HEALTH CARE CRISIS - The Search for Answers, Edited by Robert I Misbin, MD, Bruce Jennings, MA, David Orentlicher, MD, JD, and Marvin Dewar, MD, JD. University Publishing Group, Inc. Frederick, MD, 1995.

This volume is a collection of papers presented in Washington, DC, in response to a call for abstracts on the topic of health care reform. It was organized by the University of Florida with co-sponsorship by the Hastings Center, the AMA, and the American Association of Bioethics. This treatise has four sections starting with Medical Futility, Health Care Reform, Health Care Rationing, and ending with Lessons from other Cultures.

Section I, deals with well-publicized cases in which family members insisted that artificial life support be maintained indefinitely on patients who were permanently unconscious. The courts sided with the families and against the health providers who did not wish to be forced to provide futile treatment. Given the millions of Americans who lack basic health care, it is hard to understand why over $100,000 per year should be spent to maintain a patient who is permanently vegetative.

The issues are tied to considerable emotion. Rebecca D. Pentz, PhD, MD, discusses the surprisingly strong statement by the University of Texas MD Anderson Cancer Center concerning its Do-Not-Resuscitate policy. It stated: "Futile treatments need not be offered nor demands for futile treatments complied with." However, when a case demanding futile treatment arrived, the policy was "futile." It had no impact whatsoever. Pentz then discusses the "negotiation model." The physician can never unilaterally place the value of appropriateness above the value of honoring a patient's demands. With a little extrapolation, she continues, we are well on the way to viewing the physician as a cipher or as a "highly competent hired syringe." Professional judgment acquired from years of training and experience is at the core of the role of the physician. It is odd to strip physicians of their professional roles when we also ask them to participate in cost containment, an activity presumably involving even more difficult judgments than the judgment of whether a treatment is medically contraindicated.

In section II, John H. Fielder, PhD, has a chapter on Abusive Peer Review and Health Care Reform. Dr. Fielder discusses three cases of Peer Review abuse: Dr Timothy Patrick formerly of Astoria, Oregon, Dr Deane Hillsman, of Sacramento, and Dr William Reid of Oak Ridge, Tennessee. He states that these three cases illustrate failures of the peer review system in medicine, a quality control procedure, and its misuse by removing competent physicians for primarily financial rather than medical reasons. Dr Fielder cites examples in which estimates of peer review initiated for economic reasons may be as high as 70%. What we are seeing, he states, is a disturbing pattern of reliance on peer review to remove unwanted doctors, frequently for underlying financial reasons.

Dr Fielder feels hospital bylaws are fatally deficient in due process and fail to protect competent doctors who are falsely accused. It provides a convenient means for unscrupulous hospitals and physicians to remove doctors who are a threat to their interest. He states that it is difficult for physicians who have received unfair peer reviews to succeed in a lawsuit against the hospital because of the extensive legal shielding of the peer review process by courts and legislatures. Dr Fielder predicts that with the growth of managed care, economic pressures on physicians will increase and we can expect to see a corresponding growth in abusive peer review.

This glimpse at two of the twenty chapters in this volume reflects the timeliness of the entire volume. Every one of our organization's leaders needs to be conversant with the issues at the forefront of medicine. I understand that Dr Fielder is spending his entire year of Sabbatical leave researching Peer Review. If his research supports his initial concerns, we should not only read this volume, but his next volume as soon as it is available.