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Wednesday, Nov 25, 2009
Satel's lack of attention to total costs -- and to real analysis of data like the number of women in trials -- is unacceptable in any sort of rigorous argument. Search high and low for evidence of a larger trend, and all you'll find is Satel suggesting that "the anecdotal cases I have uncovered are probably the tip of the iceberg." Simply attacking what Satel considers common-sense health programs can get you painted with the same politically correct brush as the true wackos. In Charleston, S.C., in 1989, police and health officials created a harsh policy that basically equated drug use during pregnancy with child neglect or delivery of drugs to a minor. Of course, the ACLU and other groups were up in arms. Satel launches a tirade against those who opposed the policy, seeming to forget that putting pregnant women in jail is a pretty horrible idea, and that the basis of the policy -- that a fetus is a minor -- violates Roe vs. Wade.
When Satel decries affirmative action in medical school admissions, she sounds a typical conservative alarm filled with tautologies presented as stunning conclusions. For example, because of fewer opportunities at the high school and college level, minority students admitted to medical school are less prepared for the curriculum, so they do relatively poorly in their courses (and some fail and have to drop out). Then, of course, they do poorly on medical board exams. None of these revelations seems particularly earthshaking, and dwelling on them ignores the intangibles that are probably equally as important as grades in being a doctor -- intangibles that Satel spends just a page and a half on. And she offers without comment the idea that women are not rising more quickly through academic medical ranks because they're taking time off to raise families. It's 2001. Most reasonable people agree that husbands can and do now shoulder some of that burden.
The thought control Satel is trying to promote seems more dangerous than the wacky ideas of a few public health school faculty members. Satel is trying to wrest control of medicine back from patients, whom she sees as ignoramuses who can't possibly know what's good for them. Big, paternalistic government is bad, according to conservatives, but paternalistic medicine is evidently good, according to Satel, who doesn't seem troubled by the contradiction between diminishing patient autonomy and encouraging patients to take responsibility for their own healthcare. She's arguing for a remarkable sort of paternalism.
This all fits in nicely with managed care's plans for the world: Cut down the amount of time doctors can spend with patients, who will then run to the Internet for medical advice. But there they're more likely to find charlatans and snake-oil salesmen than reasonable medical opinions. Managed care, which presents more clear and present danger to the public's health than anything denounced in Satel's book, is barely mentioned. When it is, it's praised for cutting down lengths of stay in long-term mental hospitals and defended against charges that minorities aren't well represented in physician rosters. Similarly, Satel ignores the influence of politics on the medical arena when she agrees with certain policies, such as those against abortion.
Satel's thesis would be less troubling if she presented a clear vision of how to equalize the inequities in healthcare, which she acknowledges, even though she doesn't think they're the result of sexism or racism. She seems at one point to encourage "cultural competency" -- defined by the American Medical Association as familiarity with the "beliefs, values, actions, customs, and unique health needs of distinct population groups" -- although this itself is a politically laden term and her message is muddled.
Satel approvingly cites Anne Fadiman's "The Spirit Catches You and You Fall Down," the well-received 1997 book about the cultural clash that resulted when the immigrant parents of a young Hmong girl with severe epilepsy resisted American doctors' attempts to treat her. "In this account there are no villains," Satel writes. That's what the reviews all said, but has Satel actually read the book? While I agree that the book is a more balanced and powerful account of such a story than can be found elsewhere, I finished reading it with the distinct impression that the doctors were the villains, even if well intentioned. (That impression was only bolstered by hearing Fadiman at a recent conference refer to the girl's persistent vegetative state as being the fault of a medical mistake.)
Satel is a conservative ideologue in a doctor's white lab coat. Unfortunately, her voice is likely to carry a lot of weight among those who will be setting health policy in the Bush administration. Even Satel agrees that there is a problem in the delivery of healthcare to minorities. Rather than lambasting those who are trying to identify the source of the problem, conservatives should join liberals in trying to figure out how to solve it.
