Angry Doctor

Tuesday, July 29, 2008

Dumb kids spread AIDS

angry doc missed this story in the papers yesterday:

Specially for Normal stream
New Aids prevention scheme to target ‘high-risk’ students

A NEW programme to stop the spread of Aids and other sexually-transmitted infections (STI) among youth here is being drawn up by the authorities — but what is different this time is that the programme is specifically targetted at students in the Normal stream, who have been identified by counsellors working with youth as being at “high risk” of contracting such diseases.

According to details in a recent government tender posted on the GeBIZ website, the class-based component of the programme will be customised to meet the needs of students from the Normal Academic and Normal Technical streams. The change, says the tender, is based on feedback from teachers and students. The new scheme is expected to reach schools in November or December.

The programme will also equip students with the skills to delay engaging in sexual intercourse, as well as issues related to self-esteem, handling peer pressure, teen pregnancy, abortion and contraception. Currently, the Health Promotion Board (HPB) has a general STI/Aids prevention programme for all Secondary 3 students. Observers say this may be the first time that a major health prevention programme here is being targetted based on an education-linked criteria.

Replying to queries, a HPB spokesperson told Today that the health board recognises there is no “one-size-fits-all” approach and this special programme is “part of HPB’s ongoing process to constantly upgrade and improve programmes targetted at youth.”

Several groups that work closely with youth support this pro-active approach. In fact, one group even suggested that the HPB design a similarly targetted prevention programme for younger children, extending to those in primary school.

Ms Hema Gurnani, the programme director at Wings Counselling Centre, which offers medical and psychiatric consultation to youth here, said that the rising number of youth here contracting HIV show clearly that current prevention programmes “are not as effective as they should have been.” Sexually transmitted infections among teenagers are rising on average by 3 per cent to 5 per cent annually, with more than 800 infected last year, according to the Department of STI Control.

“The high risk group are the normal students. I can identify that,” said Ms Sheena Jebal, the chief executive and founder of NuLife Care and Counselling, which according to its website, deals largely with youth-at-risk, school drop outs and ‘late bloomers’. Noting that proper guidance is required for these “academically challenged” students, Ms Jebal warned that they were often unaware of the serious consequences of their sexual conduct as they may lack knowledge about these infections.

Hence the need for a customised programme to ensure different students can relate to the dangers of Aids and Stis, said Ms Theresa Soon, assistant manager at the Action for Aids/DSC Clinic. “For instance, in a Special Assistance Plan (SAP) school you can be very academic, very technical, but for normal students you should use simpler terms and language,” she said. By customising lessons, instructors can use different approaches, and relavant case studies to engage the students, she added.

While not wanting to generalise or stigmatise, Ms Jebal said that in her experience, normal stream students are at higher risk as many come from dysfunctional families, with little or no support. “Thus (they) tend to go astray,” have low self-esteem and “it is a form of escapism for them when they turn to unprotected sex.” While normal stream students are the “high-risk group”, Ms Jebel said, express stream students are not exempt. She suggested customised programmes for these students too.

The AFA/DSC Clinic has seen an increase in youth – across all levels – seeking help, from 775 in 2006 to 820 last year. One factor that some counsellors say has increased the vulnerability of some youth to STI or Aids is family background, said Ms Soon, citing examples those students parents are often busy at work or do not speak to their children on these ‘taboo’ topics.

STI is also usually treated as a science subject so most students end up viewing STI as viruses or bacteria, and fail to see how it relates to their everyday life, said project coordinator at the DSC Clinic Mr Tan Ee Han. Some teachers also cover the topic quickly so students learn little. They also have difficulty broaching the topic with their boyfriend or girlfriend, he added.

However, beyond customising class-based lessons, Ms Jebal also feels that form teachers or school counsellors should zero in on students most likely to be engaging in sex and pay them greater attention as a mass programme does “not have much impact”.

Ms Gurnani from Wings Counselling Centre, one of the first organisations to start a sexuality programme in the primary schools, also suggested that HPB look at a separate preventive programme for these younger students. “It is a concern that younger children below 12 are involved in sex and parents are ignorant of the reality,” she said.

angry doc doesn't think this planned programme is discriminating in a bad way. It is, of course, discriminating, but at face value it seems a reasonable thing to do: you want to pitch your programme at a level which your audience can understand. It doesn't mean that a less academic programme will reduce the incidences of STI and HIV/AIDS in Normal Stream pupils, since we can't be sure that a lack of knowledge is what accounts for the rates to begin with, but it sounds like it's worth a try. The problem, as always when we target a specific group in health education, is with unintended stigmatisation of the very group of people we are trying to help.

What angry doc finds interesting about the article is the observation made by Ms Jebel:

normal stream students are at higher risk as many come from
dysfunctional families, with little or no support. “Thus (they) tend to go
astray,” have low self-esteem and “it is a form of escapism for them when they
turn to unprotected sex.”

In other words, Ms Jebel recognises the fact that what puts certain young people at "high risk" is not their academic abilities or the lack thereof, but something else which we cannot easily recognise in a glance, something we do not officially label people by. But because we lack the will to classify people by their 'true' risk factor, we turn to convenient labels like what stream a child is in to tailor our health education programmes. Use of such 'surrogate markers' are sometimes necessary in healthcare, but we must always recognise that correlations do not always point to a cause-and-effect relationships. If we fail to remember this fact, we risk ending up believing that dumb kids spread AIDS, or that Malay kids are dumb.


Friday, July 25, 2008

Two wrongs make a right

A bit of good news to cheer angry doc up at the end of a long week:

Stricter guidelines for aesthetic procedure
By Hasnita A Majid, Channel NewsAsia

SINGAPORE: From November 1, doctors will need to seek approval before offering aesthetic procedures like mesotherapy and skin whitening to patients, and they can only do so as clinical trials.

These doctors need to get the go ahead from the Singapore Medical Council's newly established Aesthetic Practice Oversight Committee if the procedure is carried out at a clinic, or from the Research Ethics Committee if the procedure is done in a hospital.

These guidelines - drawn up by the Academy of Medicine, College of Family Physicians and the Singapore Medical Council - are aimed at enhancing the safety of patients.

Currently, there is no formal training for doctors performing such procedures and injuries sustained during such treatments are often unreported.

Proper documentation must also be carried out for the purpose of audit. If the outcome of such procedures is poor, then the treatment will be terminated. In addition, such procedures can only be carried out as a last resort, after all other conventional treatments have been tried.

Current aesthetic procedures will be grouped into two lists - A and B. List A contains procedures which are generally proven and considered acceptable by experts.

This list includes non-invasive procedures such as chemical peels and microdermabrations, and minimally invasive treatment such as Botox and filler injections.

Invasive procedures, such as eyelid alteration and breast enhancement or reduction, will have to be performed only by doctors who have the appropriate surgical training.

List B reflects aesthetic treatment and procedures that are currently regarded as having low or very low level of evidence and not considered well- established.

Mesotherapy - a procedure to burn fats away through injections - and skin whitening injections fall under List B. So are carboxytherapy, stem cell activator protein for skin rejuvenation, negative pressure procedures and mechanised massage.

For treatments under List B, doctors are no longer allowed to advertise them and those who wish to perform procedures under List B must register themselves with the Singapore Medical Council.

The guidelines also require doctors who wish to perform procedures that do not fall under either list to obtain approval from the Singapore Medical Council.

Any doctor who does not comply with the guidelines will be taken to task and liable for any disciplinary action. The guidelines were drawn up after several months of consultation with professionals in the industry.

Professor Ho Lai Yun from the Academy of Medicine said: "At the moment, it's a cowboy type of practice... when the guidelines come up, we give the doctors some guidelines.

"Of course, the patients will know who are the people they can go to, what are the procedures available to them, what they can expect from the procedures. So, to a greater extent, they are protected."

It's nice to see that as a result of the aesthetic "turf war", we now have a policy that recognises the importance of evidence when it comes to treatment.

For once, truth is not a casualty of war.


Thursday, July 24, 2008

Cow Dung 8

More news from Ye Olde Country:

(emphasis mine)

$2.2m for brain injury after detox diet

THE family of a British woman who suffered brain damage following a “detox” diet warned on Tuesday of the dangers of such regimes.

Ms Dawn Page received more than £800,000 ($2.2 million) in an out-of-court settlement after a diet in which she increased her water intake and decreased the amount of salt she consumed.

The 52-year-old mother of two, from Faringdon, southern England, began vomiting severely soon after starting the “hydration diet” in 2001. She was left with epilepsy and a brain injury affecting her memory, concentration and ability to speak normally.

She gave up her job as conference organiser and her family says she will not work again.

Ms Barbara Nash, the nutritional therapist she consulted, allegedly assured her that the vomiting was part of the detoxification process. Ms Nash, who calls herself a “nutritional therapist and life coach”, denies liability in the case and insists she was not guilty of substandard practice.

But Ms Page’s husband, Geoff, 54, yesterday warned of the dangers of “fad-type” diets. He said his wife was not obese but had just wanted to lose some weight.

“Just days after she started the hydration diet, she began to feel unwell ... Things went from bad to worse ... Her life has been seriously affected, perhaps ruined,” he said.

Geoff said his wife was advised to drink at least four pints of water a day. The therapy was known as the Amazing Hydration Diet. He added: “It’s important people understand how dangerous diets like these are.”

Ms Nash has a diploma from the College of Natural Nutrition, based in Tiverton, Devon.

Plexus Law, the firm that represented her in court, said all allegations of substandard practice made in the litigation would continue to be “firmly denied” and the settlement agreed was less than half the total claimed.


Dr Crippen blogged about this earlier this month.

angry doc is surprised that Ms Page's husband was not 'gagged' as part of the legal settlement. He is not, however, surprised by the fact that he took the settlement - £800,000 is a considerable sum of money, and there was no guarantee that he would have won the case had it gone to trial.

As angry doc understands it, in medical malpractice law, a doctor is "not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art". If the same principle applies to practitioners of alternative medicine, then it may not matter how little evidence of efficacy or safety there is behind a mode of therapy - as long as most other practitioners are doing the same thing, it's OK.

This legal principle, known as the Bolam Test, has traditionally relied on the opinion of the 'professional body'. It is therefore important for us to look at the body of knowledge and evidence on which each professional body builds it opinion on.

Are there any good reasons or evidence to suggest that drinking four pints of water a day while restricting salt intake is a safe and effective way to lose weight? Or that "[w]ater and natural salt, when combined together, give you everything your body and mind need"? Or that homeopathy works? For that matter, how do you know if the treatment your 'western' doctor is giving you is evidence-based?

angry doc thinks all 'consumers' of healthcare need become more critical and discerning, and develop the habit of requiring evidence from their healthcare providers. It's not only about making sure that your money is well-spent - it is also about safety.

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'My name is Dr Dabic... '

... but call me David'.

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Tuesday, July 22, 2008

How much is that kidney in the window? 2

They say that one week is a very long time in politics...

New hope for kidney patients?
Age limit of 60 raised,swap registry to be set up:
Tan Hui Leng

HE HAD said ideas such as organ trading should not be rejected just because they are controversial, and the Health Minister is considering “financial compensation” — but not before pushing altruistic organ donations to their “maximum potential” with two new initiatives.

Mr Khaw Boon Wan told Parliament the Ministry of Health (MOH) will first lift the “arbitrary” age limit of 60 years on cadaveric donors and set up a national registry to swap living donors whose tissues do not match the intended recipient with another pair or pairs in a similar situation.

More controversially, he said that the MOH is studying whether to encourage third parties to promote altruistic organ donations by providing financial compensation to donors and their families after the transplants have taken place.

Mr Khaw revealed that he occasionally receives requests from some charities and religious bodies to compensate donors “in kind and in cash ... to acknowledge their altruistic act”. But these third parties worry that this may be construed as organ-trading.

The MOH is studying if the idea, which Mr Khaw would encourage, can be feasibly implemented and if the Human Organ Transplant Act (Hota) needs to be amended.

This was a possible example of “good complementary solutions” when the demand for kidneys are not fully met.

“By forcing ourselves to think about unconventional approaches, we may be able to find an acceptable way to allow a meaningful compensation for some living, unrelated kidney donors, without breaching ethical principles and hurting the sensitivities of others,” said Mr Khaw.

In the meantime, the two new measures, which are expected to be implemented within a year, should boost transplant rates from 50 to 70 per cent in the medium term. This means seven out of 10 on the waiting list will be able to get a donation on a yearly basis.

The age limit that had been set under Hota “has unnecessarily put many organs to waste”, said Mr Khaw, who noted that many countries do not have an age limit.

“The suitability of the organ depends on its condition, rather than the age of the donor. The condition of the kidney can be determined by the transplant doctor.”

On living donor transplants, the MOH will facilitate “pair-matched donations” through the set-up of a live-donor registry. This would require proactive coordination to overcome incompatible donations in order to “meet the altruistic wishes of such living-related donors”.

Hota will be amended where required for the two initiatives.

In response to questions by MPs Halimah Yacob (Jurong GRC) and Lam Pin Min (Ang Mo Kio GRC) on the current organ trading case, Mr Khaw answered generally that “a black market of illegal transplants flourishes in many countries and not just in Asia”.

The result — and the reality — is “poor clinical results for many patients and exploitation of many in poverty”.

He added: “We must therefore take a practical approach. Criminalising organ trading does not eliminate it. But it merely breeds a black market with the middleman creaming off the bulk of the compensation which the grateful patient is willing to offer the donor.”

The MOH will take a sympathetic approach to the plight of exploited donors and the “basic instinct of kidney failure patients to try to live” even as it takes action against those involved in illicit organ trading.

Currently, three Singaporeans are being charged for breaching Hota. The trio appeared in the Subordinate Courts yesterday for a closed-door mention in chambers, and will next appear on Aug 1 for a pre-trial conference.

angry doc should be excited about these developments, but he is still suffering from the after-effects of a the rough weekend.

He hopes he can contribute to the discussion more actively later this week.

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Monday, July 21, 2008

Rough Weekend

(source: lucid tv)

angry doc had a rough weekend. Please excuse him for the lack of commentary in today's post.

How much is that doctor in the window? 10

News from Ye Olde Country...

The more lives they save, the more they earn
But performance-pegged pay means surgeons could spurn high-risk operations

LONDON — :In radical plans being drawn up by hospitals across Britain, National Health Service (NHS) surgeons are to be paid bonuses based on the number of lives they save.

For the first time, they will receive performance-related pay according to the results they achieve on the operating table, with levels dependent on how well patients recover.

Leading surgeons, critical of the proposals, said that this could deter doctors from taking on higher-risk patients — such as the frail and elderly— and from carrying out complex operations.

Patients’ groups said those facing surgery would be “horrified” by the proposals, and questioned why doctors should be paid a premium for fulfilling their basic duty.

The Government intends to link doctors’ merit payments to patient mortality and other measures, such as rates of infection, readmission and post-operative mobility.

Britain’s largest hospital trust is already preparing a pilot scheme that will link surgical outcomes to bonus payments. Imperial College Healthcare Trust has begun measuring the performance of its doctors, and Prof Stephen Smith, its chief executive, said that it intended to use the data on mortality, infection and the cost-effectiveness of its consultant teams to reward the best-performing doctors.

The pilot scheme will concentrate on rewarding surgeons for the degree of mobility that patients enjoy after their operations.

The London trust’s own surgeons admitted to risks if the plans were not handled carefully. A consultant, Mr Justin Vale, who is the programme group director for surgery and cancer, said: “We have got to ensure we don’t create a dangerous precedent, that the surgeons doing the big, complex cases aren’t discouraged from taking them on.”

Mr Ben Bridgewater, of the Society for Cardiothoracic Surgeons, said that he would be very cautious of using data on a consultant and his team as the basis for bonus payouts.

“Surgeons would be quite anxious about using these measures in this way,” he said. “They wouldn’t be confident the data is robust enough, or that it reflects the mix of patients and activity that they deal with. I don’t think surgeons will buy into this.”

Ms Katherine Murphy, from the Patients Association, said: “Patients will be horrified. There is a real risk that the most complicated cases, as well as the patients in real need, will be forgotten because they don’t get the best outcomes. Doctors already have a duty to provide high-quality care. I think a good doctor would be insulted by the idea that they will only do their best on the operating table if there is extra money in it.”

In the north-west part of Britain, 24 trusts are piloting a scheme that will pay bonuses to the 20 per cent of hospitals with the lowest rates of deaths, complications and other clinical standards linked to five common operations. Managers will be able to pass the bonuses on to doctors and nurses.

In December, the Government will publish a set of indicators to measure the quality of treatment at every NHS hospital.



Friday, July 18, 2008

Cow Dung 7

Ever wonder why Cialis is shaped the way it is?

(emphasis mine)

Almonds, a natural cure for 'half-past six'?

THE Mind Your Body supplement on July 9 carried an article 'Natural Viagra?' in which it was speculated that 'watermelons may be a natural Viagra'.

This at least is the view expressed by 'a United States researcher' and printed alongside are differing views of others who are labelled as 'sceptics'.

I fear scant justice is done to readers, who will surely end up confused by these contradictory opinions.

Decades ago, a doctor recommended almond nuts to combat 'erectile dysfunction', as it has come to be known nowadays. The Singlish description of this condition is 'half-past six'.

Viagra came to be manufactured many decades later, and is composed of chemicals whose side effects on the body have yet to be properly assessed, whereas almonds are totally 'organic' (the pun is wholly accidental).

In fact, it is almost traditional among (East) Indians, of whom the worthy doctor was one, to take a glass of milk daily, in which crushed or powdered almonds and some strands of saffron have been boiled. 'Badaam milk' (almond milkshake), as it is known, is a popular drink among Indians, with reputedly aphrodisiac virtues.

Almonds are widely believed to be a key ingredient or supplement to vitality, as well as a wholly natural pick-me-up.

Narayana Narayana

Pretty standard cow-dung arguments as usual. angry doc is no longer surprised that the ST Forum editor chooses to publish letter promoting unsubstatiated health claims; had the same claims been made by someone actually selling a product, he would have run afoul of the law.

But what harm can come from a letter promoting something as innocent as the almond nut?

Well, plenty, angry doc thinks.

First of all, Mr Narayana tells a blatant lie with his assertion that Viagra is a "chemical" "whose side effects on the body have yet to be properly assessed". Leaving aside the fact that almost everything we put inside our mouths are "chemicals" - from plain water to any active compounds almonds might contain - Viagra had been subjected to rigourous testing prior to its approval by FDA, and continues to be monitored in the post-marketing phase. All that is not to say that there are no known or serious side-effects with taking Viagra, but to say that it has not been "properly assessed" is to tell a plain lie, and undermines the efforts of all those who work to ensure that drugs that doctors prescribe to patients are tested and regulated.

Secondly, the publication of such letters promoting remedies based on cow-dung thinking indirectly promotes cow-dung thinking in the public. What the public needs, and deserves from ST Forum, is an editor who is willing and able to apply and require critical thinking in doing his or her job.

Finally, beliefs in such unsubstatiated health claims can sometimes be exploited by unscrupulous people to sell supposedly "natural" products which are in reality either useless, or at the very worst hazardous.

Belief in the properties of walnut is partly behind the recent fatalities caused by Power 1 Walnut.

Will this be the consequence of believing in the virtues of almond?

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Wednesday, July 16, 2008

Better, Longer, Cheaper

Pick two.

(emphasis mine)

Playing catch up
Issue at hand: How to improve outcomes while containing costs

EVEN as medical science progresses — contributing to longer life spans — the ways health outcomes are measured have yet to catch up.

Life expectancy has been used as a measure for years, but “there is no quality of life perspective to this, just a number”, said Mr Dean Westcott, a member of the Association of Chartered Certified Accountants (ACCA) governing council at an “ideas forum” yesterday.

There is a need for “more sophisticated measures” of healthcare outcomes, said the finance director and deputy chief executive of a healthcare trust in the United Kingdom.

This was one of the key issues raised at the ACCA session for academics and industry leaders, including from the public and private hospitals.

The roundtable discussion also identified another overarching issue — of how to improve healthcare outcomes while containing costs, which have been rising in recent years, outstripping GDP by two percentage points every year in the Organisation for Economic Co-operation and Development countries.

This is not sustainable, Mr Westcott told Today, adding: “Studies have estimated that by 2020, healthcare expenditure will triple.”

The question to grapple with is how to decide the most efficient level of expenditure.

According to Mr Westcott, the general consensus on efficient resource allocation is a focus on lifestyle and prevention and to have “equity of access”.

This means having people enter the healthcare system early, before conditions become chronic and cause complications.

But political will, patience and foresight is required for this to happen as results may take years, even generations, to realise.

Singapore is one of three cities with different healthcare financing models — alongside London and Washington — sharing its perspective on the issue of healthcare costs versus outcomes, which will shape an ACCA-commissioned study on global healthcare.

Mr Westcott, who moderated yesterday’s forum, said: “We anticipate that it will be used to inform healthcare policy decision making.”

We've discussed this topic before here, and angry doc's view is this:

The fact is people in their last year of life consume a disproportionate percentage of a nation's healthcare spending, ... every life eventually comes (or in this case ends) with a price-tag. In fact, there is also a case to be made that the older this 'last year of life' is, the greater the amount of spending in the last hospitalisation will be.


As long as we see longevity and good health as desirable commodities, healthcare spending will continue to rise.

The question then is not perhaps on how much to spend, but when to stop spending.

Reading between the lines, it seems that Mr Westcott shares a similar view when he said "there is no quality of life perspective to [life expectancy], just a number", and that there is a need for “more sophisticated measures” of healthcare outcomes.

Come on now, people.

We all know what needs to be done here, don't we?


Monday, July 14, 2008

Medicine and Morality 2

It looks like the ministry of health is willing to study the option of "legalising organ trading in Singapore" after all.

However, it seems that morality is still a consideration for the health minister when he said:

"If you allow trading, currently those who volunteer for the family members or under HOTA, they may then object and say, 'since you can now buy organs, then why should I volunteer to save my family members?'

Why should they indeed? After all, the aim of the transplant is to improve the patient's health, and not to give his relatives a chance to demonstrate their selflessness.

While the chances of finding a matching donor amongst relatives are higher, with the proper selection process and follow-up, transplants from living unrelated donor (whether a spouse or a 'seller') have good long-term results. Patients whose relatives are unable or unwilling to donate their kidneys must look to unrelated donors, living or dead.

More resistant to the idea, however, is the Singapore Medical Association:

SMA against legalising human organ trade
By Valarie Tan, Channel NewsAsia

SINGAPORE: Doctors in Singapore are split over whether human organ trading should be legalised in the country.

A medical ethics debate over the issue has been re-ignited in recent weeks after five persons were prosecuted over illegal kidney-for-sale deals.

For the Singapore Medical Association (SMA), after much internal discussion, it has come to a collective stand that it does not support legalised organ trading.

In response to queries by Channel NewsAsia, the SMA said that besides the medical risks to the organ seller, there is too much potential for abuse of disadvantaged individuals. It is also difficult to make the process transparent and equitable.

The SMA represents two-thirds of doctors and specialists from the private and public hospitals in Singapore. It said emails and discussions were exchanged over the past two weeks, and its 16-member council held an emergency meeting on Saturday to deliberate.

Dr Tan Sze Wee, a spokesperson for the SMA, said: "Within the council itself, we had a debate and the views were split down the middle as well, between those who felt that there could be a possibility of legalising it because of the good it can bring to the recipients - the quality of life, saving a life.

"However, the other point that we still felt was very important is - how are you able to administer it? The devil is in the details."

But with the number of kidney patients growing in Singapore, the SMA said the call to legalise organ trade may grow stronger in the future.

Dr Tan said: "It may, but the voice for legalising organ trade is not something that's a current topic. It has been around since the beginning of time. But we recognise the fact that the human body itself cannot be treated like a commercial property that it can be traded with a value.

"There are medical complications, short-term and long-term. The short-term risks are... the operation itself, anaesthesia for both the recipient and the donor in the surgery.

"Long-term risks are: if you have two kidneys and you donated one... what do you do when something happens to you? Some accident or some illness, then you've got no back-up plan. And, it's well documented that organ donors do suffer from, what we call, donor remorse."

The SMA was not able to comment on the implications on the growing number of patients getting transplants from non-related donors in Singapore. In 2007, 33 patients received kidneys from non-related living donors compared to 19 in 2006 and six in 2005.

However, the SMA does support the suggestion to have transplant patients screened at the Health Ministry level, instead of just leaving it to a hospital ethics committee.

Dr Tan said: "I think that's definitely better. I think that is something for the ministry to work out to ensure that such cases do not repeat again.

"There are so many things that can possibly happen that even if you want to think about ways to put safeguards in to prevent illegal activities from happening, there are a lot of details that have to be worked out."


angry doc wonders how the SMA, with it's membership "split down the middle", could choose to make a stand on the issue; essentially, SMA is making the stand of one-third of doctors in Singapore its official stand.

What is worse are the reasons SMA had given for opposing the legalisation of organ trading.

Had the SMA stuck to the moral argument of "the human body itself cannot be treated like a commercial property that it can be traded with a value", angry doc would have respected that, even if he did not agree with it.

However, Dr Tan showed that the SMA's position may stem more from a lack of moral courage than moral conviction when he argued:"There are so many things that can possibly happen that even if you want to think about ways to put safeguards in to prevent illegal activities from happening, there are a lot of details that have to be worked out," and when he asked "how are you able to administer it? The devil is in the details.".

In other word, faced with the complexity of the task of regulating organ trading, SMA has chosen to object to it than to participate in looking at whether we can create a system that will minimise unfairness to parties concerned. How noble.

Dr Tan also could not help throwing in some flawed arguments against organ trading:

"There are medical complications... The short-term risks are... the operation itself, anaesthesia for both the recipient and the donor in the surgery."

This is not a valid argument because all surgeries which are performed under anaesthesia carry anaesthetic risks. More importantly, risks to donor and recipient are similar whether they are related or unrelated. If the SMA's position is (as angry doc's is) that it is unethical to subject a person (the donor) to anaesthetic risks for a surgery that does not benefit him physically, then should it not similarly object to living-related transplant?
"...if you have two kidneys and you donated one... what do you do when something happens to you? Some accident or some illness, then you've got no back-up plan."

Here Dr Tan chose to appeal to fear, instead of providing the public with actual risks to donors in the form of statistics to allow them to make their own decisions on whether or not donation constitutes an unacceptable risk.

How many donors actually require renal replacement therapy due to trauma to their single remianing kidneys? How many donors go into chronic renal failure due to diseases which would not have affected both kidneys equally had he not donated one anyway?

If Dr Tan is concerned with the lack of a "back-up plan" for donors, will it not be better to provide for their interests by having a regulated system that covers their medical follow-up and costs, and which makes more organs available?

angry doc feels that Dr Tan had not represented the position of the half of its membership which do not oppose legalisation of organ trading adequately or fairly; by making a moral stand on the issue and backing it up with flawed arguments, Dr Tan gives the impression that the SMA is willing to impose the morality of some doctors over the public, and that its members either think that the public are too dumb to see through the flawed arguments, or that its members themselves are, when in reality it may be more a case of SMA being unwilling to tackle the issues of organ trading head-on.

The fast pace of progress in medical science means that we are now often faced with treatment options which are not available a generation ago - options which morality we, as a society, have yet to come to an agreement on. angry doc feels that while doctors are individually entitled to their own moral viewpoints, and as a profession our ethics allow us to choose whether to participate or refrain from participation in a certain type of treatment, as advocates for our patients our role when it comes to a medical issue should be one of active participation through education and provision of information. We must not try to abdicate our responsibilty while using the morality of a portion of doctors as an excuse.

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Sunday, July 13, 2008

"The History of Creationist Thought"

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Thursday, July 10, 2008

It's just a THEORY, stupid 2

Reader zhanzhao made the comment in the previous post that evolution "cannot be observed under lab conditions, vaildated [sic] nor replicated".

He is partly correct.

Evolution has been observed and validated in a lab condition, but curiously, it could not be replicated*.

Leng Hiong covered this interesting experiment briefly earlier. If you want a more detailed account but do not want to read the original paper, Bad Science has a post on an exchange between the investigator and a critic which covers some of the details of the experiment.

Both are well-worth a read.

* - Edit: On closer reading of the posts I realise that the citrate+ trait does "re-evolve" in the 'ancestors' of the populations of E. coli that evolved the trait, but not in the other 11 populations in the study, so in a sense evolution has been observed to be replicated. I apologise for the error.

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Wednesday, July 09, 2008

It's just a THEORY, stupid

Rather unexpectedly, the discussion on the "exorcism" trial has spilled over to the topic of evolution.

Since angry doc is no expert in evolution, he has decided to seek help from fellow Clearthought blogger Leng Hiong to tell us why the theory of evolution is a "theory", and not a "fact".

Do have a read.


Saturday, July 05, 2008

It still isn't an exorcism, stupid

More on the "exorcism" trial.

(emphasis mine)

Lawyer questions priest’s logic
Plaintiff’s lawyer accuses priest in Novena trial of evading question
Ansley Ng

IF A political party held a rally without a police permit and were quizzed about it, would the party be right to argue no rally had taken place because no permit was issued?

That was the analogy lawyer R S Bajwa made to explain that a “prayer session” two Catholic priests had carried out for his client Amutha Valli Krishnan four years ago was a violent exorcism rite that lacked authorisation from the archbishop and the church.

Calling the hypothetical reasoning “stupid”, the lawyer added: “I said you did all these acts; you said no. I asked why; you said you did not get permission from the bishop.”

Father Jacob Ong, the priest in the witness box on Friday, reiterated what another priest, Father Simon Tan, had said earlier — that no exorcism was carried out on Madam Amutha Valli. “The whole package must be followed. It cannot be set as an exorcism,” Father Ong said.

For an exorcism to be performed, the archbishop — the faith’s head in Singapore — has to give permission and appoint a priest to carry out the rites. An investigation also has to be carried out before the ritual.

Father Ong is among nine parties being sued by Mdm Amutha Valli over an alleged botched exorcism attempt at the Novena hurch in 2004. She claims the incident left her traumatised and unable to work.

“It doesn’t help you,” Mr Bajwa said in reply to Father Ong. “The substance is what we are interested in, not the form.”

As Mdm Amutha Valli — who at times spoke in a voice that sounded like a low male voice — struggled harder during the alleged exorcism, the group prayed harder, the lawyer said. At one “momentous” point in time, Father Tan “engaged” the spirit by talking to it, said Mr Bajwa.

Using the same line of questioning he served on Father Tan, the lawyer asserted that Father Ong and his co-defendants had pinned Mdm Amutha Valli onto the floor in a room at the church and strangled her, thinking she had been possessed.

Father Ong disagreed, saying the group merely held a “gentle” prayer session to “protect” her even as the 52-year-old woman was screaming and writhing on the floor.

Mr Bajwa also asked the priest if he had seen people who had been possessed. The priest said he had seen instances where people displayed signs of possession and cited four examples, including people who spoke in voices that don’t sound like their own while trembling.

“Would you agree that the signs displayed by the plaintiff were more severe than these examples?” asked Mr Bajwa.

The priest replied he could not tell, prompting the lawyer to accuse him of avoiding the question.

The hearing continues on Monday

At least now someone has stated the obvious: it doesn't matter whether it was an exorcism or a "prayer of deliverance" - what matters is what happened and whether what happened caused the plaintiff to become ill. (Then again, maybe even that will not matter if the defendants can prove that the plaintiff is not actually ill.)

angry doc wonders if the persons involved in the trial would have spent so much time over terminology if one of the parties involved was not a religious organisation with an organised belief system on the existence of spirits and demons, possession by such entities, and on how to cast them out. Had the trial involved alleged alien mind-control and an attempt to break the control, the judge would perhaps not have been so indulgent.

The priests seem to be caught in a no-win situaion. To prove that they did nothing wrong, they need to show that what they did for the plaintiff was appropriate, and that means proving possession by spirit or demon, something which they cannot do. On the other hand, their argument is that the plaintiff is actually faking her illness, which if they manage to prove, will mean admission that their assessment of her condition on that day was wrong, and that the subsequent intervention (be it an exorcism or a "prayer of deliverance") was also wrong.

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Thursday, July 03, 2008

It's not an exorcism, stupid‏

More on the court case which we first looked at almost a year ago:

Was it exorcism?
Priest denies accusation, says it was salvation
Leong Wee Keat

IN THE witness box, he sang hymns and showed how she had apparently slithered like a snake.

Yesterday, one of the two priests accused of performing a forced exorcism at the Novena Church about four years ago — gave his version of what transpired — the first time the High Court was hearing the defence’s story.

Father Simon Tan denied that the incident on Aug 10, 2004, was an exorcism. Instead, he called it a prayer of deliverance for plaintiff Amutha Valli Krishnan.

Cross-examined by her lawyer, Mr R S Bajwa, Father Tan also said the archbishop’s permission must be sought and a thorough investigation conducted before any exorcism could be carried out.

While he did not think she was crazy, what this Catholic priest saw that night was definitely “not usual behaviour”. Father Tan, 44, claimed it “never occurred to him” that Madam Amutha Valli was possessed or was a mental patient, and that he was “just answering the family’s request to pray over her”.

Father Tan is among nine parties — including the church, Father Jacob Ong and six church helpers — being sued by Mdm Amutha Valli over an alleged forced exorcism attempt. She claims the incident left her traumatised and unable to work.

Father Tan, who was ordained in 1998, testified that exorcism is “hardly practised” and has “never heard” of it in his ministry.

But, Mr Bajwa asked: Couldn’t the priest have stopped the prayer session as Mdm Amutha Valli was strangling herself and assuming the voice of a dead soldier?

Father Tan said he did not understand why she had manifested violent behaviour, but there were at least three occasions she snapped out of her trance.

Her family had brought her to the church to be prayed over so that she could get some comfort, added the priest.

While he did not advise the family of any risks involved, Father Tan disagreed with Mr Bajwa’s question if “safeguards” should have been in place. The priest said there were cancer sufferers, for example, who turned to the church and religion for prayers and comfort.

But wouldn’t he stop to think if a devotee had prior medical history?

Father Tan disagreed, saying the incident arose from “a simple request from her family to pray”.

He added: “If I start using my mind, be self-conscious of the risks, a lot of Catholics would suffer. I would become neurotic if I’m afraid of being sued.”

The hearing continues.

angry doc wonders if the presiding judge even cares whether what happened on the day was an exorcism or a "prayer of deliverance"; what matters more would be what exactly did the priests and other church staff do for or to the plaintiff that day, and whether those things led to the illness that the plaintiff claims to be suffering from.

Whether it was an exorcism (which it technically was not) or a "prayer of deliverance", there is probably no doubt in anyone's mind that Father Tan acted out of good faith and in good faith (and had assumed the same of the plaintiff that day!). However, under the law (the Penal Code to be precise, which presumably does not strictly apply to this case), "[n]othing is said to be done or believed in good faith which is done or believed without due care and attention".

What that means, angry doc believes, is that the law recognises that while we may help someone in need with good intentions, the person being helped may sometimes actually suffer harm from our intervention. The law seeks to protect those whom we help by requiring that the person rendering the help has good reasons to believe that his actions will help that person, and at the same time not cause harm to that person.

So does Father Tan have good reasons to believe that a "prayer of deliverance" was the correct thing to administer to the plaintiff for the state which she was in on that day?

Of course, to even decide whether or not a "prayer of deliverance" was the right thing to administer, one would have had to decide what the plaintiff was suffering from.

It seems that the Father had provisionally excluded "possession" and "mental illness", and that working diagnosis was "not usual behaviour".

Was that a reasonable conclusion to make?

Is a "prayer of deliverance" a reasonable intervention for "not usual behaviour"? How often does it work? What are the risks and benefits of a "prayer of deliverance" for "not usual behaviour"? Surely that is relevant, because the plaintiff is claiming that she suffered harm from the process.

Unfortunately it doesn't seem that the lawyers pursued that line of questioning. angry doc doubts that if the lawyers had asked Father Tan those questions he would have been able to answer with figures and statistics, because it is likely that those questions never crossed the good Father's mind - or as Father Tan put it himself:

“If I start using my mind, be self-conscious of the risks, a lot of Catholics would suffer. I would become neurotic if I’m afraid of being sued.”

Poor Father Tan. Maybe that was the problem to begin with.

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Homeopathy beats Acupuncture

Sterile water injection for pain relief? Is it evidence-based? Are there like placebo-controlled trials to prove that it works?

Well, yes. Several, in fact. It's apparently a commonly-practised non-pharmacological (and non-homeopathic) method of pain relief in some places.

But if water is the substance being tested, what does one use for a placebo?

Well, believe it or not, saline*.

Thanks to Medscape, angry doc learns something new every day...

* - Yes, I know it makes sense. Don't write in.