"All that is necessary for the triumph of evil is for good men to do nothing" Edmund Burke, 18th century Philospher.

"A long habit of not thinking a thing wrong gives it a superficial appearance of it being right." Thomas Paine

"The welfare of humanity is always the alibi of tyrants." Albert Camus

"Choice is the essence of ethics: if there were no choice there would be no ethics, no good, no evil; good and evil have meaning only insofar as man is free to choose." Margaret Thatcher, March 14, 1977

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.” ― Upton Sinclair

Explaining the Cause

I am a practicing obstetrician who is a strong supporter of patients rights to informed consent and refusal. I believe a patient has the right to choose her own path given true and not skewed informed consent. Following that tenet, just as a woman should be able to choose to have an elective c/section she should be able to choose not to have one, as well. The American system of hospital based obstetric practice has been eroding those choices for women for quite some time. Due to concerns of economics, expediency and fears of litigation women are being coerced to make choices that may not be in their best interest.

I have had a long relationship collaborating with midwives and find the midwifery model of care to be evidenced based and successful. I was well trained at Cedars-Sinai Medical Center in the mid 80's to perform breech deliveries, twin deliveries, operative vaginal deliveries and VBACs, and despite evidence supporting their continued value, hospitals are "banning" these options. Organized medicine is also doing its best to restrict the availability of access to midwives.

Home birthing is not for everyone but informed choice is. Medical ethics dictates that doctors have a responsibility and a fiduciary duty to their patients to provide true, not skewed, informed consent and to respect patient autonomy in decision making. Countries with the best outcomes in birthing have collaboration between doctors and midwives. This is not what has been happening in the hospitals of America. Its time for a change and the return of common sense.

The midwifery model of care supports pregnancy as a normal function of the female body and gives a legitimate and reasonable alternative to the over-medicalized model of birth that dominates our culture. Through this blog I hope to do my part to illuminate what is wrong with our maternity care system and what is right with it. I do not expect all to agree and that is OK. We must all understand that given honest data it is not always reasonable to expect two people to come to the same conclusion. Our differences should be respected.

Wednesday, February 9, 2011

Defining the Straw Man

Dr. Amy Tuteur continues her crusade against home birthing. She offered a challenge that no one will debate with her. As you know, I have accepted her offer to speak in a public forum however she has never responded. Instead she publishes this last night:

10 Illogical Arguments in Favor of Home Birth
Opinion by The Skeptical OB
(16 Hours Ago) in Health / Women's Health
In addition to the problem of possessing inaccurate information, homebirth advocates have another, more serious problem, the tendency to construct illogical arguments. It is apparently such a pervasive problem that a brief review of these arguments is in order.

Let's look at the various types of illogical argument constructed against my core claim "the death rate at homebirth is higher than the death rate at low risk hospital birth." To make this exercise easier to understand, lets substitute a claim of the same form that is obviously true, so we will not get sidestepped by issues of truth or falsity and can focus only on whether an argument is logical or illogical. This is important because illogical arguments are automatically invalid arguments. We'll use the claim "there are more black cars in the US than lime green cars."

I say: There are more black cars in the US than lime green cars.

Don't say:

I saw a lime green car. - Can you understand how the fact that you personally saw a lime green car tells us nothing about the relative number of black cars and lime green cars in the US? That you saw a lime green car is perfectly consistent with black cars outstripping lime green cars 100 to 1, or even 1,00,000 to 1? Similarly, the fact that babies die in the hospital tells us nothing about whether the death rate is greater at homebirth.

I know ten people and not one of them has a black car. - This is an illogical claim based on an unstated assumption. The assumption is that the small slice you observe accurately represents the whole. However, tiny samples are often unrepresentative. Knowing 10 people who own black cars is perfectly consistent with the number of black cars exceeding lime green cars, BUT it is also perfectly consistent with lime green cars exceeding black cars, so it can't be used to support a specific claim. Similarly, the fact that you know ten women who had homebirths and not a single baby died tells us nothing about whether the homebirth neonatal death rate exceeds the low risk hospital death rate.

Lime green cars are prettier than black cars. - I hope it is obvious why value judgments about lime green cars tell us nothing about whether there are more or less black cars than lime green cars. Therefore, it should be obvious that claiming that women are more satisfied with homebirth tell us nothing about homebirth death rates.

You say that because you sell black cars. - Whether or not I sell black cars is immaterial; it has absolutely no effect on the number of black cars or lime green cars. This is essentially an accusation that I am lying and offering as "proof" the fact that I have a reason to lie, but a reason to lie is not proof of lying. So don't tell me that the fact that I am an obstetrician means that I am lying about neonatal death rates.

The people who make black cars have oppressed the people who make lime green cars. - Maybe yes, maybe no, but in either case, it does not affect how many black and lime green cars are on the road. Similarly, whether doctors have oppressed midwives has no bearing on whether the neonatal death rate at midwife attended homebirths is higher than hospital births.

There is a conspiracy against lime green cars. - We are supposed to believe that the number of lime green cars would equal black cars except for a public relations campaign designed to make lime green cars less desirable. It is theoretically possible that there is a conspiracy against lime green cars, but it is far more likely that other factors account for the difference in numbers. And in any case, it doesn't tell us anything about the relative numbers of black and lime green cars. So when confronted with the fact that homebirth death rates exceed hospital rates, it is illogical to counter with a claim that a conspiracy against homebirth exists.

There would be more lime green cars if the makers of black cars helped out. - That might be true, or it might not. In either case, it tells us nothing about the truth of the claim that black cars exceed lime green cars. And while it might be true that the death rate from midwife attended homebirth would be lower if doctors were more supportive of midwives, it doesn't change the reality of the current situation.

The Association of Lime Green Car Makers say that there are more green cars than black cars. - Cherry picking certain claims and ignoring all others is likely to lead people to the wrong conclusion. A lobbying group that disagrees with almost everyone else is not a reliable source of information. Similarly, professional NCB advocates and organizations are not reliable sources of information when they disagree with the bulk of the scientific evidence.

The color of cars is influenced by culture. - That is a non sequitur. It does not oppose the claim; it simply attempts to pin responsibility somewhere else and it is irrelevant. That's why the claim that hospital birth is culturally favored is irrelevant to any argument about homebirth death rates.

There are more important things about cars than the color. - That is what is known as "reframing the debate". It is a tacit acknowledgment that there are more black cars than lime green cars and a barely concealed effort to divert everyone's attention. That's why when someone announces that there are more important things than whether babies live or die, I know they have accepted the fact that homebirth leads to preventable neonatal deaths.

My Response posted this morning:

Dear Dr. Tuteur,
Your whole lengthy analogy is based on the assumption that home birth advocates possess inaccurate information and construct illogical arguments. You have yet to prove that either of these are true making your car anaolgy cute but meaningless. When you make a statement that you have failed to support and then build on that foundation you have a tottering structure. You have constructed a canard, the only purpose of which is, to confuse readers to accept your "core claim" and unsupported positions. The largest and most respected studies on Planned Home Birth vs. Hospital Birth do not show an increased neonatal death rate. In fact, in every measure of outcome and satisfaction, low risk planned home birth with a qualified attendant is equal or superior to comparable hospital based experience. And with less interventions which likely explains why.

Until you come out from behind your keyboard and defend your vitriol against midwives and alternative birth choices in person you have no credibility. We know this and your readers must be starting to wonder about the motives behind your fanaticism. Debate publically and we can respectfully discuss point by point all the lime green analogies you want. Sincerely, Dr. Fischbein

1 comment:

  1. Alright Dr. Fischbein!!! I'd love for this Amy to come out from behind her keyboard as well. Bring it on!!!