“You are more than entitled not to know what the word ‘performative’ means. It is a new word and an ugly word, and perhaps it does not mean anything very much. But at any rate there is one thing in its favor, it is not a profound word.”
J.L. Austin, “Performative Utterances,” in Philosophical Papers 233 (2nd ed. 1970).
John Langshaw Austin, J.L. to his friends, was a English philosopher who focused on language and how it actually worked in the real world. Austin developed the concept of performative utterances, which have since come to be known as “speech acts.” Little did J.L. know that performative utterances would come to dominate politics and social media.
The key aspect of spoken words that function as speech acts is that they do not simply communicate information, which might have some truth value, and some epistemic basis. Speech acts consist of actual conduct, such as promising, commanding, apologizing, etc.[1] The law has long implicitly recognized the distinction between factual assertions or statements and speech acts. The Federal Rules of Evidence, for instance, limits the rule against hearsay to “statements,” meaning written assertions or nonverbal conduct (such as nodding in agreement) that is intended as an assertion.[2]
When persons in wedding ceremonies say “I do,” at the appropriate moments, they are married, by virtue of their speech acts. Similarly for contracts and other promising under circumstances that give rise to enforceable contracts. A witness’s recounting another’s vows or promises is not hearsay because the witness is offering a recollection only for the fact that the utterance was made, and not to prove the truth of a matter asserted.[3]
The notion of a speech act underlies much political behavior these days. When people palaver about Q, or some QAnon conspiracy, the principle of charity requires us to understand them as not speaking words that can be true or false, but simply signaling their loyalty to a lost cause, usually associated with the loser of the 2020 presidential election. By exchanging ridiculous and humiliating utterances, fellow cultists are signaling loyalty, not making a statement about the world. Their “speech acts” are similar to rituals of exchanging blood with pledges of fraternity.
Of course, there are morons who show up at concerts expecting John F. Kennedy, Jr., to appear, or who show up at pizza places in Washington, D.C., armed with semiautomatic rifles, because their credulity outstripped the linguistic nuances of performative utterances about the Clintons. In days past, members of a cult would get a secret tatoo or wear a special piece of jewelry. Now, the way to show loyalty is to say stupid things in public, and not to laugh when your fellow cultists say similar things.
Astute observers of political systems, on both the left (George Orwell) and the right (Eric Voegelin) have long recognized that ideologies destroy language, including speech acts and performative utterances. The destructive capacities of ideologies are especially disturbing when they invade science and medicine. Alas, the ideology of the Woke has arrived in the halls of the American Medical Association (AMA).
Last month, AMA issued its guide to politically correct language, designed to advance health “equity”: “Advancing Health Equity: A Guide to Language, Narrative and Concepts (Nov. 2, 2021).” The 54 page guide is, at times, worthy of a MAD magazine parody, but the document quickly transcends parody to take us into an Orwellian nightmare of thought-control in the name of neo-Marxist “social justice” goals.[4]
In its guide to language best practices, the AMA urges us to promote health equity by adding progressive political language to what were once simple statements of fact. The AMA document begins with what seems affected, insincere humility:
“We share this document with humility. We recognize that language evolves, and we are mindful that context always matters. This guide is not and cannot be a check list of correct answers. Instead, we hope that this guide will stimulate critical thinking about language, narrative and concepts—helping readers to identify harmful phrasing in their own work and providing alternatives that move us toward racial justice and health equity.”
This pretense at humility quickly evaporates as the document’s tone become increasingly censorious and strident. The AMA seems less concerned with truth, evidence-based conclusions, or dialogue, than with conformity to social justice norms of the Woke mob.
In Table 1, the AMA introduces some “Key Principles and Associated Terms.” “Avoid use of adjectives such as vulnerable, marginalized and high-risk,” at least as to persons. Why? The AMA tells us that the use of such terms to describe individuals is “stigmatizing.” The terms are vague and imply (to the AMA) that the condition is inherent to the group rather than the actual root cause, which seems to be mostly, in the AMA’s view, the depredations of white cis-gendered men. To cure the social injustice, the AMA urges us to speak in terms of groups and communities (never individuals) that “have been historically marginalized or made vulnerable, or underserved, or under-resourced [sic], or experience disadvantage [sic].” The squishy passive voice pervades the AMA Guide, but the true subject – the oppressor – is easy to discern.
Putting aside the recurrent, barbarous use of the passive voice, we now must have medical articles that are sociological treatises. The AMA appears to be especially sensitive, perhaps hypersensitive, to what it considers “unintentional blaming.” For example, rather than discuss “[w]orkers who do not use PPE [personal protective equipment” or “people who do not seek healthcare,” the AMA instructs authors, without any apparent embarrassment or shame, to “try” substituting “workers under-resourced with” PPE, or “people with limited access to” healthcare.
Aside from assuaging the AMA’s social justice warriors, the substitutions are not remotely synonymous. There have been, there are, and there will likely always be workers and others who do not use protective equipment. There have been, there are, and there will likely always be persons who do not seek healthcare. For example, anti-vaxxing yutzballs can be found in all social strata and walks of life. Access to equipment or healthcare is a completely independent issue and concern. The AMA’s effort to hide these facts with the twisted passive-voice contortions assaults our language and our common sense.
Table 2 of the AMA Guide provides a list of commonly used words and phrases and the “equity-focused alternatives.”
“Disadvantaged” in Woke Speak becomes “historically and intentionally excluded.” The aspirational goal of “equality” is recast as “equity.” After all, mere equality, or treating everyone alike:
“ignores the historical legacy of disinvestment and deprivation through policy of historically marginalized and minoritized [sic] communities as well as contemporary forms of discrimination that limit opportunities. Through systematic oppression and deprivation from ethnocide, genocide, forced removal from land and slavery, Indigenous and Black people have been relegated to the lowest socioeconomic ranks of this country. The ongoing xenophobic treatment of undocumented brown people and immigrants (including Indigenous people disposed of their land in other countries) is another example. Intergenerational wealth has mainly benefited and exists for white families.”
In other words, treating people equally is racist. Non-racist is also racist. “Fairness” must also be banished; the equity-focused AMA requires “Social Justice.” Mere fairness pays “no attention” to power relations, and enforced distribution outcomes.
Illegal immigrants are, per AMA guidelines, transformed into “undocumented Immigrant,” because “illegal” is “a dehumanizing, derogatory term,” and because ‘[n]o human being is illegal.” The latter is a lovely sentiment, but human beings can be in countries unlawfully, just as they can be in the Capitol Building illegally.
“Non-compliance” is transmuted into “non-adherence,” because the former term “places blame for treatment failure solely on patients.” The latter term is suggested to exculpate patients, even though patients can be solely responsible for failing to follow prescribed treatment. The AMA wants, however, to remind us that non-adherence may result from “frustration and legitimate mistrust of health care, structural barriers that limit availability and accessibility of medications (including cost, insurance barriers and pharmacy deserts), time and resource constraints (including work hours, family responsibilities), and lack of effective communication about severity of disease or symptoms.” All true, but why not add sloth, stupidity, and superstition? We are still in a pandemic that has been fueled by non-compliance that largely warrants blame on the non-compliant.
The AMA wanders into fraught territory when it tells us impassively that identifying a “social problem” is now a sign of insensitivity. The AMA Woke Guide advises that social problems are really “social injustices.” Referring to a phenomenon as a social problem risks blaming people for their own “marginalization.” The term “marginalization” is part of the Social Justice jargon, and it occurs throughout the AMA Woke Guide. A handy glossary at the end of the document is provided for those of us who have not grown up in Woke culture:
“Marginalization: Process experienced by those under- or unemployed or in poverty, unable to participate economically or socially in society, including the labor market, who thereby suffer material as well as social deprivation.”[5]
The Woke apparently know that calling something a mere “social problem” makes it “seem less serious than social injustice,” and there is some chance that labeling a social phenomenon as a social problem risks “potentially blaming people for their own marginalization.” And yet not every social problem is a social injustice. Underage drinking and unprotected sex are social problems, as is widespread obesity and prevalent diabetes. Alcoholism is a social problem that is prevalent in all social strata; hardly a social injustice.
At page 23 of the Woke Guide, the AMA’s political hostility to individual agency and autonomy breaks through in a screed against meritocracy:
“Among these ideas is the concept of meritocracy, a social system in which advancement in society is based on an individual’s capabilities and merits rather than on the basis of family, wealth or social background. Individualism is problematic in obscuring the dynamics of group domination, especially socioeconomic privilege and racism. In health care, this narrative appears as an over-emphasis on changing individuals and individual behavior instead of the institutional and structural causes of disease.”
Good grief, now physicians cannot simply treat a person for a disease, they must treat entire tribes!
Table 5
Some of the most egregious language of the Woke Guide can be seen in its Table 5, entitled “Contrasting Conventional (Well-intentioned) Phrasing with Equity-focused Language that Acknowledges Root Causes of Inequities.” Table 5 makes clear that the AMA is working from a sociological program that is supported by implicit claims of knowledge for the “root causes” of inequities, a claim that should give everyone serious pause. After all, even if often disappointed, the readers of AMA journals expect rigorous scientific studies, carefully written and edited, which contribute to evidence-based medicine. There is nothing, however, in the AMA Guide, other than its ipse dixit, to support its claimed social justice etiologies.
Table 5 of the AMA Guide provides some of its most far-reaching efforts to impose a political vision through semantic legerdemain. Despite the lack of support for its claimed root causes, the AMA would force writers to assign Social Justice approved narratives and causation. A seemingly apolitical, neutral statement, such as:
“Low-income people have the highest level of coronary artery disease in the United States.”
now must be recast into sanctimonious cant that would warm the cockles of a cold Stalinist’s heart:
“People underpaid and forced into poverty as a result of banking policies, real estate developers gentrifying neighborhoods, and corporations weakening the power of labor movements, among others, have the highest level of coronary artery disease in the United States.”
Banks, corporations, and real estate developers have agency; people do not. With such verbiage, it will be hard to enforce page limits on manuscripts submitted to AMA journals. More important, however, is that the “root cause” analysis is not true in many cases. In countries where property is banned and labor owns the means of production, low-income people have higher rates of disease. The socio-economic variable is important, and consistent, across the globe, even in democratic socialist countries such as Sweden, or in Marxist paradises such as the People’s Republic of China and the former Soviet Union. The bewildered may wonder whether the AMA has ever heard of a control group. Maybe, just maybe, the increased incidence of coronary artery disease among the poor has more to do with Cheez Doodles than the ravages of capitalism.
CRITICAL REACTIONS
The AMA’s guide to linguistic etiquette is a transparent effort to advance a political agenda under the guise of language mandates. The AMA is not merely prescribing thoughtful substitutions for common phrases; the AMA guide is nothing less than an attempt to impose a “progressive” ideology with fulsome apologies. The AMA not only embraces, unquestioningly, the ideology of “white fragility, Ibram Kendi, and Robin DiAngelo; the AMA at times appears on the verge of medicalizing the behaviors of those who question or reject its Woke ideology. Is a psychiatric gulag the next step?
Dr. Michelle Cretella, the executive director of the American College of Pediatricians, expressed her concern that the AMA’s “social justice” plans are “rooted not in science and the medical ethics of the Hippocratic Oath, but in a host of Marxist ideologies that devalue the lives of our most vulnerable patients and seek to undermine the nuclear family which is the single most critical institution to child well-being.”[6]
Journalist Jesse Singal thinks that the AMA has gone berserk.[7] And Matt Bai, at the Washington Post, saw the AMA’s co-opting of language and narratives as having an Orwellian tone, resembling Mao’s “Little Red Book.”[8] The Post writer raised the interesting question why the AMA was even in the business of admonishing physicians and scientists about acceptable language. After all, the editors of Fowler’s Modern English Usage have managed for decades to eschew offering guidance on performing surgery. The Post opinion piece expresses a realistic concern that proposing “weird language” will worsen the current fraying of the social fabric, and pave the way for a Trump Restoration. Perhaps the AMA should stick to medicine rather than “mandating versions of history and their own lists of acceptable terminology.”
AMA Woke Speak has its antecedents,[9] and it will likely have its followers. For lawyers who work with expert witnesses, the AMA guide risks subjecting their medical witnesses to embarrassment, harassment, and impeachment for failing to comply with the new ideological orthodoxy. Just say no.
[1] See generally John L. Austin, How to Do Things with Words: The William James Lectures delivered at Harvard University in 1955 (1962).
[2] See Fed. R. Evid. Rule 801(a) & Notes of Advisory Comm. Definitions That Apply to This Article; Exclusions from Hearsay (defining statement).
[3] See, e.g., Emich Motors Corp. v. General Motors Corp., 181 F.2d 70 (7th Cir. 1950), rev’d on other grounds 340 U.S. 558 (1951).
[4] Harriet Hall, “The AMA’s Guide to Politically Correct Language: Advancing Health Equity,” Science Based Medicine (Nov. 2, 2021).
[5] Citing, Foster Osei Baah, Anne M Teitelman & Barbara Riegel, “Marginalization: Conceptualizing patient vulnerabilities in the framework of social determinants of health-An integrative review,” 26 Nurs Inq. e12268 (2019).
[6] Jeff Johnston, “Woke Medicine: ‘The AMA’s Strategic Plan to Embed Racial Justice and Advance Health Equity’,” The Daily Citizen (May 21, 2021) .
[7] Jesse Singal, “The AMA jumps the Woke Shark, introduces Medspeak,” Why Evolution is True (Nov. 1, 2021).
[8] Matt Bai, “Paging Dr. Orwell. The American Medical Association takes on the politics of language,” Wash. Post (Nov. 3, 2021).
[9] Office of Minority Health, U.S. Department of Health and Human Services, “National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS
Policy and Practice” (2013); Association of State and Territorial Health Officials, “Health equity terms” (2018).
