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BEYOND SCIENCE: Leonard Leibovici Effects of remote, retroactive intercessory prayer on outcomes in patients with bloodstream infection: randomised controlled trial BMJ 2001; 323: 1450-1451 [Abstract] [Full text]

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Rapid Responses published:

A cautious approach is needed for the power of prayer

Andrew M Thornett   (21 December 2001)

So there is a God?!

Michael Gdalevich   (21 December 2001)

A nonsense joke for the New Year

Yair Yodfat   (21 December 2001)

There are thousands of suns in the sky above the clouds

Sergio Stagnaro   (21 December 2001)

You cannae break the laws of physics captain

John Hopkins   (21 December 2001)

Treat the control group

Martin Bland   (22 December 2001)

Evidence for Providence Based Medicine

Arthur Leibovitz   (22 December 2001)

The power of statistics, not prayer

Shehan Hettiaratchy, Carolyn Hemsley, Wellcome Trust Fellow in Microbiology, University of Oxford, UK   (22 December 2001)

I suggest to cross-over the study groups

Francesco Falaschi   (22 December 2001)

Occam's razor

j martin dace   (23 December 2001)

Irony doesn't travel well

Michael Foley   (23 December 2001)

A CHRISTMAS NIGHTMARE: AN UNETHICAL STUDY APPROVED FOR PUBLICATION IN THE BMJ

Eugenio Pucci   (24 December 2001)

TWO POSSIBLE EXPLANATIONS TO THE RETROACTIVE INTERCESSORY PRAYER EFFECT

Luis C. Silva   (24 December 2001)

An example of synchronicity?

Ian T Guy   (24 December 2001)

Re: Treat the control group

Ian Spencer   (24 December 2001)

Science and Statistics cannot explain how prayer works

Daniel O. Selo-Ojeme   (26 December 2001)

Confounding effects of future prayer?

Prisca M Middlemiss, n/a   (27 December 2001)

On behalf of the "Less Sophisticated" general public

Margaret M. Zacny   (28 December 2001)

Improbable Research

Eberhard W Lisse   (28 December 2001)

Prayer Study Design

Ronald L. Fredrickson   (28 December 2001)

Hobgoblins of Consistency

Doug Oman, Carl E. Thoresen   (29 December 2001)

Delay in publication?

Anthony H.C. Campbell   (30 December 2001)

All RCT require informed consent

Christopher I. Price   (30 December 2001)

Re: Treat the control group

Haim Shapiro   (31 December 2001)

The RCT - gold standard or golden calf?

Robert G. Newcombe   (31 December 2001)

Leibovici's paper is religious propaganda, not science

Riccardo Baschetti   (1 January 2002)

The effects of retroactive prayer: more questions than answers

Max Lagnado   (1 January 2002)

The Finger of God

Stephen L. Black   (2 January 2002)

Doctors prayer for more care

DE Barnes   (3 January 2002)

Misapprehension of principle

Stephan A. Schwartz   (3 January 2002)

Beyond Science?

Tobit S Emmens   (3 January 2002)

Efficacy of prayer underestimated?

Charles S. Harris, PhD   (3 January 2002)

Retroactive prayer - a solution to the bed crisis?

Adrian Fawcett   (4 January 2002)

Methodological concerns

William G. Taylor   (6 January 2002)

Pride and Prejudice, or Prayer?

Max Lagnado   (6 January 2002)

Time Paradox

Effi Peled   (8 January 2002)

Healing powers of the human mind

Joseph Watine   (8 January 2002)

I pray now for my own papers to be published

Luc-Marie JOLY   (11 January 2002)

Editors beware, everything is possible

Yakov Sivan   (12 January 2002)

Re: You cannae break the laws of physics captain

Michael J Brownnutt   (15 January 2002)

Re: Treat the control group

Tracey A Thomas-Falconar, n/a   (15 January 2002)

Down to earth

Santiago V Rosales   (15 January 2002)

A moment of seriousness

Dr Trevor Watts   (16 January 2002)

To whom did the prayer pray ?

Tomoyuki Hisa   (19 January 2002)

God and Us

Gabriel Onato, MD, PhD   (23 January 2002)

Blind faith in the Central Limit Theorem

Robert J. MacG. Dawson   (25 January 2002)

Therapeutic event or medical fact?

Peter Morrell   (25 January 2002)

Re: So there is a God?!

Tracey A Thomas-Falconar, n/a   (7 February 2002)

A Question From An Outsider Looking In

Alina Finn   (9 February 2002)

Regarding retroactive prayer

Gilbert J Custer, M.D.   (13 February 2002)

Religion and Science

Peter Morrell   (17 February 2002)

God Listens

William D. Misner Ph.D.   (23 February 2002)

Do the statistics add up?

Joseph T. Springer   (23 February 2002)

Randomised trials cannot be used in this way

Peter J Lachmann   (5 March 2002)

Rule of thumb

Gary S. Hurd, Ph. D.   (5 March 2002)

Author's comments

Leonard Leibovici   (12 March 2002)

Thought experiment

Timothy S. Roth, Pittsburgh, PA, 15601   (14 April 2002)

which gods ?

Joan S Brodie   (29 April 2002)

Re: Leibovici's paper is religious propaganda, not science

Michael A. Reeves-McMillan   (1 November 2002)

Re: The power of statistics, not prayer

Elliott Middleton   (2 November 2002)

Re: Religion and Science

Reginald.H. Le Sueur   (20 June 2003)

Re: A Question From An Outsider Looking In

Reginald Le Sueur   (29 June 2003)

Re: Re: Leibovici's paper is religious propaganda, not science

Reginald Henry Le Sueur   (1 July 2003)

Leibovici's paper is perfectly valid

Matthew H Lewis   (2 July 2003)

more propaganda, not science

L S Lerwis   (2 July 2003)

My manager is going to love this ...

Dr. Matthew L Grove   (2 July 2003)

Re: more propaganda, not science

Reginald Henry Le Sueur   (3 July 2003)

Re: Re: more propaganda, not science

M C Feliciello   (3 July 2003)

Re: Re: more propaganda, not science

L S Lewis   (3 July 2003)

Re: Re: Re: more propaganda, not science

Reginald Henry Le Sueur   (4 July 2003)

Re: Re: more propaganda, not science

Matthew H Lewis   (4 July 2003)

Re: Re: Re: more propaganda, not science

Reginald H. Le Sueur   (5 July 2003)

Re: Misapprehension of principle

Reginald H. Le Sueur   (7 July 2003)

Some Logical and Philosophical Objections and a Parallelism to the Newcomb Problem

Deepak N Rama, -   (6 December 2003)

Re: Some Logical and Philosophical Objections and a Parallelism to the Newcomb Problem

Reginald.H. Le Sueur   (9 December 2003)

Is the power of thought able to create successively older forms of the entire universe once every 10 to the minus 43 of a second?

Richard G Fiddian-Green   (27 December 2003)

RE: Some Logical and Philosophical Objections and a Parallelism to the Newcomb Problem

Haralabos Gouzinis   (29 January 2004)

RE: Some Logical and Philosophical Objections and a Parallelism to the Newcomb Problem

Richard G Fiddian-Green   (1 February 2004)

Effect of Remote, retroactive intercessory prayer on outcome in trauma patients

Adam Starr, William Frawley, Michael Bolesta, Christopher Espinoza-Ervin   (23 June 2004)

Re: Effect of Remote, retroactive intercessory prayer on outcome in trauma patients

Howard Mann   (24 June 2004)

Re: Effect of Remote, retroactive intercessory prayer on outcome in trauma patients

Reginald.H. Le Sueur   (2 July 2004)

Re: which gods ?

Reginald.H. Le Sueur   (2 July 2004)

Leibovici's paper is not "flawless"

Sergio D Schvartzman   (17 October 2004)

The Hospital Called Earth

Michael A. Bedar   (13 April 2005)

a test for the "scientific" community

Martin Ploederl   (4 August 2005)

Data

Paulo Hubert   (28 December 2006)

A cautious approach is needed for the power of prayer 21 December 2001
Andrew M Thornett, Deputy Head Adelaide University Rural Clinical School, University Campus, Whyalla, South Australia 5608 Send response to journal: Re: A cautious approach is needed for the power of prayer	The study by Leibovici is one of few to use rigorous scientific method to explore the role of intercessory prayer in health care.1 Using a randomised controlled trial design with a large group of patients, and selecting a range of appropriate outcome measures, the author demonstrated a statistically significant difference in length of stay and fever duration and concluded that prayer may be a useful treatment. However, these results need to be interpreted with caution. There was no significant difference between the two groups with regards to the most clinically important outcome (mortality), and the median values varied little between prayer and non-prayer on both length of stay (7 and 8 days) and fever duration (2 days each). The religous affiliation of the person saying the prayer is not given. Many religous groups do not accept the power of prayer given by those with different beliefs. If real, the effect of prayer demonstrated in this study may be unrelated to supernatural power and hence to a particular belief system, or may be belief-specific, reflecting the power inherent in a particular religion.Further work is needed in this area before conclusions can be made. 1. Leibovici, L. Effects of remote, retroactive intercessory prayer on outcomes in patients with bloodstream infection: randomised controlled trial. BMJ 2001;323:1450-1451.
So there is a God?! 21 December 2001
Michael Gdalevich, Deputy District Health Officer Barzilai Medical Center, Ashkelon, Israel Send response to journal: Re: So there is a God?!	A double blind, controlled study that proves a divine intervention? May be this is an oversiplification of the results of this study, but that's what it seems - the authors prove that there is a God. This is done by using a proven and proper study methodology. However, what about the pupose of the study? This should be defined prior to the rest of the research. How can one intend to prove an association with an unexplainable factor? If there is a God and wanted us to know (opposed to beleive) about it, he/she would find a way. If there is not - well there's always type 1 (alfa) error.
A nonsense joke for the New Year 21 December 2001
Yair Yodfat, Emeritus Professor in Family Medicine Hebrew University-Hadassah Medical School, Jerusalem, Israel Send response to journal: Re: A nonsense joke for the New Year	I would like to know how many readers believe in this nonsense paper. The research methodology was poor, non scientific and the results were most probably biased by the author's own belief.
There are thousands of suns in the sky above the clouds 21 December 2001
Sergio Stagnaro, Specialist i Blood, Gastrointestinal, and Metabolic Diseases 16037 Riva Trigoso (Genoa) Italy Send response to journal: Re: There are thousands of suns in the sky above the clouds	Sirs, I appreciate almost absolutely, without reserve, except one, ethical in nature, the conclusion of the intriguing Leonard Leibovici’s paper about effects of remote retroactive intercessory prayer on outcomes in patients with bloodstream infection in randomised controlled trial (BMJ 2001;323:1450-1451, 22-29 December ). Author’s conclusions state that remote, retroactive intercessory prayer is associated with a shorter stay in hospital and shorter duration of fever in diseased individuals. Therefore, its use in clinical practice should be considered, according to other articles conclusions, as regards beneficial effect in patients in an intensive coronary care unit, to which I dare add my recent, personal case (Last 9 July, at 5 hours a.m., I was involved by acute myokardial infarct, recognized forunately early – as “impending infarction” – , with the aid of Biophysical Semeiotic (http://digilander.iol.it/semeioticabiofisica), so that, when AMI ocurred,followed by cardiac arrest due to ventricular fibrillation, the car, driven by my young daughter was near the emergency room of our hospital, where my wife and skilled colleague were waitng for me. At first, I do not consider the “particular” condition of the retroactivity of intercessory prayer on outcomes in patients diseased with infection, due to the fact that knowledge of God is “instantaneous”. We can explain the prayer favorable influence on diseases outcome, either with extrasensory forces or with the existence of God. But does God really exists? In my opinion, scientist’s answer would sound “yes”. As a matter of fact, we scientists are, all life long, searching for truth, but know without any doubt that we reach exclusively “scientific” truths or, speaking in other words, temporary truth. Therefore, we are at a cross- roads: either the Truth does not exist (and we scientists are crazy dreamers), or there is “Esse per Se Ipsum”, Who have “constitutive and eternal” knoweledgement of truth, namely in an absolutely different way, the men are laking, since our knowlegement is “external, attributive,and thus transient” , while the former one is “Love, as knowledge sublimation”, according to Saint Gregorious from Nisc, VI century a.D.
You cannae break the laws of physics captain 21 December 2001
John Hopkins, GP Darlington DL1 5LW Send response to journal: Re: You cannae break the laws of physics captain	Dear Richard, As any student of Star Trek will tell you, the first rule of time travel is that you cannot change the course of history, otherwise you get into an infinite regress. In the case of Leibovici's study, if we accept that people can be made better by future prayer or other intervention then must have been made better at the first time of that intervention, when they were ill. In which case it would then be impossible for them to be subsequently allocated to the placebo arm of the study. That means this paper is not a randomised controlled trial. But then you knew that already ! Yours sincerely, Dr John Hopkins
Treat the control group 22 December 2001
Martin Bland, Prof. of Medical Statistics St. George's Hospital Medical School, London SW17 0RE Send response to journal: Re: Treat the control group	According to Clause 30 of the latest revision of the Declaration of Helsinki: At the conclusion of the study, every patient entered into the study should be assured of access to the best proven prophylactic, diagnostic and therapeutic methods identified by the study. To meet this ethical standard, the prayer should now be said for the control group. If the treatment is effective, this should have the effect of removing the difference between the groups. I await the results with interest.
Evidence for Providence Based Medicine 22 December 2001
Arthur Leibovitz, Director of Geriatric Ward - Shmuel Harofe Hospital Shmuel Harofe Hospital Send response to journal: Re: Evidence for Providence Based Medicine	Congratulations Dr Leibovici This is - a first Evidence of Providence Based Medicine
The power of statistics, not prayer 22 December 2001
Shehan Hettiaratchy, Fellow, Transplantation Biology Research Center Massachusetts General Hospital, Harvard Medical School, Boston, USA 02114, Carolyn Hemsley, Wellcome Trust Fellow in Microbiology, University of Oxford, UK Send response to journal: Re: The power of statistics, not prayer	It was very brave of both the author and the BMJ to publish this paper in a scientific journal and be prepared for the inevitable criticism from the outraged masses. The idea that retroactive intercessory prayers could have an influence on the outcome of septicaemia is intriguing and challenges our notions of cause and effect.However, if it is true, this is not the paper to prove it. The data on the the most significant finding,length of stay, appears to be skewed by a few abnormally high results in the control group.This is demonstrated by the fact that the median length of stay is the same in both groups but the maximum length of stay in the control group is twice that in the intervention group. This may represent a type I statistical error,despite the large sample size. From a cynical stand point, it is a shame that God cannot save your life but might get you out of hospital a few days earlier.Either way, it was a thought provoking paper but may just prove the power of statistics, not of prayer. Shehan Hettiaratchy MA FRCS Carolyn Hemsley MA MRCP
I suggest to cross-over the study groups 22 December 2001
Francesco Falaschi, medical doctor Pronto Soccorso Accettazione - IRCCS Policlinico San Matteo - 27100 Pavia Italy Send response to journal: Re: I suggest to cross-over the study groups	I suggest to treat the same group of patients inverting the study group and the control group. Any change in the outcomes would provide a clear evidence of the effect of the treatment. In other words I would pray for the other patiens too, to see if their previous hospital stay shortens. I also suggest to try to prove a dose-related response to the treatment; as there is no known adverse effect of the treatment it would be possible to use extreme doses (few seconds of prayer for multiple patients versus hours of prayer for a single patient). I would send a copy of the original paper for the IgNobel price of next year becaouse I suspect the it is the princpal aim of the author.
Occam's razor 23 December 2001
j martin dace, general medical practitioner waldron health centre, stanley street, london SE8 4BG Send response to journal: Re: Occam's razor	EDITOR - When assessing the effects of retroactive intercessory prayer, Leibovici (1.) fails to take into account Occam's razor, according to which 'It is vain to do with more what can be done with fewer'. (2.) It is more parsimonious to assume that there is some methodological problem, or even that the results are attributable to chance (despite the quoted confidence limits), than to accept that a short prayer said by one person for persons unknown except by name can affect the outcome of a set of events several years previously. Also in the discussion section Leibovici refers to retroactive prayer being 'associated with a shorter stay in hospital' and later he says 'no mechanism known today can account for the effects [of retroactive prayer]'. An association is not the same as an effect, which latter term implies causality. Even if there is an effect, Leibovici's paper does not provide evidence of a causal link. 1. Leibovici L, Effects of remote retroactive intercessory prayer BMJ 2001; 323:1450-1 (22 December) 2. Occam, W (1300-1350 CE) quoted in Russell B, A history of western philosophy, Unwin 1984:462-3 Competing interests: none.
Irony doesn't travel well 23 December 2001
Michael Foley, Consultant anaesthetist James Cook University Hospital, Middlesborough, UK TS4 3BW Send response to journal: Re: Irony doesn't travel well	The staff at the BMJ, and discerning readers, may be amused by this article demonstrating yet again the truth of Disraeli's aphorism about 'lies, damned lies and statistics'. That this is already accepted as evidence for the existence of God by one of your correspondents, and will doubtless be quoted by endless purveyors of religion and quackery, indicates that what may be entertaining to the informed reader is easily used as wool to pull over the eyes of the less sophisticated. Does the editor of the journal not have some responsibility to the wider public to point out the logical paradox in the paper? A second, cross-over trial can be performed in which the control group becomes the experimental group and is prayed for. Should the results of the second trial demonstrate that the new experimental group have retrospectively improved outcomes then that really would be a breakthrough in the study of the existence of the non-material world. Thus God would have been shown to exist and one could return to a comforting Universe where a paternal, loving anthropomorphic being gives us protection from reality. And fairies would take up residence at the bottom of my garden.
A CHRISTMAS NIGHTMARE: AN UNETHICAL STUDY APPROVED FOR PUBLICATION IN THE BMJ 24 December 2001
Eugenio Pucci, neurologist U.O. Neurologia, Ospedale di Macerata, via S.Lucia, Macerata, 62100, Italy Send response to journal: Re: A CHRISTMAS NIGHTMARE: AN UNETHICAL STUDY APPROVED FOR PUBLICATION IN THE BMJ	Dear Sir, I know that the essence of the Christmas BMJ is strangeness. But Leibovici’s article (1) is not only strange, and not scientific, but it is, above all, unethical. No informed consent was requested to participants. It has no impact in clinical practice, since, even on the basis of the menu by Oxman and colleagues (2), it is difficult to think about a retroactive consent. I argue whether a Jew would be accepted to participate in a trial in which a Palestinian prayed to Allah for him. Incidentally, what about adverse events in this randomised controlled trial? It is also unethical for a Christmas issue of a scientific paper. Investigating efficacy of distant healing through clinical trial is absurd because of the lack of a scientific rationale. Unfortunately, it is not only the case of the Christmas issue of BMJ, because there is the Cochrane review on intercessory prayer (3). It is tasteless to make jokes on the compelling and dramatic problem of the growing distrust in scientific medicine, which has brought to light a lot of alternative medicine which is trying to be scientific without having a scientific rationale. We really did not need strangeness to be added to this genre. I worry about the release of such material to the media. Here in Italy the turnover of fortune tellers and healers is enormous. People are turning more and more to the saints rather than to administrators and politicians to find solutions for a better healthcare management, which cannot be based on “beyond science” evidence of effectiveness. “Beyond science”, I prophesy that the BMJ Editorial team does not know that this is Christmas-time, the first in the New Millennium, the first of that historical period which the next generations will call the Technological Middle Ages. References (1) Leibovici L. Effects of remote, retroactive intercessory prayer on outcomes in patients with bloodstream infection: randomised controlled trial. BMJ 2001; 323:1450-1451. (2) Oxman AD, Chalmers I, Sackett DL. A practical guide to informed consent to treatment. BMJ 2001; 323: 1464-1466. (3) Roberts L, Ahmed I, Hall S. Intercessory prayer for the alleviation of ill health (Cochrane Review). In: The Cochrane Library, Issue 4, 2001. Oxford: Update Software.
TWO POSSIBLE EXPLANATIONS TO THE RETROACTIVE INTERCESSORY PRAYER EFFECT 24 December 2001
Luis C. Silva, Senior Researcher Medical Science Higher Instute of Havana 11600, Cuba Send response to journal: Re: TWO POSSIBLE EXPLANATIONS TO THE RETROACTIVE INTERCESSORY PRAYER EFFECT	After reading the study by Leibovici(1), I have considered two competing conclusions: a) There was actually divine intervention. In such a case, it seems to me more plausible (it is more parsimonious) to suppose that, instead of deciding the length of stay and fever duration of each patient, He did something simpler for Him: to decide the outcome of the coin tossing (allocating those who had longer stays in the control group). If it is the case, there was not proper randomization and Leibovici´s study doesn’t offer anything new. b) The other possibility is that God did not played any roll in this study. Then, what I conclude is that this study adds more reasons to think that p values are not only a not useful tool, as suggested in the Uniform Requirements for Manuscripts submitted to Biomedical Journals (“Avoid relying solely on statistical hypothesis testing, such as the use of P values, which fails to convey important quantitative information”), but a misleading one. If you use a new methodological approach by means of which you prove that earth is cubic (not flat, not round), I would seriously suspect that it would be better to avoid such a method in future studies. 1. Leibovici, L. Effects of remote, retroactive intercessory prayer on outcomes in patients with bloodstream infection: randomised controlled trial. BMJ 2001;323:1450-1451. 2. International Committee of Medical Journal Editors. Uniform Requirements for Manuscripts submitted to Biomedical Journals. Ann Intern Med. 1997;126:36-47.
An example of synchronicity? 24 December 2001
Ian T Guy, General Practitioner Fulcrum Medical Practice, Middlesbrough TS12 2ES Send response to journal: Re: An example of synchronicity?	The researchers seem to assume that there is a linear directionality of effect from the future to the past. It could be the other way round, for example an effect of events in the past affecting the fall of the coin used to choose the intervention and control groups. Or perhaps a more satisfy 'explanation' would be to say that the various events are acausally but synchronistically linked. Whatever the nature of the links, still a fascinating study. Jung would have loved it. Ian Guy
Re: Treat the control group 24 December 2001
Ian Spencer, Consultant Anaesthetist UHND DH1 5TW Send response to journal: Re: Re: Treat the control group	The paper would appear to demonstrate that one group of patients had improved outcomes due to intercessory prayer some 10 years later. Taking Professor Leibovici's conclusions and recommendations at face value then he has an ethical duty to treat the other group in a similar way; that this group still experienced a poorer outcome shows that he has not and indeed never will. Shame!
Science and Statistics cannot explain how prayer works 26 December 2001
Daniel O. Selo-Ojeme, Specialist Registrar, O & G Mid Essex NHS Trust, St John's Hospital, Chelmsford. CM2 9BG Send response to journal: Re: Science and Statistics cannot explain how prayer works	Editors - I congratulate the BMJ for the courage to publish the articles in the Christmas edition. I cannot understand Professor Leibovici's failure to acknowledge the simple conclusion of his study. The Coincise Oxford English dictionary defines prayer as a 'solemn request ... an entreaty to a person'. When you make a request or an entreaty, you expect it to be honoured or denied. In his study, some requests that were made were answered. It is as simple as that. We must understand that science cannot excplain the workings of God or predict the effectiveness of prayer. A creature cannot explain its creator. There is still a lot that is beyond science. There is faith and there is miracle. Competing interest: None
Confounding effects of future prayer? 27 December 2001
Prisca M Middlemiss, Medical Journalist Freelance W3 8EJ, n/a Send response to journal: Re: Confounding effects of future prayer?	Professor Martin Bland (Treat the control group) has surely said what should be the last rational word on retroactive prayer. Nonetheless, Leibovici's case rests on our abandoning any a priori assumptions about the linear nature of time. Logically, then, why has he failed to allow for the confounding effects of further, future and as yet unenacted prayers on his outcomes?
On behalf of the "Less Sophisticated" general public 28 December 2001
Margaret M. Zacny, Representative, General Public USA - 46322 Send response to journal: Re: On behalf of the "Less Sophisticated" general public	You might be interested to note that the MSN Home page featured a link to the BMJ article on rhythmic breathing through the repetition of the rosary and/or mantra. By now, I'm sure that millions of members of the general public have clicked on the available link and were able to enjoy an abbreviated version of the article. I'm also sure that, like me, millions of other members of the general public went one step further and performed a search on the words "British Medical Journal" and were then able to go directly to your site and download a PDF version of the article so that they could read it in its entirety. (You see, many of us "less sophisticated" members of the general public are rather curious, and from time to time we do such things.) While on the BMJ site, I took the opportunity to read the BMJ article on "remote, retroactive intercessory prayer.” Fascinating article!! So, explain to me how this thing works … are you telling me that if I pray for my dead Aunt Mildred, perhaps I can get her to retroactively change her will to include me this time? Please fill the general public in on how to perfect this retroactive prayer technique. After all, “enquiring minds want to know …” By the way … the general public is not amused … and we will, therefore, pray for you and your miserable little raisin-like souls (but not until later, because you’ve convinced us that it works better that way.) -- Margaret M. Zacny
Improbable Research 28 December 2001
Eberhard W Lisse, Obstetrician & Gynaecologist Swakopmund, Namibia Send response to journal: Re: Improbable Research	Editor, yet again, in your Christmas edition you publish a contender for the Ig Nobel prize, which as some of the commentaries don't seem to know is awarded by the Annals of Improbable Research.
Prayer Study Design 28 December 2001
Ronald L. Fredrickson, Retired Health Professional Home: 1567 Heredia Drive, Roseville, California, 95747 USA Send response to journal: Re: Prayer Study Design	I have yet to see a study of intercessory prayer which includes three groups: the unprayed for controls, the experimental group for which a positive prayer is used (pray for good results), and the experimental group for which a negative prayer is used (pray for bad results). I have been told that it would be unethical to pray for a bad result, but those who so believe must assume, a priori, that prayer is efficacious. In that case why do an experiment? I have been told also that God doesn't honor prayers for bad results. This presumes that the person who so believes can read God's mind. Why, then, during World War II or other such conflicts, did so many persons pray that the enemy would suffer bad results? When a prayer study is done in which the group prayed for positively immproves and the group prayed for negatively worsens, I'll become a believer. That seems to be the gist of this paper--- belief. Some things must be accepted on faith alone. No conflict of interest.
Hobgoblins of Consistency 29 December 2001
Doug Oman, Lecturer School of Public Health, University of California at Berkeley (Berkeley, CA 94720-7360, USA), Carl E. Thoresen Send response to journal: Re: Hobgoblins of Consistency	Dear Editor, "Consistency is the hobgoblin of small minds" proclaimed our countryman Ralph Waldo Emmerson. By this measure we see clearly that Leibovici, author of BMJ's newly published study of retroactive prayer,1 has no small mind, but rather one as supple and expansive as a brontosaurus, with which he himself recently declared his affinity.2 Leibovici's extraordinary intellectual suppleness is demonstrated by the new study's free-flying transcendence of Leibovici's own fervently pro-conventional argument, recently published in the BMJ, that "A deep model of the physical world is essential for choosing hypotheses to be tested and for learning from failures."3(p.1629) Yet we wonder about the depths to which Leibovici's mind may have descended, even as we marvel at his startling methodological innovations, which allow unprecedented efficiency and rapidity in study replication. "A list of the first names of the patients in the intervention group", he tells us, "was given to a person who said a short prayer for the well being and full recovery of the group as a whole."1(p.1450) When combined with instantly available "retroactively" measured outcomes, such brevity allows the intervention to be replicated many times per hour (using the same cohort but a different randomization), especially if the prayer is extremely short, and patient names are provided in electronic form. Indeed, given the BMJ editor's report that Leibovici asked "people" (italics added)4 to pray for patients, small-minded skeptics might wonder if he may already have conducted a large number of replications, not all producing equally statistically significant results. Anti-visionary or mean-spirited skeptics could argue that by employing his innovative study design, Leibovici might quickly conduct a vast number of replications - far larger than could ever be conducted in a full decade of research on most scientific topics, either "conventional" or "alternative", including even intercessory prayer as previously studied. We believe that Leibovici's radically efficient experimental design demands an accompanying innovation in reporting that is unnecessary for more conventional designs used in previous prayer studies. To exemplify responsible reporting and to facilitate future metaanalyses, we strongly urge Leibovici to offer an explicit public statement - absent from his recent article - about the total number of times he has implemented his study design using the same patient population and database. Leibovici deserves notice for a remarkable contribution, if not to science, to ethics, or to consistency, then perhaps to humor, of a sort. Doug Oman, Ph.D., School of Public Health, University of California at Berkeley, USA (DougOman{at}post.Harvard.edu). Carl E. Thoresen, Ph.D., Departments of Education, Psychology, Psychiatry/Behavioral Sciences, Stanford University, USA (Thoresen{at}Stanford.edu) 1. Leibovici L. Effects of remote, retroactive intercessory prayer on outcomes in patients with bloodstream infection: Randomised controlled trial. British Medical Journal. 2001;323:1450-1451 (text online) 2. Leibovici L. Doctors and complementary medicine: Author's reply. British Medical Journal. 2000;320:1145 (text online). 3. Leibovici L. Alternative (complementary) medicine: A cuckoo in the nest of empiricist reed warblers. British Medical Journal. 1999;319:1629-1632 (text online). 4. BMJ Editor. Editor's choice: The BMJ takes reason's last step. British Medical Journal. 2001;323:0 (text online).
Delay in publication? 30 December 2001
Anthony H.C. Campbell, Retired consultant physician Send response to journal: Re: Delay in publication?	Was this paper by any chance supposed to have appeared at the beginning of April?
All RCT require informed consent 30 December 2001
Christopher I. Price, SpR Geriatric Medicine Sunderland Royal Hospital Send response to journal: Re: All RCT require informed consent	It is understandably difficult to scientifically examine interventions that are not easily quantified. However, like previous authors studying the effects of prayer, Leibovici has presented an incomplete description of methodology and inadequate examination of confounding variables (1). In particular it is not known whether the subjects in this study had previously been prayed for, and whether this important confounding variable was also distributed in favour of the intervention group. Consequently it seems more likely that the effect of prayer was to produce a positive outcome for the study rather than a favourable outcome for the intervention subjects. The retrospective outcome measures were also unreliable: length of fever may be subject to random interference from cooling measures and recording error, whilst length of stay can be influenced by many factors other than a single episode of sepsis. The discussion did not acknowledge these important sources of bias. However my main objection to the study is that it cannot be justified on ethical grounds. Leibovici states that “we cannot assume a priori that time is linear…or that God is limited by a linear time”. Therefore it was argued that the intervention could be delivered in retrospect. However, no matter how distant the separation of the illness and intervention, the author was acting with the hope of influencing the outcome without the informed consent of subjects (who had not even given permission for their records to be examined for this purpose). No matter what the mode of intervention and no matter how good the intention of investigators, it is morally unacceptable to intervene experimentally in the routine care of a patient without their permission. Ethical issues should also not be limited by linear time. Whilst it remains possible that such interventions produce benefits, all investigators should be bound by the same rules of study design and ethical integrity that apply to the global scientific community. 1. Leibovici L. Effects of remote, retroactive intercessory prayer on outcomes in patients with bloodstream infection: randomised controlled trial. BMJ 2001; 323: 22-29.
Re: Treat the control group 31 December 2001
Haim Shapiro, Physician, Clinical Hypnosis Unit Wolfson Hospital, Holon 58100, Israel Send response to journal: Re: Re: Treat the control group	Only a randomized, controlled study can truly assess the effectivity of an intervention such as intercessory prayer.Since the control group received the best known medical treatment, the trial is ethical (except perhaps the lack of informed consent). Therefore one cannot treat the control group for methodological reasons. If we determine that intercessory prayer is effective, the control group deserve the same treatment, but giving them the treatment disqualifies the trial and therefore there is no reason to give them the treatment..... We are left caught in a bind (a direct result of research methodology)that shows just how far from perfect our assessment and understanding of reality really are ... This may be what many scientists and physicians find most difficult to accept. The need for humility may be what this trial is meant to teach us.
The RCT - gold standard or golden calf? 31 December 2001
Robert G. Newcombe, Senior Lecturer in Medical Statistics University of Wales College of Medicine, Cardiff CF14 4XN. Send response to journal: Re: The RCT - gold standard or golden calf?	Many previous correspondents have drawn attention to methodological, ethical and epistemological difficulties attaching to this study. To the former I would add just two - use of covariates, and publication bias. In an RCT comparing, say, two blood pressure lowering agents, the usual practice is to use the pre-randomisation baseline value of the parameter as a covariate - the purpose not being to remove bias, which proper randomisation does effectively, but to increase precision. In this study, both of the "outcomes" on a continuous scale that are reported in table 2 - length of stay and duration of fever - were known, or determinable, before the randomisation took place, just as were the data on gender, age, source of infection etc. shown in table 1. Yet it would be inconvenient to use each of these outcomes as a baseline covariate for itself, as the difference in outcome between intervention and control groups would of course then disappear. This illustrates that the validity of the standard RCT methodology and interpretation becomes highly questionable once we abandon the axiom that causality can only occur forwards in time. Furthermore, the p-values reported for these two outcomes are at the level that is conventionally regarded as "statistically significant", though they are neither extreme nor independent of each other. Would the study have been considered for publication, either by the author or the journal, had statistically significant benefit not been attained? (Indeed, what would have ensued had the study shown significant harm?) In this instance, the reason one feels compelled to ask this seems to be prior scepticism rather than sample size which appears to be adequate. One correspondent has stated he has no conflict of interest. I feel I must declare that I, and all of us, have a most serious personal interest when it comes to the barely disguised further agenda of this study, which many have already debated. The p-value attained in an RCT represents extremely limited information bearing on this issue, compared to the vast amount of information we have about the universe, even though the former is experimental and the latter observational. If the issue merely relates to the existence of a transcendent being that we can manipulate within an RCT, there is little to be concerned about, as we are then more powerful than this being. But - bearing in mind that this study originated in Israel - if the one in question is the God whom the twelve tribes of Israel worshipped, the God of Abraham, Isaac and Jacob, the one presented in the Hebrew and Christian Scriptures as Almighty, we dare not view the issue in a detached and disinterested manner. In these Scriptures he is presented as the rewarder of those who diligently seek him, but who is not mocked.
Leibovici's paper is religious propaganda, not science 1 January 2002
Riccardo Baschetti, CP 671, 60001-970 Fortaleza (CE) Brazil retired medical inspector Send response to journal: Re: Leibovici's paper is religious propaganda, not science	Considering that 93% of leading scientists do not believe in God [1], it is highly improbable that the poorly significant, unimpressive results that Leibovici [2] ascribes to intercessory prayer have to do with divine interventions. His unscientific paper simply represents a cunningly disguised form of religious propaganda, which is reminiscent of the so-called "scientific creationism" [3]: sheer religion camouflaged with scientific terms to convince simpletons that the earth was created by God, only about 6,000 years ago [3]. Leibovici's implicit message that God uses omnipotence to comply with human prayers, instead of being comforting, is both discouraging and worrying. It is already disquietingly absurd to believe in a good and omnipotent God capable of creating the entire universe but unable or unwilling to stop mere earthquakes, which, despite having nothing to do with the "original sin", have painfully massacred thousands of innocent babies during human history. It is even more disquietingly absurd, however, to imply that God prefers to use omnipotence to shorten, by a single day, the length of stay in hospital of some patients "benefited" by intercessory prayer. As someone stated most rightly, "religion is the rough equivalent of firing an arrow at a blank target, then claiming marksmanship by painting a bull's-eye around the point of impact". Leibovici's grotesque paper [2] concurs to paint that bull's-eye. The fact that leading scientists overwhelmingly reject God [1] should lead humankind to rely on reason, not on medieval superstitions. Reason and science unite people, whereas religions, being mutually incompatible, generate and perpetuate divisions and wars. Religions, as mere products of the last 0.1% of human evolution, should be disregarded if they are at odds with the biological ethics that have wisely guided humankind for millions of years [4]. 1. Larson EJ, Witham L. Leading scientists still reject God. Nature 1998;394:313. 2. Leibovici L. Effects of remote, retroactive intercessory prayer on outcomes in patients with bloodstream infection: randomised controlled trial. BMJ 2001;323: 1450-1. 3. Dalrymple GB. Radiometric dating and the age of the earth: a reply to scientific creationism. Fed Proc 1983; 42:3033-8. 4. Baschetti R. Use of stem cells in creation of embryos. Lancet 2001;358:2078.
The effects of retroactive prayer: more questions than answers 1 January 2002
Max Lagnado, Medical Director Chameleon Medical Communications, Park House, 111 Uxbridge Road, Ealing, London, W5 5TL Send response to journal: Re: The effects of retroactive prayer: more questions than answers	Editor– Leibovici should be congratulated for challenging us to question our thinking about the nature of time and the potential therapeutic effects of prayer.1 However, as with all scientific findings we should view them within the context of the study's limitations. In particular, can we be sure that the differences in outcomes between the intervention and control groups were due to prayer rather than due to differences in baseline characteristics? For example, were there differences in the day of the week that patients in the two groups were diagnosed or treated? This would be especially important if the control group was more likely to have been investigated and treated on a weekend, when arguably the level of care is inferior to the rest of the week. And, since the patients were treated over a 7-year period, were there differences in the distribution of the year of treatment for the two groups? If there were, changes in the management of bloodstream infection over time may have confounded the results. Also, Table 1 of the paper shows that fewer patients in the intervention group acquired their infection while in hospital. Although the difference was small (about 2%), can we assume that it had no affect on outcome? Professor Leibovici states that he had no competing interests. However, competing interests include religious beliefs, which may have affected the way this study was designed, analyzed or interpreted. Are we to assume that Leibovici had no a priori beliefs about religion and spirituality? These potential biases, together with other methodological limitations presented in the rapid response section of bmj.com, are not reasons to question Leibovici's integrity nor should they distract us from the originality of his study. However, they should serve to remind us that scientific inquiry, for all its supposed rigour, can not provide a definitive answer to every question. I thank Leibovici and the BMJ for providing me with some (non-alcoholic) cerebral nourishment during the festive period. 1. Leibovici L. Effects of remote, retroactive intercessory prayer on outcomes in patients with bloodstream infection: randomised controlled trial. BMJ 2001;323:1450–1.
The Finger of God 2 January 2002
Stephen L. Black, Professor of Psychology Bishop's University, Lennoxville, Quebec J1M 1Z7 Send response to journal: Re: The Finger of God	Applying the Talmudic method (which seems appropriate here), either this study of Leibovici(1) shows God's intervention or it does not. If it does not, then the experiment must be faulty. As Dace(2) points out, the great principle of William of Ockham leads us to prefer this explanation in science. But suppose it does show God's intervention. The time-bending aspect of this report is not of concern, as once the supernatural is invoked, the sky's the limit (literally). If God can intervene to promote faster recovery on request, then surely He can reach back in time to do so. But consider the implication of accepting what Gardner(3) calls "the superstition of the finger", that "God finds it necessary at intervals to abrogate natural laws by injecting a finger into the universe to tinker with it". Charles Darwin, for one, argued against this belief, concluding that "there seems to me too much misery in the world" to believe that God takes such a personal and protective interest in how we live our lives(4). But the argument against the God of the finger becomes even stronger if we accept Leibovici's experiment. We must only recall recent horrific events--in Afghanistan, in the Balkans, in Israel, and in New York--to realize that God is unwilling to lift his finger to prevent great suffering and death among the innocent, and is unmoved by the many impassioned prayers that he do so. Then why does he choose to respond when called upon by perfunctory, impersonal prayer on behalf of long-ago events involving far lesser suffering? The implication of Leibovici's conclusion is that God may intervene, but He does so in a profoundly cruel, capricious, and trivial manner. Those who believe in a just and loving God should obtain little comfort from the outcome of this experiment. They should pray that it is not true. 1 Leibovici, L. Effects of remote, retroactive intercessory prayer on outcomes in patients with bloodstream infections: randomized controlled trial. BMJ 2001; 323:1450-1451. 2 Dace, J. Occam's razor. Electronic response, BMJ 2001;323: 1450- 1451 at http://bmj.com/cgi/eletters/323/7327/1450#18236 3 Gardner, M. Phillip Johnson on intelligent design. In: Did Adam and Eve Have Navels? New York: W.W. Norton, 2000, p. 22-23. 4 Milner, R. The first evolutionary psychologist. Scientific American, Jan. 2002 [http://www.sciam.com/2002/0102issue/0102reviews1.html] Competing interests: none
Doctors prayer for more care 3 January 2002
DE Barnes, General Surgical SHO James Cook University Hospital, Middlesbrough, TS4 3BW Send response to journal: Re: Doctors prayer for more care	Sir -I read with interest the forementioned article that concluded with great conviction that a prayer to sub group of patients with blood borne infection led to a significantly better outcome in the interventional group. -I would like to know if this effect was dose dependant, and if the relatives and general prayers for the sick that happen across the world were banned from the control group during this period of "intervention". -Whilst I am a firm believer in god and that patients and relatives gain comfort through prayer, this study was fundamentally flawed. Furthermore I have concerns that it could be used inappropriately by those wishing to further their alternative medical practice by quoting this "conclusive evidence" from your' well respected journal.
Misapprehension of principle 3 January 2002
Stephan A. Schwartz, Research Associate Cognitive Sciences Laboratory 90212 Send response to journal: Re: Misapprehension of principle	Those correspondents who suggested that the controls should be included in a cross-over study where they become the treated sub-population in a subsequent study have, I believe, misunderstood what is going on. This study is not about reaching back from the future into the past to change it but, instead, affecting the way in which it occurred in the first instance, when these clinical events were present tense. Nor is this study a singular piece of benighted research, as others seem to suggest. BMJ readers may find the following URL of interest, http://www.fourmilab.ch/rpkp/ There they will find a number of papers addressing various aspects of this subject, and I particularly draw their attention to the work of physicist Helmut Schmidt. Readers may also want to consider a just published study carried out by researchers at Duke University’s School of Medicine, which also deals with retroactive Therapeutic Intent (TI). (1) (TI is, I think, a better term than prayer, because the now considerable literature on this subject suggests that any form of religious belief, or none at all, seems capable of achieving the effect.) Using a well-designed randomized, controlled, double-blind protocol, the Duke study involves prayers from religious groups around the world for people experiencing severe chest pains who are in danger of imminent heart attacks. The treatment they received to relief their crisis was cardiac catheterization and angioplasty. As readers will know, the emergency nature of these treatments means the procedures are carried out immediately upon the patient being admitted. That turns out to be the crucial aspect of the retro-active aspect of this TI research, because although the prayer groups were notified as soon as possible after the patient was admitted, the initiation of the actual TI sessions often began after the medical treatment had already been completed. Both treated and control groups received the same level of medical intervention. The TI practitioners had no contact with the patients, and the health professionals administering the treatments, and the patients themselves did not know about the TI involvement. The outcome measure was the number of complications each patient experienced, with the comparison being made between the subgroups. The TI recipients experienced, a 50 to 100 percent reduction in side-effects compared to the controls. Although this was just a pilot study with a patient population too small to reach any definitive conclusions, the results have proven so provocative that researchers at more than half a dozen medical centers in the U.S. have taken up this line of inquiry. The study had another aspect that should be mentioned. The TI practitioners were scattered all over the world, including Nepal, India, Israel, and France, as well as in the U.S., and their TI was expressed through a wide range of religious traditions. No difference was noted concerning one tradition being more powerful or efficacious than any other. Skeptics may find this line of inquiry philosophically offensive but the gathering corpus of research suggests that TI, whether retroactive or real-time has the power to affect clinical outcome. (1) Krucoff MW, Crater SW, Green CL, Maas AC, Seskevich JE, Lane JD, Loeffler KA, Morris K, Bashore TM, Koenig HG. Integrative noetic therapies as adjuncts to percutaneous intervention during unstable coronary syndromes: Monitoring and Actualization of Noetic Training (MANTRA) feasibility pilot. American Heart Journal. 2001;142(5):760-767. -- Stephan A. Schwartz
Beyond Science? 3 January 2002
Tobit S Emmens, R&D Manager Department of Mental Health, Wonford House Hospital, EX2 5AF Send response to journal: Re: Beyond Science?	It has been with interest that I have read this paper, the paper on the Effect of rosary prayer and yoga mantras on autonomic cardiovascular rhythms and all the associated rapid responses. I think that perhaps a more appropriate title for the section would have been: Before Science. From the beginnings of recorded time up until the fairly recent past (1700s and the advent of people such as Descartes), techniques such as mantras and intercessory prayer have formed a substantial part of any available healthcare service, and in many parts of the world are still being used today. Whether or not the science or ethics are sound in this research, we should treat techniques such as prayer with respect. Rather than mocking such research we should applaud those that are breaking "new" scientific ground. Just because we ignore, are unaware, or do not understand it does not mean that it cannot be possible. Just as, if a technique or procedure is yet to have a clear scientific rationale does not mean that it is invalid. Many thanks for such stimulating topics of discussion.
Efficacy of prayer underestimated? 3 January 2002
Charles S. Harris, PhD, Webmaster, The Nurture Assumption home page: http://home.att.net/~xchar/tna/ Middletown, New Jersey, USA 07748 Send response to journal: Re: Efficacy of prayer underestimated?	Leibovici found statistically significant ameliorative effects of retroactive intercessory prayer. Regrettably, the reported magnitude of effects was disappointingly small (see Table 2). However, it may well be that the efficacy of prayer was underestimated--perhaps greatly underestimated--in this report. As spelled out in the Methods section, "A list of the first names of the patients in the intervention group was given to a person who said a short prayer for the well being and full recovery of the group as a whole." Now, it is highly likely that some--perhaps many--of the control group members shared some of those first names. Thus an undetermined number of control group members may have inadvertently benefitted from the intercessory prayer, thereby spuriously bringing the control group's data into closer agreement with the intervention group's. Indeed, although other commentators here have decried the researcher's possibly unethical behavior in withholding effective treatment (prayer) from the control group, this trial may in fact already have had vast, unmeasured, beneficial effects on a large segment of the general public: those who share first names with the intervention group. One could ascertain whether such collateral effects have actually occurred, by comparing hospital records for patients whose first names do or do not appear on the list. Such a tally of several hundred thousand records from many hospitals would, I venture to predict, reveal statistically significant differences (albeit perhaps for conditions other than bloodstream infection and outcome measures other than duration of hospital stay).
Retroactive prayer - a solution to the bed crisis? 4 January 2002
Adrian Fawcett, Consultant surgeon Central Middlesex Hospital, Park Royal,London NW10 7NS Send response to journal: Re: Retroactive prayer - a solution to the bed crisis?	Unfortunately, it seems our management staff have got hold of this article. As a result, all elective work in surgery has been cancelled for the next week,as has all annual leave. Why? Because of a waiting list initiative. Management have decided that if retroactive prayer can improve outcomes in blood infections it may work in other cirumstances too. We, the surgical staff, have each been allocated a particular disease, and informed we must pray for all sufferers of said disease admitted to the hospital between 1990 and 2001. Though no specific training has been given, clinical governance demands we each stick to our specialities, and my firm has thus been given strangulated piles,perianal sepsis and retained rectal foreign bodies as the focus of our heavenward pleadings. Management hopes that by the power of prayer we will shorten in-patient stays of years gone by to such an extent that previous bed crises will have become (a thing of the past?) no more than a figment of our imaginations. If sufficient resources are mobilised, on our return to work we will find that so many bed-days have been saved by early discharge that we have no waiting lists, no trolleys in corridors and in fact fewer people in our clinics because some patients never came to hospital at all because they were cured at home.......or because they had heard we'd all gone crackers.
Methodological concerns 6 January 2002
William G. Taylor, Part-time tutor University of Sheffield, England Send respons