I serve on the advisory committee of a foundation whose many millions of endowment dollars are devoted to the advancement of health research. The trustees' definition of "research" has been kept deliberately flexible and wide, allowing for the support of investigations that range from the most basic studies in biomedical laboratory science all the way to those that fall into the category of public health and even medical sociology. The foundation's statement on grant-making specifically notes that its efforts are to be directed to the public interest, "particularly [to] the underserved, understudied and disadvantaged."
The composition of the committee reflects the diversity of the foundation's goals and interests. Its membership of eight men and three women traverses the spectrum of civic and scientific know-how and activism, from the research bench to the judicial bench, and includes several directors of community agencies. Our function is to advise the two trustees of the endowment, one of whom is a male attorney and the other a female executive vice president of the bank in which the organization's funds are held. I and the chair—whose specialty is internal medicine—are the only physicians on the committee. As might be expected, she and a male surgeon such as myself are likely to view issues from widely dissimilar perspectives. Such differences are among the factors that have made service with this diverse group of outspoken people an interesting and valuable experience over the years.
In 1998, the foundation was approached by a distinguished American university, whose medical school was seeking financial support for a program in women's health. The issue was discussed at several meetings of our committee, and from the very beginning it was apparent that there would be near-unanimous agreement that this was not only an endeavor of great value, but one that would be in keeping with the fondest hopes of the maiden lady (as she would have been called during most of the years she lived) the terms of whose will had left a considerable fortune to endow the fund.
The directors of the proposed program gave very convincing reasons for the necessity of their undertaking. These were carefully reviewed by our committee, most of whom were already familiar with the reports of bias against women patients and physicians that have appeared on numerous occasions in professional and lay periodicals. The elements composing the entire picture of such bias had long been of concern. It was becoming apparent that the establishment of programs such as the one that was already underway in this particular medical school (and several others in the United States) were an ideal corrective.
The descriptions of some of the accusations were unsettling, particularly as they supported certain troubling claims that feminists and others had been making for years: that women are being systematically under-represented in clinical trials of new treatment methods; that the quality of their medical care is less than that of men; that research in diseases that affect primarily men (such as prostate cancer) was being funded much more generously than research into diseases that affect primarily women (such as breast cancer); that women researchers are the subjects of discrimination in the allocation of support from federal and other agencies; that the opportunities for the career development of women physicians and laboratory investigators are far less plentiful than the opportunities for men.
For years, protests against these forms of discrimination had been voiced by medical experts, laypeople, and political figures alike. Dr. Patricia Buffler, the former dean of the Berkeley School of Public Health, had expressed the feelings of many people when she stated a few years earlier that "there is so much outrage that half the human population has been left out" of clinical trials. In 1996, an independent physician-founded organization called the Foundation for Women's Health asserted that "women are invisible in the health care system beyond their reproductive systems. The medical model using male science, male body, male culture is still the norm. Women die unnecessarily due to this male perspective." Perhaps the voice that carried the farthest was Hillary Clinton's, during the time when the former First Lady was directing the effort to reform the American system of health care. In July 1993 she told the assembled members of the Society for Women's Health Research of the "appalling degree to which women were routinely excluded from major clinical trials of most illnesses."
With all of this as background, the motion to support the medical school's request for funding was applauded by every member of the committee but one. This recalcitrant fellow was the only dissenter in an otherwise unanimous recommendation. Stubbornly, he questioned the validity of the generally accepted evidence purporting to demonstrate significant gender bias in health care. He denounced the concept of a women's health initiative as a faddish notion that was acquiring popularity in medical schools only because it had become "politically correct" and was an easy sell to well-intentioned foundations like ours. He went so far as to call the entire project a "boondoggle"—his very word—whose unstated purpose was to help to balance the school's budget, by providing funds to pay the salaries of the participating faculty members and staff. Just as emphatically, he wondered aloud whether some of these personnel might not qualify to be retained were this funding not available. These objections were respectfully heard by the committee, and just as respectfully they were discounted. Without another murmur of dissent, the trustees committed the foundation to fund the women's health program for a total of $6.5 million.
Truth be told, I was the curmudgeonly dissenter. Had a book like Sally Satel's been available during those discussions, I might have convinced a few of my colleagues that they should not be so quick to approve the medical school's proposal. Who knows? The sheer weight of the arguments that Satel provides to refute the conventional political-medical wisdom might even have resulted in a different outcome of our deliberations. I plan to put a copy of her carefully documented study in the hands of the two foundation trustees—not to convince them that they were wrong, but as a lesson in the evaluation of evidence, and as a warning to avoid hopping on bandwagons with square wheels, whose clunking is obscured by the brassy blare of the trumpeting that precedes them.
The bandwagon that Satel would like to stop in its tracks is bumping along toward an ill-defined destination called "social justice," and carrying a variegated group of vociferous critics of "the health profession's failure to make the connection between oppression—by society at large or by the medical establishment itself—and illness." Satel believes that this perception by medicine's critics is ignorant at best and mischievous at worst; that it is also, in the hands of many of them, dangerously self-serving.
Though they share a common goal, the gaudy bandwagon's clamorous riders come from a heterogeneous assortment of backgrounds and serve sundry constituencies. The voices of some are reasonable and temperate; the voices of others are strident and angry. They have names like Donna Shalala and Al Sharpton; Henry Waxman and Barbara Ehrenreich; George Mitchell and Patricia Ireland. In Satel's view, they are all misguided, and some are power-mad.
Theirs is the rhetoric of discontent. The unifying medical theme that underlies all the disparate parts is the perception by its advocates that "injustice produces disease and political empowerment is the cure." Thus Sally Zierler of the Department of Community Health at Brown University calls aids a "biological expression of social inequality." In a lecture in 1998 at the annual meeting of the American Public Health Association, she presented five recommendations for curbing the aids epidemic: "limit the power of corporations, cap salaries of CEOs, eliminate corporate subsidies, prohibit corporate contributions to politicians, and strengthen labor unions." Rodney Clark of the Department of Psychology at Wayne State University states that emphasizing personal responsibility is a "subtler form of racism." Stephen R. Kandall, chief of neo-natology at Beth Israel Medical Center in New York City, says that drug abuse is the "result of manipulation by the media, inappropriate over-medication by physicians or [addicts'] own attempts to cope with social barriers to achieving equality and self-fulfillment." Douglas Smith of the Anti-Psychiatry Coalition, a volunteer group of people who claim to have been harmed by psychiatry, states that "contrary to popular belief, psychiatry is not health care. It is a form of social control." Or, as stated in its most extreme form by one of the philosophy's advocates, Dr. Paula Braverman of the medical school at the University of California at San Francisco, "illness is caused by the power imbalance that characterizes a capitalist society."
It is Satel's important thesis that such "politically correct" or "PC" medicine ignores or is ignorant of the real causes and the real cures of sickness, and that the proposed remedies of the activists (whom she calls "indoctrinologists" for their proselytizing) not infrequently contribute to the very problems that they are meant to solve. As she observes in her introduction, "PC medicine puts ideology before patients"; and her book is an attempt to point out how this occurs, who is perpetrating it, and what the dangers are—to patients, and to the future of medical progress—if it is not exposed.
Satel has meticulously dissected the arguments of those against whom she enters the lists, and she has chosen her opponents and battlegrounds with care—up to a point. For the most part, she deals with areas in which she has great familiarity as a result of her training in a large university medical center known for its liberal policies, and her current professional role as a psychiatrist treating drug-dependent patients primarily in the setting of the inner city. Hers is a clarion call to be aware of the indoctrinologists' thus-far unimpeded growth in power, to the extent that they can influence standards for admission to medical and nursing schools, the contents of professional journals, and even the direction of medical research and its methods of combating disease. "Most disturbing, their stubborn reluctance to acknowledge each person's responsibility in preserving his own health threatens to reverse many of the gains made by the public health movement in the past century." The refrain of personal responsibility for one's own health runs through Satel's impassioned and intelligent book.
There is a certain irony in this thesis of personal responsibility, which may be a reflection of the polarization, or perhaps the confusion, of our society. At a time when the culture of medical self-help is growing rapidly—and prosperous, well-educated members of the middle class are busily learning about the physiology of their bodies, the relative virtues of aerobic and anaerobic exercise, and the nutritional principles underlying dietary choices, and eagerly seeking medical information on the Internet—the less privileged in American society, especially certain minorities, are being hectored and propagandized by agenda-driven gadflies who claim that most or all health problems are the result of societal inequalities over which the victims have no control. And yet it is evident that there is a great deal of dovetailing in these two seemingly contradictory attempts to reinvent medical practice. They both originate in a spirit of activism, with the intention of overthrowing or at least revising a care system that is seen as autocratic, patriarchal, and distanced from the individuals whom it is meant to serve.
Yet there is a significant difference. One approach is based on the role of the individual in taking charge of her or his own health, while the other calls for vast changes in the economic, political, and social landscape without which any person's own efforts to remain free of illness are doomed to failure. One approach demands personal accountability; the other eschews it. One of them asks the individual to grow closer to science, the better to comprehend the somatic realities of illness and the choices that they pose; the other asks the individual to view science skeptically or worse, as a social construction that expresses only relations of political and economic power.
Satel has no patience with this latter viewpoint. In fact, she thinks it is a menace. A focus on malign social forces, she is convinced, serves to divert attention and resources from the scientific and inductive approach to disease that has brought about the remarkable progress in clinical medicine and public health in the past century. Moreover, it discourages the personal sense of obligation to oneself and to others that is ultimately the only way that scientific medicine and public health measures can be effective. "[T]he notion that social forces are major determinants of health—that they are so overwhelming in fact that personal responsibility and self-care are reduced to quaint notions and middle-class values—is one of the most pernicious themes in PC medicine."
Basing this argument on her own clinical experience and an imposing knowledge of the pertinent literature, Satel throws herself fearlessly into one after another of the major battles that are being waged by the advocates of PC medicine. She devotes a chapter to countering the arguments of those who see the primary cause of addiction to be an oppressive society, and who seek a cure in "empowering" its victims to reject treatment even when they are pregnant mothers endangering their unborn children. In a typical sally (pun intended), Satel describes the uproar that occurred when the physicians and nurses at the Medical University of South Carolina attempted to combat the crack cocaine epidemic that hit Charleston in the late 1980s. Deeply concerned about the drug's crippling effect on fetal development and infant health, they joined forces with the city's black police chief and the county's white prosecutor to initiate a carefully thought out policy of coercing mothers in the university's prenatal clinic into treatment by threatening them with arrest if they did not conform. For their efforts, the school's medical authorities and the public officials working with them were called Nazis, and attacked by the aclu, feminists, civil rights organizations, and the Department of Health and Human Services for depriving the clinic patients of their civil rights.
But it is well-known that outside coercion is the only way to keep many of these young women in treatment. As Satel writes, "data consistently show that treatment, when completed, is quite effective in achieving abstinence. Those who enter a program voluntarily rarely complete it.... 80 to 90 percent have left by the end of the first year. Among such dropouts, relapse within a year is the rule," according to a study published in 1997 in the journal Psychology of Addictive Behaviors. Women legally mandated to treatment by a judge have been shown to stay in treatment an average of four times longer than those who entered voluntarily.
The accusations of discrimination against a group of women almost all of whom were black, poorly educated, and living below the poverty line were called ludicrous by the police chief when Satel visited him in Charleston. He also had little patience with the notion that these mothers were being punished not only for their pregnancies but also for a lifestyle over which they had no control because it was imposed by a harsh and oppressive society. "Punishment? Discrimination?" he said. "I'd consider it discriminatory if [the medical staff] didn't go out of their way to save these black babies." Yet the chief's vigorous support of the policy could not prevent the program from closing down, nor was it able to stop the death threats against the obstetrical nurse who was most instrumental in organizing it.
Satel applies her debunking methodology in the same way to other areas in which she believes that the indoctrinologists have convinced too many of the rest of us to take leave of our senses. In chapters called "Nursing Grudges" and "Sisterhood and Medicine," she takes on some of the more questionable consequences of feminist philosophies on the healing of the sick. Those familiar with current nursing literature, or who have worked in the environs of an academic nursing school, are familiar with the resentment that is constantly expressed by the profession's leaders about the hierarchy of power and income with which they must contend. Gender and racial politics have found their way into the curricula of many of these schools, and courses have been introduced that attempt to reach a level of intellectual pseudo-sophistication that is virtually postmodern in its content.
In fact, "postmodern" is precisely the word that some educators proudly use about the context of their aims. Terms such as "eco-feminist," "hermeneutics," "counter-hegemonic methodologies," "Eurocentric," "paternalistic," and "relativity of space-time" have found their way into the literature of nursing. This kind of blather is not restricted to fringe groups in the profession, or to the writings of Modern Language Association wannabes with R.N. degrees. It appears in respected professional journals, under the names of respected professionals. As an example, Satel quotes the summarizing statement of an article in 1995 in Nursing Science Quarterly called "Postmodernism and Knowledge Development in Nursing." Its author is Jean Watson, a professor at the University of Colorado School of Nursing and the former president of the National League of Nursing, one of the profession's two leading organizations. Here is Watson's conclusion:
In summary, as nursing locates itself within the postmodern condition of complexity, with its shadow and light side, and as nursing seeks a dwelling place which is open-ended, ambiguous, dynamically constructed, incessantly questioned, endlessly self-revising, never set, but floating and moving with the river of life, will nurses be part of helping nursing to mature and grow up both ontologically and epistemologically, within its own transformative praxis paradigm?
Nurses have long campaigned for autonomy and demanded a larger role in decision-making and in the actual treatment of patients. They have lamented their perceived status as second-class citizens, blaming most of the problems on the fact that the great majority of them are women in a profession dominated by repressive male attitudes. They have railed about physicians' alleged monopoly over clinical knowledge and practice, and articles in their journals have advocated the espousal of alternative medicine and other methods of treatment in which nurses are the equal of scientifically trained doctors. Among the offerings is the technique of so-called "therapeutic touch," which, as Satel points out, may be among the most crackpot of all the New Age remedies to have been loosed on our open-minded era. Not only is the theory of TT, as it is called, based on no scientific evidence, but it was exposed as a hoax in a widely discussed article in 1998 in the Journal of the American Medical Association. And yet many nurses have embraced it as a vehicle by which to assert their independence and control.
Listings of continuing education courses offered by academic schools of nursing are apt nowadays to include titles such as the following, all available at the University of Texas School of Nursing: "Using Energy to Enhance Nursing Practice: Use of Color, Music, Touch and Movement"; "Holistic Nursing: Strategies that Transform and Heal"; "Aromatherapy for Nursing Practice"; "Reflexology: Stimulating Healing in the Body"; "Spirituality in Nursing"; "Using the Power of Our Thought for Healing." Most of us, patients and doctors alike, would prefer that our postgraduate nurses be studying basic electrocardiography, fluid and electrolyte balance, the physiology of diabetes, and the management of end-of-life care.
At a time when in-hospital therapies are becoming ever more scientifically complex and patients are becoming much sicker, biological knowledge and the technology and psychology of bedside care are being short-changed in the curriculum. Hospital nursing is less able to meet the considerable challenges of skilled attention to the changing patterns of disease. Education is hurting, and some of the most rewarding aspects of nursing are treated as though they are of less consequence than the fuzzy dialectics of trendy methodologies. No wonder nursing schools across the nation report declines in enrollment, and no wonder one reads constantly of shortages in recruitment to hospital staffs. To be sure, there are many reasons that fewer people are enrolling in nursing schools, the most significant of which is the marked increase in opportunities for women in other professions, which has not been offset by the still-small enrollment of men; but no one should gainsay the effect of the new policies on the study of the human body and the nurturing of the human being, which yesteryear attracted so many dedicated and intelligent young people.
Satel brings these serious problems into the clear light of day. She is fiercely critical of the lowered academic standards that some schools have permitted in their attempts to increase enrollment. She does not shrink from asserting that the problem is exacerbated by a lack of selectivity based on affirmative action policies and the pursuit of diversity. California's experience may be more extreme than most, but to varying degrees it exemplifies the situation in all fifty states:
In California especially, the nursing shortage and affirmative action in nursing school admission have combined to worrisome effect. Beginning in 1995, according to the Los Angeles Times, state nursing programs offered by community colleges have been mandated to adopt either "discrimination-proof" admission systems based on lotteries or first-come first-served lists made up of students with at least a C average in prerequisite courses. Students with higher grades are turned away in order to ensure diversity.
The lack of selectivity has had alarming consequences. Some students are being held back because their accents are too heavy and can't be understood by patients. Several of the college instructors interviewed by the Los Angeles Times said that their students were stumped by the kind of single-variable algebra problem used to calculate drug dosages. "They can't read at a high school level ... or they have undiagnosed learning disabilities," said Sue Albert, interim dean of Antelope Valley College.
Dropout rates have soared in California; scores on statewide examinations have dropped; and the number of students needing extra time to finish the coursework has increased. Satel sums up the results of the turbulence in nursing education and nursing theory in a single sentence with which it would be difficult to disagree: "Dumbing down the curriculum, teaching pseudo-science and promoting feel-good, unproven remedies are deeply worrisome trends." And then she adds, also very properly, that "nursing schools, nursing journals, the American Nurses Association and the National League of Nursing should be taking the lead in applying critical judgement and scientific rigor and in rooting out the indoctrinologists among them."
One after another, Satel takes on the central planks in the platform of PC medicine and replies to them with a devastating barrage of documentation, leavened by her own clinical and personal observations. She is unforgiving in her attack on patients' rights advocates—many of them former patients—who deny the reality of mental illness and spread the so-called "consumer-survivor" message, among whose assertions is that schizophrenia and other serious conditions are not in themselves pathologies and may actually be caused by psychiatric treatment. Supported by civil liberties lawyers, many of those afflicted with disabling illnesses have eluded treatment. There have been more than a few tragedies as a result.
National and local conferences are held at which consumer-survivors and their supporters can learn how to organize themselves into politically successful advocacy groups for such purposes as opposing involuntary treatment legislation or discouraging patients from cooperating with the conventional mental heath system. In 1995, at a meeting of an annual consumer-survivor conference called "Alternatives," funded by the U.S. government's Center for Mental Health Services, the receptive audience heard a psychologist make the irresponsible statement that "schizophrenia has never been proven to be an illness or disease. What is called schizophrenia in young people appears to be a healthy transformational process that should be facilitated instead of treated." His listeners came prepared for what they would hear, by the conference program's description of the talk as a discussion of "how schizophrenia is a healthy, valid, desirable condition, not a disorder." Fancy that: not even a disorder!
Sometimes Satel's enthusiasm for her subject gets the better of her, and she forgets—or prefers not to remember—that certain of the issues with which she deals would better be painted in shades of gray. In a chapter bound to raise some hackles, called "Race and Medicine," she attempts to respond to charges that medical care is affected by the color of a patient's skin; and here she is less persuasive than elsewhere. Her statistics, and her descriptions of biological differences in disease patterns, read like feeble protests in the face of the experience of anyone who has ever trained in the teaching divisions of a large hospital, by which I mean the great majority of American physicians.
For conscious and unconscious prejudice pervades rounds, teaching conferences, and even decision-making. Though it is nowadays unspoken and not overt, it still continues to affect the manner in which small decisions and occasionally large ones are made—and it does so in ways that cannot be discovered by statistics, or revealed by questions asked of young people and their teachers, who are often unaware of the subtleties in their own unintended behavior. Even a bit of patronizing does not escape an inner-city black man who may already be wondering whether the doctors are as interested in his welfare as in that of the white computer-programmer in the next bed.
Are the reasons for these disadvantages racial or economic or both? The argument about the causes will never end, but the fact remains that most of the black patients encountered by residents in training are poor, and they cannot help but perceive that they are treated differently by their mainly white middle-class doctors, even should the perception be inaccurate. All the goodwill in the world has not yet managed to change this blight. Satel's assertions to the contrary, accusations of racial bias at the bedside are hardly the result of the need to be politically correct. They arise from the simple observation of everyday events, and their truth can sometimes be brought to the surface by serious endeavors in self-awareness. The attempted refutation of such charges does not belong in Satel's book, and she dilutes the value of her legitimate and important arguments by including it.
Among those legitimate and important arguments are the ones that I wish had been available to me when I was making my failed attempts to convince my colleagues not to fund the women's health initiative. Satel confronts one issue at a time, and deals with each of them by presenting an array of studies and data that turns the thesis of discrimination against women in health care on its head. It is an impressive performance, though here too, she goes just a bit too far in her determination to knock down the entire edifice so faultily constructed by the PC-niks and their acolytes.
Against the charge of under-representation in clinical trials, Satel points to major diseases such as depression, osteoporosis, and arthritis that the Food and Drug Administration has found to have been more carefully studied in women during the course of such evaluations than in men, for the simple reason that they are more common in females. Satel examined information available through the National Institutes of Health, the federal government's most important funding agency, and found that at least since 1979, the earliest year for which she could obtain data, women patients have supplied a large part of the research pool. Moreover, she writes, "the Office on Research on Women's Health at NIH, created in 1990 to respond to just these concerns, found that in 1994 research subjects for ongoing NIH clinical trials were 57 percent women, 36 percent men, and 6 percent unknown. The composition of subjects in trials funded in 1997 was 69 percent women and 31 percent men."
Like depression, osteoporosis, and arthritis, other diseases too occur more commonly in one sex than the other, and such figures are usually reflected in the mix of patients studied. But none of this easily available data seems to have affected the rhetoric of those with an extra-medical agenda. As recently as April 2000, the Harvard Women's Health Watch sent out a promotional newsletter claiming that "nearly all drug testing has been done on men." To this assertion, Satel replies with a single word: "Wrong." And "wrong" is right.
To answer the very serious accusation that women are the victims of uncaring or inferior kinds of treatment, Satel attacks the stalking-horse most commonly trundled out to support such an assertion, namely the tired accusation about radical mastectomy having been a brutal and disfiguring operation, made all the more offensive by the fact that it was often unnecessary. Although there is no doubt that certain surgeons clung to the procedure long after it had been definitively demonstrated (only some thirty years ago, by the way) that lesser techniques were just as effective in treating most cases of breast cancer, the fact is that the introduction of radical mastectomy around 1900 was the first innovation that actually saved lives; and it was such an astounding success that several generations passed before surgeons were willing to consider that less drastic ways of treatment might be of value. It is pertinent here that those less drastic treatments had previously been an abysmal failure that cost the lives of almost all the women on whom they were tried. This changed only when early diagnosis began to occur in the last quarter of the twentieth century, and the value of improved forms of radiotherapy became evident.
As for men's diseases being supported more generously than women's, here too Satel digs right into the most commonly used example, which is the supposedly underfunded area of breast cancer: "Breast cancer research has received more money than any other type of cancer research each year since 1985, when the National Cancer Institute began keeping track of cancer-specific funding. It has always received many times the funding of prostate cancer—about five times the amount in 1997 and triple the expenditure in 1999." Nor do numbers support the allegation that federal and other agencies discriminate against women in allocating funds to researchers. Between 1992 and 1998, the data indicate that men and women researchers enjoyed comparable success in the results of their grant applications. In fact, the NIH figures for 1993, the year in which the most complete information is available, are that grants were awarded to 18.3 percent of female applicants and 17.1 percent of males.
But Satel's arguments are much weaker in the area of career development. Here she seems as unaccountably tone-deaf to the medical world around her as she shows herself to be in the matter of racial bias in the bedside care of patients. It is impossible to work in an academic medical center without hearing at least a few verifiable stories of highly qualified women having been denied promotion, tenure, or some other form of deserved recognition. Even more striking are the anecdotes about misogyny and harassment by male colleagues and superiors, especially on surgical services. Although it is undeniable that some of these complaints arise from the same causes that we have always observed in the case of men, namely the subject's personality difficulties or an attempt to deflect blame for lack of accomplishment, other reports of discrimination are based on reality. Any genuinely objective observer will confirm it. Even more damaging than the comments and the events that occur with a woman's knowledge are the ones about which she never hears.
If Satel has been a victim of an episode or two of bias in career advancement, one would never know it from her vigorous defense of this portion of her argument. So determined is she to disprove the existence of any form of discrimination against women physicians and women patients that she allows her intellectual standards to suffer, and her responses to this particular charge are far less convincing than the powerful facts that she marshals to bring down the others. Satel is utterly persuasive about clinical trials, quality of care, research, and the allocation of funding, and utterly unpersuasive on the question of the glass ceiling and its varieties.
Some of the charges made by the advocates of PC medicine are not only politically correct, they are also correct. Race and class do affect medical care; and sexism does affect the career advancement of women. The perceptive investigator and the clear-minded critical thinker—and for most of her book Satel is precisely such a figure—cannot help but know these things. Her attempt to deny them, or to produce an array of unconvincing statistics to support an unsupportable disquisition, does her no credit. Worse yet, they make a reader suspect that she, too, has yielded to a political agenda, as pernicious in its own way as the one that she attacks with such diligence and courage. There are a few unexamined prejudices in her own writing that need to be overcome.
The implications of Satel's book, and more generally of her approach to notions of social justice, extend further than might be immediately apparent, and she seems to realize this, although she never gives these implications their full due. Her book is not only a straightforward assault on disturbing and dangerous trends that have entered the arena of medical care in the recently politicized atmosphere of our own time. It is also an intervention in an older and larger debate within the medical profession, which involves the field of public health.
For the PC medicine so vigorously opposed by Satel is not as new or as radical or as "postmodern" as she has portrayed it. She is attacking an extreme and sometimes hysterical manifestation of a philosophy that was first promulgated far more rationally in the writings of the great German physician and social reformer Rudolf Virchow during the latter half of the nineteenth century. And the scientific medicine so vigorously defended by Satel is not as narrowly focused as she has portrayed it. She is defending an extreme and sometimes overly reductionist manifestation of a philosophy that was first promulgated in the writings attributed to the Greek physician and medical reformer Hippocrates, several centuries before the Common Era.
The two contributions for which Rudolf Virchow occupies a leading place in the pantheon of medical history would seem to epitomize the opposite ends of the debate between social reform and science, and yet they bring them together. Virchow was the father, in 1858, of the concept of cellular pathology, the notion that the cell is the basic unit of disease. Only by studying the cell itself, he taught, can sickness and its cures be understood. This thesis revolutionized medical theory and eventually medical care, laying the groundwork for the great advances that would take place in the twentieth century, including those made possible by the study of molecular biology. And yet Virchow was at the same time his era's leading exponent of the thesis that a man is the product of his life situation. Environmental influences, occupation, social class: all of these played as strong a role in Virchow's image of the sick patient as did the pathological changes he scrutinized while peering down the barrel of his microscope.
The best medicine is practiced, Virchow asserted, when the scientific concepts and the social concepts find their appropriate places in prevention and cure. "Medicine is a social science," he wrote, "and as the science of man, has a duty to perform in recognizing these problems as its own and in offering the means by which a solution may be reached." Even more famously, "Physicians are the natural attorneys of the poor." And Virchow was not the first voice to be heard speaking this way, although he was the first doctor. A century earlier the French philosopher Pierre Cabanis had written, rather like the social activists of today, that "sickness is dependent on the blunders of society." It was Virchow's own clinical experience as a young doctor that provoked him to examine that thesis so carefully that he came to understand its truth, and also its limitations.
Virchow was determined not only that his voice would be heard, but also that action would be taken. He entered politics, and he later recalled his reason this way: "The improvement of medicine would eventually prolong human life, but improvement of social conditions could achieve this result more rapidly and more successfully." He became one of the founders of the radical German Progressive Party, and for forty-two years he was a member of the Berlin City Council, even being elected in 1862 to the Prussian House of Deputies and later the Reichstag. His opposition to the majority party was so stinging that Bismarck challenged him to a duel, which was never fought because the acid-tongued physician ridiculed both his challenger and the impending combat in a public letter. Virchow's engagement in politics did not impede his laboratory work. He continued to make landmark contributions to the science of medicine, but his political focus was on the social inequities that he felt contributed so much to disease. He is a hero to biomedical researchers, clinical physicians, public health officials, and social theorists.
But Virchow was always the quintessential scientist, expert in the evaluation of evidence and unimpressed by the fads or the follies by which less rigorous thinkers are led astray. He was known for his ability to burst the bubble of generally accepted dogma, to puncture it with data and detached observations. It was he who destroyed the myth of the German "race" and its descent from putative Teutonic ancestors, which he accomplished by means of detailed studies of unearthed skulls, and by careful measurements, and by other meticulous observations made on some 6.5 million schoolchildren. The Nazis would revile his memory for it, but they could not escape the accuracy of his conclusions.
Nothing pleased the professor more than giving the lie to popular misconceptions that seemed to have a basis in the authoritative sources of received wisdom. He would have had a field day with our indoctrinologists, even as they claim him as their precursor. He would remind them that social justice may prevent disease by changing the conditions in which it occurs, but it is no replacement for scientific thinking, scientific education, or scientific treatment. And he would no doubt remind Sally Satel that bias and discrimination will always be with us. While it is our obligation to refute those who dwell on social inequality for their own political purposes, it is also our obligation to admit to its existence wherever it is found.
In promoting his theories about the social causes of disease, Virchow was departing from the ancient Hippocratic teaching that the physician must focus his full attention on his patient only. In this view, the healer's sole obligation is to the clinical problem before him, and he must treat it in each individual who comes for care. The cure of social ills is not in his province. When a Hippocratic physician suggested a change in environment, it was meant to affect the individual and not the society.
Many of our best physicians still feel this way, believing that they can have their greatest influence on disease by focusing on a particular problem presented by a particular patient that they are treating at a particular time. Satel appears to be among them. She puts no faith in the notion that social change is the responsibility of the medical system. And this book is her manifesto of the abuses that can occur in the hands of those who feel otherwise.
Satel says many important things in her book, and most of her targets are objectionable in precisely the ways she objects to them. But there is something disquieting about the presence of her own politics and their absoluteness. She seems dogmatically oblivious to the reality of the relationship that links "uneven access to medical services, disparate knowledge of good health practices and personal attitudes" to the long-standing effects of discrimination and bias. Yet medicine has as little business being politically incorrect as being politically correct. Its business is only science and sympathy, clinical art and clinical heart, which is work enough.