Shrink Control
The limits of a psychiatrist's skepticism
PC, M.D.: How Political Correctness Is Corrupting Medicine, by Sally Satel, New York: Basic Books, 285 pages, $27
Just when you thought that Bill Maher's insipid talk show had given political incorrectness a bad name, along comes Sally Satel to redeem the concept. She is only partly successful.
It doesn't help that Satel's publisher treats political correctness as if it were a new concept. The cover of her book refers to it twice, and even though the subtitle tells you what PC stands for, olitically and orrect have been inserted in small type next to the P and C in the title. Someone at Basic Books clearly was worried that browsers would mistake PC, M.D. for a science fiction novel about a computer that prescribes antibiotics.
The cover, of course, is not Satel's fault. But what's inside—a psychiatrist's warning about the corruption of medicine by ideology—sometimes leaves readers wondering how meaningful it is to call Satel's opponents politically correct. The phrase was originally used by leftist academics to describe people who shared their political outlook, a perspective that emphasized the grievances of oppressed groups and the collective guilt of white heterosexual men. By the late 1980s, politically correct had become a term of derision, referring to the stifling intellectual atmosphere that prevailed on campuses dominated by former '60s radicals and to "progressive" standards of speech and behavior emanating from the academy.
Much of what Satel attacks in PC, M.D.—for example, the assumption that differences in health between whites and blacks must be due to racism—is reminiscent of ideas criticized in books ranging from Dinesh D'Souza's Illiberal Education to Alan Charles Kors and Harvey Silverglate's The Shadow University. But while the professors and administrators described in those books rein in dissenting students and faculty members through stigma, re-education, and Kafkaesque disciplinary proceedings, many of Satel's targets are gadflies rather than Torquemadas, challenging orthodoxy rather than enforcing it. Dismissing their concerns, Satel ends up defending authoritarian policies that go beyond anything practiced even at the most intolerant universities.
Satel, a fellow of the American Enterprise Institute and a lecturer at the Yale University School of Medicine, is most persuasive as the voice of calm reason, dissecting the abuse of science for ideological purposes. Some feminist critics of conventional medicine, for example, promote "therapeutic touch," a form of quackery that has gained acceptance at many nursing schools. The technique involves waving your hands a few inches from the patient's body to adjust his "human energy field." Satel's debunking of therapeutic touch goes beyond a rhetorical eye roll. She discusses the technique's appeal (which includes the close, prolonged attention it entails), the relevance of the placebo effect, and the potential harm of steering patients away from other therapies. Satel does not reject out of hand the possibility that there might be something to learn from alternative medicine, but she insists that its remedies be held to rigorous scientific standards.
Satel is similarly careful and thorough when she considers racial differences in disease and mortality rates. She shows that many factors need to be considered before any part of these gaps can reasonably be attributed to discrimination, whether by doctors or by society in general. She is likewise skeptical of claims that women are at a systematic disadvantage, both as patients and as health professionals, because of their sex. In both cases, Satel acknowledges historical grounds for such suspicions, including the infamous Tuskegee Syphilis Study and the casual prescription of hysterectomies. But she argues convincingly that continuing to focus on race and gender obscures the dramatic progress that has been made in the last several decades. This preoccupation with oppression is also apparent in the psychotherapeutic approaches that Satel criticizes, which assume that people's problems are rooted in their status as members of disadvantaged groups.
With her chapter on psychotherapy, Satel ventures beyond her avowed focus on medicine, but she is still dealing with a profession where politics ordinarily plays no obvious role. Not so with public health, which sits at the intersection between epidemiology and government. Politics cannot be eliminated from public health any more than it can be eliminated from public finance. Since defining the field's parameters helps define the scope of appropriate state action, Satel is rightly worried about efforts to equate public health with "social justice."
According to "social production of disease" theory, capitalism makes people sick: In a market economy, the poor are unhealthy not only because they lack the means to live comfortably and obtain good medical care but because they suffer the stress of knowing that others are wealthier. "Even if those living on the lowest rung of the social ladder had sufficient material resources," says a physician quoted by Satel, "their health would still suffer because they are deprived relative to others." The solution is the usual set of welfare programs and income redistribution schemes, this time justified as public health measures.
As Satel notes, there is a well-established link between higher income and better health. But that does not mean that poor people cannot improve their health by taking better care of themselves. Furthermore, if "wealthier is healthier," the question becomes how best to promote prosperity. The "social production" theorists cited by Satel are trying to disguise an economic question as a public health issue. And since they view inequality, not just poverty, as a source of ill health, their approach apparently requires a sweeping reorganization of society.
Less dramatically, the American Public Health Association routinely takes positions on political issues that are far afield from disease control: against aid to the contras, for "a nuclear-weapon-free world," against welfare reform, for tighter restrictions on campaign contributions, and so on. Satel thinks public health specialists should stay away from politics (in their professional capacities, at least) and stick to their proper mission. But she's rather vague as to what that is. In particular, although she mentions cigarette smoking as an appropriate target of public health measures, she does not address the field's shift from fighting communicable diseases to discouraging risky behavior. While there is a nearly indisputable case for government intervention against deadly microbes that move from person to person, the same cannot be said for state efforts to stop people from smoking, drinking, overeating, keeping guns in the house, or driving with their seat belts unbuckled. Furthermore, the choice of which risks to target (why motorcycle riding, say, but not skiing) is a political judgment disguised as a scientific one—the sort of pretense Satel decries in other contexts.
While Satel does not explicitly defend paternalism in the name of public health, she has little patience for critics of paternalism in the name of psychiatry. In a chapter titled "Lunatics Take Over the Asylum," she attacks "psychiatric survivors" (a.k.a. "consumer-survivors")—activists who feel they've been wronged by the mental health system. "Psychiatric diagnoses, consumer-survivors argue, do not exist as fixed and defined entities," Satel writes. "They are socially constructed and exist merely in the eyes of the beholders—namely psychiatrists and other members of the dominant culture." She seems to consider this contention so obviously absurd that it is not worth refuting.
Yet elsewhere in the book Satel unintentionally provides evidence that the psychiatric survivors are at least partly right. In her discussion of victim-oriented psychotherapy, she argues that "multiple personality disorder" is overdiagnosed, and she cites one expert who "is skeptical that the personality condition exists at all except as an artifact of the therapist's suggestion." So here is a condition listed in the Diagnostic and Statistical Manual of Mental Disorders, one that psychiatrists presumably continue to diagnose, that may well be a figment of their (and their patients') imaginations. That sounds pretty "socially constructed" to me.
In the same chapter where Satel casts doubt on the existence of multiple personality disorder, she uncritically accepts "borderline personality disorder," which she describes as "a condition marked by volatile relationships, poor impulse control and enormous swings in self-regard, from grandiosity to self-loathing." One reason she considers "BPD" more genuine than multiple personality disorder may be that she finds it useful in explaining the behavior of the therapists and activists she's criticizing (some of whom apply the label to themselves). And surely this "diagnosis" does apply to some people, in the sense that it accurately describes their behavior. But is it a disease? Satel, like psychiatrists in general, is hazy on this point, saying that people with borderline personality disorder "sit on the diagnostic border between psychotic and neurotic." Hence the name.
In the case of people who are forcibly subjected to psychiatric treatment, Satel does claim there is something wrong with their brains that makes them incapable of looking after their own interests. "The point of imposing treatment is to help patients attain autonomy, to help them break out of the figurative straightjacket binding thought and will," she writes. "So many people with untreated schizophrenia become incapable of facing even the modest challenges of ordinary life, much less exercising their rights as individuals. Being required to take medication is hardly a violation of the civil rights of a person who is too ill to exercise free will in the first place. The freedom to be psychotic is not freedom."
Satel does not explain how psychiatrists determine when someone is "too ill to exercise free will"—an important issue, since that judgment can transform a patient into a prisoner. What is the diagnostic test for schizophrenia? If it is simply a matter of observing what someone says and does, how is this "psychosis" different in kind from an overdiagnosed (and possibly nonexistent) "neurosis" such as multiple personality disorder? And if schizophrenia truly is a brain disease, like Alzheimer's or Parkinson's, why is it treated by psychiatrists rather than neurologists? Why is there no need for a competency hearing before the patient is deprived of his freedom?
Critics such as Thomas Szasz have been raising questions like these for many years, and Satel surely is aware of them. Perhaps she has satisfying answers. If so, it would have been appropriate to share them before rejecting the complaints of people who object to their confinement and involuntary treatment at the hands of psychiatrists. It will not do to admit past abuses while insisting that things are much better now, since coercion remains a central aspect of psychiatry. Nor can Satel neutralize the complaints of the psychiatric survivors by observing that "not all psychiatric patients oppose involuntary treatment" and offering a few examples of people who are thankful for the forcible interventions they credit with saving them. Psychiatrists cannot know ahead of time who will be grateful after the fact, and the satisfied patients cannot give consent on behalf of the aggrieved.
Satel tries a similar approach in her defense of involuntary drug treatment, citing former addicts who are glad they were forced to get their lives in order. But here she is on even trickier ground, because she does not want to argue that addiction, like schizophrenia, is an illness that overwhelms free will. "Almost all addicts are capable of reflection and purposeful behavior for some, perhaps a good deal, of the time," she writes. "This potential for self-control permits society to entertain and enforce expectations of addicts that would never be possible for someone who had a real chronic and relapsing brain disease—for example, multiple sclerosis, epilepsy or schizophrenia….The legitimacy of such demands would encourage a range of policy and therapeutic options, using consequences and coercion, that are incompatible with the idea of a no-fault brain disease." So while coercing the schizophrenic is justified because he can't control his behavior, coercing the addict is justified because he can. Got that?
In Satel's view, it's necessary to forcibly stop people from using drugs because otherwise they might choose to continue. "Addicts are notoriously poor self-disciplinarians," she writes. "Most are extremely ambivalent about giving up drugs, in spite of all the damage drugs have caused them. Addicts' problems of self-governance demand that a rehabilitative regime include limit-setting, consistency and sometimes physical containment." Tellingly, Satel conflates coercion with "external forces such as employment demands, social relationships or financial conflicts." To her mind, apparently, there is no distinction between an addict who stops using drugs because he's threatened with jail and an addict who stops using drugs because he attaches more value to his job, his friends and family, or his money. If so, Satel ought to support involuntary treatment for alcoholics as well as illegal drug users.
Satel's discussion of women who use cocaine during pregnancy also suggests a double standard. To her credit, she concedes that the scare stories about "crack babies" that got so much play in the late 1980s have proven to be largely unfounded. "In the mid-1990s better studies began to appear," she writes. "They documented that while prenatal crack exposure per se did not lead to severe mental deficits and uncontrollable behavior, as originally feared, cocaine did have a discernible, if subtle, effect on the central nervous system in many children." One review of the research estimated that "children whose mothers used cocaine had IQs measuring three points lower than those of other children." Whether this gap is actually caused by prenatal cocaine exposure, it's clear that cocaine use can lead to fetal stroke, premature labor, and detachment of the placenta. So although "most babies of cocaine-using mothers are born normal," using the drug during pregnancy, especially in the third trimester, is certainly not prudent.
The question is what, if anything, should happen to women who do it anyway. Satel thinks arresting them, as used to be the practice in South Carolina, is unnecessarily harsh (although she nevertheless attacks the lawyers who challenged that policy). Instead she would force the mothers into treatment and, if they continued using drugs, take away their babies. She does not say whether she supports a similar policy for legal drugs that can harm the fetus. Heavy drinking during pregnancy can cause birth defects, including facial abnormalities and mental retardation. Cigarette smoking is associated with premature birth, low birth weight, stillbirth, and defects such as cleft palate. Should drinkers and smokers also be forced into treatment and allowed to keep their children only if they give up their drug habits? If not, why not?
Satel's answer seems to be that illegal drug users, unlike drinkers and smokers, are apt to be bad parents, so even children who are born healthy probably will suffer from neglect and abuse. "On their own, most true addicts simply cannot take adequate care of their children," writes Douglas Besharov, a welfare researcher quoted by Satel. "Without societal intervention, their children are condemned to lives of severe deprivation and, often, violent assault." Satel notes that the experts consulted by Besharov for his book When Drug Addicts Have Children were "nearly unanimous in calling for rapid termination of parental rights if substance abuse continues."
In practice, this means that people can lose their children because of a positive drug test, on the assumption that they cannot possibly be fit parents if they use illegal intoxicants. The test does not distinguish between "true addicts" and occasional users, or between good and bad parents. There need be no actual evidence of abuse or neglect to justify taking the children away—just traces of the wrong chemical in mom or dad's urine. Since Satel approvingly cites the case of a pregnant woman who stopped smoking marijuana after the state threatened to take away her baby, she apparently includes pot smokers (all 20 million of them?) in the category of drug users who should not be trusted with children. Needless to say, no such policy would ever be seriously proposed for alcoholics, let alone drinkers in general.
Satel's failure to address such inconsistencies belies her stance as a champion of logic and empiricism, eager to challenge ideologues who ignore reality. When she discusses medicine, psychotherapy, and public health, she offers astute critiques of pernicious intellectual trends that are, if not dominant, increasingly influential. But in the areas of psychiatry and drugs—perhaps not coincidentally, her professional specialties—she prefers conformity to skepticism. One might even be tempted to call her politically correct.