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.