Medical Correctness

by Theodore Dalrymple

Beware of false prophets, which come to you in sheep’s clothing, but inwardly they are ravening wolves. —Matthew 7:14

In Russia in 1839, Custine wrote that Tsar Nicholas I was both eagle and insect: eagle because he soared over society surveying it with a sharp raptor’s eye from above, and insect because he bored himself into every tiny crack and crevice of society from below. Nothing was either too large or too small for his attention; and sometimes one feels that political correctness is rather like that. For the politically correct, nothing is too large or too small to escape their puritanical attention. As a consequence, we suspect that we are living an authoritarian prelude to a totalitarian future.

Whether medical journals be large or small depends, of course, on the importance that you attach to them. As a doctor I am inclined to accord them more importance than the average citizen might; but what is indisputable is that they are not immune from political correctness, quite the reverse. Reading them, one has the impression of being buttonholed by a terrific bore at a cocktail party, who won’t let you go unless you agree with his assessment of the situation in Somalia.

At first sight, medicine might appear an unpromising subject for political correctness. You are ill, you go to the doctor, he tries to cure you, whoever you might be: what could be more straightforward than that? But in fact medicine is a field ripe for political correctness’s harvester. The arrangement by which health care is delivered is eminently a subject of politics; moreover we live in the golden age of epidemiology, in which the distribution of health and disease is studied more closely even than the distribution of income. Inequalities are usually presented as inequities (they have to be selected carefully, however: I have never seen the superior life expectancy of women, sometimes considerable and present almost everywhere, described as an inequity, even though the right to life is supposedly the most basic of all in the modern catechism of human rights). The decent man abominates unfairness or injustice: therefore the man who abominates unfairness or injustice is decent.

Political correctness—linguistic and semantic reform as the first step to world domination—came comparatively late to medical journals. This is because, where intellectual fashions are concerned, doctors are usually in the rear, rather than the vanguard. Their patients plant their feet on the ground for them, whether they want them planted there or not; for there is nothing quite like contact with a cross-section of humanity for destroying utopian illusions. Of course, there have been politically radical doctors—many of the informants of the Blue Books praised by Marx for the honesty of their exposure of truly appalling conditions were doctors—but their radicalism has been generally of the practical variety in response to the very real and present miseries that they encountered in their work. Their reformism was neither utopian nor a manifestation of the search for transcendent purpose in a post-religious world.

Medical journals have thus gone over to political correctness—admittedly with the zeal of the late convert—comparatively recently. Such correctness, however, is now deeply entrenched. With The New England Journal of Medicine for July 16, 2016 in hand, I compared it with the first edition I came across in a pile of old editions in my slightly disordered study: that for September 13, 2007, as it happened, which is not a historical epoch ago. What started as mild has become strident and absurd.

The first article in the earlier NEJM concerned the insufficient use of typhoid vaccination in those parts of the world in which the disease is still prevalent. It was titled “Putting Typhoid Vaccination on the Global Health Agenda.” “The Global Health Agenda”: the very phrase is a masterpiece of suggestio falsi and suppressio veri, which one suspects immediately (and correctly) of having a vast hinterland of saccharine, politically correct, and potentially dictatorial sentiment. In an article titled “Global Health Agenda for the Twenty-First Century,” we find:

Health in its own right is of fundamental importance and, like education, is among the basic capabilities that give value to human life (Sen & Sen 1999). It is an intrinsic right as well as a central input to poverty reduction and socioeconomic development. Health-related human rights are core values within the United Nations and WHO, and are endorsed in numerous international and regional human rights instruments. They are intimately related to and dependent on the provision and realization of other social and economic human rights such as those of food, housing, work and education.

Apart from being execrably written, this is, where it can actually be understood, the most patent nonsense. My rights are not infringed because I fall ill; I have, for example, no right to an unenlarged prostate though I would much prefer to have one; and there can be no right to immortality as there is to freedom from arbitrary arrest.

Just because something is nonsense, of course, does not mean that people fail to believe it, and the notion that health care is a human right is now all but unassailable, and unassailed, in our medical journals (which see every sectional interest but their own). I used to ask medical students whether they could find any good reason for providing medical attention to people other than that they had a right to it: and on the whole they could not, so thoroughly had the notion of rights entered their mind and destroyed their moral imaginations.

But at least the article in the NEJM in 2007 had some medical substance. According to various estimates, between 200,000 and 600,000 people died annually of typhoid at that time, often children of school-age, and the disease is largely preventable by means of immunization which is very cheap. I think we can all agree that it would be desirable to eliminate it, or at least reduce it very considerably.

But to do so, is it really true that “the international health community will need to increase the priority and sense of urgency accorded to the control of this disease”? Is a kind of world government essential to the task?

According to the data provided, in the article, the vast majority of the problem resides in South and South East Asia, in countries such as India, Pakistan, Vietnam, Thailand, Malaysia, and Indonesia, some of them no longer deeply impoverished. In the body of the text we read:

Vaccination can provide a near-term solution, as demonstrated in Thailand, where mass vaccination of schoolchildren with injectable, inactivated, whole-cell vaccines in the 1970s and 1980s led to sharp decreases in the incidence of typhoid fever and is credited with largely controlling the disease. However, because of their high rates of side effects, these older-generation vaccines have generally been abandoned as public health tools.

But as the article itself draws attention to the existence of new vaccines that are cheap and without serious side-effects, the question might well be asked why, if Thailand could conduct a successful immunization campaign against typhoid in the 1970s and 1980s, it cannot do so in 2016, when it is considerably richer? Why does it need a, let alone the, global health agenda to do so? And what applies to Thailand applies to the other countries as well, give or take civil war whose health effects no global health agenda is likely to overcome.

In other words, what is being promoted in the article is not so much the eradication of typhoid as a kind of imperialism of good intentions, with its associated international bureaucracy (usually remunerated in Swiss francs, incidentally), for who can be found to speak up, in the name of biodiversity, for Salmonella typhi as an endangered species?

The article, though by no means watertight in its logic, is nevertheless not egregious. But a constant stream of such articles has now been published for years in all the major general medical journals, usually unopposed by any alternative view, and numbs the mind into a kind of acquiescence or surrender, with a loss of will critically to appraise what is written. For what would now be the point of doing so? It would be like trying to use a feather to keep oneself dry in a monsoon. I assume that something similar happened to readers of Pravda and Izvestia, though of course I do not mean to imply that anything worse than loss of face would result if a doctor dared to show himself against the prevailing orthodoxy of medical journals.

The object of political correctness not being to spread truth but to exercise power, the more it violates common feeling or opinion while at the same time exercising a moral terror against dissenters, the more effective it is. It is not surprising, then, that it should grow ever more extreme, and attach itself to ever more arcane subject matter. Thus the first article in the edition of the New England Journal of Medicine for July 14, 2016—Bastille Day, appropriately enough, considering that there were only seven prisoners when the Bastille was stormed—was titled “Beyond Bathrooms—Meeting the Health Needs of Transgender People.”

If Marx were alive today, he would write not that history repeats itself, appearing first as tragedy and then as farce, but that it repeats itself, appearing first as tragedy and then as bathos. The article in the NEJM begins:

One might have to go back to the era of racial desegregation of U.S. bathrooms to find a time when toilets received so much attention.

But even the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association puts the prevalence of what it calls Gender Dysphoria Disorder at about 0.005 percent: and the DSM V is not generally conservative in its estimates of prevalence, for example putting that of Dissociative Identity Disorder (DID) at 1.5 percent (that is to say, 3,000 times more common than Gender Dysphoria Disorder), though this condition and its diagnosis have more recently gone out of fashion, having enjoyed a phase of great popularity which gender dysphorics can only envy and aspire to emulate. Incidentally, did replaced mpd (Multiple Personality Disorder): nothing, after all, can stop the march of progress, especially in science. Most of us, unfortunately, are still stuck at the Three Faces of Eve stage.

To mention the psychological peculiarities of one person in twenty thousand in the same breath as the travails of a tenth of the American population before the Civil Rights movement might seem insensitive, not to say insulting, but the politically correct can see offense given only by others, never by themselves. They generally do not have much a sense of humor either, for only they could read the following without a smile at the very least:

bathrooms matter for health. Transgender people who are barred from using bathrooms where they feel safe might feel they have no choice but to suppress basic bodily needs. Delayed bathroom use can cause health problems including urinary tract or kidney infections, stool impaction, and hemorrhoids.

But this is mad. Any decent transvestite—let alone transsexual—could use a women’s lavatory without undergoing the slightest interrogation as to his chromosomal sex.

More importantly, the article demands of the reader that he performs feats of doublethink, according to which he should keep in mind that transsexualism both is and is not an illness:

In 2013, the American Psychiatric Association (APA) revised its guidelines to indicate that being transgender is not a mental disorder and that gender-affirming treatments are a valid focus of care for people who desire them; the APA has included gender dysphoria in its guidelines partly to cover people who have substantial distress or impairment and to ensure access to and coverage of desired medical interventions and treatments . . .

In other words, wishing to change your outward sexual appearance is not pathological, but when you are sufficiently unhappy at not being able to do so at your own expense, you become ill and should be able to do so at someone else’s expense.

This is perilously close to soliciting fraud, for of course anyone can manufacture “substantial distress and impairment” at not getting what he wants. But even this is not all.

The article has a box with the heading Definitions of Selected Identity Terms. We realize at once that we are in the presence of a kind of Turkish Language Reform of the soul, in which what is aimed at is not accuracy but control of your thoughts. There is a warning asterisk after the word Terms:

Some concepts are evolving, so usage may vary.

The better, one might add, to keep you in a state of fear of uttering a word or phrase subsequently declared to be offensive, and thereby to exercise continued power over you.

Only a man with a mind of marshmallow could read these definitions and not simultaneously want to kill himself and fall about laughing. Here, for example, is the definition of a cisgender man (sex nowadays is like the Jordan of old, that is to say it comes in Cis- and Trans- varieties):

A person assigned male sex at birth who identifies as a man.

How, one wonders, is a person assigned male sex at birth? By drawing lots, perhaps, or by some random number sex-assigning machine? Incidentally, the article in the NEJM is only reflecting developments in the wider culture, much as a canary used to detect carbon monoxide down the shaft of a coal-mine. The other day, for example, I came across a heart-warming story in the Washington Post—heart-warming, that is, for the kind of person whose heart is warmed by reading the Washington Post—of a ten-year-old boy who was taken to a little girls’ clothes shop by his mother and who came out wearing a pair of little girls’ shoes. “I don’t want to be a boy or girl,” he said. “I just want to be a person.” Compared with this, Little Nell was Zsa Zsa Gabor.

But the most interesting definition was that of genderqueer. None of my circle of acquaintances whom I asked to define the term had even heard of it, but I am glad to say that all those compulsory Microsoft updates that so irritate and frustrate me when I turn on my computer have included the adoption of the word as a normal term, for it is not underlined in red as being in error when I type it. Genderqueer is:

A person with a nonbinary gender identity, identifying as both a man and a woman or as neither.

In other words, being genderqueer is a bit like being a European according to the projectors of the European project: that is to say one identifies not as German or French or Portuguese, but as European.

If genderqueerism spreads, one can only hope for the future of the human race that the biotechnologists find a way of turning Man into a kind of hydra, the simple coelenterate that reproduces not sexually, but by budding. The hydra is genuinely genderqueer.

In none of the above do I mean to imply that The New England Journal of Medicine is uniquely tedious in its unctuous cleaving to the latest moral enthusiasm of the congenitally virtuous: far from it, if anything The Lancet is even worse. It still publishes much valuable scientific research, of course; but as soon as any item touches on the social or political, it adopts a sententious langue de bois that glazes over the mind of the reader. Here are a couple of examples from a single edition, taken at random from a pile of copies of old editions in my study:

In his farewell speech . . . the outgoing UN Secretary-General Kofi Annan emphasised five lessons from his ten-year tenure: the interconnectedness of the security of all people; the global community’s responsibility for everyone’s welfare; the respect for human rights and the rule of law as the indispensable foundations for our common humanity and shared belief in human dignity; the accountability of governments for their actions in the international context; and finally, the importance of a strong multilateral system—a reformed U.N.—to achieve results . . . . Only with equitable, sustainable development and health at its core will the global community have a better future.

and:

For a global culture of peace to be built, the next generation must be imbued with new systems of thinking and feeling. Such approaches are the domain of cognitive science, translated through practice into perceptual and behavioural change. (December 23–30, 2006, Vol. 368)

All of this is obviously instinct with totalitarian implication and no doubt impulse. The impression one has when reading the medical journals of entering a totalitarian microclimate is strengthened by the fact that no criticism of this anesthetizing (and therefore dangerous) bilge is ever published in the journals in which it appears. I do not know whether this is the result of deliberate exclusion of criticism, or the fact that one of the effects of langue de bois is a sapping of the will to reply: who, after all, wants to spend his time arguing with someone who believes in the existence of a global community or the future existence of a global culture of peace? Sisyphus’s task was a pleasant one by comparison.

It is instructive to contrast the language of the Lancet today with that of its language in the 1820s, when it was edited by its founder, Thomas Wakley. Wakley was precisely the kind of man that Orwell describes Dickens as having been:

a man who is always fighting against something, but who fights in the open and is not frightened, the face of a man who is generously angry—in other words, of a nineteenth-century liberal, a free intelligence, a type hated with equal hatred by all the smelly little orthodoxies which are now contending for our souls.

Wakley campaigned against specific abuses and was sued for libel at least nine times, defending himself in court and winning, morally if not quite always legally; in the end, his arguments for reform were usually triumphant. Here, again taken at random, is a passage from Wakley’s Address to the Readers of the Lancet for the volume of 1829:

With regard to hospital reports [of operations conducted in them], these, let it be remembered, were equally denounced by our enemies, when we first set the example of publishing them. The times, however, are changed, and hospital reports are now recognised by all, except by those functionaries who, by reason of their imbecility, have cause to dread them, as an integral portion of the stock of public information. But there is this material difference between the hospital reports published in this Journal, and those which have recently been put forth by our imitators, that the latter have been supplied by the functionaries themselves, who have a manifest interest in suppressing whatever facts may be unfavourable to their reputation; whereas, our interest as clearly lies in giving a faithful and impartial detail of facts, whether favourable or unfavourable to the hospital surgeons.

These are the words of a free man, unafraid and generously angry. Those in his position today at medical journals are the promoters of smelly little orthodoxies, always afraid and glancing over their shoulder lest anyone should think them less than immaculate in their political correctitude. In the process, they spread the atmosphere of fear in which we all now live.

First published in The New Criterion.