AAP not so scientific

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.