False Positives

Last month, the Preventive Services Task Force of the United States Department of Health and Human Services issued a report recommending a significant reduction in mammographic screening for breast cancer. This recommendation was received with what can only be described as hysteria. While some of the protest was a cynical ploy by those who oppose Obama's proposed health insurance reform and some of it (very little) was a serious disagreement over the Task Force's calculation of the net benefits of mass breast cancer screenings, most criticism of the report centered on the idea that it is immoral not to screen millions of healthy women if, by not screening, there is one life lost that could have been saved. "So what," these critics argued, "if the chances of saving a life of a woman between ages 40 and 50 by screening is 1 in 1900, we should do everything we can to save that life." The problem with this sort of thinking is that it completely ignores or minimizes the costs of routine mammography for the 1899 women who undergo the test but whose lives are not saved by it.

In most of those cases, the x-ray shows no sign of cancer. These women are reassured, but they do pay a price in radiation, money, inconvenience, and discomfort. They receive no tangible benefit from the test; indeed, the radiation exposure slightly increases their chances of developing breast cancer in the future. Most women who are now being screened probably think that the psychological comfort of a "negative" mammogram is worth these risks, but this "benefit" is purchased at a cost, much of it paid by other women.

In a significant number of cases, the mammogram shows a suspicious breast lesion which is biopsied and diagnosed as benign. These are the classic "false positives." These women typically receive more radiation in the form of additional imaging and suffer additional expense and pain. Most importantly, however, they understandably suffer a good deal of anxiety during the time between the "positive" mammogram and the post-biopsy "all clear" signal. Mammography advocates typically dismiss this psychological cost as trivial, but they can't have it both ways. If the emotional reassurance provided by a true negative mammogram is a good reason to do them, then the psychic pain caused by a false positive is a reason not to do them.

The group of women most hurt by being screened are those in whom the mammogram leads to the discovery of a slow-growing cancer, one which, if undiscovered, would never have cause illness or which, at least, would not have metastasized before it reached a size at which it would have been discovered without x-rays. Some of these women will be treated unnecessarily, typically undergoing surgery, chemotherapy, and/or radiation. All of these treatments are dangerous and unpleasant. In addition, these patients are deprived by the screening test of the blissful ignorance which allows them to live their lives innocent of the existence of mutated cells within them.

The same considerations apply to those women in whom mammography finds aggressive, incurable tumors. They will die with or without mammography, but without it they will have more time in which to live normal lives,free of the knowledge they they have a life-threatening disease.

While it is impossible to tell in advance which woman is in which of these groups, it is possible for scientists to make informed judgments about the relative sizes of these groups and to consider these facts in making a cost-benefit analysis of the benefit of screening mammography for different groups. That is apparently what the Task Force tried to do. Others can contest their measurements of costs versus benefits in good faith, but many of those denouncing their recommendations do so without acknowledging that there are, in fact, serious costs to mass screening of healthy people.

The Torture Debate

1. People who torture, or who order others to torture, are criminals under US and international law.

2. People who admit to having ordered torture are confessed criminals.

3. Confessed criminals should be prosecuted for their crimes.

WHAT THE FUCK IS THERE TO DEBATE?

Culture Wars

Sarah Palin's nomination is being widely interpreted as another attempt by the Republican Party to exploit the public's resentment of the cultural liberalization that began in the 1960s. I agree. An interesting thing about this iteration of the "culture wars" is the extent to which Sarah Palin herself demonstrates the fact that, while the right may have won elections with cultural issues, the cultural left consistently wins the culture war itself.

Most of the "culture war" issues relate to the perception that our culture has abandoned the strict sexual mores which prevailed in earlier times. Opposition to abortion, homosexuality, sex education, and sexually explicit entertainment all rests on a sense that society now tolerates, or even embraces, extra-marital sexual behavior which was once taboo and on a desire to restore these old strict standards.

This call for a return to old fashioned morality has worked well as an electoral political issue, but, strangely enough, no matter how many Republican culture warriors are elected to office, the culture continues to move away from the sexual shaming that is necessary to enforce sexually repressive cultural codes. Americans, no matter what their religious/political stance, now accept the fact that it is normal for people to engage in heterosexual activity before marriage. The tiny minority who "save themselves" for marriage are, depending on your outlook, either virtuous heroes or self-denying prudes, but nobody thinks that they are not statistically anomalous. Consequentially, pre-marital sex no longer carries the stigma that it did in the 50s and unwed motherhood no longer excludes a young woman from "respectability" as it did then. As proof of that, when was the last time that you heard of a pregnant teenager "going to visit relatives" so that she could give birth and put her child up for adoption. The trend toward accepting pre-marital sex as "normal" was clearly manifested by the welcome given Bristol Palin and her fiance by the hordes of fundamentalist delegates at the Republican National Convention who treated Bristol as a hero because she had decided not to have an abortion.

Of course, proclaiming this young, single mother an admirable hero instead an object of contempt, the religious right is essentially declaring its defeat in the culture wars. Whereas it once fought legal abortion because the ability to quietly end a pregnancy freed "promiscuous" women from the stigma that was their rightful punishment for violating sexual codes, they now lionize a young woman solely because she decided to keep her baby, seemingly ignoring the issue of what she did to get it. These folks have, over the last several decades, thrown out the baby and kept the bath water!

Similarly, cultural traditionalists opposed the movement of women into the workforce because it undercut God-given gender roles. Now they are supporting a married mother of young children as a potential chief executive of the United States without the slightest concern for how that might effect the "proper" division of authority within her marriage or what kind of example it might set for young women, AND they accuse anyone who opposes Gov. Palin's candidacy of engaging in improper sex discrimination, invoking a principle whose legitimacy they rejected until a few years ago! Of course, if they openly favored sex discrimination, they would be seen as outside the mainstream culture.

Inerrant

The nomination of Sarah Palin as the vice-presidential candidate of a party whose presidential nominee is a 72-year-old cancer patient raises the possibility that, in the near future, the President of the United States could be a fundamentalist Protestant who actually believes that the King James Bible is the inerrant word of God. This would represent a cataclysmic change in American politics, a fact that is recognized by the fundamentalists of the religious right, but not so much by the mainstream media or the Democratic Party. Indeed, the possibility of revolutionary change that John McCain has presented to his party's theocratic base by nominating Palin is the reason that it is now willing to overlook its multiple disagreements with McCain and enthusiastically support the GOP ticket.

Palin was baptized as a Roman Catholic but began attending the pentecostal Assemblies of God church as a young girl. She was baptized in that faith at age 12. Recently, she changed her church affiliation from the A of G to a non-denominational "bible church," perhaps to advance her political career by escaping the stigma attached to "holy roller" pentecostal sects, who practice speaking in tongues and other extreme forms of worship. While her new church may not worship in as flamboyant a style as her old one, both groups share a belief in the infallibility of the Bible. As one of her Alaska neighbors told the New York Times, “The churches that Sarah has attended all believe in a literal translation of the Bible." There is significant evidence that Palin sees her political career as a mission from God and that she understands the world primarily through the lens of her religion. As a former pastor said, ""I believe Sarah would not live in a fragmented world. The idea that Sarah would take this huge influence of the worldview that really only the Bible and the relationship with Jesus opens up ... and suddenly marginalize it and put it over on the shelf somewhere and live apart from it—that would be entirely inconsistent." As President, we could recently expect Palin to look to the Bible for specific instructions. In this she would differ from almost all of her predecessors in the Oval Office, who have generally tended to adhere to a conventional sort of public Protestantism, but have not sought much more than general inspiration from the Bible.

Recent Republican presidents have relied on support from religious fundamentalists, but have not been one of them. Nixon was a non-practicing Quaker. Reagan was notoriously lax in his church attendance. Bush Senior is a country club Episcopalian. Even "Dubya," who sometimes appears to believe that that the Lord has chosen him as president, is a mainstream Methodist whose religious life before becoming president seems to consist primarily of the belief that Jesus helped him give up Demon Rum.

Unlike her GOP predecessors who simply exploited the votes of biblical literalists, a president Palin (who ran for for her public office with the slogan that it was time for "our first Christian mayor,") might very well seek the advice of a pentecostal preacher on her Middle East policy or pore over the Book of Genesis for clues as to Jehovah's views on global warming. Let's hope she doesn't get the chance to put the doctrine of inerrancy to the test!

John Edwards

Once again, the pundits chew over the question of the relevance of a politician's private life to his public career. I am not a prude, nor do I think that I am naive about human beings' capacity for duplicity. But I do think, in this case at least, John Edwards's behavior in his private life does have something to say to us about his politics.

When this year's Democratic presidential contest was first taking shape, Edwards positioned himself to appeal to people like me: left-liberals concerned about economic inequality and the plight of the poor. Despite the attractiveness of his message, I was skeptical of Edwards's candidacy, primarily because it didn't jibe with his record as a senator and vice-presidential candidate, where he had positioned himself as Southern moderate. However, the issue which ultimately convinced me not to support Edwards was his decision to continue his campaign in the face of his wife Elizabeth's diagnosis with terminal metastatic breast cancer.

My decision was not based, however, on a belief that Edwards was selfish or evil; rather it derived from my history as the spouse of woman who died of breast cancer. Based on my own experience, I thought that John Edwards needed to be with his wife and children during the next few years whether the Edwardses knew it or not. In other words, I opposed John Edwards's candidacy for his own good and that of his family.

In light of the latest revelations (and the fact that I believe that Edwards has still not come completely clean), I see John and Elizabeth in a different light. John's cheating on his cancer patient wife is reprehensible, no matter what his role in life. But the fact that he and, apparently, Elizabeth were willing to subject their children, their party, and their country to the risk that his affair with Rielle Hunter would become public during his presidential campaign strikes me as evidence of a self-centered ambition seldom seen in American politics. It's not really surprising that a bigtime plaintiff's lawyer would be comfortable risking other people's welfare to advance his own interests, but it is still sort of shocking to me that he would risk putting a Republican in the White House to satisfy his own desires. I now see John and Elizabeth as hillbilly MacBeths: as ambitious as the Clintons, but not as principled!

Big John Cornyn

For those of you wonder what it's really like to live in Texas, check out this honest-to-god ad for our incumbent U.S. Senator. Now try to imagine living some place where someone who gets paid to do this kind of stuff honestly thinks that this will help Cornyn get re-elected. Got that? OK, now . . . a little bigger stretch . . . imagine that you're living in a place where this ad really will help Cornyn get elected.