Cultural bias and the evaluation of medical evidence: An update on the AAP
Since my article on the American Academy of Pediatrics’ recent change in policy regarding infant male circumcision was posted back in August of 2012, some interesting developments have come about. Two major critiques of the AAP documents were published in leading international journals, one in the Journal of Medical Ethics, and a second in the AAP’s very own Pediatrics. In the second of these, 38 distinguished pediatricians, pediatric surgeons, urologists, medical ethicists, and heads of hospital boards and children’s health societies throughout Europe and Canada argued that there is: “Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision.”
The AAP took the time to respond to this possibility in a formal reply, also published in Pediatrics earlier this year. Rather than thoughtfully addressing the specific charge of cultural bias, however, the AAP elected to boomerang the criticism, implying that their critics were themselves biased, only against circumcision. To address this interesting allegation, I have updated my original blog post. Interested readers can click here to see my analysis.
Finally, please note that articles from the Journal of Medical Ethics special issue on circumcision are (at long last) beginning to appear online. The print issue will follow shortly. Also be sure to see this recent critique of the AAP in a thoughtful book by JME contributor and medical historian Dr. Robert Darby, entitled: “The Sorcerer’s Apprentice: Why Can’t the US Stop Circumcising Boys?”
Flu researchers have looked deeply at their own field, and decided that everything they were doing is all fine. Where the potentially hideously dangerous H5N1 bird-flu virus is concerned,
They said that the benefits of the research in preventing and dealing with a future flu pandemic outweigh the risks of an accidental leak of the mutant virus from a laboratory or the deliberate attempt to create deadly strains of flu by terrorists or rogue governments.
Outside scientists were instead of the opinion that:
[...] if airborne transmission became possible it would lead to a deadly flu pandemic killing millions of people because most of the individuals who are known to have been infected with H5N1 die from the virus.
and even other virologists claim:
The risks are clear for all to see and the benefits are qualitative, and that’s rather weak. Civil scientists are not here to increase the risk from microbes. We are not here to make the microbial world more dangerous.
It’s quite simple here. The flu researchers are not evil people, and they certainly believe they’re doing the right thing. But it is blatantly clear that people inside their own research community, are unavoidably biased in assessing the risks of their own research.
When you think you’re doing the right thing, but all outsiders are screaming for you to stop, that is the moment to step outside your own self-assessment and stop doing what you’re doing, and think deeply before continuing.
Some researchers have fingered a surprising culprit for the crime wave that ended in the 1990s: lead, mainly from leaded fuel. We know that lead leads to development difficulties in children, and in country after country, lead emissions closely mirror the crime rate 23 years later – after those children have grown up into mature, irresponsible adults.
A nice story – only problem is, people aren’t very interested in it. We prefer to tell stories about actual human villains, morality tales with clear blame and praise and entertaining situations (contrast the amounts spent fighting terrorism versus road accidents). Lead causing crime just isn’t sexy.
So to combat this universal human tendency, that causes us to misdirect our efforts and our focus, I propose we should treat Lead as an human-like villain. In its oily lair, the demon Lead rubes its metallic hands together in glee, imagining the millions of children whose developments it is stunting, and the thousands of young men it tipped into criminality, and the wailing of their victims. It plots further increases of its empire of crime, and gnashes grey teeth in frustration as heroic regulator squeeze its powerbase out of the air, the fuel, and the water.
You should already feel your emotional priorities shifting. This alternative visions should enable us to give Lead the attention it deserves, in comparison with other lesser threats with more appealing stories. Use our story-biases in the service of good – we can feel the appropriate amount of joy when we triumph over Lead; emotions, not just reason, are needed to keep up our motivations in dealing wit these threats.
And then the demon can be joined in its dark imaginary lair by the vicious Vampire Malaria, the Zombie-Lord of the Road Traffic Accident, and the bloody Psychopathic Death Cult of Cardio-Vascular Diseases. To arms, good citizens of the world, against these sinister anthropomorphised and correctly prioritised threats!
UPDATED as of 27 May, 2013. See the bottom of the post.
The AAP report on circumcision: Bad science + bad ethics = bad medicine
For the first time in over a decade, the American Academy of Pediatrics (AAP) has revised its policy position on infant male circumcision. They now say that the probabilistic health benefits conferred by the procedure just slightly outweigh the known risks and harms. Not enough to come right out and positively recommend circumcision (as some media outlets are erroneously reporting), but just enough to suggest that whenever it is performed—for cultural or religious reasons, or sheer parental preference, as the case may be—it should be covered by government health insurance.
That turns out to be a very fine line to dance on. But fear not: the AAP policy committee comes equipped with tap shoes tightly-laced, and its self-appointed members have shown themselves to be hoofers of the nimblest kind. Their position statement is full of equivocations, hedging, and uncertainty; and the longer report upon which it is based is replete with non-sequiturs, self-contradiction, and blatant cherry-picking of essential evidence.
This is a guest post by Dave Frame. Many thanks to him for contributing!
Over the last few years, researchers have pointed out a dimension along which there is an extraordinary lack of diversity in the academic social sciences and humanities. And the response from social scientists has been striking. Usually, statistics like these trigger strident calls to reflect diversity and address systematic bias; in this case – political bias – everyone just smiles and winks. But on what basis should political diversity not matter, given how highly academics prize diversity in regards to gender, ethnicity, religion dis/ability and so on?
By Brian Earp
A fatal irony: Why the “circumcision solution” to the AIDS epidemic in Africa may increase transmission of HIV
1. Experimental doubts
A handful of circumcision advocates have recently begun haranguing the global health community to adopt widespread foreskin-removal as a way to fight AIDS. Their recommendations follow the publication of three  randomized controlled clinical trials (RCCTs) conducted in Africa between 2005 and 2007.
These studies have generated a lot of media attention. In part this is because they claim to show that circumcision reduces HIV transmission by a whopping 60%, a figure that (interpreted out of context) is ripe for misunderstanding, as we’ll see. Nevertheless, as one editorial  concluded: “The proven efficacy of MC [male circumcision] and its high cost-effectiveness in the face of a persistent heterosexual HIV epidemic argues overwhelmingly for its immediate and rapid adoption.”
Well, hold your horses. The “randomized controlled clinical trials” upon which these recommendations are based are not without their flaws. Their data have been harnessed to support public health recommendations on a massive scale whose implementation, it has been argued, may have the opposite of the claimed effect, with fatal consequences. As Gregory Boyle and George Hill explain in their exhaustive analysis of the RCCTs:
Are ethical people happier? Many philosophers have claimed this, from Plato and Aristotle onwards. A new study claims it is empirically true, or more exactly that ethical people are more satisfied with life.
The 2009 study looked at cross-country data from the World Values Survey from the US, Canada, Mexico and Brazil. It looked at people who agreed with the view that it is never justifiable to engage in ethically questionable behaviours like avoiding fares on public transports, cheating on taxes or taking bribes (35%) compared the rest. Controlling for things like gender, income, age, health, being married etc. the study found being ‘ethical’ by this standard increased the likeliehood of being very satisfied with life fairly significantly. The effect size is like a modest increase in income. A good reason to try to become a better person, or (as the paper suggests) for governments that are trying to increase subjective well being to do it by improving moral conduct… or is it?