- Email: [email protected]
USA: Government rules vs clinical judgment
1275
of the US Navy, which from early post-war days has set the rates for many major research universities, Stanford’s indirect rate has been reduced from 70% to 55-5%. The change is expected to cut Stanford’s receipts from Washington by$26 million, equivalent to 10% of its current receipts from government research agencies. Private contributions to Stanford have declined sharply in tempo with the revelations, but, given the anaemic state of the economy and large successes in a fund-raising drive before the scandals, a connection is not necessarily present. However, a severe expression of dismay has been issued by Stanford’s leading financial benefactor, David Packard, co-founder of Hewlett-Packard, a billionaire who has given the university$70 million, along with indications of more to come. In a newspaper interview, Mr Packard assailed the university for its indirect-cost billings on items unrelated to research and ominously suggested he was rethinking his philanthropic intentions. Donald Kennedy, the president of Stanford, has survived in office so far. He initially sought to tough it out by asserting that Stanford was a victim rather than a beneficiary of the Government’s system for financing research. But after taking an awful beating in the press and from many members of his own faculty, he adopted a gentler stance. Telling an alumni group that he accepted full responsibility for Stanford’s difficulties, Dr Kennedy said, "I take some comfort in the lines of Ernest Hemingway: ’The world breaks everyone, and afterwards many are stronger at the broken places’ ". If Dr Kennedy does not last out the year at Stanford, many there will not be surprised. For Dr Baltimore, further trials lie ahead. He has retracted the disputed paper and apologised to the heroine of the case, Margot O’Toole. But Dr O’Toole charges that his "apology does not go to the heart of the matter", which she insists is his failure to acknowledge that, in 1986, he knew that his co-author, Thereza Imanishi-Kari, then at MIT, had fabricated data for the paper. The basis of her certainty, Dr O’Toole says, is that she was present when Dr Imanishi-Kari admitted to Dr Baltimore that she had not obtained the results reported in the paper. Nonetheless, he persisted in defending the paper and depicting inquiring Congressmen as enemies of science. The relationship between science and government will, of course, survive these ugly events, since the partners need each other and can find no alternatives. But serious damage has been done to habits of trust forged between them over many decades. Daniel S.
Greenberg
Round the World Germany: Consultants and abortior Observers of previous meetings of Deutsche Arztetag, the annual parliament of the now 285 074 German physicians, wondered how colleagues from the East would make their presence felt.
They did it with aplomb. A keynote speaker
from Magdeburg concluded: "We are not accustomed... to
practice with economic realities. Thus in a danger that economic yardsticks will be applied uncritically and interfere with the physicianpatient relationship". Reverberating through all the debates combine medical
the New States, there is
was
the
clash
between
the
advocates
of absolute
"westernisation" of East German medicine and those who wished to preserve some of the time-honoured institutions. Almost two days were spent on proposed new specialties and the upgrading of existing ones. The existence of different specialty boards in East and West presents a special difficulty. Much time was also spent in debating the length of postgraduate training for GPs. This is important since the sick-funds accept only physicians with at least 3 years’
specialty training in general medicine. One of the few issues be resolved was the re-establishment of the title Specialist physician (Facharzt fur ...), so we now have specialists in general medicine. The delicate discussion about quality assurance was postponed because of lack of time, but a controversy about
to
the role of physicians in legal abortions was highlighted by a speech from the new Minister of Health (a woman). After a long and politically coloured debate the physicians concluded that they could make a judgment only on medical reasons for termination of pregnancy-a verdict that was not to the liking of the Minister. One outcome of the general debate was a resolution to label all alcohol beverages with an alcohol-embryopathy warning; this will not go down well with the vintners.
Karl H. Kimbel
USA: Government rules
vs
clinical judgment
Officials of the Texas Medical Association have taken the US Government to court to protest against a 20 000 fine imposed on Michael L. Burditt, an obstetrician, after he refused to deliver an indigent, uninsured Hispanic woman’s baby. On May 2 they asked a federal appeals court in New Orleans to nullify the penalty on the ground that it is intrusion into a medical decision "by persons with no medical training". The US Department of Health and Human Services maintains that the penalty was imposed for violation of the "patient dumping" law, which requires private hospitals receiving Medicare funds to provide treatment to emergency patients even if they are uninsured and can’t pay. The objective is to prevent patient dumping-the transfer of indigent patients by private hospitals to public hospitals without treating them, thus shifting the cost to the taxpayers (Lancet, Jan 5, p 38). The events that precipitated the lawsuits started with the admission of Rosa Rivera to the emergency department of the privately owned DeTar Hospital in Victoria at about 4 pm on Dec 5, 1986, in an advanced stage of pregnancy and with a blood pressure of 210/130 mm Hg. Jean Herman, a nurse, examined her and found her to be in active labour. Dr Burditt, to whom Mrs Rivera was assigned, disagreed but said that her extremely high blood pressure was probably contributing to a growth-retarded infant requiring the services of a neonatal intensive-care unit. Declining to accept her as a patient, he had her transferred to the in Galveston, Texas, which has neonatal intensive-care facilities. Galveston is 170 miles from Victoria. At about 7.30 pm Mrs Rivera was delivered of a healthy baby boy in the ambulance taking her to Galveston. She made an excellent recovery. Both the Texas Medical Association and its parent organisation, the American Medical Association, defend Mr Burditt’s medical decisions, but the government lawyers disagree. "No reasonable physician", says their brief, "would have transferred her". A primary reason Dr Burditt distanced
tax-supported John Healy Hospital
1276
himself from Mrs Rivera, the government lawyers say, was his fear of a malpractice suit in the event of a calamity such as a stroke or even death. They also say that Dr Burditt signed a statement at that time, which he knew to be false, that the benefits of the transfer outweighed the risk to mother and fetus. Going beyond the Burditt case, attorneys for the Texas Medical Association contend that the patient dumping law itself is unconstitutional, since it requires physicians to provide free services to the poor. "Congress", said the Association’s brief, "has required physicians to shoulder a buden that the constitution requires should be borne by all". Michael J. Astrue, general counsel of the Department of Health and Human Services, demurs. "Set aside the fact that physicians are the highest paid people in the country other than professional athletes, averaging$155 000 a year", he says. "No one forces any physician to provide emergency services. They cut whatever deal is within their self interest.
The federal Government spends almost$150 billion a year on Medicare. Ifyou’re taking federal money, directly or indirectly, you’re going to play by the rules of the game." The Government expects the New Orleans court to make its decision by fall and believes the patient dumping law will survive even an unfavourable ruling. The Texas Medical Association says the outcome will "determine whether physicians are safely able to transfer seriously ill patients to facilities that are equipped to care for them without fear of having medical decisions reviewed and found to have violated federal law." J. B. Sibbison
Australia: Do informal
carers
suffer?
The Victorian Health Promotion Foundation is going to fund research on informal care-givers in Melbourne. This Foundation, an independent statutory authority, is the result of Victoria’s Tobacco Act (1987), which places a 5% levy on the wholesale price of tobacco products. The money, currently$A30 million per annum, and designated for general health promotion, research, and replacement of tobacco sponsorship for sports and the arts, is administered by the Foundation. The Act is being taken up by other States in Australia and by New Zealand, and places such as Canada and parts of the USA are examining it with keen interest. The$A1 -5 million grant for work on informal carers is one of the largest given to health promotion in Australia and goes to researchers from the Universities of Monash, Melbourne, and, offshore, Toronto. What is this all about? Families and other unpaid care-givers in the home are important sources of support for people of all ages with This has become severe and chronic disabilities.12 increasingly so with the reduction of all hospital beds and added attention being given to outpatient and community care. In effect, governments are passing the clinical load from trained hospital staff to untrained kith and kin at home. This move is a leap into the dark because, although governments will save on health-care dollars, there is no knowing, currently, of the bearing the charge will have upon families. These informal care-givers, unlike community workers, are unpaid, and they look after disabilities of all kinds. Who
are these people? Overall, most care-givers are middle-aged women although there is a sizeable group of elderly men looking after demented and frail wives. There is curiously little known about care-givers as to the nature,
hardship, or otherwise of their task. Do they suffer? This is difficult to say. Relatives complain infrequently and those who have been asked may well be a skewed sample. Furthermore, little is known about cultural diversification. The "set" in Western society is that caring is burdensome and this is perpetuated by the perception of those in health who deal with the more difficult cases. What about the research? Hitherto, much attention has been paid to the putative burden of care but generally the work has not been controlled. In other words, is looking after the disabled really a burden? To compound the problem, this kind of research suffers from lack of an underpinning theory. The Melbourne group has adopted a stress-and-coping conceptual framework to explore the relationship between major life roles or stressors and mental and physical wellbeing. The investigators argue that this framework may identify effective interventions, which might include group support, psychoeducation, respite care, domiciliary services, as well as changes in social policy. Notwithstanding, there have been few studies of efficacy, care
especially long term. Melbourne is taking
a lead in this field. The plan is to the extent and survey types of care-giving in the community and to assess the range of interventions designed to assist care-givers. A household survey will permit a contrast of care-givers with matched non-caregivers. Thereafter, there will be an evaluation of interventions for specific groups of care-givers. The results, it is hoped, will help families and other informal care-givers to look after disabled people at a reasonable cost to themselves. This may sound banal but represents important philosophical shifts. Health care used to be in the home and then, as a function of "progress", it moved to the hospital. It is now reverting to the home. Will it work? Since the population is ageing, the prevalence of some disabilities will increase, particularly those such as dementia. It should also be borne in mind that nowadays 60% or more of women work. Employed, middle-aged women may justifiably argue that looking after others is outside their
bailiwick, like it or not. Informal care-giver research
will enable us to learn whether the so-called burden of care is a shibboleth or not. The Australian research may decide that it is complicated and a function of diagnosis, age, relationships, culture, and whatever. Governments may not normally fund this kind of research, but they surely need the results.
M. R. Eastwood H. E. Herrman
B. S Singh 1.
Leven E, Sinclair I, Gorbach P. Families, services and confusion in old age. Aldershot: Avebury, 1989.
1989. 2. Grad J, Sainsbury P. The effects that patients have on their families in a community care and a control psychiatric service: a two year follow-up. Br J Psychiatry 1968; 114: 265-78.
Medicine and the Law Medical
confidentiality and expert evidence
A case in Canada, heard in 1990 and lately reported, and article in a UK law journal last month raise issues about medical confidentiality and the doctor as an expert witness. Medical confidentiality is not absolute, and a patient’s decision to bring an action in negligence waives the normal rules on confidentiality in respect of the defendant, and his an
of the US Navy, which from early post-war days has set the rates for many major research universities, Stanford’s indirect rate has been reduced from 70% to 55-5%. The change is expected to cut Stanford’s receipts from Washington by$26 million, equivalent to 10% of its current receipts from government research agencies. Private contributions to Stanford have declined sharply in tempo with the revelations, but, given the anaemic state of the economy and large successes in a fund-raising drive before the scandals, a connection is not necessarily present. However, a severe expression of dismay has been issued by Stanford’s leading financial benefactor, David Packard, co-founder of Hewlett-Packard, a billionaire who has given the university$70 million, along with indications of more to come. In a newspaper interview, Mr Packard assailed the university for its indirect-cost billings on items unrelated to research and ominously suggested he was rethinking his philanthropic intentions. Donald Kennedy, the president of Stanford, has survived in office so far. He initially sought to tough it out by asserting that Stanford was a victim rather than a beneficiary of the Government’s system for financing research. But after taking an awful beating in the press and from many members of his own faculty, he adopted a gentler stance. Telling an alumni group that he accepted full responsibility for Stanford’s difficulties, Dr Kennedy said, "I take some comfort in the lines of Ernest Hemingway: ’The world breaks everyone, and afterwards many are stronger at the broken places’ ". If Dr Kennedy does not last out the year at Stanford, many there will not be surprised. For Dr Baltimore, further trials lie ahead. He has retracted the disputed paper and apologised to the heroine of the case, Margot O’Toole. But Dr O’Toole charges that his "apology does not go to the heart of the matter", which she insists is his failure to acknowledge that, in 1986, he knew that his co-author, Thereza Imanishi-Kari, then at MIT, had fabricated data for the paper. The basis of her certainty, Dr O’Toole says, is that she was present when Dr Imanishi-Kari admitted to Dr Baltimore that she had not obtained the results reported in the paper. Nonetheless, he persisted in defending the paper and depicting inquiring Congressmen as enemies of science. The relationship between science and government will, of course, survive these ugly events, since the partners need each other and can find no alternatives. But serious damage has been done to habits of trust forged between them over many decades. Daniel S.
Greenberg
Round the World Germany: Consultants and abortior Observers of previous meetings of Deutsche Arztetag, the annual parliament of the now 285 074 German physicians, wondered how colleagues from the East would make their presence felt.
They did it with aplomb. A keynote speaker
from Magdeburg concluded: "We are not accustomed... to
practice with economic realities. Thus in a danger that economic yardsticks will be applied uncritically and interfere with the physicianpatient relationship". Reverberating through all the debates combine medical
the New States, there is
was
the
clash
between
the
advocates
of absolute
"westernisation" of East German medicine and those who wished to preserve some of the time-honoured institutions. Almost two days were spent on proposed new specialties and the upgrading of existing ones. The existence of different specialty boards in East and West presents a special difficulty. Much time was also spent in debating the length of postgraduate training for GPs. This is important since the sick-funds accept only physicians with at least 3 years’
specialty training in general medicine. One of the few issues be resolved was the re-establishment of the title Specialist physician (Facharzt fur ...), so we now have specialists in general medicine. The delicate discussion about quality assurance was postponed because of lack of time, but a controversy about
to
the role of physicians in legal abortions was highlighted by a speech from the new Minister of Health (a woman). After a long and politically coloured debate the physicians concluded that they could make a judgment only on medical reasons for termination of pregnancy-a verdict that was not to the liking of the Minister. One outcome of the general debate was a resolution to label all alcohol beverages with an alcohol-embryopathy warning; this will not go down well with the vintners.
Karl H. Kimbel
USA: Government rules
vs
clinical judgment
Officials of the Texas Medical Association have taken the US Government to court to protest against a 20 000 fine imposed on Michael L. Burditt, an obstetrician, after he refused to deliver an indigent, uninsured Hispanic woman’s baby. On May 2 they asked a federal appeals court in New Orleans to nullify the penalty on the ground that it is intrusion into a medical decision "by persons with no medical training". The US Department of Health and Human Services maintains that the penalty was imposed for violation of the "patient dumping" law, which requires private hospitals receiving Medicare funds to provide treatment to emergency patients even if they are uninsured and can’t pay. The objective is to prevent patient dumping-the transfer of indigent patients by private hospitals to public hospitals without treating them, thus shifting the cost to the taxpayers (Lancet, Jan 5, p 38). The events that precipitated the lawsuits started with the admission of Rosa Rivera to the emergency department of the privately owned DeTar Hospital in Victoria at about 4 pm on Dec 5, 1986, in an advanced stage of pregnancy and with a blood pressure of 210/130 mm Hg. Jean Herman, a nurse, examined her and found her to be in active labour. Dr Burditt, to whom Mrs Rivera was assigned, disagreed but said that her extremely high blood pressure was probably contributing to a growth-retarded infant requiring the services of a neonatal intensive-care unit. Declining to accept her as a patient, he had her transferred to the in Galveston, Texas, which has neonatal intensive-care facilities. Galveston is 170 miles from Victoria. At about 7.30 pm Mrs Rivera was delivered of a healthy baby boy in the ambulance taking her to Galveston. She made an excellent recovery. Both the Texas Medical Association and its parent organisation, the American Medical Association, defend Mr Burditt’s medical decisions, but the government lawyers disagree. "No reasonable physician", says their brief, "would have transferred her". A primary reason Dr Burditt distanced
tax-supported John Healy Hospital
1276
himself from Mrs Rivera, the government lawyers say, was his fear of a malpractice suit in the event of a calamity such as a stroke or even death. They also say that Dr Burditt signed a statement at that time, which he knew to be false, that the benefits of the transfer outweighed the risk to mother and fetus. Going beyond the Burditt case, attorneys for the Texas Medical Association contend that the patient dumping law itself is unconstitutional, since it requires physicians to provide free services to the poor. "Congress", said the Association’s brief, "has required physicians to shoulder a buden that the constitution requires should be borne by all". Michael J. Astrue, general counsel of the Department of Health and Human Services, demurs. "Set aside the fact that physicians are the highest paid people in the country other than professional athletes, averaging$155 000 a year", he says. "No one forces any physician to provide emergency services. They cut whatever deal is within their self interest.
The federal Government spends almost$150 billion a year on Medicare. Ifyou’re taking federal money, directly or indirectly, you’re going to play by the rules of the game." The Government expects the New Orleans court to make its decision by fall and believes the patient dumping law will survive even an unfavourable ruling. The Texas Medical Association says the outcome will "determine whether physicians are safely able to transfer seriously ill patients to facilities that are equipped to care for them without fear of having medical decisions reviewed and found to have violated federal law." J. B. Sibbison
Australia: Do informal
carers
suffer?
The Victorian Health Promotion Foundation is going to fund research on informal care-givers in Melbourne. This Foundation, an independent statutory authority, is the result of Victoria’s Tobacco Act (1987), which places a 5% levy on the wholesale price of tobacco products. The money, currently$A30 million per annum, and designated for general health promotion, research, and replacement of tobacco sponsorship for sports and the arts, is administered by the Foundation. The Act is being taken up by other States in Australia and by New Zealand, and places such as Canada and parts of the USA are examining it with keen interest. The$A1 -5 million grant for work on informal carers is one of the largest given to health promotion in Australia and goes to researchers from the Universities of Monash, Melbourne, and, offshore, Toronto. What is this all about? Families and other unpaid care-givers in the home are important sources of support for people of all ages with This has become severe and chronic disabilities.12 increasingly so with the reduction of all hospital beds and added attention being given to outpatient and community care. In effect, governments are passing the clinical load from trained hospital staff to untrained kith and kin at home. This move is a leap into the dark because, although governments will save on health-care dollars, there is no knowing, currently, of the bearing the charge will have upon families. These informal care-givers, unlike community workers, are unpaid, and they look after disabilities of all kinds. Who
are these people? Overall, most care-givers are middle-aged women although there is a sizeable group of elderly men looking after demented and frail wives. There is curiously little known about care-givers as to the nature,
hardship, or otherwise of their task. Do they suffer? This is difficult to say. Relatives complain infrequently and those who have been asked may well be a skewed sample. Furthermore, little is known about cultural diversification. The "set" in Western society is that caring is burdensome and this is perpetuated by the perception of those in health who deal with the more difficult cases. What about the research? Hitherto, much attention has been paid to the putative burden of care but generally the work has not been controlled. In other words, is looking after the disabled really a burden? To compound the problem, this kind of research suffers from lack of an underpinning theory. The Melbourne group has adopted a stress-and-coping conceptual framework to explore the relationship between major life roles or stressors and mental and physical wellbeing. The investigators argue that this framework may identify effective interventions, which might include group support, psychoeducation, respite care, domiciliary services, as well as changes in social policy. Notwithstanding, there have been few studies of efficacy, care
especially long term. Melbourne is taking
a lead in this field. The plan is to the extent and survey types of care-giving in the community and to assess the range of interventions designed to assist care-givers. A household survey will permit a contrast of care-givers with matched non-caregivers. Thereafter, there will be an evaluation of interventions for specific groups of care-givers. The results, it is hoped, will help families and other informal care-givers to look after disabled people at a reasonable cost to themselves. This may sound banal but represents important philosophical shifts. Health care used to be in the home and then, as a function of "progress", it moved to the hospital. It is now reverting to the home. Will it work? Since the population is ageing, the prevalence of some disabilities will increase, particularly those such as dementia. It should also be borne in mind that nowadays 60% or more of women work. Employed, middle-aged women may justifiably argue that looking after others is outside their
bailiwick, like it or not. Informal care-giver research
will enable us to learn whether the so-called burden of care is a shibboleth or not. The Australian research may decide that it is complicated and a function of diagnosis, age, relationships, culture, and whatever. Governments may not normally fund this kind of research, but they surely need the results.
M. R. Eastwood H. E. Herrman
B. S Singh 1.
Leven E, Sinclair I, Gorbach P. Families, services and confusion in old age. Aldershot: Avebury, 1989.
1989. 2. Grad J, Sainsbury P. The effects that patients have on their families in a community care and a control psychiatric service: a two year follow-up. Br J Psychiatry 1968; 114: 265-78.
Medicine and the Law Medical
confidentiality and expert evidence
A case in Canada, heard in 1990 and lately reported, and article in a UK law journal last month raise issues about medical confidentiality and the doctor as an expert witness. Medical confidentiality is not absolute, and a patient’s decision to bring an action in negligence waives the normal rules on confidentiality in respect of the defendant, and his an