PC, M.D.: How Political Correctness Is Corrupting Medicine, by Sally Satel, M.D. Basic Books, 256 pages, $27.00.
Are you concerned about the fact that 44 million Americans lack healthinsurance and that millions of senior citizens are struggling to pay for medicineprescribed by their doctors? Are you troubled by the denial of necessary care byHMOs--or by other well-publicized abuses of "managed care?" Do hospital closingsin your community make you worry about how long it will take to reach anemergency room if you ever have chest pains or an accident? Do you wonder whatkind of treatment you'll receive in the hospital or a nursing home amidst aserious national nursing shortage?
Well, Sally Satel--a psychiatrist and fellow of the American EnterpriseInstitute--has news for you: While these issues are "pressing," you're frettingabout the wrong things. What's really hazardous to our health in America is aplague of "indoctrinologists." These are people who have "swooped in under theradar" to unleash an epidemic of political correctness in the nation's hospitals,clinics, nursing schools, doctor's offices, and public-health programs.
"Indoctrinologists" are not some new type of medical specialist. You can be onewith or without a medical degree. Among them are the psychotherapists who urgepatients to uncover repressed memories of childhood abuse and "multiculturalcounselors" who "presume that nonwhite patients' personal difficulties largelystem from their efforts to adjust to a racist society."
Also threatening us are public-health professors who, "in the course of expandingthe purview of public health to encompass the quest for social justice ... arewarping the indispensable mission of their profession: the practical,here-and-now prevention of injury and disease." They are joined by those in themental health field who "revile medication and fight against public policies thatmake sure psychotic patients take antipsychotic drugs" and by people who campaignfor the "freedom" of drug-addicted women to "use cocaine during pregnancy."
And let's not forget women's-health and minority activists--"especially blackAmericans"--who, according to Satel, undermine the authority of physicians bymaking unsubstantiated claims that racism and sexism affect how doctors treatnonwhite and female patients. Or last but not least, the growing cabal offeminist nurses who are fueled by "a fiery resentment of the medicalestablishment, the so-called male medical elite" and whose "antipathy representsa thoroughly postmodern rejection of the prevailing medical culture wherein doctors direct the patient's treatment and nurses carry out many of thosedirectives."
If any of these health-care-system bogeymen (or bogeywomen) seemunfamiliar--particularly in light of the real problems sick people face everyday--Satel's conservative muckraking technique is tediously familiar. Satel usesthe method perfected by Dartmouth grad Dinesh D'Souza, the scourge of politicalcorrectness in higher education: Set up a straw man and knock it down. PC,M.D. thus greatly inflates the influence or role of fairly marginal players and ideas within the health care system; it glosses over the factual record (usually through a highly selective use of studies and sources); it minimizes the impact that social and economic inequality has on health care; and it ignores the power imbalance in doctor-patient and doctor-nurse relationships, a dynamic that can indeed have an adverse impact on the quality of patient care.
The result is a book that is more of an exercise in witch-hunting thanwhistle-blowing. Its description of alleged trends in public health and nursingis typical of the author's approach. According to Satel, a group of left-wing"social productionists" have attained enormous influence within the public-healthfield. As she defines them, social productionists believe that "socialdisenfranchisement can lead to infirmity and shorter life expectancy" through"the stress of oppression ... and material disadvantage and inferior access tohealth care."
In a brief nod to those who might accuse her of willfully ignoring widespreadsocial problems, the author does allow that "on average, people who are furtherdown on the socioeconomic ladder are less healthy and do not live as long asthose above them." But social productionists go too far because they refuse toacknowledge the role of personal responsibility in maintaining health. They tryto advance their public-health agenda not by generating dry statistical reportsthat gather dust on library shelves but rather through promoting critical publicdebate. According to Satel, "documenting" the effects of social conditions onhealth and "calling them to the attention of civic leaders is one thing."Public-health "indoctrinologists" have a broader mission--"opposing the freemarket system, supporting affirmative action and derailing welfare reform." Bypursuing these and other causes, they have, according to the author, actuallydiverted resources from useful public-health endeavors like "discrete vaccinationprograms and cancer screening campaigns."
While it is true that liberals and leftists are more active in public health thanin most other medical and nursing fields, the idea that there has been some sortof Marxian takeover of public-health programs would come as a surprise to most ofthe professionals under attack in PC, M.D. When I informed one public-health professor that "social productionism" was, according to Satel, now triumphant in the nation's public-health schools, he responded: "I had no idea. What a relief!"
Left-of-center members of the American Public Health Association--or anyone who'sever attended an APHA national conference--would similarly have troublerecognizing the group in Satel's description of its activities. At the APHA'sannual gatherings, for every panel on social-justice topics, there are literallyhundreds more devoted to traditional professional concerns like epidemiology,dental health, and maternal and child care. The same priorities are reflected instate public-health budgets, which are not, in fact, skewed toward much-neededcampaigns to address poverty and inequality but instead support the verynuts-and-bolts programs--dealing with substance abuse, smoking, communicablediseases, AIDS, and so forth--that Satel supposedly favors.
If the growth and effectiveness of these programs has been hampered, it has notbeen the result of left-wing faddism but rather because opponents of "biggovernment" have succeeded in cutting public-health funding, both in the UnitedStates and abroad. As Laurie Garrett documents in her excellent new bookBetrayal of Trust: The Collapse of Global Public Health, the real scandal in the field is the drastic curtailment of the public sector's role in disease prevention, a shift that is exposing millions of people to the risk of frightening new diseases and a recurrence of some previously contained old ones.
As someone who has spent much of the last decade writing about the nursingprofession, I was astounded by Satel's account of recent developments in thefield. Displaying little understanding of the profession's history or politics,she depicts R.N.'s as succumbing to the siren call of women's studies programsand the nostrums of radical feminism--despite the fact that nursing has long hada tense and conflicted relationship with the women's movement.
In the chapter "Nursing Grudges," Satel's straw women are women's studiesprograms and something called "therapeutic touch"--a healing therapy that usessupposed exchanges of energy between patient and therapist to promote physicalhealing. Satel insists that this is part of some dangerous feminist currentwithin nursing--one that has become so strong that it has already washed over theprofession in Great Britain.
"Thirty years ago British nurses were expected to observe rules of silence, ritual and courtesy," Satel writes. "They were barred from getting married whilein training, personal jewelry was banned and hair could not be longer than shoulder-length." As nurses struggled to overturn these strictures, they have,Satel argues, abandoned the basics of bedside care. "By 1995," she claims, "allthe traditional nursing schools had closed. Nursing training was expanded toinclude sociology, politics and race and gender awareness. Patient caresuffered."
Her first mistake is to attribute the growth of therapeutic touch to feminism.Whatever one might think of this therapy's validity, it does not spring fromnursing's "grudges" against medicine but from some nurses' long-standinginterest in alternative therapies. While it is taught at a few nursing schoolsand does have its devotees, it is by no means a staple of nursing education.Even if it were, Satel wouldn't have much to worry about in most hospitals today,since their main problem isn't too many nurses busily applying therapeutic touchbut the absence of enough nurses to provide basic traditional care.
Satel makes similarly overblown claims about the influence of women's studies onnursing education and what she insists are resulting antidoctor campaigns withinthe profession. Though understanding gender is crucial to a mainly femaleprofession, there hasn't been enough contact between women's studies and nursingon university campuses. Moreover, Satel is utterly blind to the kind ofdysfunctional nurse-doctor relationships that prevail in most health careinstitutions--relationships engendered by doctors' beliefs that nurses are theirhandmaidens (or, as Satel puts it, mere extensions of the "doctor's directive").If more nurses openly protested this definition of their profession, patientswould be better off.
Just as it wasn't feminists who closed hospital-run nursing schools in Britainand the United States (the shutdowns occurred largely because hospitals andinsurers no longer wanted to bear the costs of nursing education), it is notfeminist nurses who are depriving patients of good nursing today: The problem iscreated by hospital administrators--who continue to view nurses as a cheap,disposable labor force--and by business and political leaders, who have failed toprovide adequate funding to support nursing research and university education asthe standard entry into practice for all registered nurses
And on it goes. Satel concedes that some doctors have mistreated mentalpatients, women, and African Americans. But all that happened back in the DarkAges. Today's M.D.'s apparently are free of any taint of racism and sexism andare unaffected by the corporatization of medicine. Driven by antifeminist zeal,Satel assails women's-health advocates who have exposed the problem ofunnecessary hysterectomies. Confusing medically appropriate hysterectomies withthose performed for no compelling medical reason, she seems to suggest that eventhe latter are good for women because they enhance sexual function and decreaseurinary incontinence.
Relying on only those studies that support her point, she insists that ifblack Americans get fewer heart surgeries and angioplasties it's not because ofprejudice or poverty but because blacks have more serious physical problems thatincrease the risk of such procedures. The idea that these risk factors might stemfrom historical inequities does not seem to occur to her. And when Satel contendsthat affirmative action programs designed to attract black candidates to medicalschools are unnecessary because many of the nation's hospitals serve minoritycommunities, she again ignores evidence to the contrary: An ongoing study beingconducted by Alan Sager of the Boston University School of Public Health that hasbeen tracking 1,200 hospitals in 52 U.S. cities since the mid-1930s hasdocumented that the race of neighborhood residents near a hospital is one of thetwo or three strongest long-term predictors of whether the hospital will close.
Scattered throughout PC, M.D. are some good--albeit fairly obvious--points. Some of the heroic medical procedures that advocates for women and minorities seek may do more harm than good, and some of the therapies she targets are indeed flaky. In criticizing feminist demands for more female role models at top levels in health care, she points out that this absence has clearly not discouraged women from entering the profession (although it may have discouraged them from challenging the kind of hierarchical attitudes toward patients, nurses, and other health care workers that Satel has so thoroughly absorbed). If she had devoted more energy to a nuanced exploration of conflicts in contemporary health care, she would have produced a more useful work--one like Anne Fadiman's book The Spirit Catches You and You Fall Down, which she so admires; or Of Two Minds: The Growing Disorder in American Psychiatry, by T.M. Lurhmann.
But Satel's goal does not seem to be open inquiry and critical debate. Rather,she stands rigidly opposed to creative or innovative ideas that might bepercolating on the margins of health care if such initiatives in any waychallenge physician hegemony and free market ideology. Consider, for example, herthin-skinned response to a recent critical review in the New England Journalof Medicine (NEJM). As reported in The Boston Globe, Satel initially chose not to write a letter to the editor defending her position--the usual resort of authors whose books have been critiqued. Instead she had her lawyer send the NEJM a "demand letter," often the prelude to a libel suit, insisting on a formal apology and published correction. Talk about political correctness.
Not to range too far afield, but as I was reading Satel's book, news reports werecoming in from Afghanistan about the Taliban's destruction of ancient religiousicons. You might think that leaders in such a place as Afghanistan would begrappling with societal crises like the widespread hunger, unemployment, andhomelessness that afflict millions of their countrymen. Instead, they're busyblowing up statutes of Buddha that few people paid attention to anyway. Satelalso has an odd choice of targets. Her Rx for our troubled health care system isa purge of therapeutic-touch courses, the muzzling of "feminist and multiculturalpractitioners," the elimination of funds for health care "survivor groups," and so on. Even if one agreed that political correctness was a problem in Americanmedicine, after its few small monuments were reduced to rubble, would the rest ofus be any better off?
