From the January 2000 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

Practicing ethics

Dr. Kirsch raises a crucial issue not just about doctor-patient communication, but also about health policy. ("Is physician decision-making as ethical as we think?" November ACP-ASIM Observer, p. 2.) The issue of full disclosure to patients is only part of the problem. The greater problem is that insurance companies are making decisions about what is appropriate care motivated by the interests of shareholders rather than patients. Patients lack equal access to tests, specialists and medication because each plan makes its own decisions about how to balance patient needs with profits. Meanwhile, both health insurance premiums and the number of uninsured are rising.

We can avoid the ethical conflict that worries Dr. Kirsch by removing the profit incentive. Universal health insurance with universal standards of care would reduce the conflict between the care we would recommend and what is actually covered. Reducing administrative overhead and duplicative paperwork would increase the health care dollars available for patient care and reduce the time physicians spend negotiating treatment plans with insurers and patients.

Daniel H. Pomerantz, ACP-ASIM Member
New Rochelle, N.Y.

I fear the soul-searching and self-doubt embodied in Dr. Kirsch's commentary is only going to escalate as the insurance industry becomes bolder and bolder. For years, I have maintained that it is a conflict of interest to deal with the Medicare program. There are basic ethical dilemmas inherent in continuing to practice medicine in an environment clearly controlled by third-party payers and the government.

Physicians can avoid conflicts of interest and compromised medical care for their patients only when they are allowed to practice medicine without interference and second-guessing from third-party payers. It is time that we wake up and reassert our role as patient advocate and caring clinician.

Thomas J. Romano, FACP
Wheeling, W. Va.

Unhappy alliance?

I was disappointed when I recently visited ACP-ASIM Online and looked at the section encouraging members to support the College's campaign for universal coverage. When I clicked on the "Join the Fight" button on the Web site, I expected to bring up a form to register support through ACP-ASIM, but I instead was linked to a registration form on the Catholic Health Association Web site.

Yes, the Catholic Church has a long history of contributing to bioethics and speaking out for social justice. However, its guiding document, "Ethical and Religious Directives for Catholic Health Care Services," imposes conservative sectarian policies that limit choice, intrude on doctor-patient decision-making and seek to adopt a "religious gatekeeper" role.

I strongly urge ACP-ASIM to provide members with a pathway to "Join the Fight" that is through our own organization, not tied to a religious health care system.

Edward A. Oppenheimer, FACP
Los Angeles

Response from ACP-ASIM President Whitney W. Addington, FACP:

The College has joined with the Catholic Health Association in a petition drive to encourage our national leaders to engage in a dialogue on providing affordable health care coverage to all Americans. The petition appeared in last month's ACP-ASIM Observer and is included on the Web sites of both organizations.

As President of ACP-ASIM, I have made a commitment to use my presidency to advance the cause of universal coverage. In July, the College's Board of Regents approved an expenditure of almost $1 million to advance this cause in the 2000 presidential and congressional elections. The CHA had already made a similar commitment. It makes more sense to join the CHA and other organizations that share our goal of providing affordable coverage to all Americans than to divide our efforts.

One of the lessons learned from the failed last attempt to provide health insurance to all Americans is that any solution, in order to succeed, must have broad public support from physicians, hospitals, patients, business and labor, and also from grassroots organizations, both secular and non-secular, that represent them. The CHA is just one of a wide coalition of organizations supporting universal coverage that have joined ACP-ASIM in this campaign. Our agreement to work with the CHA, or any other organization that supports universal coverage, does not and should not imply agreement or disagreement on any other public policy issues.

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