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Letters

From the March 1999 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

Ethics and capital punishment

I was delighted by the announcement that the College's Board of Regents voted to create the new ACP-ASIM Center for Ethics and Professionalism. ("Regents approve new ACP-ASIM ethics center, December ACP-ASIM Observer, p. 1.)

I hope that the Center will take up the question of capital punishment and consider developing a policy statement calling for the abolition of the death penalty in the United States. The death penalty is regarded by human rights groups around the world as a violation of the fundamental principle of all human rights: unqualified respect for the dignity and value of life itself.

It should be noted that the American Bar Association last year called for a moratorium on capital punishment in the United States. In its position, the ABA cites the racially discriminatory application of the death penalty, the grossly inadequate legal representation of defendants and the restrictions on appeals to the federal courts even in cases where new evidence is presented that points to the innocence of the condemned prisoner.

It is important for professional organizations such as ACP-ASIM to show leadership when fundamental moral issues are at stake. With more than 3,500 death row inmates awaiting execution (that number includes 69 persons who committed their crimes when they were under the age of 18), I strongly urge the College's new ethics center to address the issue of capital punishment at the earliest possible moment.

Abraham L. Halpern, FACP
Mamaroneck, N.Y.

Death of the stethoscope

The commentary by Michael Kirsch, FACP, about the premature demise of the stethoscope and its deleterious effects on medical practice hit the spot. ("The death of the stethoscope: murmurs of discontent," December ACP-ASIM Observer, p. 2.)

American internists fondly remember Sir William Osler, MD, as an illustrious forefather who exemplified a master clinician. It is doubtful, however, that Dr. Osler would reciprocate those warm feelings if he were around today, given the painful decline in bedside diagnostic skills among physicians at large.

However, in fairness to current day clinicians, it must be stated that a lack of proficiency with the stethoscope is not unique to them. The preface of Clinical Auscultation of the Heart, written 50 years ago by the legendary duo of Samuel A. Levine, MD, and W. Proctor Harvey, MD, contains the following: "In writing this treatise, the authors were impressed with the fact that a great many physicians ... were not applying all the information that can be obtained from simple auscultation. In the present era, where complicated apparatus, such as the X-ray and the electrocardiograph, are often essential adjuncts in diagnosis and treatment, and when the cost of medical care is necessarily increasing, it is imperative to derive all possible help from such an inexpensive and expedient tool as the stethoscope."

Since the 1970s, with the explosion of new technology, physical diagnosis has suffered from not-so-benign neglect. Medical students and housestaff suffer the consequences today, as there is no one around to teach them the finer points of physical diagnosis.

It is true that some of the classic teachings of the old masters are invalid today due to changes in the patient population or the practice environment. In fact, some of their beliefs were just plain wrong. But for all its faults, there are times when competent physical diagnosis can make the difference. In the final analysis, it is the patient who loses when key findings like a rub in pericarditis, an S3 gallop in congestive heart failure or Gottron's papules in dermatomyositis are missed or misinterpreted.

The challenge for modern-day researchers and educators is to find out what components of bedside diagnosis are effective and practicable in today's environment. Only then will mainstream clinicians incorporate bedside diagnosis into routine clinical practice and teach it enthusiastically to the next generation.

Ajit N. Babu, FACP
St. Louis

When doctors go retail

I read with considerable angst the article, " When doctors go retail: Is it OK to sell products? " (January ACP-ASIM Observer, p. 13.)The answer in most cases is an unequivocal "no."

There are always conflicts of interest in medicine. Our goal should be to avoid all but those that cannot be averted. Selling nutritional products is one conflict that is avoidable.

Our profession is already considered excessively mercenary by many; let us not make it worse.

Ernest W. Crow, FACP
Wichita, Kan.

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