out to be
fundamentalist only in relation to the first few books of the Old Testament,
and many never read much beyond Genesis (hence their rejection of Darwinism –
though not, oddly enough, of Copernicus, Galileo, Newton or Einstein). They are
better regarded as Old Testament Christians, for if they were New Testament
fundamentalists they would understand that the aim of Jesus and the apostles was to liberate the Jews
from the burdensome Mosaic/Abrahamic laws, and they would adhere to St Paul’s
prohibition of circumcision. Most fundamentalists are biblical literalists only when it
suits them: it is pretty safe to say that very few Jewish people abide by the 600-plus rules and
regulations laid down in Leviticus, Numbers, Deuteronomy etc. And if the 80% of Americans who claim to be
Christians really were, they would follow the directives of St Paul and
resolutely reject circumcision as a Jewish superstition.
As Shaw points out, surgical fashions are
far a more a matter of supply and demand than of what we would now describe as
the necessary consequence of evidence-based medicine.
Private medical
practice is governed not by science but by supply and demand; and however
scientific a treatment may be, it cannot hold its place in the market if there
is no demand for it; nor can the grossest quackery be kept off the market if
there is a demand for it.
A demand, however, can
be inculcated. This is thoroughly understood by fashionable tradesmen, who find
no difficulty in persuading their customers to renew articles that are not worn
out and to buy things they do not want. By making doctors tradesmen, we compel
them to learn the tricks of trade; consequently we find that the fashions of
the year include treatments, operations, and particular drugs, as well as hats,
sleeves, ballads, and games. Tonsils, vermiform appendices, uvulas, even
ovaries are sacrificed because it is the fashion to get them cut out, and
because the operations are highly profitable. The psychology of fashion becomes
a pathology; for the cases have every air of being genuine: fashions, after
all, are only induced epidemics, proving that epidemics can be induced by tradesmen,
and therefore by doctors.
Of course, Shaw had
his blind spots and quirks, such as opposition to vaccination and rejection of
Darwinism; these do not, however, invalidate his sceptical attitude to the medical
profession, and the Victorian doctor-initiated fashion for circumcising baby
boys is a textbook illustration of this principle.
No comments:
Post a Comment