Wednesday, October 10, 2007

New attack on free speech in Britain

Post below lifted from Midnight Sun. See the original for links

Worldwide suppression of free speech - is it possible? On the first of this month (October) in Great Britain, an upgrade to existing `hate crime' legislation came into effect by which a British blogger can be imprisoned for seven years and slapped with an unlimited fine for criticizing any religion, which of course means Islam.
The new Act was passed to close a loophole: To date, only Jews and Sikhs were protected by the provisions of incitement to racial hatred. According to the Government, some extremists exploited this loophole, using religious terms to identify victims whom they would have previously identified using racial terms. From next month, the law will extend protection to followers of all religions.

However, the Act is a diluted version of the bill that was first introduced by the Government to Parliament after a high-profile campaign by free speech advocates including comic actor Rowan Atkinson.

The bill originally outlawed words and behavior that insulted or abused religious groups. The House of Lords removed those provisions and limited the offense to those who used threatening words or behavior only. They also removed the `reckless' element of the offense, restricting it to intentional offenses. The Government's failure to overturn these amendments was blamed on miscalculations by Government whips, who had not called in sufficient MPs to win the vote.

The new offense can be committed by broadcasting, writing in a blog or on a website, recording sounds which are threatening, or in the performance of a play if there is an intent to stir up religious hatred. Offenses can be punished by a prison term of up to seven years and an unlimited fine.

Basically the original law was introduced. It was protested by free speech advocates (joined by `Mr Bean' - Rowan Atkinson) so the government amended it. While they seem to be making it fairer, they've actually added more provisos. Lawyers say it leaves room for free speech: There is a wide exemption for freedom of speech. The Act states:
"Nothing in this Part shall be read or given effect in a way which prohibits or restricts discussion, criticism or expressions of antipathy, dislike, ridicule, insult or abuse of particular religions or the beliefs or practices of their adherents, or of any other belief system or the beliefs or practices of its adherents, or proselytizing or urging adherents of a different religion or belief system to cease practicing their religion or belief system."

Sounds pretty subjective and open to interpretation and manipulation to me. And why are they making this kind of law to start with? Something is changing and if you're following global trends, it's certain to be another step downhill.

Here's how I think it's going to play out. The law has been changed to include `discrimination' against Muslims. There are plenty of British blogs which would fall into this category. They'll pick on the most politically incorrect ones first, possibly the BNP connected ones, and this will break down any community resistance. Then it's going to game on for all right wing blogs (which they always connect with `racism' anyway both politically and in the broader community). British bloggers will run for higher ground as Belgian bloggers have done and move their blogs to international servers to avoid detection.

Sooner or later, the E.U. will opt for standardization across the board in Europe. Then, as the E.U. pushes for more power as they have been lately, they will push for variations of the same law to be enacted worldwide. The governments we have right now might resist, but elections are coming up. What will future governments do?

Now add to that the rise of Jihadi gangs in prisons and their attitude towards those incarcerated for religious `vilification' and you've got a time bomb the implications of which don't bear thinking about. Now I've got myself into trouble making predictions in the past and I could be wrong here, but I'm just setting out a hypothetical scenario.

Hats now incorrect

According to a report in London listing magazine Time Out, a growing number of London establishments are enforcing a `hat ban' on customers wishing to drink on their premises. It is one thing for pot-bellied landlords to tell customers they've had `too much to drink' and `clear off home'. It's another thing serving up strong sartorial diktat. Just who do they think they are? Don't they want our hard-earned cash and custom?

`We operate a smart casual dress code', a barmaid told me at the busy Porterhouse pub in Covent Garden in central London. `And that means no hats allowed in the pub.' Surely a nice trilby hat or a cream fedora hat fits the criteria of `smart casual'? She replied with unblinking primness: `We can't have one hat rule for some and one hat rule for others.' In other words, whether you are sporting a chavtastic Burberry cap or some designer item of millinery straight out of Royal Ascot, you won't be heading to the bar in a hurry. If Rat Pack stars like Frank Sinatra were around today, they would no doubt be turfed out of such premises for their anti-social headgear, no matter how much cash they were prepared to put across the bar.

Needless to say, the `smart casual' policy at the Porterhouse and some branches of All Bar One in central London is not really the justification for this ludicrous hat ban. It seems publicans have taken their cue from shopping centres such as Bluewater on the outskirts of London. Security staff there ban shoppers from wearing hoodies on the basis that any covering of the face prevents the wearer from being identified on closed-circuit television cameras (CCTV). `Yes, that's true', says the Porterhouse pub's barmaid, agreeing with Bluewater's policy on hooded tops. `Hats do obscure someone's face and CCTVs need to see them in case there's any trouble.' She's not alone with this explanation either. A barman at an All Bar One told Time Out: `We don't allow hats to be worn in the bar. We absolutely don't allow it. We need all faces to be seen by the CCTV.' (1)

Whilst such nit-picking bans might be a shock to the good liberals at Time Out, it seems this development has been in operation throughout the country for a while now. In March 2006, retired teacher Betty Wilbraham was told by staff at The Hereward pub in Ely, Cambridgeshire, to remove her black rain hat because `its CCTV camera would not be able to see her face clearly enough'. Pub licensee Tony Love said it was pub policy to always ask people to remove their hats. `It's all to do with the CCTV. We have 13 cameras inside the pub and we cannot be seen to be discriminating between the youths and the elderly people.' (2) Elsewhere at The Wheatsheaves in Frome, Somerset, one publican failed to get into the Christmas spirit last year by banning anyone who wore Santa Claus hats for the same reason. The Wheatsheaves' publican, Sam Ingram, proved that the deadhand of Scrooge was alive and kicking by bluntly stating: `Just because they're dressed up as Santa doesn't mean they couldn't start a riot.' (3) No doubt Ingram spends his time behind the bar on Christmas Day crying `Humbug!' to anyone who'll listen.

Is it really the case that hats of any description obscure someone's face? If so, what will be next? Will Amy Winehouse be refused entry into pubs because her perfectly coiffured beehive obscures her face? Will bowl-headed indie kids be ordered to have their fringes cut before they can get served? And why does it matter if someone's face is obscured anyway? Why this poisonous presumption that pub dwellers are automatically out to cause trouble?

The enforcement of such a bizarre rule as the `hat ban' may be an attempt to assert control in the name of tackling crime - there has always been a `Little Hitler' tendency among door staff and publicans. But the fact that such a ban seems to have been accepted at all shows how a demand for security and safety permeates society at present. It's interesting that while respectable pensioners have kicked up a fuss at the hat ban, younger people have tended to acquiesce to the demand to remove their headgear. In fact, surveillance is more or less seen as acceptable if it leads to a greater sense of security. And if that means toning down the headgear in the name of peace and quiet, then so be it. The way landlords justify the ban is also a kind of artificial `zero tolerance' policy where bouncers or staff are seen to flex their authority by telling a customer what is and what isn't permissible. A barman from an All Bar One branch in Soho told me, `a customer would think twice about causing trouble if a doorman has already told them off. The hat ban acts as a deterrent.'

What lies behind such demand for safety and security is a perception that individual autonomy is problematic in and of itself. Thus all individuals need some kind of rules and regulation because anyone can suddenly `get out of hand'. Forcing pub goers to remove their personal choice of headgear is done to constrain someone's free will and independence, lest that free will leads to aggro and arguments - the dress code implies a behaviour code, too. Indeed, there is something servile about forcing customers to `remove their hats', with ugly echoes of the `doffing your cap' reverence to society's supposed `betters' in the past. In this case, it's a reverence to New Britain's principles of authority, order and knowing-your-place. At root lies nothing but contempt for pub-going folk, as the aforementioned `I predict a riot' publican makes abundantly clear.

To be fair, other establishments are strongly against this growing fad for hat bans in pubs. As one barman from Bar Soho told me: `In this pub we leave it up to the individual to think for themselves. It's not our job to tell people what they should or should not wear.' Nevertheless, the fact that there's a growing number of pubs operating a hat ban at all reveals much about the overwhelming Culture of Unfreedom in the UK. It's not simply the property of a crudely authoritarian government like New Labour, but something that influences all aspects of society.

So the government hasn't made wearing hats in pubs illegal (yet), nor have the authorities adopted the logo of Eighties one-hit-wonders Men Without Hats and stuck it in all pub windows. But despite the smoking ban, pubs are still relatively unregulated public spaces and so jumpy landlords and bouncers apparently feel the need to issue such daft rules. When such a ban is introduced, even in a few establishments, it invites further and more heavy-handed intervention from the authorities, too. How long before a politician proposes on-the-spot fines for wearing hats `in closed public places'? Making people take their hats off isn't the end of the world - but it fits into a corrosive, creeping process of restricting our freedoms, large and small. One of these days, this endless procession of Looney Tunes restrictions on our liberties will deprive us of any meaningful rights - or as Bugs Bunny might say: `Hat's all, folks!'


Brits getting poorer under socialism

While the average household gross income has climbed over the past decade from 34,796 to 53,835 pounds, people have far less of that money to spend each month after they have paid essential bills. In 1997, when Labour came to power, people were left with 34.5 per cent of their gross income once they had paid taxes, national insurance, mortgage or rent. Now they are left with 32.6 per cent, says a report by uSwitch, a price comparison website.

It is the latest survey to highlight how millions of households have failed to benefit from the strong economy because of rising taxes and escalating bills. Ernst & Young, the accountants, calculated this year that the average family had 838 pounds left to spend each month, compared to 899 four years ago. The uSwitch report makes clear that many household bills have actually risen more modestly than people's salaries, including the monthly, electricity, water and gas bills.

Increases have hit four key areas in the past 10 years. Petrol [gasoline] - often the biggest cost for a family after their housing - has increased by 55 per cent and phone and internet bills have risen 77 per cent as millions more use broadband and mobile phones. The cost of getting on to the housing ladder has more than tripled, but taxes are perhaps the most significant cost. Council tax rose from an average of 688 a year to 1,321 - an increase of 92 per cent, or three times the rate of inflation.

Mike Warburton, one of the City's most senior accountants, said: "The Government can argue that tax rates have not gone up and that they are merely benefiting from people's rising incomes. But a lot of indirect taxes have gone up, especially council tax. This is why pensioners - on fixed incomes - are so badly hit. The squeeze is definitely on." The report from uSwitch comes a week after it emerged that stamp duty had risen by more than 40 per cent in the past year alone, as the Government cashed in on ballooning house prices.

More here

On scientific medicine

When doctors attack alternative medicine or appear sceptical to its much-trumpeted claims, we are often accused of being bigots with closed minds, protecting a closed shop. Nothing could be further from the truth, but it has taken a layman, the late, great John Diamond, to find the words to set the record straight. For that reason, I would like to quote from his posthumously published book Snake Oil and other Preoccupations (1). Diamond wrote: `I am not an academic and this is not an academic book, even though the facts I list in it have a perfectly good scientific basis to them but when it comes to human motivation I am working blind. I can only guess why most people seem to prefer the unproven to the proven, the anecdotal to the rigorously demonstrated, and the so-called natural to the scientific.' There is much within that passage on the nature of proof, the nature of the scientific method, and the use and abuse of anecdotal evidence.

The alternative practitioner can trace his roots back to Galen in the second century, and a metaphysical belief system based on the balance of natural humours. For example, Galen believed that breast cancer was due to an excess of black bile (melancholia). Inductive support for this belief came from the observation that breast cancer was more common in post-menopausal women than pre-menopausal women, and this was thought to be because the menstrual flux in pre-menopausal women got rid of the putative excess of black bile. The therapeutic consequences of this belief therefore were purgation and venesection (bloodletting). The inductive `proof' that this approach worked were the anecdotes about women with breast cancer who were treated by purgation and venesection, and who lived for several years after diagnosis. Those who died were the victims of the blood-letter who didn't have the courage of his convictions, or the patient herself who lacked the constitutional vigour to sustain prolonged bloodletting.

There is a neo-Galenic doctrine, based on the view that breast cancer is indeed due to an imbalance of nature, only substituting energy fields for the natural humours. According to this view, to restore perfect health you have to restore the balance of these metaphysical energy fields. This might be achieved by acupuncture balancing out the yin and the yang, homeopathy (simularis simulabum curantur), or strange balancing diets.

The Gerson diet, in particular, is very fashionable. In fact, one of my patients, seeking to improve my education, gave me a book describing this approach (2). The first half of the book formulates the hypothesis why this strange diet should improve the balance of the immune system, and the second half of the book consisted of 50 anecdotes of patients with cancer, who were only given six months to live by the medical profession, and who took to the diet and lived for a long time.

The trouble with that kind of evidence is that although we know the numerator (50) we don't know the denominator - for example, 50 out of 1,000 cases treated by neglect could indeed live for many years while the indolent disease progresses on the chest wall. Furthermore, from the evidence available in the book, some of the diagnoses were a little bit shaky and the author neglects to mention whether or not these patients receive conventional treatment at the same time as the magic diet. Finally, I know of no oncologist who gives a patient six months to live. We may say that the median survival for a group with advanced cancer is six months, but among this group certain individuals may lie at extremes of survival. These individuals are the substance of the anecdote.

Perhaps I should leave the last word on this subject to Robert Parks, author of the wonderful book Voodoo Science. Parks wrote: `Alternative seems to define a culture rather than a field of medicine - a culture that is not scientifically demanding. It is a culture in which ancient accretions are given more weight than biological science and anecdotes are preferred over clinical trials. Alternative therapies steadfastly resist change often for centuries or even millennia, unaffected by scientific advances in the understanding of physiology or disease.' (3) If that is the case, then who are the bigots and the ones with the closed minds?

Deductive logic and the randomised controlled trial

The alternative to alternative medicine should be scientific medicine, not `orthodoxy'. By science I mean the application of deductive logic. The deductive approach starts with the formulation of the hypothesis, but for a start the hypothesis must be rational in its explanation of the disease process or therapeutic intervention. By `rational' I mean built upon the growth of knowledge of human biology and physiology from the past 100 years or so, without invoking magic or metaphysical principles.

Even so, the new hypothesis is still perceived as a fictional account of reality and subjected to rigorous test by the design of experiments challenging the new theory with the `hazard of refutation'. These experiments in medical or surgical therapeutics must have control groups treated by observation, placebo or `best available therapy'. Without the control group, we merely have a series of anecdotal reports. What I have just described is in fact a randomised controlled trial.

Breast cancer and the randomised controlled trial

As I have mentioned, up until the eighteenth century, if breast cancer was treated at all it was treated according to the principles of Galen. It wasn't until the mid-nineteenth century that it became widely accepted that cancer was a disease of cellular pathology originating within the breast and spreading centrifugally along the lymphatic system. The therapeutic consequence of this belief led surgeons to embark on radical surgery that involved removing the breast and all the regional lymphatics. It was left to William Halsted in the 1890s to refine the operation into the classic radical mastectomy, with the intention of ridding the body of the primary cancer and its lymph node secondaries. Sadly, the only support for this radical treatment was anecdotal. If the patient survived it was due to the success of the surgeon. If the patient died it was either because the patient came too late or the surgeon lacked the courage of his convictions to complete a truly radical operation.

It was only when Dr Bernard Fisher in the 1960s challenged the conceptual model of the disease that progress started to be made. In other words an antithesis was constructed to challenge the prevailing dogma. Fisher taught that contrary to popular belief, breast cancer cells spread throughout the body through the venous drainage of the breast, and at the time of clinical presentation of the disease, the majority of breast cancers were in fact systemic disorders. If that was indeed the case then there are two therapeutic consequences. Firstly, that radical surgery is shutting the stable door after the horse has bolted. Therefore the role of local therapy is local control, which would equally well be achieved by breast-conserving techniques such as lumpectomy and radiotherapy. The second therapeutic corollary is that if indeed the disease is systemic at the time of diagnosis, then the only way to improve cure rates is through chemotherapy or hormone therapy.

However, the greatness of Dr Fisher, ably supported by surgical acolytes all around the world, was not simply to accept a new set of beliefs in place of an old set of beliefs, but to challenge the new paradigm using deductive logic: in other words, through randomised controlled trials. One of the great success stories of modern medicine has been the painstaking series of randomised controlled trials in the management of early breast cancer over the past 30 years. We now know with extreme confidence that breast conservation is a safe alternative to radical mastectomy; although not in itself improving cure rates, it greatly enhances the patient's quality of life. We also know with extreme confidence that treatment using either endocrine or cytotoxic regimens will improve survival. The final demonstration of that truth has been the dramatic fall in breast cancer mortality in the UK and North America since 1985, following the first publication of the world overview of trials (4).

Using breast cancer as an example, we can demonstrate that the philosophy of science that underpins the randomised controlled trials has led to the dramatic improvement in length of life and quality of life for women inflicted with this dread disease. However, this isn't the end of the story, as new biological hypotheses are being generated with new therapeutic consequences, all of which will be tested in the randomised controlled trial, which is now accepted as the most scientific and ethical way of conducting medicine in times of uncertainty.

The impact of government interference

For both political and humane reasons, governments of all persuasions like to meddle in this process and add guidelines, targets and unwelcome advice on top of our carefully collected evidence. Two examples from the recent past illustrate the dangerous law of unintended consequences when well-meaning meddling is applied on top of clinical science. The first is teaching the practice of breast self-examination (BSE) and the second, applying the two-week target for the urgent diagnosis of cases suspected of having breast cancer.

BSE is superficially attractive in making it the responsibility of women themselves to `catch their breast cancers early' and thus reduce breast cancer mortality. It's a good theory and was introduced as policy in many countries, and also provides an excuse for the women's magazines to publish photographs of beautiful young women fondling their own breasts (which in itself gives out the wrong message that breast cancer is a disease of young women). However, the important point to note is that the advice is based on an assumption - not on evidence. Over the past 10 years, three large randomised controlled trials have compared the outcomes of women who have been intensively trained in BSE with a matched population of women left to their own devices. The outcomes of all three studies were counterintuitive. There was no difference in breast cancer mortality, but those women practising BSE were twice as likely to experience false alarms and unnecessary surgery. This prompted the Canadian Medical Association to issue a warning against the practice!

A more recent example is the two-week rule. Primary care doctors in the NHS were advised to prioritise women with breast symptoms as urgent or not urgent. Those in the former group had to be seen within two weeks and the rest could take their turn. Note the two false assumptions in these guidelines: a) breast cancer is an emergency and even a few weeks can affect outcome; and b) women with breast symptoms atypical of breast cancer can happily wait for up to 12 weeks. Pretty much as predicted, the law of unintended consequences kicked in. So many worried-well pushy middle-class women were seen as emergencies, and so many cancers appeared in the non-urgent group that the net result was a greater delay in cancers being diagnosed than before (6).

Finally, I wish to illustrate the extreme folly of the two-week target for seeing patients suspected of cancer, with an anecdote about a patient I saw recently. The patient who attended my NHS clinic was a charming and sensible woman in her early fifties, with a family history of breast cancer. Three weeks before, she had seen her GP complaining of passing bright red blood at stool. He referred her urgently under the two-week `target' rule to the colo-rectal clinic. The referral was flagged up by some clerical officer in the audit department and the clock started its countdown. Since the colo-rectal clinics are overwhelmed with patients with lower bowel symptoms, nurse-led clinics were set up to take the pressure off the specialist surgeons. The nurse ticked the boxes and the patient was referred for colonoscopy. This examination showed haemorrhoids (piles), the commonest cause of bleeding at stool, and no signs of cancer. Her next appointment followed soon afterwards and she had a CT scan of her abdomen and chest. This was reported as showing a secondary cancer in her right lung. She was then referred for positron emitting tomography, which suggested that she might have cancer in her right breast not her right lung. Note that at no time had anyone actually examined her.

By the time she came to see me she was a confused nervous wreck. After taking a careful history I asked her to disrobe and sit up on the couch. One glance was enough to confirm the breast cancer from the dimple in the lower outer quadrant on the right side. Palpation and biopsy confirmed the diagnosis. After counselling at length she was booked for the next vacant slot on the operating list, which was just over two weeks off. She went off satisfied, but the audit office was not. Apparently we were in breach of the two-week target for cancer.

So in the end, all these delays and unnecessary investigations wasted about 3,000 pounds, and caused substantial anxiety for the patient - and yet they passed the two-week target rule. At the point when the patient is diagnosed and treatment ordered, the computer finds that targets have not been met. This upside-down logic shows the unintended consequences of ill-considered and non-evidence-based political interference.


I hope those examples illustrate the dangers of government intervention in the practice of evidence-based medicine. This is what I choose to describe as ignorance-based interference (IBI). Other examples of IBI include so-called `patient's choice', censoring the right of the National Institute for Clinical Excellence (NICE) to evaluate alternative medicine, and the constant `re-disorganisation' of the NHS (7). My call to the government is this: provide us with the tools to practice evidence-based medicine and then please leave us alone.


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