I number of my posts have links to my old blog. I’ve moved my old blog to a new server, and the permalinks no longer work (and I’m probably to lazy to hunt them all down). If I send you to a blind link, sorry ’bout that. Just go to whitecoatunderground.com and search by title.
Month: November 2008
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Why male circumcision and female genital mutilation are not morally equivalent
NB: Believe it or not, I actually had to close comments, the first time I’ve ever had to do it. They had become so offensive without any useful content that it’s no longer worthwhile to keep it going. Sorry.
I have repeatedly vowed to stay away from this topic, but in defense of my colleague, I must speak out. Harriet Hall, from sciencebasedmedicine.com wrote a brief piece examining the medical literature regarding male circumcision. As part of the discussion, she mentioned having performed many of these procedures during an earlier part of her career. In response to her interesting post, she received comments such as this one:
Dr. Hall needs to confess her guilt for the intentional injury of scores of infant males and reexamine her motives in writing this document.
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Does alternative medicine have alternative ethics?
We’ve talked quite a bit about ethics in this space, especially medical ethics and “blog ethics”. Today, though, we will specifically examine the nature of medical ethics as they apply to so-called alternative medicine.
First, and perhaps most important, I am not an ethicist. I do not have the depth of reading, the knowledge of terminology, or the specific education to lead a formal discussion on ethics. What I am is a practicing internist, who must make ethical decisions on a daily basis. Most of these decisions are of necessity made “from the heart”, but it is not infrequent that I must evaluate a situation more formally and fall back on some of the ethical principles of my profession.
Ethics are not static. They are not a divine gift bestowed on each of us as we don our white coats. They are a living part of our specific cultures, and of the profession we serve. Some of the modern principles of medical ethics are newer than others. Beneficence, non-maleficence, and confidentiality are ancient principles of medical ethics, which continue to be relevant today. Patient autonomy is a more recent value, reflecting a shift in how society views the relationship between patient and physician. These ethics must be mutable, as the profession itself is ever-changing. Despite this fluidity, there is an identifiable line of “doctor-hood” that has existed for at least the last century, and the members of this guild have always tried to adhere to some type of code of behavior.
Alternative medicine poses real challenges to the principle of medical ethics. First, we’ll discuss who, in fact, is bound by these principles, then the way in which alternative medicine is or is not compatible with medical ethics.
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A Problem with Using the Plastic
I have a love-hate relationship with credit and charge cards. They’re incredibly convenient, but my few puritan instincts tell me that they’re the spawn of satan.
And the fees! The fees! No, not the ones for paying your bill late, or for paying your bill on time over the phone, balance transfer fees, application fees, balance transfer fees, overlimit fees, or even annual fees. (Did you know that banks make more money from fees now than from investments?) I’m talking about the fees that the card networks charge to merchants. Jane Birnbaum explains in Thursday’s Times:
A typical merchant card payment has two parts: an “interchange fee,” which includes an average 1.7 percent of the sale price and a flat per-transaction fee, and a separate fee that goes to the merchant’s bank. Take, for example, a driver who pays for a $1,000 car repair with a credit card. The bank that issued the consumer’s card receives an interchange fee of $17.10 (including a 10-cent flat fee), while the repair shop’s bank gets $4, or four-tenths of 1 percent of the total sale. The repair shop pockets $978.90.
On a large, $1,000 sale, one could just consider this a cost of doing business. Who is going to walk around with $1,000 in cash in their pocket anyway? Checks are dowdy and raise unmanageable fraud risks (a subject for another post). So, the card is most excellent in that situation.
On small transactions, these fees can have a large impact; they cause merchants to lose money on a sale. Because credit cards are used more than cash now in the US, the fees add up to an enormous tax on consumers. Birnbaum continues:
In 2007, merchants paid $61.56 billion in electronic payment fees, up from $48.58 billion in 2005, according to the Nilson Report, a payment systems industry newsletter…
Obviously, this is passed onto the consumer. But instead of passing it onto just the plastics, merchants spread the costs among all customers, even those who use cash or checks. This is because under the guise of consumer protection, California and other states have laws that prohibit businesses from charging customers more when they use plastic (however, merchants can advertise “cash discounts”). Agreements between credit card networks and merchants prohibit policies setting a minimum amount for credit transactions.
Straight outta Locash!
So, next time you’re in line at the 7-11 behind the 18 year old using plastic for a $2.32 purchase, remember that you are paying for it with both your wasted time and money!
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Palin as Populist Chic
I am enjoying the news post election, because what was once news media “liberal bias” about Sarah Palin is now simply common sense.
Even more fun is the frank conversation about the conservative movement. Today’s Journal has a must read by Mark Lilla on how the very conservatives who valued intellectualism and elites were corrupted by “populist chic.” Lilla recalls Jane Mayer’s recent article on Palin, noting how conservative intellectuals chose Palin as a candidate that was appealing to the masses. But in so doing, conservative intellectuals mirrored their liberal rivals. Lilla explains:
Back in the ’70s, conservative intellectuals loved to talk about “radical chic,” the well-known tendency of educated, often wealthy liberals to project their political fantasies onto brutal revolutionaries and street thugs, and romanticize their “struggles.” But “populist chic” is just the inversion of “radical chic,” and is no less absurd, comical or ominous. Traditional conservatives were always suspicious of populism, and they were right to be. They saw elites as a fact of political life, even of democratic life. What matters in democracy is that those elites acquire their positions through talent and experience, and that they be educated to serve the public good. But it also matters that they own up to their elite status and defend the need for elites. They must be friends of democracy while protecting it, and themselves, from the leveling and vulgarization all democracy tends toward.
He concludes:
…As for political judgment, the promotion of Sarah Palin as a possible world leader speaks for itself. The Republican Party and the political right will survive, but the conservative intellectual tradition is already dead. And all of us, even liberals like myself, are poorer for it.
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Stop the RFK Jr. appointment NOW
I would beg everyone who reads the scienceblogs and cares about science to contact the transition team in the Obama administration as Orac has requested.
It should be clear by now to readers of this blog that pseudoscience is not a problem of just the right. The left wing areas of pseudoscience are just as cranky, just as wrong-headed about science, just as likely to use the tactics of denialism to advance a non-scientific agenda. We have been dealing with the denialism of the right more because they’ve been in control. Now is the time to nip the denialism of the left in the bud so it doesn’t take root in this new administration.
RFK Jr. is a crank (Orac for more), and one of the problems with cranks is Crank Magnetism. When people have one type of pseudoscientific belief it tends not to be isolated. Instead it reflects a general incompetence in understanding science, evaluating the quality of evidence, and what constitutes good science. RFK Jr.’s crankery will not be limited to vaccines and autism. He will undoubtably become the poster boy for all sorts of left wing crankery – be it environmental extremism, toxin/radiation paranoia (we’ll never get public wifi), or his already well known anti-vax crankery.
My letter to the transition team is below the fold. Please join me in trying to prevent this terrible error on the part of the Obama campaign.
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Migraines prevent breast cancer!!!!!!!
When reporting on science, reporters and editors like sexy stories. Since most science isn’t particularly sexy, there’s usually a hook. If you can squeeze “risk” and “cancer” into a headline, an editor sees good headline. What I usually see is a sensationalist article that is going to get it very wrong.One of the questions most often asked in the medical literature is “what is the risk of x?” It’s a pretty important question. I’d like to be able to tell my patient with high blood pressure what their risk of heart attack is, both with and without treatment. And risk is a sexy topic—the press loves it. Whether it’s cell phones and the “risk” of brain cancer, or vaccines and the “risk” of autism, risk makes for cool headlines. Take this one for example:
Migraines cut breast cancer risk 30 percent: study
What does this mean? Should I tell my wife to go out and find some migraines? What the hell is risk, anyway?
Risk, in the most basic sense, is a causal association. If, for example, I find that members of the “Thunderstorm-lovers Golf Association” have a higher incidence of being struck by lightning than golfers who don’t belong to this odd club, I may have stumbled upon a measurable risk. There is both a measurable association, and a plausible reason to causally link the associated variables. If I find that members of the National Association of Philatelists have a higher incidence of heart disease than other folks, I may or may not have stumbled on a risk. Is there a reason that philatelists should have more heart disease? Is it a coincidence? Is it worth investigating further? Is there a confounding variable, e.g. are philatelists in general older, and did I fail to control for this?
Then there is the question of the degree of risk. How strong is the risk observed?
Statisticians have ways of measuring risk, but many of these terms—such as relative risk, absolute risk reduction, odds ratio—are not intuitive concepts.
Let’s take the study in question. The premise is interesting. Migraines and breast cancer are both associated with estrogen. Many breast cancers are estrogen-dependent, and the risk of developing breast cancer correlates with exposure to estrogen.
Migraines appear to be associated with estrogen as well, but negatively. This is a much more tenuous connection. It has been observed that migraines tend to wax during estrogen-poor times, and wane during estrogen-rich times—high estrogen, fewer migraines; low estrogen, more migraines. Or so it’s been observed.
The authors of this study invoked migraine as a negative risk factor for breast cancer. The English meaning of “risk” is a bit lost here—what they are saying is that women who have migraines are less likely to develop breast cancer than women who don’t have migraines. This shouldn’t be all that surprising, as migraines and breast cancer are both associated with, well, womanhood.
But all this aside, it’s the “30%” headline annoys me. That a big number! Get me a migraine, stat! But thirty percent is an “odds ratio“, which is a mathematical way of describing an association in a case-control study such as this one. Odds ratios are not intuitive, and as a measure of risk, they tend to break down when looking at common occurrences, such as migraines.
If we look directly at the data from the study, the data used to calculate the odds ratio, we see something else. In this study, the control group was post-menopausal women without breast cancer. The case group was women with breast cancer. Among women without breast cancer, 19% had ever had a migraine. Among women with breast cancers, 14-15% had ever had a migraine. So, there was about a 4-5% difference in migraine rates between women with and without breast cancer. Does that still sound like a big number?
Statistics are non-intuitive. I have to work pretty hard to try to dig out the clinical meaning from stats, and I still get it wrong sometimes. The press gets it wrong much more often. Be very wary of banner headlines about risk. Besides the difficulty of understanding the difference between risk reduction and odds ratios, what does it mean in the real world?
To be perfectly frank, I think the authors have studied a question that no one is asking. We already know that estrogen is positively associated with breast cancer, and we suspect that estrogen reduces migraine frequency (maybe). What is the point of looking at the relationship between two secondary outcomes? In other words, if a and b are both dependent on c, does it even mean anything to say that a and b vary inversely? I don’t think so. Do you?
References
R. W. Mathes, K. E. Malone, J. R. Daling, S. Davis, S. M. Lucas, P. L. Porter, C. I. Li (2008). Migraine in Postmenopausal Women and the Risk of Invasive Breast Cancer Cancer Epidemiology Biomarkers & Prevention, 17 (11), 3116-3122 DOI: 10.1158/1055-9965.EPI-08-0527