Correspondence (May/June 2000)

Slouching Towards a Duty to Die

Dear Editor,
The contents of your article "Slouching Towards a Duty to Die" (Medical Sentinel 1999;4(6):208-210) are so sad, unfortunately. The article is superb and accurate.

I have been in solo practice now for over 45 years. I still make house calls. Beyond that I oversee three active educational foundations and do radio and television programs, as you know, to halt unlawful government, and preserve our foundations of liberty and the ethics of Hippocrates.

So often, however, we hear too many of our colleagues say "I am too busy, I really haven't got time" --- in fulfilling the responsibilities of citizenship and do all possible in gratitude and thanksgiving to preserve, protect, and pass on our great American heritage and legacy of freedom -- even for the sake of future generations, if you will.

As often as not, my humble response is --- "Yesterday hundreds of thousands if not millions of people, died all over the world. But, by the grace of God, you and I are still alive! We are still here! We do have time! We must critically prioritize as to what to do with the gift of time! God said --- "Seek ye first the Kingdom of God and all these other things shall be added unto you." And again --- "What will it avail man if he gains the whole world and loses his soul."

Freedom is the privilege, opportunity, and responsibility to do that which ought to be done and not do that which ought not to be done --- according to the Law of God, Moral Law, Natural Law, the Declaration of Independence, and the U. S. Constitution.

Freedom and responsibility are mutual and inseparable. To the extent one departs from the responsibilities of freedom, one progressively compromises freedom - to its demise, and to the ultimate demise of a free society.

The greatest contemporary moral leader and perhaps the greatest for many centuries, Pope John Paul II, has recently stated that apathy is worse than hatred.

We the people hardly take time to fulfill our responsibility of American citizenship. During the last election, less than 32 percent of the eligible and registered voters voted; among physicians it was even less.

Millions upon millions of sons and daughters of America have fought, suffered, and nearly two millions died to pass on to us our great American heritage and legacy of freedom. Are we not betraying them and future generations by our indifference not to halt unlawful government?

In addressing the responsibilities of private practice the physician cannot, must not, compromise the ethics of Hippocrates.

Patrick Henry, who would have chosen death rather than slavery said - "Is life so dear or peace so sweet, as to be purchased at the price of chains and slavery? Forbid it, Almighty God! I know not what course others may take; but as for me, give me liberty or give me death!" (Maximum material security is a lifetime prison sentence!)

I think we ought to act and halt further unlawful government intrusion, invasion of patient privacy and erosion of medical record confidentiality. I doubt any other medical group will act as swiftly and resolutely as AAPS, the Delta Force of American Medicine and the Patrick Henry Bunch. If we fail to act on the Unique Patient Identifier, then we will have delivered the medical profession to authoritarianism and old-style socialism.

Nino M. Camardese, MD
Norwalk, OH

Annual DDP Meeting

The 18th annual Doctors for Disaster Preparedness meeting will be held June 30-July 2, 2000 at the San Francisco Airport Marriott. Among the speakers will be Prof. John R. Lott, Jr. on "Guns versus Crime." Medical Sentinel readers may want to call (520) 325-2680.

Labor Bosses and Democrats

Dear Editor,
I received the latest issue of Medical Sentinel, January/February 2000. As usual, I began to browse which article to read. When I came across Dr. Edward R. Annis's article, "Labor Bosses and Democrats ---The Beginning of Government Medicine in America," I read his article first. I have admired Dr. Annis's ability to articulate the messages that physicians and Americans need to hear. His leadership is so much in need today. If only he would be able to express his views on the "talk shows" that bombard the airways on Sundays to offset the liberal agenda that prevails and are orchestrated by "informed, motivated, and active people who persevere until they make things happen."

Most people are under the impression that "things just happen," like it was fate. The corollary to this is that in this world there are three classes of people: the ones who sit by idly, doing nothing; those who make things happen; and those who after things happen, ask "what happened?" The apathy that exists in the medical profession is reminiscent of Edmund Burke's dictum, "The only thing necessary for the triumph of evil is for good men to do nothing." That appears to be what has been occurring today. I was happy to read that Dr. Annis in his opening remarks in his article stated, "In our society, things don't just happen."

His review of the history in "Labor Bosses and Democrats --- The Beginning of Government Medicine in America" should be a wake up call for physicians to become politically involved so they can also make things happen.

Unions assess their members hefty dues and look what they have accomplished. Dr. Annis tells it all in his article. Physicians are trying to unionize as though this will solve the profession's problems. It will not, and will serve only to alienate further the patient-doctor relationship. So why not join as many organizations that can help in whatever way and simply look upon all those dues as simply "union dues?" Certainly, AAPS membership is a must along with the AMA and one's respective professional society.

I hope that many more of your readers will see the light and message that Dr. Annis has so well expressed in how the "socialization of American medicine" has occurred.

I want to acknowledge the wonderful way in which AAPS has risen to the occasion in representing the private practice of medicine in the past few years. Physicians are waking up and have discovered AAPS. Your articles are great, well written, easy to read and to grasp the message.

I would like to make one last point in how AAPS is making things happen. A few years ago I attended a monthly meeting of the Board of Trustees of the Medical Society of New Jersey (MSNJ) in which Dr. Lois Copeland requested permission to address the Board. She presented her views on trying to get Congress to allow physicians to be able to privately contract with patients as an alternative to Medicare. No one seemed to pay any attention. "It would be futile as Congress would not allow it": was the sentiment of the advice given after her presentation. She attended several months later with a few of her members from her county medical society. This time, the MSNJ paid attention to this "lonely voice." She obtained support from AAPS and the rest is history. Private contracting is still unresolved, but in time, it will be whereby physicians will be able to have private contracts for the rendering of professional services without the fear of action by governmental agencies. This is an example of how one doctor made a difference with the help of AAPS.

Frank J. Malta, MD
Toms River, NJ


Dear Editor,
Many thanks for publishing some of my strong views regarding labor bosses and their influence on our governmentIn case you overlooked this brief note in The Wall Street Journal, it merely affirms my observation labor bosses never give up --- and neither should we!

Edward R. Annis, MD
Miami Shores, FL

Dozens of Union Members won public office on Election Day, says the AFL-CIO, which has set out to put 2,000 trade unionists in various local, state and national seats next year. Last month's winners include Manchester, N.H., Mayor Bob Baines, a member of Teamsters Local 633; Moreland Hills, Ohio, Mayor Chuck DeGross, a member of Communications Workers of America Local 4340; and Ansonia, Conn., Mayor Jim Delta Volpe, a member of Service Employees International Union Local 511.

Busting the Busters: The AFL-CIO soon will use its Web site to track anti-labor consultants. The new database, protected by a password, will list the consultants, tactics they use and what unions should do to counter those moves. The site is meant to provide tips to union organizers who often encounter the same consultants during various representation drives. (The Wall Street Journal, Dec. 28, 1999)|

Patient Safety and Self-Managed Medical Care

Letter to David M. Lawrence, MD
Chairman and CEO
Kaiser Permanente
Oakland, CA

Dear Dr. Lawrence,
Would health care be safer with control like air traffic (as you suggested at Town Hall in November --- or with self-managed medical savings accounts?

Evidence from self-managed MSA vouchers seems to confirm Bastiat's conclusion of The Law with, "Now that legislators and do-gooders have so futilely inflicted so many systems on society, may they finally end where they should have begun, may they discard all systems and try liberty."

...You cited illustrative anecdotes about hospital mistakes. Anecdotes also suggest how self-management improves safety. Last week, a 4-month-old girl with cough was not improved by a week of the new standard for treatment of bronchitis, albuterol.

My careful examination with stereophonic stethoscope revealed both rales and faint wheeze. Were these audible to managed physicians, forced to spend more time doctoring the record than doctoring the patient?

With nebulized corticoid and oral cephalosporin, the symptoms cleared in 3 days. Cost to the parent was $40 (including medicine) --- much less than for work lost to get "free" care.

A retired teacher had an ominous whoosh in her neck, "I've been telling my [Kaiser] doctor for a year my bridge and golf are off. She listens to my neck but doesn't say anything!" Carotid echograms showed "under 60 percent obstruction" to the contracting radiologist who might wonder about contract renewal if frequent surgical indication were found. Because of an endarterectomy revealing 95 percent obstruction, the retiree again enjoys bridge and golf. Self-management improves safety.

Howard Long, MD, MPH
Pleasanton, CA


Dear Dr. Long,
Thank you for your letter dated December 16, 1999, concerning patient safety and self-managed care. You pose interesting questions about safety and self-management of care. However, you argue as though the choices are either/or ones. I think this obscures the matter considerably. Here's my perspective.

All the evidence I've seen suggests that greater self-management and regulation are required to improve patient safety. Moreover, Medical Savings Accounts can alter incentives in such a way that people take greater responsibility for their care and the quality of care they're receiving. Based on what we've learned from looking at other fields, health care will also benefit from better organization and more safety-focused internal operating systems, especially in those places where errors can have the most disastrous result (e.g., prescription drug use, surgical suites, anesthesia, invasive procedures, and the like). Unfortunately, medical care is not well organized and all of us have over-relied on the myth of perfect performance at the expense of safety systems development.

There's no evidence to support the assertion that managed care, HMOs, or Kaiser have reduced safety or quality. The Institute of Medicine's report published in 1999 in JAMA (September) concluded that quality of care problems are ubiquitous and unrelated to managed care. Most quality of care problems identified in the major studies of the issue predate the introduction of managed care, in fact. In other words, quality and safety problems aren't now and can't be laid at the feet of the way health care is financed.

Finally, I don't think all regulation is bad. I favor regulation that creates a safe legal climate within which to conduct investigations for purposes of learning about causes of errors that result in death or injury. We don't presently have this. I favor regulation that creates a place responsible for capturing and analyzing significant errors, again for purposes of learning. I favor regulation that provides funding for research into new ways to understand and prevent errors from occurring. And I favor regulation that enables voluntary reporting of "near misses"...errors that occurred but didn't result in injury or death. Other industries have found them to be the primary source of insight into error causes and prevention. Our experience in health care in adverse drug event and anesthesiology suggest that the opportunities in health care are similar.

David M. Lawrence, MD
Chairman and CEO
Kaiser Permanente
Oakland, CA


Dear Dr. Lawrence,
Thank you for your letter dated 01/12/00...I agree that, "especially in those places where disastrous results (e.g., prescription drug use, surgical suites, anesthesia, invasive procedures, and the like), care will also benefit from better organization and more safety-focused internal operating systems."

Indeed, lower cost (and presumably greater safety) has been observed when catastrophic care was combined with MSAs. Internal operating systems function better with incentives for personal responsibility, like MSAs. Could a Kaiser catastrophic option and MSAs increase Kaiser profits and patient safety?

Howard Long, MD, MPH
Pleasanton, CA

Washington State Single Payer Iniative

Dear Dr. Orient,
The March/April 2000 issue of Medical Sentinel includes a response from you to a letter from Dr. Philip Ranheim, Everett, WA, that is factually incorrect.

You state that Dr. Ranheim and his colleagues in Washington State are "about to undertake a new such experiment (referring to government-run health care or socialized medicine) with the approval of the Washington State Medical Associa-tion." This is not true. A ballot initiative to create a single payer health care plan has been filed in this state. Proponents of this initiative urged the Washington State Medical Association (WSMA) to endorse the initiative last fall at our annual meeting. This was not done.

In November, at the direction of our House of Delegates, the association reviewed the draft initiative. To quote our subsequent letter to the initiative campaign:

"Comments received thus far have been universally negativeThe reaction has been that this is an ill conceived, poorly written initiativeThe initiative reinforces the appearance that the equation at work is that the citizenry are infantilized and the providers are criminalized."

It is no small irony that both you and the initiative campaign have incorrectly represented our position on this issue. As I stated in my letter to the campaign, I feel that we should not hold the AAPS to a lower standard than the initiative campaign.

Physicians in Washington State are exceedingly frustrated with the current market chaos and managed care mess. In response, some have decided to support a single payer approach. Others have concluded that the only proper way to resolve the current conundrum is to return to a time when there was no third-party interference in any way with the physician-patient relationship. Both sides can make valid arguments to support their positions. Both sides can get lost in their ideologies, as well. What we need is reasoned discourse. Members of the WSMA who also belong to the AAPS are contributing to this discourse. We hope you do, too.

By the way, you and your readers might find it interesting (and no surprise) that a series of seminars the WSMA is presenting across the state on how to practice medicine by opting out of relationships with insurance companies is enjoying an outstanding response.

AAPS publishes a fine journal. Clearing up this misunderstanding will only add to its luster.

John G. Gollhofer, MD
President, WSMA


Dear Dr. Gollhofer,
Thanks for your letter. I am glad to hear that WSMA is not going to endorse the single payer initiative; I hope that you will oppose it strenuously. I am very sorry that I made a statement to the contrary. In November 1999, when I dictated a letter responding directly to Dr. Ranheim, I had been told by a Washington member that WSMA was considering an endorsement; no information about the outcome was available at that time. My apologies are in order. This was simply an error; I had no intention of misrepresenting the WSMA position.

Jane M. Orient, MD
Executive Director, AAPS



While lobbying to extend and improve MSAs is crucial, at the same time we must work diligently to get every physician who can open an MSA to do so. Health care is the largest industry in the United States and even a small fraction of our number would make a "helluva" dent in the HMO marketplace! If we don't do it for ourselves, why would our patients do it?

For my part, in California, my wife is an independent insurance broker dedicated to MSA insurance coverage. My family has an MSA and we are in the process of converting the San Diego County Medical Society to MSA insurance. Now is the time to strike at the pocketbook of managed care.

James G. Knight, MD
San Diego, CA

Presidential Election 2000

In the midst of reading the Medical Sentinel, though I admit I haven't read every issue, I've not found support of any particular candidate for president. Is this a rule set by the editorial committee? If that is the rule, I believe it is important to set it aside in this particular instance.

We now have a candidate who is little known; primarily because the media does not care to deal with him. His name is Alan Keyes, PhD. Dr. Keyes is a staunch supporter of the Constitution and the Declaration of Independence. Some people may be fearful of what Alan Keyes may do because he is a very moral, very Christian human being. But, if we were to read the story of the Bible from which he takes his foundations up to the Constitution, and the Declaration of Independence, we will find that Dr. Keyes has read the biblical story. He takes to heart the fact that in the story Christ was offered control of the entire world by the devil in the desert, and that Christ chose to refuse that offer, and actually chose to go on to die for his message.

Dr. Keyes proposes some very fundamental changes in our country's systems of government. Your Editor's Corner, "Death and Taxes at the Turn of the Millennium" (Medical Sentinel 2000;5(1):11-14), evaluates the development and effects of the tax code in the United States with proposed options for change set forth by various congressional representatives. Alan Keyes proposes that we eliminate the income tax. Think of the far reaching effect that would have. It is so fundamental it frightens us when we think about it. We would no longer have the need to hide our medical care as a business expense. Therefore, insurance would not be a tax loophole any longer, and there would be no need for the government to regulate such a private thing. Dr. Keyes' thoughts strike a resonant cord with everything that AAPS stands for; in that, he is so unusual and a welcome breath of fresh air. I must suggest that the membership and the Medical Sentinel look more intently on his candidacy.

R.E. Dwight, DO
Sandusky, OH

[Dr. Keyes was the featured speaker at a past AAPS annual meeting. Although the Medical Sentinel does not endorse candidates, AAPS-PAC does support political candidates who stand for the AAPS mission. Those who wish to help should send their contributions to AAPS-PAC, P.O. Box 511315, Punta Gorda, FL 33951-1315. ---Ed.]

Correspondence originally published in the Medical Sentinel 2000;5(3);73-77. Copyright©2000 Association of American Physicians and Surgeons (AAPS).