Undercover Care: The Abuse Exposed

Watch this on the BBC: "Undercover Care: The Abuse Exposed". And then reflect on the failings of the Care Quality Commission in this case* and whether they could detect or act to investigate any similar case in the future**:

"A specialist residential hospital in Bristol is being investigated by police after secret filming by BBC Panorama found a pattern of serious abuse.

"During five weeks spent filming undercover, Panorama's reporter captured footage of some of the hospital's most vulnerable patients being repeatedly pinned down, slapped, dragged into showers while fully clothed, taunted and teased.

"The programme decided to secret film after being approached by a former senior nurse at the hospital who was deeply concerned about the behaviour of some of the support workers caring for patients.

"Mr Bryan reported his concerns to both management at Winterbourne View and to the government regulator, the Care Quality Commission (CQC) but his complaint was not taken up.
Ian Biggs, regional direction of the CQC for the southwest, said an opportunity to prevent abuse was missed when Mr Bryan's complaints were not investigated."

* Headed by the former chief executive of West Midlands strategic health authority (SHA) who presided over the Mid Staffordshire scandal lest we forget, so she has relevant expertise in this area!

** Still, at least the unit concerned probably had policies for dealing with dog mess, so it can't have been all bad as far as the CQC are concerned.

Nostalgia

From BBC 4 - 'Movin' On Up: Pop Hits from 1991' - a look at the early nineties Indie/Dance crossover scene. I have a particular weakness for 'Can You Dig It?' by the Mock Turtles.

Panorama and migration

Vaguely watching this dull Panorama, sensationalised and tabloid as all Parorama documentaries have become, about population pressures in the UK, concentrating, it will not surprise you, on blaming it all on immigrants: "there's a widespread belief that migrants get preferential access to housing...[insert glaring lack of any attempt to actually answer whether this is the case or not]"

But I was struck by the figure of immigration benefiting the UK by "only 60p per person per week" (contrast this with Migration Watch's previous figure of 4p) apparently sourced from this Lords report (although I can't find that specific figure), and contrasted with the 'misleading' government use of the benefit to GDP of immigration.:

The total size of an economy is not an index of prosperity. The focus of analysis should rather be on the effects of immigration on income per head of the resident population.

The report makes an interesting point about how while in the short term migrants fill vacancies in he economy but in the long term the economy proportionately expands (increasing vacancies again). But in emphasising the raw monetary figure of per capita increase in GDP I think it is equally if not more misleading than the government approach. In particular I take issue with their rejection of the argument that a large proportion of the UK population are not of working age, whereas new immigrants are largely young or working age such that they swell the (shrinking) working age population which contributes (proportionately) the majority to the economy and state coffers - so that dividing immigrant contributions over the whole population is unfair because they are largely not addding to the dead wood of the non-working populace (who actually cause most of the costs to the state). The report says:

Arguments in favour of high immigration to defuse the “pensions time bomb” do not stand up to scrutiny as they are based on the unreasonable assumption of a static retirement age as people live longer and ignore the fact that, in time, immigrants too will grow old and draw pensions. Increasing the retirement age, as the Government has done, is the only viable approach to resolving this issue...

 Lord Turner argued that as people live longer, it is reasonable to assume that the extra years of life are divided between working years and retirement so as to keep roughly stable the proportions of life spent working and retired. Under this assumption, half of the projected increase in the dependency ratio disappears, when compared with the simplistic case in which the retirement age stays unchanged.

First of all I'd like to make clear that it is generally considered that for every additional year of life expectancy you can expect at best 6 months of relative health and 6 months of ill-health such that the policy of incrementally increasing the retirement age with life expectancy is basically aiming to work the populace until they are sick and to erode the few years of healthy retirement they might otherwise have expected*. It is also worth noting that immigrants can have a tendency to return to their country of origin after a few years. So while it is true that increasing the working age population will increase the number of retired people eventually (although to a lesser extent in the first generation due to decreased life expectancy compared to the UK population as a whole) it is still more sustainable in the short term than increasing the retirement age until people are being worked right to their death beds (in order to pay for the current older generation's nice early retirements at 60-65yrs old with over 10 yrs of life expectancy). 

In this vein, if we're going to talk about how much immigrants add in 'per capita GDP' we have to compare them to other members of the population - old people or the unemployed for instance - what do they cost in per capita GDP?  Averaging over a homogeneous UK 'indigenous' population is completely misleading because compared to significant proportions of the UK population immigrants use much lower poroportions of national expenditure.  The question should be how many 'indigenous' people does each immigrant support? And 'per capita GDP' can't answer this.

To look at it another way, if we consider a British person who contributes exactly the average per capita GDP to the country, are they having zero effect on the country or a net benefit? According to the 'per capita GDP' measure of economic contribution they are giving nothing to the country - despite working, paying taxes etc. - whereas common sense shows that they are helping to pay for those people who are a net cost to GDP (the economically inactive like the old, the young, the sick, the unemployed).


* Another gift from 'The Most Selfish Generation'

Gotta persecute me some Christians

Amusingly partisan documentary on the 'persecution' of Christians. Damn those 'New Atheists', still at it. Of course I have some form, after all, 'ultimately you are either for or against baby Jesus', oh why do I hate the baby Jesus so?

"It is true that a number of muslims have failed to win the right to wear the full veil at work, but even so..."

Call of Duty: Modern Warfare 2

Off to get the new Call of Duty today (because at heart I'm just a little boy). I was watching the review of it last night on Newsnight Review - it was rather bizarre, while I haven't seen the controversial level that's got so much coverage, most* of the reviewers (who also appeared to be unfamiliar with computer games in general) seemed to object to the overall violence (in a first person modern warfare shooter!) because, as far as I could tell, killing people 'is like bad, m'kay?'

Now I totally agree that killing people is bad, but I'm pretty unclear how computer simulated violence has quite the same moral ramifications as actually killing someone**, particularly when our reviewers didn't extend their objection to all those films about killing people, or films with other morally dubious things like rape, or infidelity***, or just being mean.

I suppose you could make a more specific objection that in computer games you are taking on an active role rather than being a passive observer - this seems to have been behind some of the objections to the controversial level in Modern Warfare 2 - but the reviewers didn't actually seem to make that point. But if that was the direction you were going, arguing that taking part in simulated violence has some negative impact on an individuals moral integrity (does that include paintball, laser quest, archery even?) then why should we not extrapolate that out to other immoral acts as I've intimated above? And why are actors not faced with such opprobium for playing roles in films about, for example, incest - roles where they are getting a whole lot more involved that someone bashing the plastic controller on their games console?

At one point Paul Morley bemoans that there has been this divide between gamers and non-gamers with the latter dismissing the condemnation of the former because they 'just don't get it' - sadly I think the latter are correct, non-gamers seem to be condemning something they don't understand and fear because of that - Morley seems to be making a pretty penny watching and writing about X-Factor at the moment, I wonder does he feel morally degraded through his complicity in that nasty piece of voyeurism?

ETA: This is hilarious:

Video games depicting war have come under fire for flouting laws governing armed conflicts.

Human rights groups played various games to see if any broke humanitarian laws that govern what is a war crime.

The study condemned the games for violating laws by letting players kill civilians, torture captives and wantonly destroy homes and buildings.

Hmm, perhaps the authors ought to concentrate on having real life violations of humanitarin law prosecuted first, before defending out pixelated friends.


* Admittedly one of them thought it was great

** You also have to wonder whether the thousands of people being blown to bits in wars around the world might be worthier of our defence before we start helping out the little pixelated pretend people from being killed by by teenage boys

Grow your own drugs

No, not the good kind, there is a new TV series being heavily trailed, by that title:

...James Wong, a 27-year-old ethnobotanist (a scientist who studies how people use plants), wants to change our minds. He passionately believes that safe, natural remedies can be made from the everyday plants you find in hedgerows, the back garden or local garden centres.

...In Malaysia, where Wong grew up, everyone treated themselves with natural remedies. Food, too, was used as medicine...

The problem, Wong believes, is that there's a big cultural dividing line between conventional medicine, which is thought of as effective, proven and serious, and herbal medicine, which has the reputation of being a bit flaky.

But, as Wong says, up to 50 per cent of over-the-counter medicines are based on chemicals that were first isolated from plants. "Aspirin, for example, is made from the same chemicals that were first isolated from willow, which has been used for thousands of years as a painkiller.

...Wong, who trained at the Royal Botanical Gardens at Kew, is quick to point out that the herbs and plants he recommends all have a long history of use and no record of toxicity.

So, presumably aspirin, which is derived from plants after all, has 'no record of toxicity'? This doesn't bode well.

Embarrassing illnesses

Who the hell is so embarrassed about their illness that they don't see their GP about it for years, yet will go on TV to show their ulcerated genitalia and other yucky bits as soon as Channel 4 roll into town?

The doctor who hears voices

Watching this at the moment - know how it ends (of course the average length of a manic episode is about 6 months anyway) - might share my thoughts later.

UPDATE
So, not a bad film (certainly better and more interesting than Poppy Shakespeare), a bit of background: It's the story of a junior doctor who has a past diagnosis of bipolar disorder (manic-depression) and appears to be having a psychotic episode (including suicidal command hallucinations). She's naturally not allowed to work as a doctor and is currently trying to get over the episode and back to work, who she needs to convince she is safe and taking her medication, but clinical psychologist (and recovered schizophrenic) Rufus May is helping her to recover without medication (May gives the background here). Naturally they don't show the real doctor but instead she is played by an actor, Rufus May apparently plays himself.

Her symptoms don't appear to include overactivity or other typical manic symptoms (more like a mixed episode maybe), they seem to be mainly hallucinations of some sort (it is never established if they are true hallucinations), mostly a single voice talking to her, and some fairly transitory delusions, including persecution, reference, and grandiosity. She also appears to have a history of self harm and there is some family bereavement (but no other social or family information). May himself seems a rather volatile and 'interesting' personality (I don't think I'll say any more than that).

After over six months of May's therapy (they're never clear what that exactly involves but from his comments I take it that it is somewhat psychodynamic, perhaps a bit cognitive, see here) which seems to involves her getting worse rather than better (she starts off with mostly the hallucinations) she fools the hospital review board and returns to work as a doctor. They imply that they have some kind of breakthrough where she 'discovers' the voice is someone who bullied her at school, and that she is then able to deal with the voice (although she seemed to deal with it ok before the breakthrough) and she still has the voice at the end (this is potentially less worrying than it sounds, I've met a few patients recovered from psychotic illness with residual voices that I'd be happy practising medicine).

Obviously you can't make a diagnosis from a dramatisation, but you'd want to consider a personality disorder, affective disorders like depression, bipolar, and schizoaffective disorder, and obviously schizophrenia. It is difficult to see what the current episode is supposed to be, she isn't very manic, her mood seemed low, but she was certainly somewhat psychotic with some grandiosity.

So how revolutionary is this treatment from Rufus May then? Well the average length of a depressive or manic episode is six months, so I'd say taking over 6 months for remission plus continuing residual symptoms is not exactly spectacular, particularly given that we know both depression and psychotic symptoms will respond to CBT. I suppose she wasn't hospitalised, and the psychiatrist (Trevor Turner) in the piece indicates that he would probably have sectioned someone with these symptoms and refusing medication if necessary to bring them into hospital*. On the other hand, Rufus May sails rather close to the wind with her safety, and looks pretty worried at one point, whereas most psychiatrists would be held legally liable for that sort of behaviour, which is why they are rather more cautious about suicide risk (May says at one point, 'she's only a risk to herself' - which is really rather the point, although she also says the voices tell her to kill others, and I don't think I'd have been too happy being her patient while she had her delusion about having a cure for AIDS, or that a fish tank was an ECG).

Plenty of doctors have bipolar disorder so there's no reason to think she can't function as one, the real question is whether she's going to relapse - you'll expect most bipolar people to relapse at some point, on average every couple of years. A good psychoeducation programme will help you to identify early signs of relapse early enough to take action (e.g. sorting out your sleep to avoid a manic episode) so let's hope she's been given these skills by May. Drug prophylaxis has a proven benefit in reducing relapse, and residual symptoms are a poor prognostic indicator, let's hope she's ok, but until we know she's 'cured' (which will take years) you can't really conclude anything.


* Actually I think if he'd actually seen her, rather than just heard a hypothetical description by a TV producer, he would have seen that she actually had pretty good control and insight, resisting the voice and delusions, and managing to hold down a job as a care assistant. But she'd probably have benefitted from engagement with local mental health services with crisis team involvement checking up on her everyday and access to formal psychological therapy rather than being managed at arms length by someone in Bradford.

Poppy Shakespeare

WTF? Adapted from the novel (which I haven't read) which received nothing but plaudits, and it looks like the film will be treated the same, but it seemed to me like the sort of work I'd expect from a middle class re-imagining of 'One Flew Over the Cuckoo's Nest' for today (sane woman driven mad by the 'system') supplemented with, at most, a cursory familiarity with modern psychiatric services (although apparently the author, Clare Allen, has a fair bit of experience of mental health services).

Frankly it didn't resemble any psychiatric service provision I've ever seen, from secure unit to day services - most strikingly the patients were bizarre one-dimensional cut-outs with no sense of humanity or even mundanity (psychiatric patients are everyday people after all). Sam Wollaston in the Guardian also notices:

"...a fine performance from Anna Maxwell Martin in the lead - the only convincing "dribbler", actually; the others overdo it, and look like actors pretending to be mentally ill."

Many reviewers talk about how this was some unsettling commentary on the modern British mental health system, on mental illness itself, or on 'institutional structures' - since most of the plot depended on unbelievable and contrived devices (e.g. a pathetically engineered 'Catch 22' where you must 'prove' you are mad to get 'MAD money' to fund an appeal to prove you aren't mad, and get you discharged) I think this is a pretty credulous reading.

The one negative review by Andy Boyd on Amazon says something similar:

"How this book was ever published is hard,very hard to imagine. Allan seems to have had in her mind another "Cuckoo`s Nest" She is no Ken Kesey.

A little research would have gone a long way.I am a Mental Health Project Worker and a user of services.I find her descriptions of mental health issues at the very least down right insulting with one dimensional characters of no substance whatsoever.

She cannot describe the reality of mental ill health,which,I agree has many moments of humour,empathy and understanding comes with it.

I suggest Ms Allan writes about something she remotely understands.This book is a total turn off she cannot explain the benefits system properly and continues a rant all through the book about "MAD" money - her reference to Disability Living Allowance which is irritating and downright wrong!!

At a time when we are trying to de-stigmatise mental illness and raise awareness of it Ms Allan only serves to describe a mental health system that does not exist - get a reality check!!!"

And another reader responds to him in the way I imagine the author and the book/film's fans would:

"The author, from what I have read, has a great deal of personal experience of the mental health system. I appreciate your stance, but this is a work of fiction."

But this is just a combined appeal to authority with an 'it's just fiction' get-out clause - because the book can't both be a searing indictment of psychiatric services and also a completely innacurate made-up story*, I submit it is the latter, and as such tells us fuck all.

"...Allan has given us something indigestibly, potently true"

My arse.



[* it has obviously occured to me that there is supposed to be a 'blurring of reality' thing going on - with the most implausible events not 'real', but that weakens it even more as both a story and a reflection on psychiatry - a much more interesting tale could have been told from the perspective, for instance, of the brushes with psychiatric services of someone diagnosed with a personality disorder, where there are real and interesting questions of both the patient's skewed perceptions of what is going on, and the attitudes and actions of mental health services to these people]

We only made up 20% of the results, it is still significant at p<.05!

Working nights I'm not following the Policy Exchange/Newsnight spat, but the comments on this Comment is Free thread were fascinating. A good number of people seem to be arguing that if you can prove that 5% of the Mosques actually had forged evidence that they were selling extremist material then the conclusion is that we should continue to take the Policy Exchange report at face value and just revise down the estimate of the number selling extremist material from 25% to 20%.

Perhaps it is just me, but when a study has methodology as demonstrably suspect as this I'm inclined to reject the whole thing. We are not supposed to give the benefit of the doubt, even to think tanks. Imagine when a scientific fraud is perpetrated the journal concerned doesn't publish a retraction of the study but rather withdraws only those figures or results that have been demonstrated to be fabricated, and stands resolutely behind the rest.

Dispatches on abortion II

Something's come up so I haven't got time to comprehensively go through this, but actually the programme was pretty similar to the Mail article, which I've already talked about.

The programme basically followed the standard bad science documentary by having 'amazing new research' that everyone has ignored/has only just come to light that is actually nothing of the sort. It also ended on a rather jarring partisan note with first the anti-abortionists making their claims, Sunny Anand is allowed to say something like 'the balance of scientific evidence shows that foetuses feel pain at 20 weeks and below', despite there being no evidence that this is the case, and only a single pro-choice advocate is presented, who says nothing about the science at all, (and no sign of Stuart Derbyshire who is the only scientist who appears to argue the scientific consensus earlier in the documentary)

The primary flaw was to imply that they had discovered brand new research from Sunny Anand that shed light on the question of foetal pain - in fact he has been making the same arguments for years, and has no scientific evidence to support him (he doesn't even do research in this area). There's some nice euphemistic talk about the 'top bit of the brain' that people think supserves emotional and other higher cognitive processes - somehow I think most people would understand reference to the 'cerebral cortex', but then that would probably draw out the contrast with the claim (based on currently no evidence at all) that the subplate mediates foetal pain, and then dies off in development, and the cortex then takes over pain perception (so foetuss have a special bit of the brain that only lasts a few months but is designed so they can feel pain whilst in the womb, but that then largely disappears to be replaced by a whole other neural system to serve the same purpose when the baby is actually born). So there is no reason to believe that this is the case, unless you happen to need to believe that there must be a mechanism that underlies foetal pain because you already believe that foetuses feel pain - can you say post hoc rationalisation?

They also rather slyly try to imply that this 'new evidence' (that isn't) was ignored by the RCOG panel when they came up with their advice on the issue (that's right, not just magic new science, but also suppressed science - these documentaries write themselves!) There was also constant reference to bringing the limit down to 12 weeks (as in many places in Europe) without any explanation as to why this age might be chosen given the discussions around viability or pain at 20-24wks. They showed what they called a foetus that was 'at least' 24 weeks old but implied that this was representative of foetuses earlier than 24wks, which I thought was rather misleading.

There was one amusing moment where the interviewer points out to Prof. Campbell with his 4D images of foetuses that they aren't really smiling or crying because they don't have the requisite neural connections, and he pauses for a long time and essentially says, 'yes, but look at them, they're cute, this'll stop people having abortions', scientific debate-tastic. There was also an interesting point made that before about 22 weeks the lung is too immature to function so that would represent something of a hard limit on foetal viability for the forseeable future.

UPDATE
The Royal College of Obstetricians and Gynaecologists (RCOG) respond to the dispatches programme:

"We are unaware of the work of Dr Anand or any other work that contradicts the
basic findings of the review. Perhaps Dr Anand could direct us to the work he is
referring to. "

Heh, what an understated way to call bullshit.

A few other reactions, mostly of the 'in last night's TV' variety, such as in the Times:

"Abortion: What We Need to Know was “what we needed to know” if we were as keen, as the programme obviously was, about advocating that the time limit on having an abortion should be reduced from 26 weeks to 20 weeks."

and the Guardian:

"Like most viewers, I think, the arguments and spokespeople marshalled by the documentary team in Dispatches: Abortion - What We Need to Know (Channel 4)have probably been largely obliterated by the footage (filmed by US anti-abortion activists) of bloody foetal sacs being pulled from vaginas and dozens of tiny, jellied crimson limbs spread before us, a massacre of the innocents laid out on a hospital towel. It was shocking as an image, and arguably shocking as an inclusion in a documentary purporting to be an unbiased look at the controversies surrounding the issue of terminations before MPs gather to discuss possible changes to the law in a few months' time. "

UPDATE 2
Thanks to an anonymous commenter, Stuart Derbyshire responds to the documentary:

"The programme was a dreadful mess. Anyone who was hoping to be enlightened on the question of fetal pain will have been disappointed. If American researcher Sunny Anand has new evidence demonstrating that pain is possible due to activation in the brainstem, which fetuses possess, I would have liked to see it. But that evidence was not forthcoming in the programme.
...
I didn’t fare any better in my appearance, being reduced to stating that nothing in the past 10 years changes the view that the biologically necessary components for pain are not in place until about 26 weeks’ gestation. My arguments about the importance of the cortex relative to the brainstem and the necessity to understand pain as a conceptually driven, rather than a biologically driven, experience were all cut.
...

Ultimately the Dispatches programme was flat-out biased. In the online forum discussion after the show, Davies claimed the show was not biased because all the comments were balanced by objections from the experts being interviewed (8). The problem, however, is that Davies’ voiceover controlled the show and she was evidently keen to get the law changed. Towards the end, Dr Evan Harris, a UK Liberal Democrat MP who is a member of the Science and Technology Committee currently considering abortion legislation, was berated by Davies for having already made his mind up about viability and fetal pain (9). Harris defended himself well, but in case you missed the point about him having already made his mind up, the programme makers helpfully cut in Sunny Anand to explain that there are ‘none so blind as he who refuses to see’."

Dispatches on abortion

I intend to use this post to keep track of the coverage that the Dispatches report on abortion is going to generate, as well as the Commons enquiry:

Sounds like Deborah Davies has been doing the rounds, promoting her Dispatches programme.

The Today programme had a discussion between Prof. Campbell (who wants to reduce the age limit for abortion) and David Steel (who also wants to lower the limit) so was obviously very balanced - and, contrary to gimpy, the debate was again framed in terms of viability and 4D ultrasound images. To the credit of the interviewer she at least challenged the scientific merit of 4D ultrasound over the emotive aspects. Also reported by the Mail on Sunday.

Yesterday's news contained the revelation that members of anti-abortion campaign groups have been asked to declare their affiliation when they give evidence to the Commons committee:

"Evan Harris MP, the Liberal Democrats' science spokesperson, said:
"This inquiry is specifically about the scientific evidence not moral or religious arguments and our witnesses need to be evidence-led not ideologically or theologically driven. The CMF [Christian Medical Fellowship] risk undermining the inquiry by getting people called as expert scientific witnesses when they are not."

Two witnesses who will give evidence today, Chris Richards, a paediatrician and honorary clinical lecturer at Newcastle University, and John Wyatt, a neonatal paediatrician at University College London, are members of CMF, but did not disclose that on their original submission."

As with a number of outlets the Observer focuses on the Dispatches programme showing footage of abortion, as well covering calls for nurses to perform early stage abortions.

The Telegraph reports that:

"A row has broken out over the 24-week time limit for abortion after conflicting scientific studies clashed over the survival rate for babies born at that stage.

Epicure 2, a nationwide report from a Government-linked organisation, revealed that the chance of survival lay between 10 and 15 per cent, according to evidence submitted to the Science and Technology Committee at the House of Commons.

But other evidence given to the committee - which will make the decision whether to recommend a change in the limit - contradicted the findings and claimed survival rates were as high as 42 per cent at 23 weeks and 72 per cent at 24 weeks gestation."

The Guardian reports that the RCOG (in line with the BMA) want to keep the 24wk limit and abolish the need for 2 doctors to approve.

The Times reports that:

"Marie Stopes International, which carries out 60,000 abortions a year at its nine clinics in Britain, says the 24-week limit ought to lowered to 20 weeks because of evidence that the foetus is “potentially viable” before 24 weeks. This shift in policy leaves opponents to a reduction in the time limit, who include Tony Blair and many Labour MPs, increasingly isolated.

"As part of any reform, however, Marie Stopes would also want women to be eligible for abortions up to 12 weeks without having to gain permission from doctors — two must now give their written consent for the procedure. It says women seeking a termination between 13 and 20 weeks should have the signature of one doctor."

The Telegraph likewise, also saying:

"A Telegraph poll last month showed that most
people, including a large majority of women, agree with him that the upper limit
should be cut back. It found that 55 per cent of voters of both sexes would
welcome new laws reducing the time limit."

According to Channel 4:

"The survey by Marie Stopes International (MSI), the leading abortion services provider outside of the NHS, found 52% of GPs want women to be able to request an abortion in the first 14 weeks of pregnancy.
Currently, two doctors must give written consent before a woman can go ahead with an abortion.
The poll of 1,000 registered GPs across Britain found 80% described themselves as broadly "pro-choice", while 20% said they were "anti abortion".
Almost two thirds of doctors (65%) thought the current 24-week time limit for abortion should be reduced. Of those who wanted a reduction, 62% agreed with a 20 to 23-week limit.
Three in five doctors (62%) said current guidelines allowing under-16s to have an abortion ithout the consent or knowledge of their parents were satisfactory.Findings from the survey will feature in Channel 4's Dispatches: Abortion: What We Need To Know, which screens on Wednesday. The documentary will also look at scientific research into foetal pain and pre-term infant viability."

---------------------------------------------------
There have been some fairly divergent figures reported for foetal viability at 20 weeks plus (25% have a normal life according to the Today programme, whereas I reported 30% survival at 24 weeks) so I though I'd have a look at the literature (these are articles listed as related by medline to the Belgian source I used in the previous post, and where the abstract looked relevant, and I could get data for 24 weeks or less, and it came up before I got bored - remember that infants born premature may conceivably be less viable than aborted infants at the same age):

Belgium 1999-2000 (previously mentioned study): 22 wks 0%; 24wks 29% survival to discharge (hmm, looks like it may include some late abortions though!)
22-23 wks 7%; 24wks 35% of NICU admissions discharged alive
24 wks 4% NICU admissions survive with no major sequelae of prematurity ('intact')

German tertiary centres 1999-2003: 22-23 wks 52%; 24 wks 70% survival to 8 days
22-23wks 56-76%; 24 wks 74-88% survive to discharge with life support at all gestational ages 36% have no major complications of prematurity

Japan 1991-2000: 22wks 40%; 24wks 50% 1 year survival
22wks 0%; 24wks 74% free of handicap

Canada 1996-1997: 22wks 15%; 24 wks 54% survival to discharge

Austria 1999-2001: 22wks 17%; 24wks 57% 1 year survival
22wks 6%; 24 wks 14% survival with no major complications

This gives us a range of survival at 22 wks of 0%-17%, for 24wks 29%-88%; and a range of disability at 22wks of 94%-100%, 24wks 26%-96%.

The abortion debate II

Further to this, Channel 4's Dispatches has a programme called Abortion - What We Need to Know on Wednesday at 10.40pm. There's a preview in the Daily Mail (!) by the Dispatches reporter Deborah Davies***:

"In next Wednesday's Dispatches programme on Channel 4 we reveal the deep concern among many doctors who, like Dr Argent, work within the abortion service and are passionate supporters of a woman's right to choose, yet who still believe the current law urgently needs changing."

Sounds like we have a nice sensationalist documentary, but we'll have to see*:

"In the mid-Nineties, partly in response to growing public concern about such issues, he RCOG put together a panel of experts who came to the reassuring conclusion that the foetus couldn't feel pain until 26 weeks gestation - safely beyond the abortion time limit.
...
But we found disturbing research in America that directly contradicts this established view. It came from Dr Sunny Anand, who has a distinguished record in helping to prove that very young babies can feel pain. When he was based at Oxford University in the 1980s his work helped to ensure that newborn babies were routinely given pain relief for surgical procedures.
...
He's found similar changes in their hormones and their blood flow, suggesting that foetuses can indeed respond to pain.

Note the distinction between a physiological response to noxious stimuli and feeling pain is elided here.

"He says that while the adult uses the very top section of the brain, the foetus has the first flickerings of sensation in the area below that. Crucially, this part of the brain develops before 26 weeks.

His conclusions could have enormous consequences for the abortion debate. He told Dispatches: "I believe that foetuses can feel pain very likely by 20 weeks of gestation and possibly even earlier.""

I'm not sure how great the consequences of his work are for the abortion debate. In actual fact I can't find any evidence that Anand has done any research in this particular area, rather this follower of guru Sathya Sai Baba has been a high profile advocate for the view that foetuses feel pain in the media**. Presumably he's talking about pain fibre projections to the subplate (rather than the thalamus, which I've never heard anyone claim in any way mediates the feeling of pain). It is highly controversial to say the least to claim that these cells, never previously shown to have any role in pain, and generally believed to have a developmental, but not cognitive role, might mediate foetal pain. As Anand and colleagues said themselves only this year (in the only reference I can find on medline for 'subplate' and 'pain'):

"Connections to the thalamus begin at 14 weeks and are completed by 20 weeks, and thalamocortical connections are present from 13 weeks and are more developed by 26 to 30 weeks. However, it is not possible to measure evoked potentials from the cortex before 29 weeks. Thus, many scientists suggest that it is not until 29 weeks gestational age that there is objective evidence that a peripheral stimulus can cause cortical activation."

There is also further discussion of viability in the article - I wonder if there is a basis for their figures? I wonder how many of the surviving infants could be considered 'intact'?

"Back in July, we filmed a newborn baby named Hope in the neo-natal intensive care unit of Liverpool Women's Hospital. In her incubator, Hope was almost invisible under a pink blanket, surrounded by wires and bleeping monitors.

She had been born at 23 weeks - one week before she could have still been legally aborted. And here she was, three weeks later, still clinging to life with the frailest of grips.

Hope lived for two months, with her parents constantly at her side, before she died. In Britain, modern drugs and high-tech treatment meant she had about a 25 per cent chance of survival - hich would have doubled if she'd been born a week later. The odds were against her from the outset.

But those statistics are changing all the time. In America the chances of her survival would have been better, and what happens over there will inevitably filter through to Britain."

* I'm not confident the way that the reporter for the programme chooses to frame the article. I predict a combination of "but then, Sunny Anand discovered..." and 'he said', 'she said' equivalence of opposing views with no attempt to establish any kind of overview of the scientific consensus. In short, journalists fuck up one more science story, only this time it has repercussions in the real world.

UPDATE
Abortion Review has a good article on the background to this debate.

** Spiked has an interesting article on the partial birth abortion debate in the US, and Anand's role in it:

"...the trials will have a lasting consequence because of multiple damaging testimonies from Dr Kanwaljeet (Sunny) Anand on the issue of fetal pain. The potential for fetal pain was already becoming a common part of the argument against abortion but it is now guaranteed to form a more central role.
...
It was this evidence that enabled Anand to make the following claim during the course of the trial in New York: ‘I can state my opinion to a degree of medical certainty that all fetuses beyond 20 weeks of gestational age will experience severe pain by the partial-birth abortion
procedure.’

But the statement is pure hyperbole and nonsense, for many reasons (12).
...
Anand has made this mistake again and again and again and has now done so to the detriment of women seeking abortion. Distressingly these points were never made at trial, and the Plaintiffs might even have made the situation worse by pointing out that if D&X is painful then D&E must be excruciating. Moreover, in his concluding decision, Judge Casey was able to state that Dr Anand’s testimony went unrebutted by the Plaintiff’s, and provided ‘credible evidence that D&X abortions subject fetuses to severe pain’.

While Anand has done much to advance the clinical treatment of neonates and to preserve early life, he has also done much to confuse the understanding of pain and has now damaged the credibility of medicine. His testimony in California, Nebraska and New York, for which he was paid $450 an hour, plus expenses, by the current US government, was based on an evidently dubious and shaky claim of ‘medical certainty’.

It is understandable and proper for physicians and medical experts to wield their expertise in defence of practices that they believe to enhance clinical care, but it is quite another to wield
expertise against clinical care and in defence of hypothetical and unproven experiences. Unfortunately Anand has long interchanged what he believes with what he can prove and now he has done this in the service of reactionary political objectives.

Anand’s testimony has spawned the ‘Unborn Child Protection Act’, which is a Congressional-sponsored attempt to curtail late abortion on the basis of protecting the fetus from pain (21). Similar attempts to introduce fetal pain legislation have already occurred at the State level. In
2003, for example, Minnesota successfully introduced legislation requiring women to be informed of the possibility of fetal pain when seeking a second-trimester termination (22). The state of Virginia attempted to introduce similar legislation in 2004 but the proposal was defeated (23).

Sponsors of the Unborn Child Protection Act have cited Anand’s testimony and those on the
pro-life side of the debate believe that this legislation will replace the Partial-Birth Abortion Act as the main focus of anti-abortion activity, especially now that George Bush has returned to the White House (24)."

*** Oh dear, looks like Deborah Davies also did the Dispatches report on liver disease which diagnosed liver disease in 50% of people tested using an ultrasound and garnered much press coverage (Metro, Daily Mail, Sun, you know, the quality press). This had me shouting at the TV at the time for its sensationalism and scientific and medical flaws:

"Professor Chris Day, professor of liver medicine at the University of Newcastle, said there was no published study that verified a fibroscan could pick up early signs of disease caused by alcohol.

'In really heavy drinkers about 10% will get liver cirrhosis. The test can only really pick up when the liver is badly damaged – which, if they're picking up half, makes you realise the test must be rubbish.'"

The Verdict

Ok, so the BBC's rape trial dramatisation concluded last night. The football player/selling the story angle was unnecessary and just muddled the case (if you buy their argument that what they were making was an informative documentary). The story is girls meet football players, go back to their room because they can't get food in the bar and have to order room service, one girl leaves and one of the footballers leaves, remaining girl alleges that she was then raped by remaining footballer, then by other footballer returning, and by unnamed third man. Friend of girl tapes her talking about the rape and sells it to a newspaper.

The jurors themselves were a motley crew, Archer, convicted felon, ex-football player Collymore, admitted domestic violence, and advocate of dogging (odd sexual behaviour), Megaman, eventually acquited of inciting his mate to murder someone (the mate went to prison for said murder), Sara Payne whose daughter was abducted and murdered.

I really have to ask just how stupid is Jeffrey Archer? I'd always know he ws a fantasist but the drawling way he delivered his pseudo-profound points was breathtaking. Portillo managed to come out of it better than the rest, it was probably only his IQ keeping them in double figures, the guy from Blur and the entrepeneur also seemed ok.

Megaman and Collymore were never going to convict, probably whatever the evidence, the former because he had been tried three times before being acquitted, and the latter for such great reasons as "footballers are always being accused of rape, but it never comes to court, therefore they don't rape", and "only 5% of rapes are convicted, therefore..." Collymore spent the entire case (ably assisted by Megaman), acting as the defence's representative on the jury, dismissing all evidence and barracking anyone who disagreed with him. I'm told that it is common to have one jurer who refuses to believe in the guilt of anyone, and sometimes another who thinks everyone is guilty, whatever the evidence. Not sure there was a representative of the second group. Collymore and Megaman showed that amusing characteristic people have that when they believe something they think that all evidence supports them and cannot understand that there can be alternative interpretations. There was also some usual "wouldn't have happened to me" type reasoning from a female jury member (think she was in a soap).

The victim having been showed to be lying about being a virgin was also further water muddying and I was surprised by the way the barristers were able to make unsubstantiated claims and insinuations without backing them up ("isn't it always the convent girl types..." was a great line, of course if she'd had a more colourful sexual history that'd also damn her - doesn't seem like there is a woman you can rape without it being her fault). The substance of the arguments, both by the barristers, and in the jury's deliberations, consisted of making up stories, narratives that make sense of the facts available, I guess that's the law for you, very postmodern. The lack of forensic input was disturbing when a fair bit came down to questions of physical injury, and even down to arguments over interpretation of the injuries - you'd think they'd be able to get a pathologist into court with some hard figures.

As to my impressions of the case, there was physical evidence consistent with and suggestive of the allegation, the allegation was plausible, the defendants' stories were inconsistent, I think I'd go for a conviction. But the jury went the other way, essentially their burden of proof cannot be passed unless there is an independent eye witness or admission of guilt. Much was made of the unique nature of rape, where the requirements of reasonable doubt are tested to the extreme: "it is his word against hers". I'm not sure I'm convinced by that reasoning, why isn't theft thought of like that? "Oh, she just gave it to me guvner", it seems to me that the burden of proof has been shifted somehow in raoe trials, and listening to the jurors, that would seem to be their impression, that the woman has to "prove" that the man raped her.

Anyone can concoct a scenario roughly consistent with the facts of the case (see the rough sex defence in "Consent"!) so essentially no rape case can ever be beyond reasonable doubt or "be certain" (which I think was the wording used by the judge, actually harsher than reasonable doubt in my opinion) because there will always be a story given by the defence that could be true. In this case the story wasn't concocted until after the arrest, and after the defendant denied sex at all initially.

Scarily Archer was on the convict side, but then when it went to 9:3 he changed his mind allowing a 10:2 not guilty verdict. But Archer was mostly revelling in the attention and I'm not sure how genuine his belief was (and if it was his belief how valid his change of heart was - to spare the two men another trial despite believing that she was raped by them). The other two guilty verdicts were from two of the more normal individuals Jacqueline Gold (Ann Summers Chief Exec) and 'entrepeneur' Dominic McVey.

As with "Consent" I'm not sure anyone learned anything, and it was a rather unedifying spectacle watching the celebs laughing away during the trial (although they did seem to take it seriously most of the time). Sadly I can see why many women say they wouldn't report a rape - currently it seems to be almost impossible to meet the standard of evidence set by British juries, and at least some of that seems to be due to the assumption that women consent to sex with anyone unless proven otherwise.

Consent?

Watched the Channel 4 docudrama "Consent" last night. Troubling viewing. It took the familiar format of real barristers and judge, ordinary members of the public selected from the electoral role, and actors playing the victim and defendant. Strangely it mostly consisted of a dramatisation of the events (minus the rape scene itself, which was shown at the end), with the trial itself making up a small part of proceedings, and the jury deliberations (which took 3hrs) briefly shown at the end.

The particulars of the case were work colleague acquaintance rape, victim showing bruising on the wrists and clavicle, defence's case that they were engaged in consensual "rough sex", and that the victim was jealous about a promotion given to the defendant.

Personally I was inclined to believe that the guy was guilty - his explanation for the bruising was unconvincing, but the prosecution barrister didn't quiz the defendant too long on how exactly he knew that someone pushing him off was engaging in consensual rough sex rather than just trying to get him off because they didn't want to have sex with him. There were also points where the defendant said things that weren't consistent with the dramatisation (e.g. "I didn't say X", when we saw him say it), which muddied the waters unnecessarily.

As I expected, the jury spent their time arguing off at tangents and justifying their preconceptions with convoluted rationalisations and refusing to entertain the possibility of counterfactuals. I've never served on a jury myself, but I'm told by those that have that this is very much the way that things go - can't say I'm inclined to throw myself at the mercy of a jury of my peers should the need arise (unless I'm clearly guilty - in which case I might get away with it).

Most of the women didn't seem to believe the victim's story because she didn't protest hard enough for their liking (the standard, "I wouldn't have let him do that" stuff), some of the jurors didn't seem to believe that rape was all that traumatic and wouldn't accept that someone could be in shock afterwards and not report it straight away (nicely supporting the proposals that experts give evidence as to the psychological impact of rape; and what would the make jurors think of male rape?). One juror, a crazy looking bloke (who reminded me of Pop from the League of Gentlemen) picked up on the unusual injuries the victim had sustained, which I was surprised the prosecution didn't dwell on - bruising on the right wrist plus bruising on the right clavicle, which the defendant said was due to him supporting his weight (with his right arm!) during sex.

Eventually they come to a 10:2 verdict of not guilty and we're shown the rape scene where it does indeed look like rape.

I was left wondering what it is about rape that leads to such a degree of blaming the victim. There were no discussions of whether or not there was reasonable doubt - something that we're often told is the difficulty in these him vs. her cases. In fact they seemed to have decided he was innocent based mostly on gut instinct.

I know there is a hard core of men who believe that once a woman flirts with them, and certainly if they come home with them, they've pretty much forfeited any right to say no. And the psychology of women blaming the victim to deflect the fear that they could be victims is also understandable. But it seems like there is more to it. I can't help wondering if it is something about the way we think about sex itself, the way it is portrayed as a discrete event. So while kissing is a continuous process, something that you can terminate any time, once you start having sex, and that event seems to begin way before the clothes come off, you somehow don't get to back out - it's too late. Maybe that has got something to do with the way we coyly sidestep around talking about the process of sex, the nitty gritty, whether that is in talking about it, or portraying it on tv.

I'm waiting with baited breath for the celebrity version.

Some other comments on "Consent": Pillock's Pad, FallingStar