Sarah Palin burst onto the national scene slightly more than a year ago at the Republican National Convention. Since then she has gone from disaster to disaster: she fatally weakened the Republican ticket, committed countless ethical violations, and couldn’t even manage to govern the State of Alaska. Through it all, she has demonstrated herself to be simultaneously a blithering idiot and a confirmed narcissist.

On the eve of publication of her new book, it is worth examining Palin’s one outstanding talent, her ability to incite hatred. The contemporary GOP is a party fueled on hate. Hate is the stock in trade of O’Reilly, Limbaugh and Beck, so it is no small feat that Sarah Palin could claim to be the hater-in-chief. In her rapturously received speech to the Republican convention she gave what amounted to a clinic in inciting hatred. It is worth looking back at that speech and how she did it.

Psychologists have recently published findings on the five steps in the development of collective hate (Making a Virtue of Evil: A Five-Step Social Identity Model of the Development of Collective Hate, Soc Per Psych Compass 2/3 (2008): 1313–1344) and Palin seems to have embraced the model enthusiastically. According to the researchers:

The five steps are: (i) Identification, the construction of an ingroup; (ii) Exclusion, the definition of targets as external to the ingroup; (iii) Threat, the representation of these targets as endangering ingroup identity; (iv) Virtue, the championing of the ingroup as (uniquely) good; and (v) Celebration, embracing the eradication of the outgroup as necessary to the defence of virtue.

Let’s look at how Palin accomplished those aims.

Identification, or I’m just like you: Palin led with a description of her family, proudly proclaiming, “Our family has the same ups and downs as any other … the same challenges and the same joys.” She emphasized her large family size, her family members in the military, her special needs child, her husband’s blue collar job and her parents’ background as farmer and small business person.

Exclusion, defining the other: Palin was quick to claim that her opponent talks one way in Scranton to working people (us) and another way in San Francisco (them, and they’re gay, too) supposedly deriding religion and gun ownership. Palin invokes the Washington elites (them) as if the Republicans didn’t hold the presidency, vice presidency, Supreme Court, and other major positions of power.

The threat: Her opponent supposedly wants to turn his back on victory in Iraq; her opponent wants us to be threatened by oil producing nations; and, worst of all, terrorists are trying to attack us and her opponent still cares about the Constitution.

Virtue: Her group is uniquely good. She implies that they, and they alone, are the people who care about family, about religion, about patriotism, about sacrifice, and she is sure that God cares uniquely about her group.

Celebration: Finally, the call to action, the insistence that the defeat of the other is required to defend the values of family, religion, patriotism and sacrifice.

Not only was the structure of the speech designed to evoke hate, the very words and the delivery were chosen to ridicule, demean and denigrate. She made is quite clear that her opponents are not merely political opponents, they are people unworthy of the basic respect that should be due to any individual, let alone two Senators who have served their country well.

Sarah Palin was perhaps more honest than she intended to be when she described herself as a pit bull with lipstick. She implied that she is vicious, immoral, bred to attack, and fed on misery and hate. The crowd lapped it up. She carefully followed the script for inciting hatred and the audience responded with thunderous applause. It was a virtuoso performance in the art of hate.

For its fall project, Ms. Taylor’s pre-school class decided to tackle healthcare reform. According to Ms. Taylor, who has taught the Teddy Bear class of three-year olds for the past 20 years, “Instead of drawing autumn leaves and learning the ABC’s, I wanted to try something new this year. And since every American thinks no actual knowledge is necessary to have an opinion on healthcare reform, I thought my three-year olds ought to give it a try.”

Ms. Taylor continued, “You might think that three-year olds would have trouble with a topic like this, but they understood it right away. They were especially talented at issue spotting.” Consider:

No sooner had the dimensions of the problem been explained than little Michelle Bachman, a pert toddler with adorable brown curls, exclaimed, “My healthcare is the bestest healthcare in the world. Everyone else’s healthcare is ugly, ugly, ugly. Only mine is pretty, and it’s mine, all mine.”

Following up on that theme, Rush, a sturdy little boy who spoke while simultaneously knockiing down the building block castle of another child, declared, “I’m not going to share my healthcare with anyone and no one can make me.”

Several children agreed with this sentiment. As little Glen Beck explained, “My mommy says nice boys share, but when I’m holding a toy, it’s mine and I’m not gonna share it. The teacher has to pry it from my cold, sticky hands to let anyone else have a chance. I’m not sharing my healthcare, either.”

There was a bit of a commotion when Ms. Taylor explained to the class that healthcare isn’t free and everyone would need to contribute to making healthcare work. Anne Coulter began to whine, “I don’t want to be a helper. I’m tired. Everyone else should help but not me and my friends. We’re too busy doing other stuff.”

In fact, there was universal agreement on this point. Every child thought that the other children should be helpers, but not them. Being a helper is boring, and that’s not fair.

Suddenly Sarah Palin began to cry. “If I share my healthcare with other kids, they’ll come to my house and take away my toys and my food. And then they’re going to hold playdates without me and plan to kill me.”

When Ms. Taylor tried to explain that no one was going to steal her toys and food, and no one would plot her death, Sarah refused to be consoled.

“No, no, no, they will try to kill me. They’ll hold special playdates to plan it and I won’t be invited. Theyll call them ‘death playdates’.”

When Ms. Taylor tried to explain that some children had no healthcare at all, Dickie Cheney became defiant. “Tough noogies for them. I’m not going to share and you can’t make me.”

Maxie Baucus summed it up best:

“I want the prettiest healthcare in the world, and I don’t want anyone else to have pretty healtchare. It’s not fair if I have to share my pretty healthcare and it’s not fair if I have to do anything to earn it.”

Ms. Taylor proudly reflected on her students’ precociousness. “People often underestimate pre-schoolers” she said. “They think the children are immature, self absorbed and selfish, but I think we’ve proven them wrong today. They exhibited an understanding of healthcare worthy of any member of the GOP.”

Ms. Taylor continued happily:

“We’re planning a field trip next week to our Congressman’s local town meeting. I’m sure others who oppose healthcare reform will welcome the children’s insights.”

The fallout from my post Should we lament the disappearance of Down Syndrome? continues to percolate through the blogosphere. What is striking to me is how the reaction seems to be taken directly from the anti-choice agenda.

The whole notion that parents who elect to terminate a DS pregnancy need to be “educated” bears a more than passing resemblance to the approach of pregnancy “crisis” centers that attempt to talk women out of their decision to abort. The idea that women facing a DS pregnancy don’t understand their options (as if they don’t already know that they could bear the child or give it up for adoption) makes about as much sense as the idea that women seeking abortion don’t understand their options.

The idea that women facing a DS pregnancy can only be “educated” by those who have elected to continue the pregnancy is offensive. The claim that women who have not solicited the advice of strangers should be given the contact information for strangers with an agenda is grossly inappropriate. Those parents are in no more need of the advice of strangers than a woman contemplating an abortion is in need of the advice of strangers.

Although those who support “educating” DS parents claim that they are not anti-choice, the resemblance in inescapable. For me, the most telling behavior is the way that parents who have DS children treat those parents who are overwhelmed by DS children. Only a few such women posted among the more than 400 comments, but the response was alarming and illuminating. Those women who vilified in the most crude and cruel fashion.

If parents of DS children were truly interested in supporting the decision to raise a DS child, they would provide the most support to the people in the most need: people struggling to raise a DS child, and faltering under the burden. I did not detect the least bit of compassion for these women; there was only harsh condemnation.

Inadvertantly, through their reaction, parents of DS children revealed their true agenda. It is not to support those who are raising DS children. It is to vilify those who terminate, bully those who might terminate, and cruelly turn away from anyone who won’t pretend that raising a DS child is “enriching.”

The most common mistakes of alternative health advocates are mistakes of logic. They assume that what “makes sense” to them is automatically true. Thomas Kida, a professor at the UMass Isenberg School of Management, explains why this assumption is unjustified in his book Don’t Believe Everything You Think: The 6 Basic Mistakes We Make in Thinking.

The 6 mistakes are:

Mistake #1: We prefer stories to statistics. Stories are easy to understand; statistics are hard. The problem is that particular stories which may not be representative while statistics, which are merely the aggregation of thousands or millions of stories, offer a realistic assessment of what typically happens. Vaccine rejectionists’ striking reliance on anecdotes shows how alternative health advocates embrace this mistake.

Mistake #2: We seek to confirm our opinions, not challenge them. Homebirth advocacy is a perfect example of this mistake. To my knowledge, there is not a single homebirth advocacy website or publication that contains accurate information about homebirth. Nonetheless, homebirth advocates actually think that they have done “research” simply because they read the opinions of others who agree with them. In contrast, they generally make no effort to read websites and publications by those who offer information that does not support predetermined conclusions.

Mistake #3: Lay people often do not understand chance and coincidence. Most people have no idea of incidence of various risks. They grossly overestimate the chances of rare events and grossly underestimate the chances of common events. Homebirth advocates grossly overestimate the chances of death from a labor epidural, while simultaneously dramatically underestimating the chance of death from homebirth, which is more than a thousand times higher.

Mistake #4: Our personal perceptions about what is happening are often wrong. Unfortunately, the level of confidence in our perceptions is often entirely unjustified.

Mistake #5: We tend to oversimplify our thinking. Oversimplification is easy; reality is hard. While some simplification is necessary, particularly for lay people when first learning about complicated concepts, we must always keep in mind that simplification introduces distortions. Simplification is the merely the first step in thinking about complicated issues. It does not lead us to correct conclusions.

Mistake #6: Our memories are often inaccurate. This has actually been studied quite extensively. People tend to alter their memories to create a “narrative” that makes sense to them. Reality is not a narrative, however.

These mistakes are a vestige of the thinking processes that served us well in the hundreds of thousands of years of evolution in the wild. Statistics did not exist, so stories were the best way that we had to understand the world around us. Our perceptions were all we had available to us, and oversimplification is almost always the first step to understanding. In other words, there was a time when reasoning from what “makes sense” was the only thing that we had. Now those methods have been superceded by other, more accurate methods, but some people are still stuck in the past.

The typical homebirth advocate, or the typical vaccine rejectionist, does not know about or does not understand the new, more accurate methods for evaluating the world around us. They revert to more “primitive” forms of reasoning because they literally do not know any better.

This post originally appeared on Homebirth Debate in May 2008

During my years of medical training I learned about the many causes of illness, but evidently that understanding is outmoded. Sophisticated Americans know that illness is a choice. People bring it upon themselves by their own choices. This new understanding is incredibly liberating. No need to feel sorry for people who are sick because it is their own fault. No need to provide healthcare, since poor health is attributed to bad choices. Best of all, no need to worry about getting ill. If illness is a choice, all you have to do to stay healthy is slavishly follow the socially mediated goals for weight and exercise, and nothing bad will ever happen to you.

Unfortunately, illness is not, by and large, amenable to choice. The new understanding of healthcare, what everyone knows to be true, is that diet and exercise are magically protective, that preventive medicine is the only medicine that counts, and that illness is a sign of slovenliness and lack of self-discipline. This new understanding tells us more about the psychological needs of the people who believe it than it tells us about health and disease.

Only a small fraction of illness is caused by lifestyle choices. The leading cause of disease is aging. The wear and tear on the human body inevitably leads to breakdown, whether the breakdown is physical or cognitive. No one chooses to get shingles, suffer from Alzheimer’s or to succumb to diseases like the flu that would be far less serious in younger adults.

Infectious diseases, caused by viruses or bacteria, are not amenable to choice, either. Viral or bacterial illness is usually caused by nothing more than being in the wrong place at the wrong time, being exposed to an illness that someone else has. Fortunately, preventive care for infectious diseases is highly effective. It is called vaccination and it saves ten of thousands of American lives each year.

Some diseases are genetic. These include diseases with obvious genetic causes like sick cell anemia or Huntington’s Disease, but other diseases like cancer almost certainly have a genetic basis, too. That genetic basis may be a propensity to develop the disease through mechanisms that we do not yet understand. It is likely to turn out that cancer, auto-immune diseases, and even heart disease are mediated by our genes.

It is true that some lifestyle choices behaviors impact the chance of developing illness, in particular smoking, drinking to excess and eating to obesity. Yet it is far from clear that even these behaviors are entirely amenable to choice.

Many of the worst excesses are the result of addiction. People do not make a conscious choice to become alcoholics or drug addicts. Yes, the decision to drink for the first time or to use drugs for the first time is a choice, but being gripped by addiction is not a choice at all. Indeed, there is some evidence that there is a genetic predisposition to addiction. While most people can drink alcohol without any permanent effects, alcoholics have a different reaction, one that leads to an inability to stop drinking.

Even making the choice to engage is a behavior known to be harmful does not mean that one has chosen to become ill. Most people who smoke don’t get lung cancer, and many people addicted to tobacco assume that they will avoid that dreadful outcome; they certainly don’t choose to get lung cancer.

The bottom line is that there is no evidence that illness is a choice. So why do many people persist in believing that it is a matter of choice?

It’s not difficult to understand their rationale. If illness is a choice, then they can choose not to be ill. If illness is a matter of failing to meet socially mediated goals for weight and exercise, staying healthy is easy: just meet those goals by dieting and exercising. In addition there’s need to feel sorry for people who are sick because it is their own fault. And there’s no need to provide reform the healthcare system, since poor health is attributed to bad choices.

Pretending that illness is a choice minimizes both fear and guilt. Sadly, it is nothing more than wishful thinking.

According to The Wall Street Journal, Novartis is developing a system that reminds patients to take their medications.

The company is testing inserting tiny microchips into the pills as part of a system that tracks whether patients are taking their meds as prescribed. When patients veer off course, they get a text message reminder.

The technology has significantly improved adherence in a very small group of patients taking the company’s blood pressure medicine Diovan …

The benefits of this technology could be huge. Patient compliance is a very serious issue, and anything that promotes compliance is likely to improve health. But the technology has disturbing implications that we ought to explore before it is widely implemented.

Bioethicist Summer Johnson points out:

…The tiny little microchip inside the medication would monitor one’s blood level and when it slips too low it sends a message to the patient saying, “Hey dude, time to take your medication!” It’s efficient, simple, and could potentially save your life. No complaints here, right?

Wrong! This invades patient’s privacy and a patient’s right to be delinquent taking medication and screwing up their dosing. It makes it much more difficult for patients to ignore doses or to say, “If I don’t want to take medication, I don’t have to” with a microchip inside their body beaming out text messages to a device annoying them all the time. Particularly if that device can send its data to their physician or worse yet to their insurance company reporting them as a non-compliant patient.

Dr. Johnson dismisses these concerns:

But isn’t that the point? To motivate patients to be compliant? Personally, I think the more we can do to encourage chronic disease management that actually works and compliance with long-term dosing regimens that work, the better.

If this drug can actually do what it promises, I hope they make more of them.

I am surprised at that response. Didn’t we learn in ethics 101 that the ends do not justify the means? Although the goal is admirable, the privacy concerns are real and should not be dismissed out of hand.

The technology could represent a substantial benefit for patients who want help remembering to take their medications. Individuals suffering from complex medical conditions and elderly patients often have difficulty remembering to take medications that they fully intend to take. No doubt those patients would appreciate the reminder, and might also appreciate the fact that their doctor (and family) could be notified if they forget to take a particular medication.

Most of us, though, could buy a simple pillbox alarm if we felt we needed help remembering to take medication. It is not clear if there is any additional benefit to the micro-chip technology and there are substantial privacy concerns.

Taking medication is a personal decision. Although I as a doctor may lament the fact that some patients are non-compliant, should I employ tools to guarantee compliance? Should doctors be receiving minute-by-minute information on patient behavior? Should insurance companies have access to this information? Should they be allowed to terminate coverage if they learn that patients have not taken each and every recommended pill as directed.

Inserting micro-chips into medication is a form of surveillance. And as with any type of surveillance, the argument can be made that you have nothing to worry about if you are not doing anything wrong. Yet the police are not allowed to put cameras into people’s houses to make sure they are behaving behind closed doors. That’s because we value the right to privacy. That right to privacy should extend to medical decisions like whether or not to take blood pressure medication on time, or whether to take it all.

The vociferous response to my post Should we lament the disappearance of Down Syndrome? advocating choice in terminating a Down Syndrome pregnancy alerted me to an organized effort by DS parents to “educate” everyone else. It reminds me of, and shares many characteristics in common with, efforts by pregnancy “crisis centers” to “educate” women experiencing unwanted pregnancies. In both cases, the efforts are rather transparent attempts to get women to change their minds.

The movement was profiled in a 2007 piece in The New York Times.

Convinced that more couples would choose to continue their pregnancies if they better appreciated what it meant to raise a child with Down syndrome, a growing group of parents is seeking to insert their own positive perspectives into a decision often dominated by daunting medical statistics and doctors who feel obligated to describe the difficulties of life with a disabled child.

Their concern is hardly selfless:

A dwindling Down syndrome population, which now stands at about 350,000, could mean less institutional support and reduced funds for medical research. It could also mean a lonelier world for those who remain…

“If all these people terminate babies with Down syndrome, there won’t be programs, there won’t be acceptance or tolerance,” said Tracy Brown, 37, of Seattle, whose 2-year-old son, Maxford, has the condition. “I want opportunities for my son. I don’t know if that’s right or wrong, but I do.”

Interestingly, the vast majority of parents who elect to terminate are not complaining about being “uneducated” either at the time of termination or years later. And certainly no one in the community of DS parents is complaining about the “education” of those who were encouraged to continue the pregnancy. In fact, the only complaint emanating from the community of DS parents appears to be that people who make different decisions must be receiving inadequate education.

The approach, on view in the comments section of my previous DS post, is fairly formulaic:

… [T]he richness of their children’s lives, parent advocates say, is poorly understood. Early medical intervention and new expertise in infant heart surgery stave off many health problems; legally mandated inclusion in public schools has created opportunities for friendship and fostered broader social awareness of the condition.

The effort to “educate” other is remarkably intrusive:

… [P]arents are arranging to meet with local obstetricians, rewriting dated literature and pleading with health care workers to give out their phone numbers along with test results.

The medical community has been unimpressed. They understand that their obligation is to present unbiased information, not to present false hope in an effort to sway their patients’ choices.

Genetic counselors, who often give test results to prospective parents, say they need to respect patients who may have already made up their minds to terminate their pregnancy. Suggesting that they read a flyer or spend a day with a family, they say, can unnecessarily complicate what is for many a painful and time-pressured decision…

There is certainly no objective evidence that Down Syndrome counseling is inadequate. There is only the conviction of some DS parents that people who make a different choice are making the wrong choice. Their effort to “educate” other parents is nothing more than an attempt to pressure them, and, as such, it is wrong.

I first noticed difficulty with my vision in the early spring of 2000. Sitting at Little League Games I often had trouble focusing on the action. Over time I realized that the problem was intermittent double vision.

As the weeks went by, the double vision got worse. My optometrist suggested that adjusting my contact lens prescription; that didn’t seem to work. Over time it became apparent to me, despite my vigorous attempts to pretend otherwise, that this was not a problem with my eyes, but almost certainly a problem inside my head. I made an appointment a highly regarded neuro-ophthalmologist, a hospital colleague.

I read up on double vision. There were three principle causes of double vision in otherwise healthy patients: idiopathic, which is the technical term for unknown cause; multiple sclerosis, and, least likely, a brain tumor. I convinced myself that I had idiopathic double vision, distressing because there was not cure, but certainly better than having multiple sclerosis or a brain tumor.

I arrived for my appointment on time. I had to spend an hour and a half in the waiting room because the doctor was “running behind,” but, as an obstetrician, I’m hardly in a position to complain about waiting. Finally, the doctor flung open the exam room door and swept into the room.

“I can’t see you today,” he announced. “My secretary is an idiot. You have double vision and double vision requires an extra long appointment. She booked you for a regular appointment. You’ll have to come back another time when I have more time to see you.”

“I don’t think so,” I responded. “I’m here now and you can start the exam in the time we have available. If we need more time, I’ll make another appointment.”

The doctor looked irritated, but after learning I was a colleague of his, he seemed mollified. From that point forward, he was on his very best behavior. Considering how he treated me, I feel very sorry for his patients who are not doctors.

The doctor did a few simple tests, asked me to look up and down, side to side and follow his finger. In less than 5 minutes he announced findings.

“You don’t have to come back,” he said. “I already know what you have. You have a sixth nerve palsy. The nerve that controls one of the muscles of your eye (the sixth cranial nerve) is not working. You can’t move your left eye to the left, that’s why you have double vision, and why it happens intermittently. You only get double vision when looking to the left.”

“There are three main causes of double vision,” he continued. “Idiopathic, but I don’t think it’s that; multiple sclerosis, but your story is wrong for multiple sclerosis; and brain tumor. You must have a brain tumor. I’m sure of it.”

That was it. That was how he broke the diagnosis. I had known about the possibility, of course, but I was stunned nevertheless.

“How are we going to find out whether I really do have a brain tumor?” I asked.
“Oh, you have a brain tumor,” he responded emphatically. “We need to get an MRI to find out how big it is and where it is located. I suspect that it’s benign, and based on its appearance on the scan, we should be able to confirm that.”

He continued, “You can have an MRI on Monday, then you can come back on the following Monday and I’ll tell you what it showed.”

“Wait a minute,” I was beginning to recover from the shock. “What do you mean that I find out the results the following Monday? The radiologist can see the findings during the scan itself. Why can’t you get the results from the radiologist by phone on Monday?”

“You know those radiologists,” he confided. “They’re all foreigners, Pakistanis, Indians; who can understand what they say? I can’t, so I’ll just wait for them to write me a letter.”

Even in my shocked state, I recognized that it was pointless to try to deal with this doctor. I determined to deal with the radiologists directly.

I told my husband what had happened. I related the doctor’s comments about the foreign radiologists. He was appalled by the blatant racism, but then he smiled.

“As it happens, I know those radiologists. I am one of their lawyers. My contact person in the group is Dr. Z, He’s Pakistani, but I have no trouble understanding him. He speaks better English than we do.”

My husband called Dr. Z who assured him that he would come down and read my scan after it was done, and tell us the results immediately.

On the day of the scan, as I slid out of the MRI machine, a radiologist approached and stuck out his hand.

“Hi, I’m Dr. Z and I’ve already looked at your scan. Come out to the computer and I will show you what I found.”

He was warm and engaging. He spoke perfect English with a slight British accent. I had no trouble understanding him. I followed him to a large computer screen.
“Good news,” he said, with a smile. “Your brain tumor is benign.”

The room started to spin. I asked for a chair and sat down with a thump.

“I can’t have a brain tumor,” I said stupidly. “My son is having his Bar Mitzvah in two months and now is not a good time.”

He looked at me kindly. “I’m not sure what that is, but it doesn’t prevent you from having a brain tumor. But look at the scan. The tumor is small and well contained. It looks like a meningioma, a very common type of benign tumor. See how it is pressing on the sixth nerve. That’s why you have double vision. Don’t worry, though, a neurosurgeon will be able to remove it, and you’ll be fine. They typically don’t come back.”

I wasn’t counting on brain surgery, and this did not seem like good news to me. However, when I realized that Dr. Z was genuinely happy to be sharing this news, I understood that he had worried that the scan might have showed something far worse.

Later that afternoon, I got a call from the neuro-ophthalmologist. Dr. Z had informed him that I already knew the results of the scan. I’m not sure why he called since he did not impart any helpful information.

“I’ve looked at the film,” he reported, “and you have a small tumor that is almost certainly benign. It’s only a half inch across, but it is located deep inside your brain and pressing on lots of important structures.”

Then he added: “I’d hate to be the neurosurgeon doing your case. That sucker is sitting in a lake of blood. The surgery’s going to be a mess.”

To be continued

This piece originally appeared on Open Salon in October 2008.

Homebirth advocates have a fallback position when presented with reams of data that homebirth increases the risk of neonatal death. They declare that the evidence is “conflicting” and that “there’s no way we can solve this.” But, of course, there are neutral ways to establish the truth, and I’d like to offer them publicly to homebirth advocates.

The following was originally posted on RH Reality Check in response to a piece by Amie Newman entitled What’s So Scary About Home Birth? I offer this proposal to her, and if she doesn’t accept, to any and all homebirth advocates:

“I’m sure you would agree that American women deserve to know the truth about homebirth. The best way to do that would be to present the information from both sides in a way that everyone could understand and make their own decisions.

I propose that RHRealityCheck sponsor a homebirth debate. I am willing to debate any professional homebirth advocate at any time. I would welcome the opportunity to present my claims side by side with those of homebirth advocates. I am very confident that when women see the actual data, they will realize that professional homebirth advocates have not been completely honest about the safety of homebirth.

Of course, the real problem will be finding a professional homebirth advocate willing to debate. They know what I know and they know that if they are forced to publicly defend their claims, they will be unable to do so. Hence they will do anything possible to avoid a debate.

Last year I was invited to participate in a childbirth conference by the organizers of the conference. They thought that my controversial status in the homebirth community would be an excellent draw. I agreed that I would attend the conference, but with one condition attached. I would only appear in a debate with a professional homebirth advocate, many of whom were already planning to attend.

The conference organizers thought this was a great idea. I warned them that no one would agree, including those who were already planning to attend. Professional homebirth advocates never appear in any forum where they can be challenged by people who are equally knowledgeable. Sure enough, much to the surprise of the organizers, they were turned down by almost everyone. Ultimately they managed to cajole a very prominent homebirth advocate into participating and I made plans to attend the conference. Then, predictably, the homebirth advocate announced that he had changed his mind and would not participate. I did not attend the conference.

I’m hoping that you could be more persuasive, but I am not optimistic. Professional homebirth advocates are afraid of me, and anyone else who has command of the data and scientific literature. They cannot afford to appear in any type of debate because their claims would be eviscerated in short order.

Second, since it is highly unlikely that any professional homebirth advocate would participate in a debate, I offer an alternative way of settling the controversy. Let’s hire a professional statistician to analyze the data and present his or her findings to the public. We could find a mutually agreeable statistician who has no previous connection to the homebirth issue. I am so confident about the results that I am willing to pay for the analysis by any mutually agreed upon professional statistician.

We may not be able to solve the controversy by arguing with each other, but you, in your role as a professional journalist, are capable of presenting a public analysis of the evidence, either by sponsoring a debate or by agreeing to publish the results of an independent statistical analysis.

Check with the executive staff of RH Reality Check and see what they think. It seems like the perfect forum. RH Reality Check is committed to providing women with accurate information on reproductive health topics. This is a chance to inform the public and get lots of publicity and traffic as a result. And, as I said, I’d even be willing to pay for it.”

Is Down Syndrome disappearing? Is that a bad thing? Brian Skotko asks these provocative questions in a recent article in the journal Archives of Childhood Diseases, With new prenatal testing, will babies with Down syndrome slowly disappear?.

The proportion of children born with Down Syndrome is declining rapidly. That’s not because the incidence of Down Syndrome is declining. The cause is the dramatic increase in prenatal testing and the high abortion rate for Down Syndrome babies. As Skotko explains:

…[W]omen are waiting longer to have children. Because advanced maternal age is associated with increased chances of having a child with DS, the birth incidence of DS would have been expected to climb. However, the worldwide birth incidence of DS has actually decreased from what it could have been … For example, in the U.S., there would have been a 34% increase in the number of babies born with DS between 1989–2005, absent prenatal testing. Instead, there were 15% fewer babies born, representing a 49% decrease between the expected and observed rates.

Down Syndrome is a chromosomal anomaly with a straightforward cause. Human beings have 23 pairs of chromosomes for a total of 46. Individuals with Down Syndrome have an extra chromosome for a total of 47. Chromosomes pairs are numbered and Down Syndrome is the result of an extra chromosome 21. The extra chromosome leads to effects of varying severity throughout the body. Down Syndrome individuals have mental retardation, distinctive facial features, low muscle tone and medical problems such as congenital heart defects.

A major genetic defect like an extra chromosome is relatively easy to diagnose by amniocentesis. More recently, we have developed less invasive methods of screening for Down Syndrome such as the triple test or quadruple test. Further improvements in prenatal testing are on the horizon. Skotko wonders if improved testing will further decrease the proportion of Down Syndrome children:

…Several factors suggest so. First, the new tests will be offered in the first trimester … Consequently, women will be able to receive a DS diagnosis and make a decision about the continuation of their pregnancies in private… Second, the new tests are noninvasive, carrying no risk to the fetus …

Thirdly, in countries like the U.K., where women are only offered CVS or amniocentesis if their screening test is deemed “high risk,” the new tests would afford everyone an opportunity to know definitively if their fetus has DS … Lastly, the new tests are projected to cost less than amniocenteses …

Stotko, who has a sister with Down Syndrome, laments these advances, under the dramatic heading “our genetic future.”

While DS might be the first genetic condition that can be definitively diagnosed in the first trimester on a population basis, others will undoubtedly follow… ACOG issued an opinion opposing obstetric practices that perform terminations based on fetal sex alone. Barring work-up for sex-limited genetic conditions, sex selection could be interpreted as “condoning sexist values” and creating a “climate in which sex discrimination can more easily flourish.” By contrast, in its support for DS prenatal screening, has ACOG endorsed a climate in which disability discrimination could more easily flourish?

Skotko has strong feelings on the subject, dramatically concluding

…Parents who have children with Down syndrome have already found much richness in life with an extra chromosome. Now is the time for the rest of us to discuss the ethics of our genetic futures.

Richness? The use of that term is patronizing to both parents and to people with Down Syndrome. It is patronizing to parents because it implies that the lifelong burden of caring for a disabled child should be perceived as “enriching.” It is patronizing to people with Down Syndrome by suggesting that their primary value is to enrich the lives of others.

Interestingly, Skotko pays very little attention to the myriad of genetic diseases for which testing and termination are also available. He does not advocate the “richness” of life with a child who has a terminal neurologic condition like Tay-Sachs, or the “richness” of life with a child who has similar but more serious chromosomal abnormalities like Edward’s Syndrome (extra chromosome 18) or Patau’s Syndrome (extra chromosome 13). Evidently these disorders are not “enriching” enough to justify his concern.

Skotko is right to raise these issues, but he is wrong to substitute his judgment for the parents who face these decisions. Raising a child with a serious genetic anomaly is a major burden, one that never ends and one that often gets harder as the years go by. It should be up to those parents to make the decision, and they should be entitled to the most advanced and least invasive technology with which to do so.