Sally Satel, M.D.
Oasis Clinic, Washington, D.C.
American Enterprise Institute
"How Political Correctness is Corrupting Medicine"
February 13, 2002

Sally Satel: I realize that my subject may seem provocative PCMD, "How Political Correctness is Corrupting Medicine". But what I have to say today, I think, is not at all radical. It is about putting patient’s best interest before the ideology of practitioners, researchers, and policymakers who are entrusted with their care.

I am going to start out with an example, actually one just hot off the press that I heard yesterday. I was speaking to the Psychiatry Department about the encroachment of political correctness into psychiatry and psychotherapy in particular. And one of the faculty members told me about a very interesting practice that I subsequently want to confirm. But, I will tell you the outlines of it. And it is really quite amazing.

What he told…what this gentleman told me that in certain psychiatric facilities, I believe in Virginia, that before a patient can undergo shock therapy…electro convulsive treatment, which is in many cases a front line therapy for very, very severe, major depression. And it works quite well. But, that before a patient undergoes this that the case has to be reviewed. But, not reviewed by other clinicians…in my view that would be a little unusual. I mean it is not an experimental procedure and you know there is nothing particularly…as I said, unique about it. But, nevertheless, it wasn’t another psychiatrist or clinician had to review the case. It is that the case had to be reviewed by three consumers.

I don’t know if you are familiar with the term consumer. It is very much the politically correct term for patient in my field. Another word is consumer survivor. Survivor not being used in the way we think about breast cancer survivor. You know someone who has survived breast cancer, but someone who has survived the psychiatric system.

So, the reason why patient in some circle is actually considered politically incorrect is because it implies the notion of hierarchy, it implies a notion of paternalism that one person knows more than the other. Well, I certainly would hope so. That is why we seek experts.

Well, it gets more bizarre. Apparently one of these three consumers…it is permissible for one of these three consumers to be mentally retarded. So, what you have is a situation where a physician’s considered judgment could be [end of side A] [beginning side B] overruled or at least questioned by someone with an IQ of 80. Now, this is really very bizarre. And as I say, I guess I present this in a provisional way because I want to talk further with this faculty member.

But, the point is that I understand this. I mean this kind of scenario that he painted for me is consistent with what I know to in fact be going on in psychiatry. It is vintage political correctness.

And let me now define political correctness. You hear that term all the time but often you don’t get a definition. My definition is that political correctness is an orthodoxy intended to maintain a victim status. And that is exactly how these consumer survivor folks see themselves. They are former psychiatric patients. And luckily for them they are actually doing quite well. These are people who were diagnosed often at some point in their life with schizophrenia or some sort of psychotic illness. Maybe they were misdiagnosed, we don’t know. But, nevertheless, they are doing quite well now. And that is quite wonderful. But, they have devoted their activism, essentially, claiming they are representing the severely mentally ill, but really as I said, being social activists. In fact they get a fair amount of federal money.

But these consumer survivors really do consider organized psychiatry a tool of oppression. They cast themselves as victims of the drama of the dominant and the disenfranchised. In fact, in their literature, they will call themselves the last minority. There is a disdain for professionalism. I think that is reflected in the language used about the consumer survivor. And in fact, in some cases the goal is actually to run the system itself. To become the providers and to run the treatment system.

In fact, what is quintessentially pc about this movement is the contempt for the notion that there is a better way to perceive. There are established and proven treatments for certain kinds of problems. And that this is factual. This is something that you can look up in the journals. It is not merely some arbitrary construct that has been put forth by those in power. This is the classical post-modern construct. That truth is just a…really it is a fiction, it is an illusion, it is something that has been deemed correct because the folks in power traditionally you know, white men, heterosexual white men have deemed it so.

And what I find most troubling…I have devoted a whole chapter to these folks and their movement in my book, is that, as I said, they are pretty well organized. They have taken a fair amount…I mean a relatively small amount of federal money and leveraged it into some pretty darn successful lobbying to try to undo or to block involuntary commitment laws at the state level. And I am sure you all know what those laws are. They are for folks who are an imminent danger to themselves or others. And even now, some states want to apply a standard of helplessness so that if not necessarily that a person who is severely mentally ill might be…might have a knife to their throat or yours, but that they are psychotic, they are lying in the street in negative four degree weather, suffering frostbite, lying in excrement. I mean, that is a standard of helplessness and that these folks we should be able to bring them into a hospital as well and keep them safe.

There are also laws now in the states called outpatient commitment…you are familiar with that. This is to require extremely mentally ill folks who have a habit of going off their medication and then spiraling down into homelessness or violence. To require them to take their medication so they can live out in the community. There are legal protections built in. I think it is a very responsible system and life saving for patients.

But, these consumer survivors, the more radical ones are against that. A lot of them are against medication as well.

So, I am the first to say the psychiatry system certainly needs help. It can certainly be improved. And it’s history and horrific shadows cast over it and the asylums in the ‘30s, ‘40s and ‘50s were ghastly. There is no question. I am not making apologies for that. But, these are remedies now that are not in the best interest of people, of patients. And this is the kind of threat that falls under the category of political correctness as I define it that I wanted to expose in the book.

Another way in which I would say political correctness is corrupting to medicine is in the teaching of alternative medicine. Now don’t misunderstand. I certainly think health professionals need to know about the kinds of remedies and herbs and sorts of things that patients are going take. So, they will know how they interact with other medications they might be taking. Perhaps a handful of them are effective. I am not familiar with too much data that supports alternative treatments. Most are harmless. Some are not. But, these are things you want to be able to tell a patient. I have had a number of folks ask me about St. John’s Wort for depression. This sort of thing. And we should be able to answer them. So that is fine and I am certainly all for studying this…these interventions.

But an attitude of unconditional endorsement of alternative medicine as effective is something very, very different. And unfortunately many medical schools have courses that do promote alternative medicine as treatment in a highly, uncritical way. A colleague of mine, Dr. Wallace Sampson at Stanford, conducted a survey of course instructors of alternative medicine classes. And here is what some of them said when he asked about what their attitude is and you know, about teaching. One of them said, we are non-judgmental. Another one said, we are tolerant. A third one said, we believe in the first Amendment. And a third one…a fourth one said, we allow students to choose what they want to hear. I don’t know what that is about. What is a technical education for if it is not about learning how to make judgments about more effective treatments based on evidence, not based on feeling or attitudes, but based on evidence?

And when alternative medicine is taught in a nonjudgmental manner that frankly often ends up being judgmental. But, judgmental in a direction that tends to be sometimes dismissive of what is called western ways of knowing. Objectivity and logic versus Intuition and Sentimentality. I am sure you are familiar with that dichotomy. Then alternative medicine…these courses become essentially become tutorials in pseudo-science and feel-good inclusivity. Some see it as a basically an avenue towards multiculturalism. But, essentially they become tutorials that challenge the superiority of rational inquiry.

Some nursing schools have taken this a step further. I was talking medical schools before. Now I am talking about nursing schools. Talk about teaching alternative medicine unskeptically, they have taught it with the expectation that nurses will actually practice it. Not every nursing school and not every nurse. Don’t misunderstand, but enough. I am going to give you a sense of how popular this is in a moment. But, let me first describe one of the techniques that they are…that is frequently promoted. And that is something called therapeutic touch. It was developed in the 1970s by a nursing professor at NYU. And it supposedly cures ailments from high blood pressure to yeast infections to hang nails by smoothing out the energy fields that supposedly surround us. It is not even touch. I mean you don’t even get a massage out of this. It is just basically an unruffling, hands hover three to five inches above your body and they unruffled the energy field. The idea is that somehow this field is blocked; it will result in physical illness.

Well, needless to say this is nonsense. Biophysicists have never identified an energy field surrounding the body. Studies comparing therapeutic touch have not use controls so that if a patient does feel better after undergoing it, and I don’t doubt that some might, it is most likely because a caring person has spent some time with them. And that is very important and probably counts for a lot of the success of alternative medicine…something that we should pay attention to certainly.

Do all nurses believe in this and practice it? Of course not. Most nurses are professionals. They are worked to the bone these days. But nonetheless, therapeutic touch is endorsed by the American Nursing Association, which is the nurses’ AMA. The National League for Nursing which is the accrediting body for nursing schools. And in fact, the National League for Nursing produces a diagnostic manual…or rather the diagnostic manual for nursing diagnosis. And there is actually a diagnosis called energy field disturbance. And therapeutic touch is the recommended therapy for this. And it is taught in about 80 nursing schools in North America. Some nurses have gone so far as to practice therapeutic touch as a political statement as a way to reject what they consider the technical problems of doctors and the "male-medical hierarchy".

A while ago there was an interesting article in JAMA. You might remember reading it. A girl who had practitioners of therapeutic touch try to determine just which hand she had under their hands. They were supposed to put their hands out like this. And she had her hand under one of their two. And they were just supposed to say…they had their eyes closed…in fact there was a blind between them and this young girl…they were just supposed to tell which hand her hand was under. Could they perceive the energy field to then tell her? They couldn’t even do that with a greater rate of chance. This was in JAMA. The girl was on the Today Show, People Magazine, all over. She was nine years old. This was her science fair project. And in JAMA a few weeks later, there were many irate letters from nurses. And one of them said that JAMA shouldn’t have published this article. And the only reason they did was "they felt threatened by…another word for this…human aura therapy because it means that their power and money might be taken away." Not that the science wasn’t there but you know…that they felt threatened in some way.

Another manifestation of political correctness in medicine is the allegation that medicine is male dominated. It used to be. And some professions still are…surgery…but, but more importantly not so much that it is male dominated, but that this male domination has made it somehow hostile to women’s health or at least neglectful of women. This is a big theme in the women’s health movement. I am tempted to take a show of hands and ask how many times have you heard that women’s health has not been taken seriously by the research establishment. I mean it is really like a verbal tick. You read anything about women’s health and you will see…until 1992 when the NIH re-authorized whatever, whatever, there were no women in clinical trials. Women were not included in clinical trials. Hillary Clinton, a 1993 remarked on a quote the appalling degree to which women were routinely excluded from major clinical trials of most illnesses.

Last June I got something from the Harvard Women’s Health Watch which is generally a very good newsletter. But, it said, "Nearly all drug testing has been done on men." This is not true. I have a whole chapter devoted to it. But, I will just tell you some of the highlights. In 1979, way back in 1979, NIH funded 293 clinical trials. 268 of them included women. In 1997, which is the last year for which the most recent year for which there are data on NIH funded extramural trials, 69% of all research subjects were women. Breast cancer research has received more money than any other cancer since 1985 from the National Cancer Institute. 1985 was the year in which they started keeping track of funding by disease. I could go on but I think you get the picture.

There is another allegation…this one of course is I think even more sensitive about allegation of bias as a motivating factor behind the health disparities we see by race. Referring to different morbidities and mortalities…black and white, Hispanic…are the gaps in health status between blacks and whites. Most definitely one of the most striking ones is infant mortality rate. It is…there are 14 deaths per 1000 live births among African-Americans and 6 per 1000 among whites. Interestingly…this is very interesting actually, among immigrant, Mexican American women, before they become enculturated it is 6 per 1000 live births too. Which speaks, I think, volumes to their culture and how seriously they take pre-natal…not that they have pre-natal care…in fact, Mexican American immigrants are the least…have the lowest rates of insurance in the country as you might guess. And I mean public insurance as well. But, there is a real cultural prohibition against smoking or drinking while pregnant, and care of oneself. And that manifests in large part through this infant mortality rate. It is not exclusively…even…you may know that even African American women at the high end of the socio-economic spectrum still have a higher infant mortality rate than their white counterparts. Which is very interesting and an issue that there is research on and is important to investigate.

So, my point is though, these disparities exist but increasingly the reason put forth is that there is bias in the healthcare system. This has been alleged by the US Civil Rights Commission, by the American Association…Association of American Medical Colleges. I believe we will see themes of this in a report coming out of the Institute of Medicine on health disparities.

What there is evidence for…I have a whole chapter on this…I tried to look very carefully through the data alleging this bias…It is a reasonable enough hypothesis to have when you see differences based on race. Well, that could be one of your many hypotheses. So, I don’t certainly criticize having that as one thing to consider. However, when you do look at the studies that have been put forth as evidence of bias, what you really find is the differences in health status are typically due to socioeconomic factors. And those do correlate with race. With attitudes about one’s own health and the healthcare system. And with attitudes about accepting procedures.

So, this is a very tricky issue. I know, but I want to call it to people’s attention because it is finding its way into the mainstream media as sort of…almost an urban myth now that this is…that the reason why certain segments of our society are sicker is because of discrimination in the healthcare system. And we really have to be careful when you, in looking at the data before you jump to a conclusion like that. And when we do find it, we should act on it for sure. But, as I say, I am not convinced by the evidence.

And it is a real problem to allege bias when there is no evidence because obviously it engenders distrust. And there is quite a history of distrust built up as you probably know in hospitals were segregated for many years in our history. And in fact, up until the 60s there were still some hospitals…a handful…but still some hospitals in the south that were segregated. And not segregated…not separate but equal. Obviously everyone knows the Tuskegee legacy. So, if you have already got a back drop on which there may be reasons for distrust for historical reasons, it is very, very dangerous to give people false evidence that these kinds of practices…in less dramatic forms, but may be considering. Because folks are too ready to jump on it.

Also, I think, it can be…it really can be a waste of resources to go hunting. I mean there is a lot of hunting for bias. If we want to close the gap and we do and we should, the most…I would say if you have scarce resources, and you want to invest them, you would be wise to put it in health literacy, in grassroots efforts. A lot of really effective work goes on through the black churches and helping folks get screened for cancer, and hypertension, diabetes, this sort of thing. And you know, quit smoking, exercise programs…this sort of thing.

The question is, what do these purveyors of pc medicine…the new age nurses, the health activists, the consumer survivors, the people who tell us that women and minorities are short changed because they are women and minorities. I mean, what did they all have in common? And what they have in common is the conviction that the medical profession has failed to make a connection between oppression either society oppression imposed by society at large or by the medical establishment itself…connection between that and illness.

I would say the most enthusiastic proponents of this idea are folks in the field of public health. A few years ago I attended the annual meeting of the American Public Health Association. And saw on vivid display their commitment to the concept that our health is almost entirely at the mercy of social forces. I mean there is an element of social forces, of course. There is also a large element of personal responsibility. That did not emerge.

Draped across the main hall of the lecture room was a banner announcing the theme of the conference, which was "Social Justice in Public Health". And indeed the American Public Health Association has issued position statements on aid to the Contras in Nicaragua, war in the Middle East and Campaign finance reform. That is on top of my list in terms of public health problems. To my absolute amazement, after September 11^th, the American Public Health Association published twelve guidelines…that was what the document was called…twelve guidelines on bioterrorism. And the first one was address poverty, social injustice, and health disparities that may contribute to the development of terrorism. Not stockpiling vaccines or fixing the public health infrastructure…to be fair they did get to that later on. But, the fact…the simple fact that this would be their headlining recommendation speaks volumes about what some folks in that profession are beginning to see as their province. And I think the former dean of the Harvard School of Public Health said it pretty well. He said a school of public health is like a school of justice. One community health professor…and this is not fringe at all…this is a major theme within schools of public health…this gentleman of public health…community health professor said, the practice of public health is to a large degree the process of redesigning society. It is more about closing the power gap than the knowledge gap. His rational was pretty simple. Since health is related to wealth and social position…which it is…there is a correlation, the causal relations are complicated. But since there is this relationship, then as public health professionals it falls within our domain to try to equalize power in society in the name of health.

I think in public health we are on the threshold of what I call a fourth era. Most Americans are familiar with the first three: Sanitation Era, the Biological Era and the Lifestyle Era. The first of these, Sanitation Era even goes back to the Bible when Moses was leading the people through the wilderness, there were rules to observe. Not drinking water that had dead animals in it, to wash hands, to burn clothes of people who had died from contagious disease. Fast forward to modern times where we have civil engineering with water purification, refuse disposal, as we all know this has probably added 30 to 40 years onto people lives. A huge advance in our longevity and health. The second revolution, biological, vaccines, antibiotics. The third seemed to take off more in the ‘70s and ‘80s…the 1970s and ’80…the lifestyle era…don’t drink, don’t smoke, wear a seat belt, wear a helmet…this sort of thing. And those have been very helpful as well.

But I think now we are sort of on the threshold of a fourth era…what I have called pc medicine…politically correct medicine. Which is powered by the idea that injustice produces disease and that political empowerment is the cure. Now, I should say, in closing that public health in particular always had a reformist spirit. And I think that is inevitable and a good thing. In the mid-1800s, a famous German physician and statesman, Rudolf Vercav, called physicians the natural attorneys of the poor. Recognizing of course that health and fitness were directly and inextricably linked to improving dismal living and working conditions such as malnutrition and no heating and this sort of thing. But, latter day public health issues and these are now being called pathogens…poverty is being called a pathogen. Income inequality is being called a pathogen. Oppression. Are not so obviously linked to…I should say income equality is not so obviously linked…poverty can be obviously linked to poor health.

And besides, we also know things like good education, even marital status, religious affiliation; those are also correlated with better health. But, you don’t hear the folks in the American Public Health Association pushing for school vouchers or marriage or going to church. Now, I am not saying they should do that. I would say that is outside their realm as well. But, it is an interesting bias that they have. It is largely in the direction of redistribution of resources. And I think that reflects their own political agenda.

So, pc medicine won’t enhance health. But, it will blur the focus of health professions and dilute their resources. It is also pretty demoralizing especially in public health, which is where there has been the most discussion of this, actually. Ronald Beher who is a professor at Columbia University School of Public Health lamented that many of his colleagues, "believe that public health officials can do little or nothing to change the prevailing patterns of morbidity and mortality in the absence of social change." He calls this public health neolism. And he has ample targets for this because so many folks will in public health now a days are actually saying if we believe income equality correlates with poor health, then as a health prescription, just as much as we might be fighting you know pointing out that at best….is a pathogen, we have to point out also that income inequality is one. And we have to basically lobby for a more shallow dispersion of income in our society. I mean, this is…that is fine if you believe that. That is your own political and economic worldview, but again, it has a place. And the place is not in the world of public health.