Morality and God, Part II

Prevailing_world_religions_mapDistribution of World Religions

While writing Part I of this essay the other day, I had an epiphany (a moment of sudden revelation, not a manifestation of something divine). I thought I’d better write it down before I forget…I am of that age. So if there is some repetition here, from Part I, forgive me, but this is important (maybe all of you already know). It suddenly struck me that…

God is an Atheist Hoax!

One of the most irksome and unsupported bits of Jabberwocky is the idea that non-theists (atheists, agnostics, etc.) have no morality on which to base their lives. No one has ever successfully demonstrated a causal link between lack of religious belief and immoral behaviour, although a logical association is certainly possible to conjure up, and the correlation is certainly obvious, and for good reason. When you go looking for law-abiding people, you tend to find them among groups dedicated to abiding laws.

But we all know that correlation does not equal causation, and to extrapolate to the idea that non-theists are immoral is illogical. To conclude that non-theists cannot be moral is ridiculous, and there are lots (billions) of counter-examples. Examining the issue conclusively is probably a waste of time. There are simply too many confounding issues.

Human History and Law/Morality

The earliest evidence for something human is millions of years ago. Various forms of our pre-historic ancestors date back 1 to 3 million years. Our modern form of human…bipedal, increased brain size, with longer childhoods and increased differences in gender appearance (sorry ladies, apparently ancient hominids were more feminine, or at least, more easily differentiated from males), leading to social learning, language and other cultural pursuits…developed no less than 50,000 years ago. It took a while to get out of the hunter-gatherer stage, but about 10,000 years ago civilizations, in terms of agriculture and communal living, began to develop.

The timing is mildly important, because the laws as codified in the Bible and set down on paper (or papyrus, or stone, I suppose), were written about three thousand years ago. And yet, historical evidence of formal laws date back to four or five thousand years. While the Old Testament dates back to about 1200 BC, parallel civilizations in Greece, Egypt, Rome, India, China and Mesopotamia all had codes of behaviour.

The point is, there is good reason to believe humans are capable of producing, and indeed did produce laws to live by long before the god of the bible gave his rules to Moses.

Alternative Explanation

Suppose there is no god to hand down rules. Almost by definition, the final arbiter of rules to live by, if you are inclined to believe in an absolute morality, is God. This, at least, is the argument given by William Lane Craig. Existence of absolute morality implies a god. In fact, this argument is circular because existence of absolute morality is God.

I cannot really think of any other method of getting to absolute morality. Could there be a supreme sets of laws somewhere that has no living embodiment, no intellectual existence? If there were, one could never prove it, not without some live (even if historical) being to defend it.

Could there be two supreme intelligences, both giving different accounts of an absolute morality. This is even more complicated than one god, and puts the definition of supreme in question. So lets agree for the moment that absolute morality and God are essentially the same thing.

Non-Theists and Relative Morality

We all ‘feel’ that there is a right and a wrong to most, if not all questions. Sometimes, in fact, we are sorely puzzled by the position taken by others, and we look to colleagues to agree with us, essentially expecting such agreement out of hand. It may be that this feeling of knowing, this empathy or understanding of some human plight, is basic to our biochemistry and DNA. Or it simply may be tacit, almost subliminal, learning, often by modelling behaviour from those we know, respect and love.

This overwhelming feeling of ‘knowing’, what I have referred to (metaphorically) in the past as ‘listening to the voice of God,’ may indeed be a stimulus to concluding the existence of absolute morality, and thus that God exists.

I have argued, also in the past, as have others in publications, that morality is a result of natural selection and communal living. Rules of behaviour leading to control of anarchy and chaos tend to improve the survival of communities and thus promote the dissemination of DNA. Such sensations as empathy, guilt and fairness would then lead to a general understanding of what is considered ‘right’ or ‘wrong’ without really thinking about it much, reinforcing that feeling of some ‘voice of God’.

Morality thus arises in us as a selection advantage.

Short-Cuts to Morality

We were all, once upon a time, non-theists. We may have thought periodically that maybe some god existed because we didn’t understand things like thunder and lightning, but at some point, formal theology didn’t exist.

Gradually all these non-theists evolved morally, and taught their children and their community members. But, as always, a group or groups misbehaved, and would not respond to general rules. “So you say…but I believe otherwise.” With all the work to be done, who has time to explain the need for communal behaviour to these recalcitrants and miscreants? So the non-theists used threats of violence, and punishment, but implementation was always a problem that could only be settled by more threats of violence and chaos.

“You need to do this.”

“Who says?” Bingo.

“God says.” Brilliant. In one fell swoop, a whole bunch of problems can be addressed.

Atheists created God in order to keep theists in line. And it worked. The theists took the bait, hook, line and sinker. They ran with it.

Sorcerer’s Apprentice

The non-theists returned to their fields, content they had taken care of law and order, and the theists ran with it. The concepts of God and redemption, forgiveness and sin, Hell and everlasting torment, Heaven and everlasting paradise, all became carrots and sticks for new theists who needed moral tutelage. Before we knew it, the whole thing had run amok.

Hundreds of religions, sects, cults, hundreds of rules monitored and implemented by clever people who saw a sinecure. A whole new industry of largesse. A whole new industry of control . Methods to keep people in line, to obtain power, to control entry into the elite, to justify inequities like slavery and economic gaps, anti-democratic power distribution.

Subtle refinements, such as supporting the poor and the sick gave justification to protection from taxation or military service, influence peddling and power-mongering.

And the ever-present promise of forgiveness, if only you would choose the right church, the right religion.

Survival of the fittest lead to survival of the church, using the same basic rules. If you take the fears and exploit them, create a political base of believers, you can win by force of ‘conscience’ others to your side by supporting their favourite cause: white nationalism, jingoism, racism, anti-Semitism, even slavery and elitism. Even anti-science disdain for experts. Even excuses for property hoarding, misogyny and other inequities and iniquities. Even protection of paedophiles because the image of the church is more important than anything secular.

Even war: “Onward Christian Soldiers.” Religion is the great recruiter. Only family competes successfully with religion when it comes to recruiting for a fight.

So the original good idea of using an all-powerful all-knowing god to enforce rules of civil behaviour in people who do not feel the empathy required for fairness and ethical or moral behaviour has been used by those self-same guiltless heartless people to achieve their own goals. Of course, not every theist is a psychopath. Very few, in fact. Most are good-hearted kindly people who have been gathered up by all these arguments, who believe earnestly in the idea of loving their neighbour and helping where they can. They believe non-theists about them will suffer badly if they do not comply and convert. They are full of good intentions, with their eyes firmly fixed on the values and morals of the past, of the original contractual obligation with the non-existent God. A few will recognize it for what it is, a hoax, though very few will see that the hoax was originally the atheist’s hoax. And maybe the original huckster thought, “Maybe there is a god, and if there is, he would do this, providing a tool to control the community. Maybe the concept of the god is faulty, but you have to admit, the tool it is a great idea!

And little by little, people would add to the tool, to promote ideas they favoured (for example, celibacy of priests, once they’d had their fun), to remove adversaries from positions of power (excommunication of non-believers), to promote friends in high places (royalty by divine right), to advance their personal views of moral behaviour (protection from legal consequences for people discriminating against homosexuals), to control competing religions (entry into heaven only through Jesus Christ).

Religion As A Tool

Viewing religion as a tool to solve community control issues addresses a number of problems, largely by providing a forceful reason for believing. It clarifies a powerful incentive to the development and continuation of an idea which has no visible evidence. People support this idea of organized religion because it works, because it has worked in the past, and because many others agree.

It explains why there are religions in most cultures on earth, whether they be theistic or not, because of its civil order need. If one geographical section of the world was largely out of reach, it developed a parallel but similar structure to control its people, a different religion.

It explains why something with virtually no evidence can persist in the minds of intelligent people. But it also explains why the strength of its arguments falters as the populace becomes more educated.

It explains the need to proselytise. It explains the desire to encompass all. It explains the incredible popularity of religion. It explains the public display of what many might expect to be a very personal relationship, the believer and God. Non-believers need to believe, or need to be seen to believe. Even non-believers know they need to be seen to believe. And so they do. And so they hide their true belief.

It explains why religion cannot change, because God had to be always right to provide absolute morality to all people. After all, absolute morality cannot change…it’s absolute. It explains why holy books can never be revised. It explains why certain contentious parts of the Bible get ignored.

The tool is weakened by disbelief, by non-acceptance. So impossible parts of the story are skipped, contentious parts are reinterpreted, certain policies are characterized as parables, myths, fantasies or literary devices.

“We don’t stone people for apostacy.”

“But the Bible says…,”

“No. No. That’s just literary license.”

“Well, how am I going to figure out what is correct, God damn it…”

“Don’t take the Lord’s name in …” and punishment is applied.

Yes, viewing religion as a tool explains its popularity, its past almost total acceptance, its intransigence, as well as its inconsistencies.

God is an atheist hoax. And it got away from us. Boy, did it get away from us!

Morality and God, Part I

William_Lane_Craig

 

Dangerous Man?

William Lane Craig argues that he has proved there is a god, that god teaches that homosexual activity is abhorrent and that therefore it is right and proper to condemn the behavior, if not the gender preference. He is somewhat more modern than many, or at least he reduces his cross-sectional area as a target, by pointing out that nowhere in the Bible does it say that being a homosexual is bad;  rather that homosexual activity is bad. Homosexuals, then, must abstain to be good people. Craig does seem to admit that homosexuality is not the gay person’s choice, but nevertheless, this is their cross to bear, unfairly perhaps (but who ever said God was fair: certainly not Job, nor Abraham, nor even Jesus, really).

The two criteria are that according to the absolute morality given to us by God, we must eschew homosexual behavior, and that there really is a God who defines this absolute morality.

It is an interesting position to take, to claim to be moral by doing God’s bidding. Craig is clever enough to consider a…to him hypothetical…thought experiment.

What if God Does Not Exist?

One of Craig’s arguments appears to be that absolute morality exists and therefor God exists. To show that absolute morality exists he appeals to emotion; torturing babies is bad…everyone agrees (well, everyone except baby torturers, I suppose).

But I would like him to imagine that there is no God, and then answer the following question? Is torturing babies no longer bad?

Let’s pretend he says torturing babies is still bad, then his line of reasoning that morality comes from God loses some support, the quantum of which is dependent on just how good he is at imagining stuff. Here, he would have to admit that the morality he relies upon is coming from humans, not God. He will deny this and say he cannot put the specter of God out of his mind sufficiently to rid himself of God’s absolute morality.

OK.

Try anyway. Consider the state of affairs where there never was any God, and two people on the desert island are told that a baby is about to be tortured. One is told he must oppose such an evil act, or he will be immediately shot in the head and killed. He complies, and his behavior in this test is consistent with a moral person. The other is told nothing of the sort, simply asked what he thinks, and let’s suppose his answer too, is consistent with the behavior of a moral person.

Assuming you can quantify morality, and I guess you can, who is the more moral?

I do think Craig, and most sentient people, would argue in favor of the guy who makes the right decision without the gun to his head. Well, Dr. Craig, that is the atheist. The first guy, the one who needs a gun to keep him moral, is the theist (I admit that not all theists require this coaxing. In fact, I think most theists would be quite moral without God, they just don’t realize it). God was created by atheists (among others) to keep the rest of the populace in check, as a quick method of teaching morality. Atheists knew that people needed something, something to keep them on the straight and narrow, so they created God. And it worked. Sort of. It was not our greatest invention, but it served its purpose.

The above is hyperbole, clearly, but the point is that the person who requires hell and damnation to be moral, is not moral, they are simply rule-abiding and risk aversive. In fact, the guy who only occasionally tortures babies is more moral than the guy who never does this because of the gun, but who would always do this if God did not exist.

Rules of civil behavior have developed over time, and pre-dated the Bible by at least a thousand years. It’s hard to argue that such civil behavior was demanded by God before the Ten Commandments, or rules in Leviticus, because prior to that is seems God had not voiced His concerns. Thus there is every reason to think some people, including all those who never heard of God, live on another planet, can’t read, or whatever…there is every reason to think some people figured out some semblance of morality before being taught by a deity. History tells us that rules of law pre-dated the Bible, anyway.

Animals Have Rules

Look at animals. Those who spend any time with animals can see evidence of love and nurturing, as a mother and newborn, certainly among the mammals at least. Such bonds clearly develop between dogs and their owners, and while I realize the anthropomorphic attributes we project onto them are problematic, many of us, myself included, have been helped by our pets. As a young boy, my dog tried to pull me out of a fast running river.

Of course, among the carnivorous animals (which includes us), there is a competition of behavior. Eating your enemy is a pretty efficient way of a gaining a useful quantity of energy. But rampant cannibalism is held in check by…what? By rules of civil behavior. By instinct. By species memory or whatever instinct turns out to be. By social learning.

There is a component of volition in instinct, as opposed to reflex, and sometimes the drive can get muddied, as in breathing, for example. Or sex. Or eating. No one seems to question these issues of instinct or inherited memory, but somehow civil behavior is interpreted by theists as taught by God. We atheists often suffer the “Oh, how can you have a moral code if you don’t believe in God?” Bigotry much?  Since God ‘taught it’, there must be absolute morality. This leads to the circular argument that God creates absolute morality, and thus there is an absolute morality, and because there is an absolute morality, God must exist (do I need to provide the reference for that one?).

But no one seems to question that animals, in the varied hierarchy of life, show evidence of instinctual behavior, of volition, of empathy and nurturing, of friendship and even of codes of civil behavior. Do animals listen to the voice of God? Well, I suppose the theist can argue about that, and I have no idea what the Franciscans might say, but if you think, as I do, that ‘the voice of God’ is a metaphor for our code of behavior, I would say, “Yeah,” animals have a code which they consider, and which is subject to their own volition, and which varies from species to species as well as from individual to individual.

If humans get theirs from God, where do animals get it?

Let’s back up a bit. A lot of Craig’s argument seems to centre on the existence of absolute morality. But is there such a thing, really?

Thou Shalt Not Kill

Unless God tells you to, in some sort of indemnification by divine command. Unless you are defending yourself, which to the best of my knowledge does not show up in the bible. And when this commandment was handed down (written in stone, no less, just to emphasize the point), there was no equivocation about the perp stealing, or murdering, or messing around with someone else’s husband (remember, there are gender distinctions in the Bible…this degree of punishment is pretty straight forward for the female…if you can define what female is, which is a whole other story). Thou shalt not kill is pretty absolute. And yet, very few God-fearing individuals quibble with it in all circumstances.

War, punishment, self-defense, treason. All of these are stimuli for looking the other way when it comes to this commandment, this absolute morality. In fact, it seems to me that the only time the theist really complains about justifiable killing is when it is done in order to help the person being killed, as with the relief of pain and suffering. Very strange, don’t you think?

Slavery

Is keeping slaves contrary to some absolute morality? Certainly the bible, the word of God, mentions slaves several times, though never that I am aware of in some way that suggests slavery is wrong.

And whosoever lieth carnally with a woman, that is a bondmaid, betrothed to an husband, and not at all redeemed, nor freedom given her; she shall be scourged; they shall not be put to death, because she was not free. Leviticus 19:20 (KJV)

We certainly accept this to be wrong now, and have done so for the last 200 years (well, 150 or less for the Americans) though most people are hard-pressed to see the obvious slavery inherent in the socioeconomic ‘gap’.

One can safely infer that absolute morality has changed. To me, this means it is not absolute. [Please, biblical scholars, don’t quibble that slaves are different from bondmaids. Other translations of the bible call them slaves in the spirit of literary honesty, and the author of the bible could have given his writing more clarity, if he had been concerned about misinterpretation.]

Relative Morality

Moral relativism asserts that different groups have different codes of conduct, and that there is no absolute morality. The problem with denying absolute morality is that religious apologists lose their best circular argument for the existence of God. And unfortunately, I believe that is what guides their arguments. Instead of reviewing the facts to develop the conclusion, they appear intent on finding the ‘facts’ that support their conclusion.

But we all know that torturing babies is wrong (though we treat neonatal cancers and leukemia). And that killing is wrong (though we defend ourselves to the point of lethal force). And that keeping slaves is wrong (though on this the bible does not seem to concur). And that homosexuality is wrong (though we don’t know how to define same-sex intercourse, because we really don’t know how to exhaustively define gender. See second half of LGBT).

Where Does Morality Come From?

When we think of morality, it seems to me most of us are thinking about some internal guide, some innate knowledge that certain things are wrong. Not simply that God declares it wrong. To be truly moral, we have to feel that it is wrong. Like those two guys on the desert island. What I like to call, “Listen to the voice of God,” in part because it confuses my theist friends. Morality, to me anyway, is not simply a list of rules, but is an instinctual or learned deep seated knowledge that some behavior should not be carried out.

How did we get it, those of us who have it, those non-sociopathic members of our society.  To answer that we learned from our parents, and others in our community, is ducking the question. To say ‘God gave it to us’ is the result of our arrogance that we think we should be able to explain everything (and when we cannot, it must be God). I think it is evolution. I think there is random variation in possible behavior with respect to morality, and that the selection advantage of Darwinian evolutionary theory promotes communal living as an survival improvement over isolationism. The survival of the community of fittest beats out the survival of the fittest every time.

We evolved to be moral, though it is by far a work in progress, and is easily subverted. We evolved toward moral behavior. And then we started teaching our children. How much is in the gene, and how much is in the meme, I don’t know. But given that memes may be hard things for other animals to develop, I would have to guess there must be a lot in the biochemistry and physiology. All for the general purpose (anthropomorphizing again) of promoting our DNA.

Jared Diamond points out (Guns, Germs and Steel) that getting people of the same religious faith to spill blood for you is the next most successful recruiting device to getting family to fight for you. Which, by the way, may well be the selection advantage of theism over atheism.

Why Do I Think WLC Is Dangerous?

I have spent a lifetime interviewing people and quickly getting a measure of them by appearance, behavior, ideas, body language, education, demeanor and so much more. I have probably treated close to 25,000 patients in the course of my career, and have interacted with many times that in terms of family. It is rare indeed that my initial impressions prove wrong.

I have listened now to several talks, debates and speeches given by WLC, and while I have heard of disagreement from others, I really find him to be amiable, pleasant, and kind. I know, as with any prominent individual, that opinions will vary, and I am aware that some find fault with him, his education in spite of two PhDs, his logic (which I also question, well, mostly his premises), and his tactics in debates. I do know that I am at one extreme of people who truly have to find something egregious and undeniable about someone before I relegate them to the categories of nasty and indecent.

So, I think I would quite like WLC if I met him, recognizing that such an opinion necessarily is shallow. So what. I don’t like everybody, but largely because I don’t know everybody.

But I think William Lane Craig is dangerous, as many moderate theists are, because the moderates provide guidance and shielding for the radicals.

I can’t get away from the feeling that if WLC were convinced there was no god, no higher authority, he might well make up his own mind that homosexuality and homosexual behavior is not immoral. Although I have read or heard him make some highly questionable and derogatory statements about disease in homosexuals related to sexual behavior, setting those rather breath-taking misunderstandings of the medical and physiological aspects aside (as examples, I suppose, of trying to find facts to support your conclusions), with time he might come to accept that there is no inherent immorality in homosexual behavior. But as it stands now, his view of the existence of a God which has condemned homosexuality as an abomination, essentially by Divine Command, can lead to hate crimes in people who believe WLC.

If a man also lie with mankind, as he lieth with a woman, both of them have committed an abomination: they shall surely be put to death; their blood shall be upon them. Leviticus 20:13 (KJV)

Combine that with WLC’s reported acceptance of genocide as justified by Divine Command Theory, it is not so much of a stretch to think some misguided disciple of WLC could use an AK-47 on a gay night-club.

William Lane Craig would consider such an horrific action to be, itself, an abomination, but I think he would still have blood on his hands. Words matter; words are powerful; unintended consequences can be predicted sometimes. I just don’t think it is worth all the sophistry.

Evaluating Evidence: Oncologists Do It Best

NormalThere is one crucial area of thought, one discipline where the vast majority of people could really use some education, and they are not getting it. You can see it everywhere. Some of the world’s most prominent and respected people are just really bad at it, have never been taught how to do it, and for the most part, do not need it.

Or they don’t think they need it, but a lack of understanding in this crucial area is leading to all manner of problems.

Evaluating evidence.

It sounds easy enough. We do it every day. We take in data, and try to predict what is going to happen, we get it wrong and reassess, and then stumble along doing it all over again.

Gradually, some enterprising individuals learn to put some order into it, learning that cloudy days may require an umbrella, or a flirtatious look and smile may be the beginning of a beautiful relationship. We come by that sort of thing naturally, without thought, but the lack of thought is what gives us away.

There are days when the cloudy skies mean snow, and days when that ‘look’ was for the guy behind you.

Politicians and Intellectual Ability

Political animals usually are smarter than average. The defined mean of Intelligence Quotient is 100, and most people who get into high school (though not necessarily out) have at least this much. There is a broad distribution, estimated by the typical ‘Bell Curve’ or normal or Gaussian distribution depicted above. Such probability distributions describe the variations of intelligence (and many other randomly organized characteristics), although the skewing of the underlying shape can look quite different. Generally, there is a lot of the population around the mean (average), tapering out to much smaller numbers at either end.

People reading about this often become defensive, thinking somehow that they are responsible for whatever level of failure or success they have in this area. While I know the brain is like a muscle in many respects, the more you think the smarter you get, most people are completely innocent of their particular level of intelligence. Knowledge is another thing, but even with knowledge, the level of acquisition of knowledge is related in many ways to what you were born with, and there is not a lot you can do about what you were born with.

People with IQs of 80 or less should not feel guilty about their abilities, any more than short people should blame themselves for not being able to dunk a basketball. But since only ten to fifteen percent of individuals have IQs in this range, for most it is not really an excuse to misunderstand the evaluation of evidence if they work at it a bit.

Politicians have the ability to understand evidence, as does the vast majority of the population.

But it is what you do with what you’ve got that is important, not what you were born with.

Evaluating Evidence Can be Tricky

There are, of course, wide variations in success of evaluating evidence, which do trend toward a correlation with intelligence, but if you never focus on the issue, lots of times you don’t know what you don’t know. Necessity, though, is the mother of invention.

Years ago, physicians caring for people with malignancy had a hard time figuring out what therapies helped, and what didn’t. In some disciplines, success of treatment can be recognized by simple observation. Common practice demonstrated pretty quickly that immobilizing a fracture was at least helpful for the pain, and putting bones back into alignment, and then keeping them there, was key to a functional recovery.

Obvious. Double blind clinical trials were really not terribly necessary for such a gross end result. To some extent, this type of observational study is anecdotal, but since it happens many times the world over, and the anecdotes add up, the evidence starts to approach a quality that is reliable. There are fundamental mathematical explanations of this, but it is also intuitively obvious that larger numbers of observations almost always lead to greater confidence in the conclusion. Almost.

And that’s one place where is gets tricky. But I’ll come back to that.

The Trouble With Oncology

Cancer is one of that last areas of medicine to bow to therapeutics. There is always a level of ‘noise’ when examining the results of any observation. Things happen to people in many random, or seemingly random, ways. It is not really random, but because the causes of variation are so numerous, it sure appears random.

People with cancer have life spans which vary considerably, even amongst those with the same disease, even amongst those diseases with the same stage. I routinely cared for patients with stage IV lung cancer, and when asked for timelines (which patients often request) average survival without treatment was four months, and with treatment they might get out to eight or ten months (it is finally getter better than that, by the way). We could tell them that on average, 90% would die within the year, 65% if they took treatments of some kind.

Notice that in medicine, physicians, especially specialists who can focus in smaller areas of interest and concern, give such answers in terms of probabilities. It has to be given with care and sensitivity, but, in my opinion at least, it ALWAYS has to be accurate. It is a rule of mine. You want your patients to believe you far more than you want them to like you. Never lie to the patient. Express doubt, even ignorance, but never lie.

I have had some patients (not generally lung cancer) live for ten years with metastatic disease, and others live only a matter of days or weeks. If you plot these kinds of events, such as survival over time, within this wide scatter is a trend. The more events you have, the clearer is that trend. At five years, virtually all lung cancer patients with stage IV disease on presentation have passed away. But around that trending curve of deterioration over that five years is incredible variation.

So how do you know, when a patient lives for two years on a specific treatment, that the treatment had any effect? If you compare two patients, one with the treatment and one without, it could end up either way. The problem was, with some treatments, the variation was so large (the noise), that even a hundred patients, or a thousand patients, was not enough to separate random fluctuation from actual treatment effect.

And that is about the same time that very clever people started to use sophisticated mathematics, probability analysis, and experimental designs, to establish a difference we could rely upon. Treatments in cancer were so poor, we could not see the differences within the noise, without very detailed and complicated analysis. To this day, at the extreme of complexity, understanding the science behind all of this is out of reach for any but the few who study such techniques all their lives.

The wide variations and poor efficacy of cancer therapies meant that oncologists had to learn a lot of these sophisticated techniques, and from my experience over the last forty years, we did so before lots of other specialties, because we had to. Otherwise we could not see the improvement over the background noise. Establishing clear proof was also necessitated by the fact that oncology treatments were so toxic. The physician’s maxim, “Primum non nocere,” or “First, do no harm,” was pretty difficult to follow in oncology.

As good as physicians doing this type of research get, it’s not good enough. Every major study using statistical techniques in medicine has a statistician or two in the background working with the authors to plan the experiment and evaluate the data. I entered medicine after an undergraduate degree in mathematics, with a lot of statistics in my repertoire, but I would never dare publish an article without formal professional statistical analysis by a statistician.

Pitfalls of Experimental Design

There are lots of ways, we discovered, of messing up an experiment or an observation. Just understanding the definition of randomness was a start. I remember well sitting in a seminar at the Princess Margaret Hospital in Toronto, forty years ago, where members of the team treating cancer patients were agonizing over the fact that survival curves of treated and untreated patients eventually fell back together…no matter how dramatic the initial improvement…until one observer pointed out that everybody dies eventually, so all survival curves come together. The survival curves were getting out to the normal lifespan, and nobody noticed that the results were competing with human age limits.

Studies,over twenty yeas ago, at my current centre showed that patients who underwent chemotherapy after surgery for esophageal cancer lived longer than those who didn’t. One might think this means chemotherapy helps. It actually does, but this study failed to show that because the two groups were selected retrospectively (not randomly or prospectively with a plan), and the groups were not identical apart from the treatments received. They were different in age by an average of ten years, for one thing, and the group that started ten years older did not live as long, of course. Additionally, it was recognized that patients who failed to adequately recover from the surgery they went through did not then always receive chemotherapy (they were too sick), thus biasing the results towards chemotherapy (basically proving only that sick people don’t do as well as healthy ones).

This last point is subtle. It basically noted that patients who got chemotherapy did better, but also noted that patients who got chemotherapy started off better. Such problems in experimental design have lead to concepts demanding similar populations and analysis based on the original ‘intent to treat’ (patients who are planned to get a treatment get counted in the treatment group even if life’s problems prevent them from starting or completing it).

The analysis of this study was clearly flawed by the selection bias and the age difference…something that the vast majority of people might easily overlook, but that Medical Oncologists are geared to, and trained to, understand. It was also NOT a randomized prospective study, it was an observational study looking back at a bunch of patients. When you look closely at the data, it basically proved that patients who do well with a complex treatment tend to do well. Not really very helpful.

Most experimental designs of clinical trials demand that the two populations being compared are ‘identical’ in every aspect EXCEPT the treatment they receive. If the control group is ten years older than the experimental group (as occurred in that study of patients with esophageal cancer above) one could expect they would die ten years sooner, thus confounding the treatment effect. This is a clear example of bias that can creep in when you are not looking, and extremely intelligent people fall victim to this obscuring effect if they are not extremely vigilant. It becomes pretty clear that people who do not do this stuff all the time may fall prey to confounders and experimental bias. It is subtle. It is powerful.

After all, we are all human, and we really want to see good results.

Because lives depend on understanding this stuff, Medical Oncologists are constantly immersed in this type of evaluation of evidence. But you can understand that not everybody else is. Most treatment effects are less subtle, and most other professions and disciplines have far less profound effects when they make a mistake.

Second Nature

So it all becomes second nature to us, those who practice medical oncology. When someone argues that a comparison of two groups, or a correlation of two populations with subsequent events, suggests a cause and a direct resulting effect, we stand back and look for all the confounding biases. And to us, because we live with this stuff every day, its all pretty easy to see coming. Correlation does NOT equal causation.

A few weeks ago, during a debate between Bernie Sanders and Ted Cruz on health care funding, Senator Cruz argued that patients who obtained private health insurance lived longer than patients who relied on Medicaid. Bernie had no answer to this, it seemed, though in this context he may never have got a chance to respond, or he may have felt the explanation would be lost on the audience. To those of us who understand the relationship between health outcomes and socioeconomic status (physicians, nurses, social workers, health care administrators) the answer was pretty obvious, and not at all clearly related to the quality of insurance or the delivery of health care. People in higher socioeconomic class ALWAYS live longer: more money means better education and better health life style including food, drugs, alcohol and smoking issues. There is simply no need to introduce the insurance aspects to explain the difference, but that is exactly what the politicians did, because they don’t understand evaluation of evidence and experimental analysis.

If a physician, particularly a research physician, made this claim on this evidence, we might suspect fraud, so egregious is this mistake. We recognize he might be right in his conclusion, though totally wrong in how he got to it, and we might still call it fraud, or at the very least, lazy ignorance.

Trump Does Not Understand Evidence

One thing we teach our medical students is to protect their brains. If they read something somewhere, a year later they cannot possibly remember where that informational tidbit came from. So don’t read that stuff, we tell them. Sources of information vary hugely in their quality (so do sources of news).

We teach our students to evaluate everything carefully, but we understand that they must delegate this work to others from time to time. So it is that we teach them to rely only upon peer-reviewed journals of high impact and integrity. Journals in medical information gain a level of respect which allows us to accept their findings based on historical activity. Something published in the New England Journal of Medicine, for example, is well known to be highly credible because editors scrutinize the studies, and peers review the results and report in letters, meetings and other journals. The Journal (NEJM) struggles to maintain that reputation, and if they ever fail, they are outed VERY quickly. In fact, reputable journals like NEJM and The Lancet usually out themselves. The Lancet retracted the Wakefield article connecting vaccines to autism when it realized the level of fraud involved in its production. It already knew the work was inaccurate, but it was the deception that prompted the first retraction for that journal in its history. [see Vaccines… this blog] Inaccurate reports are worthy of discussion. Fraudulent reports are worthy of ridicule (and discussion…this one, among some others, lead to major changes in rules governing authors’ activity in publishing medical journal articles, and medical journal editors in accepting them).

So the reputable journals try very hard not to fail. They do that by having extensive peer review by experts in the field, by having internal evaluations, and perhaps most importantly by inviting and receiving ‘letters to the editor’ arguing for or against certain studies. And they publish opinion articles by experts which lay out arguments for and against articles that appear in their (and other) journals.

There are, unfortunately, many journals where that degree of professional integrity is not maintained. There are some, in fact, that have an preconceived agenda, either because they are actually produced by a pharmaceutical industry, or have a major connection to an organization with a vested interest in an ‘end result’. Some, for example, want to promote religious belief, and the power of prayer, or the power of Christian values. We know that, we know which journals carry this type of bias, and we take that into consideration whenever we evaluate evidence, starting with avoiding those sources completely. And we teach our students not to read those journals.

Because a year later they cannot possibly remember where that informational tidbit came from.

Many people do NOT understand this structure of evidence evaluation. Those of us who deal in evidence every day know that we have to start with an evaluation of the source of evidence, then of the logic of the evidence, then of the design of the experiment or observation. One thing upon which we all agree is that wonderful statement by Christopher Hitchens: “Anything which may be asserted without evidence, may be dismissed without evidence.” Dismissed as proof anyway. But idle chat and random thoughts, as well as disciplined thoughts, can and do lead to hypotheses to be investigated and tested.

It is somewhat similar to the another principle, this time in physics: “If the event cannot be observed in any way, it does not exist.” Physicists argue that if you cannot observe something, it is sort of pointless to talk about it.

Trump does not understand evidence. He is not alone, although many people seem to come by some form of evidence evaluation naturally, without formal education.

The source of information is clearly extremely important. Certain news agencies do not cut it because they have a history of not cutting it. “Future behavior is best predicted by past behavior.” If one of my very intelligent friends who never says anything without good supporting evidence, actually says something, I am more inclined to believe them than I am someone who never gets it right.

So when Trump uses politically motivated sources of information, it is suspect. When he uses sources that often get it wrong, it is even more suspect. When he uses Fox News, when they offer no evidence, and restates a meme without other independent evidence, his argument can easily be dismissed. Because in that context, if it is true it is completely coincidental.

The problem is that Trump never cites any evidence. He does not have the evidence to cite. Indeed, it seems he does not care about it. The people he speaks to are not waiting for evidence, they are waiting for him to make the same claim three times, usually in rapid succession.

“Fake news. Phony. Fake.” This was his claim at the CPAC speech. No evidence, just the claim. But he never points to an example. Indeed, often it is in response to corrections the media has made of his comments, pointing out his fake news, such as the claim of a landslide victory, which his election result clearly was not.

“Believe me.” He says this repeatedly, as an alternative to evidence. “Believe me.” Why? Nobody ever answers ‘why’.

“That Which May Be Asserted Without Evidence May Be Dismissed Without Evidence.”

So when Trump states that Hillary Clinton lied, if he cannot provide evidence, that statement should be dismissed. When he says some terrorist action occurred in Sweden last week, and provides no evidence (outside of saying “Someone said it,” or “I heard it from some people,” both very common Trump supporting statements), the thought he expresses should be dismissed. The big problem is that Trump NEVER accurately identifies his evidence, and you really have to assume he has none, if none is supplied. I have listened to him assiduously, to my extreme detriment, for the last year, and could count on my fingers the number of times he refers to some article, never to a source which is as reliable as a scientific or medical journal.

Trump makes such blanket statements all the time. “I inherited a mess,” he has said. No evidence. If you dig, the evidence is actually contrary. Trump says something is a disaster (well, he actually says this about everything) but never gives any evidence. Consider unemployment. Trump says unemployment is a disaster, though all apparent evidence suggests unemployment is at one of its lowest rates.

There are times he gets more sophisticated about his dishonest comments. The rate of change in murders jumped in 2015, in part because the rate was so low in 2014 (probably a reporting and clerical error, but murder rates are based on a huge number of variables). He jumped on that point to promote his fear riddled approach to his underlying desire to promote authoritarian rule through police and military. He overlooked the reality that murder rates (not rate of change) are massively lower now than they were thirty to forty years ago. In addition, the background ‘noise’, as in any ongoing observation of large numbers, does not allow us to figure out if this rate change is anything other than random variation.

But ‘cherry picking’ (taking results which are favorable to your agenda) is really the same as lying, if you know you’re doing it, or simply lazy, if you don’t.

Lies

If I tell you two plus two equals five, and I do not understand addition, that is not a lie. It is a mistake.

If I say two plus two equals five, and I know it equals four, that is a lie.

If I say two plus two equals four, and I really think, because I am not too bright, that it equals five, that too is a lie, even though the statement is correct.

If I say two plus two is five, and I know it is four but I say it is hyperbole or humor when someone catches me on it (but I say nothing if no one objects), that is a lie.

That’s what Trump does when he says Obamacare is a disaster. Or when he says Mexicans are rapists. Or all the other countless exaggerations for which he is forgiven in the right wing media that supports him. “Oh, that’s just Trump,” they say, dismissing complaints of lying because getting truth from your president isn’t as important as promoting the right wing agenda.

We humans project. We actually try not to lie, for the most part. We tell ourselves we never lie, though we know we do a little bit (“No dear, that hat looks lovely”). And we treat other people as if the potential for lying, real lying, is very rare. We are always surprised when it happens. The blatant lie right to your face, the ‘gaslighting,’…we simply do not expect or anticipate that, and much of our communication is colored by what we expect.

Evidence suggests that I have a pretty stable, confident brain that takes time to carefully decide things. And yet, thirty years ago I observed an event which I could not believe was possible, which I could not emotionally deal with. I pushed it out of my mind. I denied it. No one else was really hurt by this decision of my subconscious brain, and I hope that had there been any detrimental effects on others that my facing this event could avoid, I would not have denied what I saw. About a year later when the consequences of that event doubled down with other similar events, I remembered it, but it was the clearest, most powerful example of cognitive dissonance that I have ever seen, and it was all mine. To this day I find it hard to believe my brain is capable of that kind of self deception. It makes me shiver to think about it. The lesson is that we can deny what we do not wish to believe.

As a medical friend of mine suggests, “There are none so blind as those who refuse to see, none so deaf as those who refuse to hear.”

Accepting that someone can lie at every opportunity is too threatening to our world view to accept.

Professional Lying

Lying in medicine occurs very rarely. Even when is does, it may not be in the awareness of the authors. Generally, medical authors believe what they are concluding, even if they fudge the data a bit to support what they believe to be true. But when it does happen, as it did years ago in a specific breast cancer treatment, or in the retracted article about vaccines and a relationship to autism, it takes everybody by surprise, and it takes a long time to sort out. We project our honesty on to the person telling us stuff, and we simply do not expect anyone to lie all the time.

Lying in politics is probably far more common than in medicine (I’m not really denigrating politicians here; in medicine your thoughts are carefully written down and analyzed. In politics they can be ‘off the cuff, in the moment’ and getting it all as right as I describe here can be close to impossible), but mostly it amounts to making claims without supporting evidence, or ignoring data that doesn’t agree with your preconceived conclusions. Lying to shore up your own reputation, to support your exaggerated opinion of your own value, lying to make the claim you are better than everybody, at everything, is actually very rare. “I understand better than the generals do,” or “I understand…better than anybody.” When he says that, what are you thinking?

We humans are not used to dealing with someone who lies all the time. Even as I say this about Trump, who I know by now lies almost every day, I find it difficult to accept, to believe. We hear people right now simply saying that ‘that is Trump’ and setting the dishonesty aside. Rick Santorum, last night after Trump’s first speech to Congress, when cont=fronted with some of these lies replied that is was pretty minor stuff for a president.

When Trump stated there were crowds lining up to hear him at the CPAC (a ticketed event with no line-ups), he didn’t care that he didn’t know that. When he said he had the highest electoral college result in history, and was confronted with the truth, his response was simply to say he had heard this somewhere, the implication being that this was sufficient justification for this lie. “Some people say,” and “many people think,” are phrases he has used, phrases which are the closest thing to evidence he appears to cite.

I remember wondering what Trump would do when people started to see the patterns, started to recognize that nothing he says is reliable. I remember how long it took me to unblock that terrible event I observed.

But I should have known. Trump told us what he would do. He would counter-punch.

And so now Trump is attacking the news sources that are finally calling him out on all his lies. They are ‘fake news’ and he has banned the most reliable ones from a recent media event.

“Fake news. Phony. Fake.” He says it three times, often punctuated by, “Believe me.”

And that’s all the evidence he gives.

In truth, I do not know if Trump can evaluate evidence. The example of murder rates says he cannot. But the constant lying says evidence is not important to him. Maybe he can understand evidence. “I have a very good brain.” “Only I can fix it.”

Even a Medical Oncologist can see the problem with evidence here.

It’s not just that Trump doesn’t understand evidence. He just doesn’t use it.

 

 

Karate and Health

Fighting Brian

The author, a socially inept introvert, is on the right foreground, is about to be gently kicked by his friend, Tom. Many other friends in the background will also kick him during the course of this class. Don’t worry. It doesn’t really hurt.

Introduction

I came across this essay in my files, cleaning house getting ready to move. Sadly, I was forced to retire from martial arts training and teaching a few years ago. I was 65 years old at my last black belt grading in East Lansing, Michigan, retiring shortly thereafter at the rank of Sandan in Shidokan Karate, with a previous rank of Yondan in Chito-ryu Karate.

One of the greatest highlights of my life has been helping to start Grand River Karate with Sensei Fortunato Restagno (and a host of so many others), and now my grand children are about to start this journey, too. Because of their youth, and the subsequent natural ‘worry’ of their parents, I have taken the opportunity to dust off this essay. I have not changed it since the day I submitted it, and was ultimately awarded my first degree black belt by Sensei Jake Klaus and visiting dignitary Sensei Cezar Borkowski. Thus it lacks a certain maturity, and the medical references are not ‘up-to-date’; in particular, the fitness craze is no longer novel.

But there is much truth in these thoughts, and I think much solace to be gained in parents worried about engendering violent behavior in their children, or injury to their loved ones. Karate is a beautiful sport, under appreciated in our society still. I have never been in a fight since I was fifteen, long before I entered a dojo, but I am convinced karate saved my life. You may wish to read to see if you can figure out how and why.

Karate and Health

Brian Dingle, BSc, MSc, MD, FRCPC

1985

Submitted as part of Shodan Requirements, KW Karate (Sensei Jake Klaus)

“Health is a state of complete physical, mental and social well- being and not merely the absence of disease or infirmity”. This all-encompassing definition is included in the constitution of the World Health Organization (3), and provides a suitable standard against which the effects of any life-style may be evaluated. To establish the benefit of any life pattern to the health of an individual, be it the absence of smoking, the choice of diet, or the program of physical activity, one must look at the physical, mental and social implications of that pattern. On superficial examination, the study of a martial art would appear to benefit only the physical aspect of health; that the mental and social aspects of health are also developed is perhaps inherent in the meaning of the words Karate-do, for as the master, Gichin Funakoshi, writes
” True Karate-do is this: that in daily life one’s mind and body be trained and developed in the spirit of humility; and that in critical times one be utterly devoted to the cause of justice.” (5)
As a physician, I am dedicated to the “promotion of health” In the broadest sense of the phrase; to show the reader that the practice of Karate approaches this goal is the purpose of this essay.

Social Well-Being

“Karate-do begins and ends with courtesy. If superior to their teacher in skill, the disciples should never forget to respect their teachers.”

Zenryo Shi madukuro
1909-1969 (5)

As with any group endeavor, the practice of Karate requires talking and cooperating with other people. Being adept at these social skills is the essence of social well-being. Most adults and many teenagers have acquired these skills, though there is wide variation as to the degree. There is a moderately rigid social structure to Karate with both a hierarchy and a ritual, as in any religion or society. The structure provides comfort for those less socially secure, for the choice of behaviour in any social interaction is removed: the individual knows the ritual and so knows what is expected of him. He bows to Shomen (the front of the dojo) on entry and exit to show respect for the masters and the art; he bows to his partner or opponent before and after any practice session; and he bows to the instructor at the beginning and end of the class. He refers to his instructor with a special term of respect, ‘sensei’, and he soon views other higher belts (quickly identifiable by the colour) with a similar but “pro-rated” respect regardless of their age or social background outside the dojo. Importantly, he expects and receives similar treatment. There are no lingering doubts to this social interaction, and the individual can relax within this structure; even though he meets and talks to new people, even though he is called upon to touch or even “attack ” other individuals, the anxiety is limited because the structure of his behaviour is already set down. Even the most shy of us can do it, and its repetition buiIds confidence that inevitably extends to life outside the dojo.

The rituals of Karate at first may seem silly to the observer, but they have become second nature to those of us within the sport. Few of us think of these rituals but all of us practice them when we enter the dojo. The repetition and practice of the social rituals within Karate are of benefit to all: the child or the adult, the recluse or the socially adept. They are carried out even in the most adverse situations, as when experiencing exhaustion or defeat, or when facing someone (even someone unknown) who has just inflicted pain. Under such adversity, to smile, bow, and quietly walk away is a significant measure of social maturity.

Both the discipline of the class and the respectful behaviour displayed provide a useful model for children. Additionally, in contrast to North American “macho ” virtues popularized by television violence, the “no first strike” philosophy of Karate is emphasized; the training forms or kata always begin with a block of an imaginary attack. Participants are taught to run rather than to fight, to avoid confrontation in the first place for “…to win one hundred victories in one hundred battles is not the highest skill. To subdue the enemy without fighting is the highest skill.”(5) The self-confidence gained by the knowledge and practice of a martial art helps prevent playground fighting. It is the ego of the child in all of us that pushes us to submit to the urge of violence, and it is far easier to resist this urge when we know in our hearts that we could win.

Thus, in a general sense, the karate-ka practices the skills of social well-being with both friend and foe. More specifically, the camaraderie in the dojo may lead to lasting friendships, perhaps one of the most important aspects of social well-being.

Mental Well-being

“The ultimate aim of Karate lies not in victory nor defeat, but in the perfection of the character of its participants.”

Gichin Funikoshi
1869-1957 (1)

Mental well-being is, of course, closely allied to social well-being, but deals more with how the individual perceives himself. Mental health refers to “the ability to maintain an even temper, an alert intelligence, a socially considerate behaviour, and a happy disposition.”(8) There is little doubt that exercise in general can improve mental well-being, and exercise programs are prescribed by physicians to help patients both physically and emotionally.” (10) Paradoxically, chronic fatigue, often a sign of depression, responds well to an exercise program, in spite of the fact that most patients worry the added exertion will only wear them out further.

Most of us have experienced depression or stress at some time in our lives, and are well aware that hard physical exercise helps to suppress or even eradicate these feelings. While the mechanism of this improvement is still unknown, alterations in certain hormone levels and increased blood flow to the brain during peak physical activity probably play a large part.

While valuable for mental well-being, as is any exercise, Karate is not simply a form of physical exertion. “Traditional Karate training has always been concerned with deeper issues pertaining to self-discipline, self-awareness, control, mind body harmony, mental strength and relaxation, and personal development.” (8) The concentration required in a normal class drives other issues from conscious thought, providing a form of mental relief from the day’s stresses.

Drs. Konzak and Boudreau have attempted to measure the development of mental skills and personality changes in eighty-four Karate-ka (Karate participants) at two schools in Toronto. Their findings implied an improvement in a large number of personality factors including intelligence, self-sufficiency and tender-mindedness.(8) They conclude that studying Karate “…can enable (an) individual to experience a sense of personal physical and mental competence that is consistent with…mind/ body harmony and well-being.”

Karate has been of particular help to me in the management of stress. Caring for the terminally ill can be an emotionally draining experience, and forgetting this work at home can be difficult. I had tried other sports, but all left me thinking of my patients even as I participated. Karate was different. The effort in concentrating, the exhaustion, even the ritual meditation at the beginning of class made me forget the problems of my work. Soon this became a conditioned response, so that now I find my mind emptying even as I enter the dojo for a class. Colleagues and friends have asked how I can find the time for such a sport, but I have no doubt that Karate has helped increase my “productivity” above the time spent at it.

Physical Well-being

“It is my aim and ultimate goal to assist in the mental, physical, and spiritual development of our youth so that in the future they can better contribute to the demands of our society…”

Dr. Tsuyoshi Chitose
1898-1984 (5)

Few would deny that exercise is beneficial for physical well-being. Indeed, as the fitness craze takes North America by storm, doubters are considered heretics; all forms of miracles are attributed to running, squash, dancercise and some of them are even true.
In a very general sense, repetitive exercise allows an individual to complete the same amount of work more efficiently. Strength is increased, and the ability to transfer oxygen to the body’s tissues is enhanced. The same degree of work gradually requires less effort, and can be sustained for longer periods of time.

The amount of exercise necessary to improve fitness is substantial, generally estimated to be thirty minutes of moderately intense activity at least three times a week. The intensity of the exercise must be such that the body is achieving seventy per cent of its maximal oxygen consumption. As maximal oxygen consumption increases with improved fitness, the exertion required to continue progression also increases, so that all will eventually reach a plateau.

Signs of achieving seventy per cent oxygen consumption are mild to moderate perspiration, (warm, not the cold drenching sweat of illness or extreme exertion), mild breathlessness (still capable of speech and upright posture) and a pulse between 1 40 and 160 (for those aged 20, seven beats less per decade thereafter). As this degree of exertion must be maintained for thirty minutes, we’re not dealing with a walk in the country or a game of golf. A Karate class usually covers this requirement, with room to spare.

As an individual becomes more fit, the heart expands slightly, increasing the amount of blood pumped out each beat. The tissues extract a greater amount of oxygen, and consequently the resting heart rate drops. Blood pressure drops, the level of cholesterol available to harden arteries decreases, and the heart and lungs acquire greater reserves for times of illness or trauma. As muscles supporting the various joints and spine strengthen, common rheumatologic conditions such as chronic backache, fibrositis, and unstable joints improve.

The question is not so much whether exercise can produce these benefits, but rather which exercise can do so safely. Those watching an advanced Karate class might well be concerned over both the intensity of the exercise and the possibility of trauma.
Recent publicity of deaths of marathon runners, particularly the death of the fitness author James Fixx, gives cause for concern over vigorous physical exercise. However, medical researchers and epidemiologists have shown that although the risk of sudden death is greater during hard physical exercise, the overall decrease in risk at times other than exercise more than offsets this small hazard (9). Thus for the average healthy person, one need not be worried about participating in vigorous exercise; one rather should be worried about abstaining.

Trauma is a problem with any sport, each sport seeming to have its own peculiar “brand” of common injury: knee and shoulder injuries in hockey, football, and basketball; eye injuries in squash; head injuries in boxing; shin splints in running. Disregarding the pulled muscles, stiffness and minor scrapes that occur in all sports, the incidence of injury in Karate seems to contradict the apparent “violence.” In one large study it was found that serious injuries occur only rarely(1) and then mostly during sparring in competition. This is largely because of the control that is emphasized in all styles of the martial art. Certainly Karate compares favourably to football and hockey where deaths and paralysis are known to occur.

The usual injuries in Karate are pulled or torn muscles (generally the hamstrings in the thigh), digital injuries (toes and fingers), and hyperextension injuries of the elbows and knees. All are due to faulty practice or technique, and tend to decrease as the participant becomes more experienced. Proper warm-up and stretching routines are strongly emphasized (much more than in any organized sport or physical education class I’ve observed). The injuries I have seen in class or as the attending physician at competitions have always been minor, rarely resulting in time off from training. 

Conclusion

Karate is an individual sport which can be practiced as a group, or a group sport which can be practiced individually. Each participant progresses according to his own effort, age, and body type, and room for improvement is always present regardless of an individual’s proficiency. Special equipment is generally not required, and any medium sized room or lawn is sufficient space. Thus the sport can be continued throughout an entire lifetime, barring serious illness. The practice of Karate advances social,
mental and physical well-being.

In every sense of the phrase, Karate promotes health.

Bibliography

  1. Birrer, Richard B., and Birrer, Christina D.: Martial Arts Injuries. The Physician and Sports Medicine, 101(6): 103-108, June 1982
  2. Borkowski, Cezar: Modern Shodokan Karate; Masters Publications, Japanese Karate Academy Ltd., Hamilton, Canada, 1983
  3. Clark, Duncan W. and MacHon, Brian: Preventive Medicine J&E Churchill Ltd., London, 1967
  4. Feld, Michael S., McNair, Ronald E., and Wilk, Stephen R.The Physics of Karate.Scientific American 240: 150-158, April 79
  5. Funakoshi, Gichin: Karate-Do Kyohan; Kondasha International Ltd., Tokyo, New York and San Francisco, 1980
  6. Funakoshi * Gichin: Karate-Do, My way of Life; Kondasha International Ltd., Tokyo, New York and San Francisco, 1982
  7. Higashi, Shane Y.: Chito Ryu Karate; Chito Kai, Toronto,
  8. Konzak, Burt and Boudreau, Francoise: Martial Arts Training and Mental Health: An Exercise in Self-Help. Canada’ s Mental Health 32(4: 2-8, Dec 1984
  9. Siscovick, David S. et al: The Incidence of Primary Cardiac Arrest during Vigorous Exercise. The New England Journal of Medicine Oct 4, 1984
  10. Walker, Herbert E.: Occupational Therapy and Other Therapeutic Activities, Comprehensive Textbook of Psychiatry/ IV, Vol 2, Fourth Edition, Williams and Wilkins, Baltimore, 1985

Fast forward, December 20th, 2016: For those parents reading who are in London, Ontario, or Guelph Ontario, two other excellent affiliated dojos are London Shidokan Karate, Sensei Larry Bowlby, and ShidoKan Canada, Sensei Roy Paul. In Kitchener-Waterloo, of  course, is Grand River KarateThese are great schools with kind, welcoming instructors, and are part of the same much larger international organization Beikoku ShidoKan, lead by Sensei Seikichi Iha, Hanshi from Michigan, USA, which also includes Grand River Karate. Sensei Iha, in particular, sets the tone of these dojos emphasizing friendship as the most important value.

“You’re Grounded for Doing a Trumpy”

Donald_Trump_August_19,_2015_(cropped)

“Keep your head down, keep on working, and always keep the police on your side.”

It’s the only way to get through this. Learn from it, deal with it.

The day after someone like Trump wins the election, all the pundits in the world can examine the data, but those of us who are clever and are survivors will think of what to do.

What to do.

They are rioting in the streets today.

Usually such degree of unpopularity in a president is only achieved at the end of their terms, not at minus seventy-two days!

A Pettiness I Must Expiate

I do not like that the American people have elected such a man. I do not like his surrogates on CNN, who bristle with largely ignorant hubris to my eye, and for them to end up winning, and gloating, is very hard to bear. I am offended and insulted, and aggravated by their assumption of correctness that I cannot dent. It is a pettiness of mine.

The only way to bear it is to recognize that the majority of Trump’s supporters do not approve of his arrogance, his dishonesty, his misogyny and his braggadocio.

But What About the Children

I watched Van Jones, tearfully, asking, “How do I explain this to my children. I have friends who ask if they should leave the country…this was a whitelash!”

What to do. Van Jones will come to the answer, but I know what to do. And he will too.

“Keep your head down, keep on working, and always keep the police on your side.”

This has been my mantra for years, though I change it subtlely when I work in a hospital, as I normally do: “Keep your head down, keep on working, and always keep the nurses on your side.”

In politics, obviously, you have to take the good with the bad. You never get everything you want in a single candidate. That is the essence of democracy. You only get one president, and whoever they are, they cannot be all things to all people.

 What Were They Thinking?

The realization that came to me this morning, after many tears in the middle of the night, was that our friends to the south were not embracing the hubris in their president. Nor were they embracing the misogyny. They don’t really want their president to be a failure as a business-man, who declared bankruptcy four to six times to milk the system. Nor do they want their president to stiff his creditors, or cheat the tax man, or to brag so egregiously. They don’t want their president to rape women, or even to grope them, which is essentially the same thing. They don’t really want him to be a liar, or a cheat, or an ignoramus. In fact, they probably want him to be a hero, but nobody can be a hero in this day and age.

But you have to take the bad with the good. They wanted a change…a change from the politicians who they think are fixated on self-interest, and continued unrelenting control. They wanted a change from the stagnant economic doldrums, even though no leader can deliver them from those doldrums. They wanted someone to re-establish American hegemony, when such power has quite naturally passed them by. They wanted someone to make them lovable again, when years of self-centered American dirty trick foreign policy which created the hatred they feel so keenly in the backs of their necks, make them anything but lovable.

They wanted a miracle and they thought change in any form would give it to them. Or at least give that miracle a chance.

It was an unholy alliance of the con and those who wished to be conned.

 The American Dream

Americans want the American Dream again, but it is a mirage. They want to know that if they work hard, they too have the chance to become a Trump, or a Buffett, or a Gates, or another billionaire, when in fact, such occurrence is based often more on good luck than good management.

The American Dream has always been built on slavery. Of some kind, anyway. Four hundred years of slavery, which in latter years has been transformed into the more subtle ‘gap.’ Instead of ‘work for nothing,’ it is ‘work for pittance,’ when the 1% control the wealth of the 99%. And rich white old males reap the American Dream while asking others why they cannot succeed, others who can only pine for the excesses enjoyed by the few. But that distant allure only encourages them all to persist with a system that seems to make such dreams possible.

The Donald epitomizes the American Dream: inheriting wealth which self-perpetuates no matter how incompetent the beneficiary happens to be. Maybe they inherited money, or fame, or status, or class, or education, but whatever it was, that quality put that individual a step above others, and that advantage is what every American Dreamer pines for.

To get ahead.

Like the two hunters, one putting his shoes on while the other urges him to run, the first explaining that he doesn’t need to out run the bear that is coming, he just needs to outrun his friend who is urging him on.

In the end, as superficial as it was, old white males, and a whole bunch of their followers, decided to ignore Trump’s obvious faults, Trumpies, if you will, and instead decided to follow him over the cliff if only to get some kind of change.

Maybe that desire for change is healthy, after all. It’s what Bernie offered too, but in the end, the system decided Trump might succeed where Bernie would not. Or perhaps one part of the system knew that Bernie would succeed, and so he needed to be suppressed.

Basically, the American people decided that Trump’s obvious faults, the Trumpies, were ones they could live with and ignore, as long as he also provided the change they saw in his empty promises.

And it all makes a bizarre kind of sense. Americans, for the most part, do not need a role model to demonstrate how to behave. They know already that they should not be liars, or sexual predators, or braggarts, or cheaters, or conspiracy theorists. So they don’t really have to worry too much if their president is one of those, or even all of those. What they want is someone who will deliver them from the doldrums, who will return them to the prosperity they enjoyed in the past, even if all reality informs them they can never enjoy it again in the future.

So they voted for someone with empty promises balanced against faults they need no instruction to avoid.

“Grab their pussy if you must. We know that’s wrong, and we won’t do that. But while you are at it, could you show us how to make American great again without all the cheap labor from slavery? Could you show us how to do that? If you do, feel free to grope women, because we think it is probably worth it to old white male dominance, to know how to make America great.”

So, What to Do?

Americans, for the most part, do not need a role model to demonstrate how to behave. Not when they have something almost as good: a role model to demonstrate how NOT to behave.

Maybe the president should not primarily be a good positive role model. Maybe that’s too much trouble, and generally unachievable except rarely, as in Carter or Obama.

After all, there are excellent negative role models out there that even an outsider like me  can see: Nixon, JFK, Clinton (Bill, of course).

But What About the Children

What to do for our children?

This is an ideal win-win opportunity. Trump, as an example, can teach our children two major lessons.

The first, of course, is that the political democratic process can, and does, put despicable people into positions of power. Not everybody who becomes a major leader is worthy of respect. We all know that. Now we can point to a prominent example that can explain the issue to our children.

The second is to point to the individual obnoxious characteristics:

“Grab them by the pussy.” No son. Don’t do that. It is illegal and you could end up in jail for ten years. It is an assault and is disrespectful of women. Women are people (since 1920 anyway…). Yes, you can tell your children about the historical white male dominance that persists in many subtle and not so subtle ways. You can point out how a disparity in physical strength does not justify it’s use, any more than disparity in financial or political power, or even intellectual power, can justify any related abuse.

“I know more than the generals do.” Ideal examples for the six and seven year olds (Donald’s arrested development?). When they challenge their adult overseers that they know how to dodge traffic on a busy highway, you can call it a Trumpy. “He doesn’t know more than the generals do, and he doesn’t know how to dodge traffic. And neither do you.”

“Many people say…” Here we can teach the children the difference between logical fact based argument and sleazy innuendo weasel words. “Notice how the president uses language which cannot be disputed but is totally specious. Never say ‘Many people say…’. That’s a cop out. It’s a weasel argument; it’s a lie. It’s a Trumpy.”

It is an opportunity to show children how questioning the birthplace of someone clearly born in the United States is a not so subtle bigotry that is certainly designed to discriminate against their race. “You have no right to question something like that without at least a hint of evidence that raises the concern, and having a middle name that is from another religion is simply not enough. And it’s a silly antiquated law anyway, designed for a different time.”

“They’re bringing drugs, they’re bringing crime, they’re rapists and SOME I ASSUME ARE GOOD PEOPLE.” No, daughter dear, such smear statements of fear have no place in the polite conversation. Such generalizations are inaccurate and unfair, and dishonest in terms of numbers and predominance. And ethnic discrimination like this is never an acceptable method of argument.

“God has chosen President Trump.” No son. God did not choose president Trump. Why would he? If there were an omnipotent, omniscient, all powerful deity, would he pick a dishonest, adulterous, uncivil, ill-mannered man who brags about groping women, hell, who brags about everything? Of course not. No. If there were a god of the bible, he would not choose a Trump. He probably would not even choose a Clinton. If there were a god, and the deity made a choice, they would not even be as fallible as an Obama. No son, there is no evidence of a god. We have to make it on our own and make better choices next time.

World Leaders are Not Infallible

There is a tremendous lesson in finding such fault with a world leader. We hold these people in too great esteem. To be able to point at the president and explain the fault to a child is a powerful message. And with this man, there are so many opportunities, so many Trumpies.

If we accept that the election of a man like Donald Trump is not a celebration of his obnoxious characteristics, but instead a frustrated call for some kind of change, if we accept that the American people have decided that their president need not be a saint…if we accept that the vote was, rather, a repudiation of the status quo, then we have a wonderful opportunity to advance the education of appropriate civil behaviour for our children (while also feeling a little better about the American people themselves).

We can achieve this so easily now by pointing a finger at the new president and saying, “Don’t do that. For god’s sake, don’t do that. If you do, you’re grounded for doing a Trumpy.”

Obsessed With The Trumpster

 

Writer’s Block

It has been a long time since I have been able to write. Writing is a personal thing that takes more out of you than I thought.

“Writing is a very personal thing. Writing is working with words in a way that exposes intimate parts of oneself, that reflects who you have become and even how you have become it. Writing is a labor, a travail, a molding and caressing of thought and experience, to be worked and reworked, in times of explosive creativity that cannot be resisted, or later in struggling emptiness of thought. It is a task, which is at the same time an unwanted compulsion and a nagging fruitless exertion.

And it is Sisyphean. Completion is always just out of reach.

The introspection of writing can be narcissistic and selfish. It is doubly selfish in that if the task never ends, perhaps I will not have to leave.”

Excerpt From: Brian Henry Dingle. “TROJAN: Nefra Contact.” Chapter One: Postlude. Available at Smashwords and Amazon and other fine eBook stores. 

Writing is tenuous and fragile, in my hands at least. I have been unable to write for many months. The quotation above is from my first book, second to be published (well…self-published, anyway). One of my fans liked this passage, and asked me if it were mine. I was actually very proud of that question. Thanks Barnie.

Tenuous and fragile, I have been unable to write during these months of the American election primaries. ‘Feel The Bern.’ Oh Bernie. You are so good, I wish it had turned out otherwise.

 

Donald_Trump_August_19,_2015_(cropped)

Trump Terrifies Me.

 

I’m not afraid of a lot of things, but Trump terrifies me. One of the fundamental characteristics of a good physician is self-reflection. We teach our students this, and we examine their ability with it. It is probably important in many endeavours, but I would argue none more so than in medicine, for we cannot police everything that doctors do; we must rely on their ability to self-reflect. That’s why it is so important. Lives depend on it.

Trump terrifies me.

Why does Trump terrify me?

I realized several months ago that the ‘idea’ of Trump is not the terror, narcissistic, ignorant, belligerent bully that he is. There are lots of these. We all know some, though, I confess, I’ve never really known one as bad as Trump. I’ve certainly known some serious narcissists, blowhards and know-it-alls, but mostly they are powerless, and so not so much terrifying as embarrassing.

No, it is the idea that Trump has so many who follow him; that is the terror.

 

 

The Blowhard

 

“I have a very good brain.”

He was asked about whom he consults for advice. He could think of no one better than himself. Surely there is someone else? Are not two heads better than one?

“I have said a lot of things.”

Yes, not all of them very good, though.

The self-aggrandizement of this man is breath-taking. Truly. It’s like being hit by that inside line-backer as you try to come through the line. Breath-taking.

“I am very smart.”

Who says this stuff? Virtually with everything Trump says, I am reminded of Christopher Hitchens (Hitch). Whenever someone presents a position and claims that it is an argument (irony here: Trump does this ALL the time), simply think ‘Hitch,’ whenever you see or hear unsupported assertions.

There are ways to paraphrase Hitch, but his words are good enough: “That which may be asserted without evidence, may be denied without evidence.”

Wonderful.

Another form, and I cannot remember who said this: “If you cannot show it, it does not exist.”

When I first heard Trump say that he, Trump, was very smart, it was in the context of attending the Wharton School of Business. I assumed he had done an MBA. I, academic snob that I am, assumed no one would brag about anything short of a graduate degree. An MBA from Wharton (the toughest school to get into, according to Mr. Blowhard) is credential enough for anything, for riches and success, for the highest office in the land, for Commander–in– Chief, he appeared to be assuming.

What does Trump have? Two years at U Penn, and a transfer to Wharton for two years in Real Estate finance?

I wonder how many assumed it was better than this, simply because he said he attended one of the best schools. Rumours that he stood first in his class have never been denied by the Donald, as far as I know. And he has the best brain. And the best words.

“I have the best words.” He really said that.

Maybe he does. He just cannot string them together very well. I am waiting for, “I have the ‘goodest’ grammar.” I’ve certainly heard him have trouble with objects versus subjects, and adjectives versus adverbs, and I suspect he has no knowledge of subjunctives, but I have trouble with that. If I were him…well…

Apparently his classmates don’t remember him. Worse yet, it seems they really don’t want him to talk much about his connection with Wharton. But I cannot be bothered to look up that particular post, so, think Hitch, and dismiss that thought.

What I really would like is to see his transcripts. There are words out there that Trump has never disputed, that claim he stood ‘first in his class.’ I guess that depends on what you mean by ‘his class.’ The best arrogant rich-kid?

He has never produced his transcripts (or his taxes) so maybe they are like Obama’s birth certificate. Except we now know that Obama really was born in Hawaii, while we are pretty sure Trump really was not Magna cum Laude. In fact, he wasn’t Magna cum Anything. Maybe Magna cum Narcissism. Magna cum Digiti Minimi. It’s Latin, Donald. Like Bigus Dickus in that movie, “Life of Brian.”

Think Hitch. “That which may be asserted without evidence…” Do we need more evidence? No. This one is too easy, he is a blowhard.

 

Leadership

 

Why do we need a civil leader in the White House? Americans would call this civility, ‘Presidential.’ There are lots of people out there in the Global Village who do not have the same culture, the same context. There are people out there who may think that if the leader of the free world calls them a ‘disaster,’ that they need to raise the ramparts and dust off the nuclear warheads.

From our point of view (the Canadian point of view), the biggest current threat to our sovereignty is American foreign policy. If American relations with some nuclear power, formal or terrorist, disintegrate to a level where their opponents just say, “Ah, f*** it,” and sneak a dirty bomb into New York, Canada and the USA could be blown back to the early eighteen hundreds or late seventeen hundreds, or worse, just from the economic fallout.

This is probably the greatest threat from a Trump presidency.

“The greatest honour comes not from defeating your opponent in battle. The greatest honour comes from defeating your opponent without even fighting.” Gichin Funakoshi, Father of Japanese Karate. Trump does not understand this concept, but Obama does.

Obama has tried to talk to his enemies. He was chastised for this in the last election campaign by the Republican hawks, who seemed to deride the idea of ‘talk’ as over-rated. The deal with Iran over nuclear proliferation is an example. Trump calls it a ‘disaster’. If it works, Iran will never have nuclear weapons. Might be worth it.

Talk is cheap. Cheaper than nuclear fallout in the stock exchange.

It is simply far too easy to bring a nuclear device into North America, and as a Canadian, in the words of Tom Lehrer, “When the bomb that drops on you, gets your friends and neighbours too, there’ll be nobody left behind to grieve. And we will all go together when we go. Every Hottentot and every Eskimo…”

There are other quotes, like Robin Williams: “Canada is like that cozy little apartment sitting above a meth lab.”

Talk is cheap. Cheaper than nuclear fallout in the stock exchange. But some talk is specious.

“We’ll beat ISIS so fast. Believe me.” Twenty billion tons of TNT will not prevent the devastation of one dirty bomb in Washington. That’s what tough talk can get you. Why not listen for a change?

You want to know that your leader is not going to push the button for just anything. If the ISIS leaders call him Little-Finger, (Lord Baelish), what nuclear conflagration will follow as Trump’s face turns red in his fury?

 

Knowledge

 

This requires the least argument. To understand Trump’s knowledge, or lack thereof, one only has to listen for a little while.

His statements are vacuous and spurious. He has positions, not arguments (I read that somewhere…wish I could find the reference). Everything he says begs the question, ‘How,’ but is never answered. This anticipated two-step, position supported by explanation, is followed by his voters for only one step. The little dance is never finished. They never get to the second step. Never realize its importance.

“Believe me.” That is Trump’s only second step. Argument over. Trump out.

‘Disaster. Incredible. Sad. So sad. Terrible.’ These are his statements of the first step. Simple and effective in themselves, only thinking people (not Trump followers) ask for the second step, and by that time Trump is off doing something else. Tweets do not lend themselves to a second step, and Donald’s only language is tweet.

He speaks tweet.

Take any Trump policy about any issue, and I can tell you what it is. “We will destroy [insert issue] and I will make it great again. Believe me.”

Next topic.

 

Bigotry

 

There is a dichotomy here. Bigotry often means an inappropriate bias against a minority or ethnic group, or a gender group. Ivanka’s defence of her father about his statements about women seem to ring true. He isn’t bigoted against women. He treats everyone like that.

Intolerance toward those who hold different opinions from oneself.  

In this dictionary definition, Donald Trump is clearly bigoted, but then, a lot of people are. In the usual sense of the word, though, is his intolerance dictated by race, religion, or gender?

Much of the time, I must admit, he seems to be intolerant of those who are evil, such as rapists and murderers, and those who are ugly, such as women he calls ‘fat pigs’ and other despicable epithets, and those who are terrorists. But he conflates rapists and murderers to Mexicans who cross the border, and Islamic Terrorists to all Muslims. He compliments the objectified woman whom he would like to have sex with, and vilifies women who disagree with him by insulting their appearance: “Look at that face.”

And he doesn’t discriminate here, when he really should. About Ivanka, he said, as she squirmed, “Maybe I’d be dating her.”tj5qdp4yur7rfbmelfiv

Yes, maybe. What are those parrots doing, by the way.

 

 

 

 

What he appears incapable of doing is differentiating the groups in his conflation, or selecting the words (of which he has ‘all the best’) to succinctly describe the group without the obnoxious conflation.

It is OK to be bigoted against rapists and murderers. It is not OK to be bigoted against Mexicans. Donald Trump’s idea of protecting USA is to discriminate against all in order to avoid one.

Of course, sometimes it is ‘discriminate against one’ to avoid judgement: Judge Gonzalo Curiel. Was his racism here prompted by expedience, or the other way around? In this case, it probably does not matter.

But there are also accusations the he discriminated against ethnic groups in his rental properties, which is obviously racist and bigoted, if true. Actually, positive discrimination for some ethnic groups, such as wanting Jews to take care of his money…hard to say that that attitude is really positive, of course.

So, is he bigoted, or just stupid and inarticulate? I don’t really know. I think he is both.

 

Empathy

 

The ability to understand and share the feelings of another. 

Medical schools make a big thing about the differences between empathy and sympathy, but it doesn’t really matter here, because Trump demonstrates neither. The closest thing to empathy I have seen in Trump was his comment during the primaries that we cannot have people dying in the streets because of lack of healthcare. Ironically, this led him to policy considerations that put him at odds with the rest of his party, by implying the need for some kind of universal health coverage.

But the most recent peek at Trump’s level of empathy was the Khan family’s presentation at the DNC.

“You sacrificed nothing and no one.” The controlled anger of the father of the brave marine Captain, decrying Trump’s bigotry at banning Muslims from entry, was met with comments from Trump insulting the mother, Ghazala Khan, because she was too distraught to say anything.

Her pain was so OBVIOUS. Obvious to everyone, her husband said, except Trump.

Even a pet dog would have started looking balefully around, tail between its legs, trying to disappear somewhere at the sight and sensing of that mother’s pain. She did not want to be there, remembering an event in her life that will haunt her forever.

A mother’s son, killed in action saving his men, the ultimate sacrifice. Her son. She did not want to be there, in the limelight of the DNC, but she went to support her husband who was doing something terribly important…for their son, and for their country.

The horror is that Trump could not see her pain, and instead of empathy, he expressed insult. Set aside every other despicable thing about Trump, this alone should frighten all the troops under his command. Then he insulted her, twice. The mother of the dead marine.

“Shame on you,” they said the next day. The world said it too. “Shame on you,” is still reverberating through the airwaves of the globe. And at the same time as we express that horror, we really know there is no shame here. A pillar of salt feels no shame, and cannot be blamed for lack of empathy; neither can Donald Trump.

“Don’t boo; vote.” Obama said, in another context. Don’t shame either. It’s as useless as the ‘boo’.

“Shame on your family.”

This startled me. I immediately attributed it to the Khans’ pain and their anger, for this seemed unfair. I tried to think of the closer cultural family unit as perhaps they perceive it, unfamiliar to me, and how the shame would be felt, that the innocent family would feel it, and that this phrase might simply be an expression of their empathy for the Trump family that had been shamed by their patriarch.

Were the Khans holding Trump’s family members partially responsible? Was that fair? Or do they simply not see the boundary separation of family members as starkly as I do.

I had to think about this. Then that nasty Trump surrogate, the blonde one with the black eyeliner and the upside down mouth, one of many surrogates who constantly twist and turn in the wind to make every despicable comment by Trump look good, impossibly and unconvincingly–that image and memory popped back into my mind.

Her defense of Trump’s rejoinder came back to my mind. She started to defend. She worked it. But within a few seconds she hit a wall. There are military in her family, it seems, and she baulked. You could see the hesitation, the softening of her voice. Unlike her employer, she has some empathy.

She could not do it. She disagreed with her boss on this one, and I damn near fell off my chair. The nasty blonde one with the black eyeliner and the upside down mouth could not abandon her own family. She disagreed with the Trumpster!

Surrogates are connected to Trump by money. Powerful stuff. Family is connected by blood. Powerful stuff. Trump’s family is connected to Trump by blood and money. Really powerful stuff, and you have to wonder which is the more powerful.

“Shame on your family.”

Every now and then you open the lid and see a glimpse of good character in a Trump surrogate, but I suspect money weighs heavily on that lid.

Trump’s character is shaped by his family, the Khans are saying. We know his surrogates are the next best thing, though with much less history, less chance of changing their boss.

A child with integrity and empathy would take their father to task over the despicable comments he has made. If Ivanka (her brothers are certainly not capable of this)

images-2
Heroic Trump Sons. Will they Stand up to the Donald?

were thinking and smart, she would tell her father to apologize, and if he did not, and she were honourable, she would denounce his unfeeling comments and unapologetic stance. She may yet, whether through true empathy or political expedience of her future goals. There would be a huge cost, of course, but there is no heroism without danger.

I am wondering how much longer we will see that nasty blonde with the black eyeliner and the upside down mouth. Will she still have her job, or will Trump even notice. Trump’s handlers might be wise not to tell him, if he didn’t already know. She is a little less nasty today.

I wonder when we will see Ivanka critical of her father.

“Shame on your family.” Yes. That is a fair comment. They have that responsibility too. Family ties and money ties can only go so far, especially if the whole country is your family. Especially if the whole world is at risk.

To paraphrase Obama, “Don’t shame. Vote.”

Donald Trump doubled down, insulting the wife. He claimed it was wrong and unfair for Khan to stand in front of millions and claim that Trump had not read the constitution. He suggested the Hillary Clinton campaign had written the speech.

The next day Khizr Khan explained about his wife’s illness, that his wife still could not see the picture of her son without breaking down.

Trump sure picked the wrong victim to re-victimize.

Khizr Khan tripled down, unbent. He said the support for him, and the outpouring of love and affection has been over whelming.

He stated that the President of the United States must have two qualities: moral compass and empathy. In his opinion, Trump has neither. His wife had asked him to leave this part out of his speech, but Mr. Khan said it was OK to say this today (his unspoken thoughts, almost certainly, now that Trump has despicably insulted his wife).

Khizr Khan keeps the copy of the constitution with him, always. He believes in its words about equality and freedom. He believes in his son, who was defending the constitution, which he thinks Trump either has not read, or does not understand. What he left out at the DNC was an appeal to Republican leaders Paul Ryan and Mitch McConnell, to repudiate their support of Donald Trump, or, as he put it, “Their lapse of moral courage will be a burden on their souls.”

Perhaps, “Shame on your family,” is a metaphor. Perhaps it includes Trump supporters. It should. The Khans’ imposition of shame on the family is casting a wide net. So it should. People closest to Trump need to stand up and protect the world.

Returning to Physician Assisted Death

 CPSO

My college has taken a welcome proactive stance on Physician Assisted Death (PAD), with, I think, excellent results. It is necessarily a work in progress.

 Background

As I mention in an earlier blog post, the Supreme Court of Canada, in the case Carter vs. Canada, unanimously determined that an absolute prohibition on Physician Assisted Death violates the Charter of Rights and Freedoms. Currently this service is accessible only through exemption from a superior court judge, but it is anticipated that this legal requirement will also disappear by June 6, 2016. The College, not content to leave physicians of Ontario without guidance, has published its Interim Guidance on Physician-Assisted Death in the current issue of Dialogue, Volume 12, Issue 1, 2016.

Interim Guidance

The document lays out professional and legal obligations, criteria for PAD, and guidance on the practice related issues. It reminds us first that ‘professionalism’ in the medical context includes compassion, service, altruism and trustworthiness, the key values which are the foundations of medical teaching to this day.

These values are reflected in the behaviors we all expect from of physicians: respecting patient autonomy, ensuring all patients receive equitable access to care, communication effectively and sensitively in a manner supporting the patients’ autonomy, and demonstrating competence (clinical, legal and professional).

From the Interim Guidance, it is possible and probably necessary to create a checklist:

  1. The patient must be a competent adult;
  2. The patient clearly consents to termination of life (this presumes they are informed);
  3. The patient has a grievous and irremediable condition (illness, disease, or disability); and
  4. The patient experiences enduring suffering that is intolerable to them.

The checklist can continue as a form of process map:

  1. First request is to the attending physician, whereupon the attending physician either refers to someone for this service or assesses the patient to ensure that criteria 1. through 4. have been satisfied;
  2. The physician reminds the patient they have the ability to rescind the request at any time;
  3. The attending physician finds that the patient meets these criteria, and documents the assessment with the date of the first request. If the physician finds that the patient does not meet criteria 1. through 4., the patient is entitled to make a request of another physician, who would then follow this procedure.
  4. A period of reflection follows, the length undefined;
  5. The patient makes a second request, which requires formal documentation;
  6. The patient’s written request, or transcribed oral request must be dated and signed by the patient, countersigned by an independent witness, and signed by the physician;
  7. A second consulting physician must again follow criteria 1. through 4., 6. and 7.;

Options of Service

  1. The patient may be given the prescription for a fatal dose of medication to take at home, or receive voluntary euthanasia administered by the physician;
  2. In the former case, patient and caregivers must be educated with respect to safeguarding the medication and ensuring that the process can actually be managed by the patient. Additionally, the physician must educate the patient and caregivers on what to expect;
  3. Physicians should consult Ontario government for guidance with respect to completion of the death certificates.

Frequently Asked Questions

The College document is supported by a section in the Journal issue referred to as ‘College’s bridging document on physician-assisted death’ starting on page 9. This has obviously been a contentious issue, and the article includes an FAQ.

There is important discussion of age (physicians are pretty used to this being fuzzy, recognizing the wide variation) which incorporates capacity and maturity, especially when the patient is less than 18 years of age.

Grievous and irremediable is more commonly a legal term, but the important issue for physicians is that imminent death is not a requirement, nor is the patient required to follow advice or treatment recommendations of physicians for their condition to be determined irremediable.

Intolerable suffering is determined by the patient, reminding me of Dr. Balfour Mount’s famous statement, “Pain is what the patient says it is, when the patient says it is.”

Capacity is required to the end; the patient must be in a state of being capable of declining the service and rescinding the order until the treatment is given successfully completed.

No patient is to be excluded from this service by virtue of mental illness; rather the important issue is their capacity to comprehend, and to receive and understand in order to provide informed consent.

The College does not address the concern of objecting family members in their document, but our Canadian Medical Protective Association is fully aware of the issues, and is willing to provide help to physicians facing such difficulties.

Conscientious Objection

This issue has perhaps raised some of the greatest concerns among a small section of physicians and general public. In the extreme, it has been argued that some physicians who object to providing this service also object to discussing it with patients or referring to others who would do so.

Notwithstanding those objections, the College does indicate what it considers to be the appropriate response of such a physician:

  1. The physician must respect the patient’s dignity.
  2. Physicians must not impede access to PAD even if it conflicts with their religious beliefs.
  3. Physicians must communicate their objection directly to the patient, and do so with sensitivity, pointing out that this decision is their personal decision, not a clinical decision for the patient.
  4. Physicians must not express personal moral judgments about the patient’s beliefs, lifestyle, identity or character.
  5. Physicians are required to provide information about all options for care that may be available; they must not withhold information about the existence of any service because it conflicts with the physicians’ conscience or religious beliefs.
  6. The physician is required to make an effective referral to a non-objecting, available and accessible physician or agency.
  7. Patients must not be exposed to adverse clinical outcomes due to delayed referral.

My Opinion

The message here is clear. Physicians may not rely on their conscience or their religious beliefs to avoid compliance with this guidance. The will of the people and importantly, the patient, take precedence over any conscientious or religious objection, frankly, very much as is required for abortion services.

My other blog has referred to the inflammatory and insensitive reference to PAD or euthanasia as ‘killing’, a word that seems to be used by the religious leaders as a means of imposing their authority over the issue. In addition, it is clear that the act of referring a patient to another physician does not ensure that PAD will actually take place. In fact, my impression is that the availability of PAD will actually go on to save lives, as one of my friends wrote to me the other day (thank you J. McG.) because the knowing of this option being readily available will help the patient endure trials of other treatments.

And for those physicians who cannot comply? In my opinion, your options are clear. Either you remove yourself from the conflict, or you lie and pray that nobody ever complains, because if you willfully fail your patient with regard to this guidance, you expose yourself to the allegation of professional misconduct.

Of course, there is a second problem for conscientious objectors who cannot compromise and do not withdraw themselves from the conflict (practice in areas of medicine where they can never be asked for this such as pathology, laboratory services, maybe radiology). If they think this through carefully, they can never refer to a physician who is a non-objector, lest that lead to offering the service of PAD against their conscience or religious beliefs. Is ignorance of the beliefs of the consulting physicians a reasonable defence? Not inside their conscience or religious beliefs, it isn’t.

I hope the conscientious objectors do compromise enough to refer these patients to others, realizing that the patient may not choose PAD. I know some of these doctors personally, who are fine physicians. We will have patients and families in our midst who object to this type of service because of religion and other beliefs, and it is important that the population of physicians reflects the population at large. The conscientious objectors provide services to these and many others, and while I may disagree with their premises and conclusions, I cannot dispute their discipline or integrity on the basis of their beliefs.

I hope that the understanding of PAD as a comforting option (that may actually help patients to take some ease in their end-of-life decisions) even if their patients never use PAD, will allow the conscientious objectors to accept what may be the greater good: that they compromise by making effective referrals and continue to provide the excellent care that all our patients deserve, thereby helping that many more.