Dear Al,

I should have preferred to answer you directly,
but I cannot find your e-mail address on your posting.
Since the message has to be public, I shall take
the opportunity to clarify my positions on issues previously
addressed.  Please feel free to make any use of my postings to
the Health Care Reform mailing list, now or in the future,
that you see fit. I ask only that any quotations out of 
context not be attributed to me.

In order to avoid misunderstanding, I should like to say
that I do not consider myself a defender of the status quo
in the delivery of medical services. Nor shall I conceal
my disapproval of our government for its barbaric indifference
to the drowning at sea of refugees to our shores, its
maintenance of concentration camps for refugees in Cuba
and Panama, and its abysmal insensitivity and indifference
to human suffering in our prisons and in our cities. 
How ironic, that just at Christmastime we should want to
deprive unwed mothers of their welfare checks and take
their children from them to be put into orphanages.
It would be incorrect to compare this government with the
one under which I lived from 1933 to 1939; but it is certainly
true that the contemporary American public is just as obtuse
to the human tragedies that its government creates as was the
public which "did not know" about the existence of Buchenwald
or Auschwitz or Dachau. 

I have indulged in this brief excursion into political morality
to remind us that health care reform is far from our most
pressing political challenge. Indeed the very urgency which
we attribute to our concerns may be a sign that we ourselves
are afflicted by the disorder of common sense to which we presume
to design remedies.  Perhaps also we are in error as physicians,
albeit self-appointed, to the body politic, in presuming to possess
the cure to all societal ills, as we should appear charlatans,
at least in each others' eyes, if we presumed to possess the cure
to all ailments of the human body. I see a close analogy between our
duty to acknowledge disease and death as limitations of individual
existence, and a possible duty to accept political ills
which we cannot allay as limitations of our societal existence.
Such modesty, I believe, is eminently apposite to our debate
about health care reform.

There is current in much of the contemporary Health Care Reform
debate a tacit assumption, which, if I infer correctly, also
informs Sheldon Jolson's criticism of me, the assumption, namely
that medical services are defined mechanical transactions which
lend themselves to inventory and accounting. This assumption
is false. It is the expression of a crude economic positivism
which is persuasive only to individuals whose emotions are
immature or dystrophic. It is an assumption which, when put
into practice, makes it impossible for serious and sensitive
individuals to practice medicine, and in the crisis situations
is sometimes catastrophic for the patient's well-being.

It is true that much medical activity can be construed to appear
mechanical.  But such appearance is sustainable only in the
trivial case, when the patient is healthy. For a patient who is
ill or who fears for his life, the taking of the history already
is more than the collection of data. It is a dialogue which become
the foundation of mutual understanding and respect between
the patient and the physician, a foundation which is often
far more important than the facts elicited.
Each step of the subsequent examination contributes to that
inapparent bond between the patient and his physician which
is conventionally referred to as the doctor-patient relationship,
but for which our technically and commercially oriented language
has no descriptors. It is the bond between human beings who live
and work in close proximity, be it within the family or elsewhere,
who have learned to rely upon and to trust one another.
Such relationships are thorns in the flesh of insurance executives
because they interfere with the economic rationalization of medical
care. To them the physicians they hire are but names on a roster,
interchangeable modules that they manipulate to suit their
economic strategies. It is necessary to recognize that initially
a substantial proportion of patients also wish to be nothing more
than consumers, purchasing the most convenient services at the
lowest price.  That works so long as they are well or feel unthreatened
by their illnesses. But as soon as they become frightened
by the prospects of pain, disability or death, they grope
for a more substantial bond to their physician, and it is at
this point that the insurance company's betrayal of their
trust becomes obvious.

A number of contributors to the List have inquired about
the wisdom of physician's forming a labor union with a view
to going on strike for their rights. I do not believe that
such a course of action is feasible. Those of us who are fortunate
enough to have private patients will not abandon them. Those of
us who are employed and prohibited from having private patients
would be targets of reprisals by their employers if they went
on strike. A strike, therefore, would probably not be successful;
and if it were, it would likely be counter-productive in that
it would demonstrate to our patients how many of the services
they demand of us, even under "managed care" plans, are superfluous
and dispensable.
 
A final word about the logic of litigation which I raised
in my original reply to "Who will take care of my dogs?"