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- Anthony N. DeMaria, MD, Editor-in-Chief, Journal of the American College of Cardiology* ()
- ↵*Address correspondence to:
Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 630, San Diego, California 92112
I often wonder how many people, if any, read the Editor's Page. Past surveys have indicated that it is one of the lesser-read sections in the Journal, although even that may be an overestimation. Therefore, it is always heartening to receive some correspondence on any of these essays. While I do, of course, prefer laudatory comments, and do receive some from time to time, critical comments are also of value. Needless to say, I have received some of those as well.
Over the course of the last year or so a number of Editor's Pages have provoked e-mails containing criticism. Naturally, in some cases I felt that the writers had misunderstood my intention. In other cases the points made were well taken. In any event, now that I have taken delivery of several such letters I thought I would dedicate a Page to replies.
The first Editor's Page to incite a spirited rebuttal dealt with euthanasia. This most certainly was not unanticipated, as the article was entitled “Euthanasia: Great Heat, Little Light” (1), and included the statement that the topic was exceptionally controversial and capable of stimulating passionate debate. A particularly thoughtful letter came from John and Staci Mandrola of Louisville. They emphasized that palliative care was a process that coordinates care across settings; communicates information about condition, prognosis, and treatment options; and assists patients and families with the dying process. They objected to the concept that euthanasia, physician-assisted suicide, or palliative sedation therapy had a role in palliative care, and contended that symptom relief and supportive care should rarely require inducing unconsciousness. They took me to task for suggesting that intravenous fluids and feeding tubes might be considered ordinary therapy.
In reply, I would point out that I tried to carefully delineate the rationale advanced by both those who favored more active participation of physicians in eliminating a prolonged, physically, and emotionally painful course to death and those who did not. I indicated my own ambivalence to any physician-assisted death, while stating why it was understandable that others might feel differently. In fact, it seems that the only significant difference between the Mandrolas and me relates to palliative sedation, which I find to be a more acceptable concept than it appears they do. However, I do clearly believe that the role of the physician in the difficult end-of-life decisions, which often arise in patients with terminal disease who have been subjected to prolonged physical and emotional suffering, is not black and white. It is my belief that there are considerable gray areas, and that the medical community continues to grapple with many of these issues. Therefore, I must disagree with their contention that euthanasia, physician-assisted suicide, and palliative sedation therapy do not belong in a discussion of palliative care. It is only through continued dialogue that a consensus can be reached on the optimal therapy of these very unfortunate patients.
Several letters were received regarding the Editor's Page entitled “Radicalized Physicians” (2). That essay addressed the special horror associated with the taking of lives by physicians, a group who had dedicated their careers to preserving life and relieving suffering. This Page was prompted by acts of terrorism occurring over a relatively brief period of time by three highly-visible physicians. Unfortunately, all three were Muslims, and thus the Page seems to equate radical physicians with radical Islam. This, of course, is not correct; many examples exist of radicalized physicians who were not Muslim. There is evidence that Josef Mengele of Germany, Ishii Shiro of Japan, and Radovan Karadzic of Serbia all participated in the killing of innocent civilians despite their medical degrees. Che Guevara, who was mentioned in the Page, exchanged medical practice for war. So, with my apologies to the Muslim community, I acknowledge that this paper may have conveyed an inappropriate emphasis upon radicalized Muslim physicians.
The greatest number of critical emails was provoked by the Editor's Page entitled “What Do You Think About Health Care Reform?” (3). I clearly hit a nerve with that article. The essay was written during the debate about the healthcare reform legislation that would ultimately be the Patient Protection and Affordable Care Act, now often referred to as ACA. I was impressed that my colleagues at UCSD seemed strangely unengaged, and almost disinterested, in the topic. I myself did not feel very knowledgeable, nor did I have any great desire to delve into the specific and often arcane details of the legislation that was being proposed. I argued that, given all of the uncertainty imposed by the economic recession, we physicians were pretty fortunate; we would always have the enormously satisfying job of taking care of those who became ill. All we really needed was adequate access for patients, and for us to have all the necessary tools and support (implying reimbursement) to deliver the best care possible. I actually thought that it was praiseworthy that my colleagues and I were more concerned about how to provide the optimal care than how it would be financed.
A number of sincere and thoughtful individuals wrote decrying the lack of attention to and active participation in the healthcare reform debate that I had described. They argued that some reform measures under consideration could change medical practice to the detriment of both patients and physicians, and that all physicians owed it to their profession and their patients to be involved and to argue for the system that we deemed best. They pointed out that we in medicine are in the best position to judge what will be most beneficial or harmful to achieving the optimal health for our country. Some suggested that the academic life I lead had become too insulated from the real world to appreciate the effects that healthcare legislation was already having upon the practice of medicine, or the potential effects that future changes could impose. I was particularly taken to task since, as Editor-in-Chief of JACC and a visible representative of the profession, I should be a role model for physician participation in the healthcare reform debate.
There are valid points on both sides of this issue, and I suspect that I may have slightly overstated my position. One thing is certain, it is clear that the academic community is not isolated from healthcare legislation, and that such policy changes fully affect both academic medical centers and faculty. So, any indifference that my colleagues and I seem to have was not related to being immune from the impact of policy modifications. I am, of course, aware of the legislation that was proposed and enacted, and of the potential consequences that it could have upon the practice of medicine. However, many of the specifics were and continue to be challenging to understand, and their ultimate effects appear difficult to predict. In addition, there is always the inertia inherent in the consideration of whether a single individual can do anything meaningful to influence the process. Finally, I really do have a sense that society will demand and we will strive to provide the highest quality medical care regardless of reimbursement, and that the satisfaction provided by grateful patients will overshadow any monetary reward we derive from practice. Accordingly, while I do strive to be informed about legislation and certainly recognize its importance, and I endeavor to form opinions and to express them whenever the opportunity arises, my primary attention is to identify and practice the highest quality of medicine. I will continue to trust those who have a genuine interest in these matters and have taken the time to master the issues to represent me, and will support them as vigorously as possible. In doing so, I feel comfortable that I will have discharged my responsibility to my profession and my patients.
I certainly do not mean to imply that these are the only critical comments that I have received in response to my Editor's Pages. However, these were the greatest in number and passion. Feedback is beneficial, and I am grateful for all those who take the time to write and express their opinions. Thought does go into these Pages, so I appreciate the knowledge that people are reading them, whether they disagree or (hopefully) agree.
- American College of Cardiology Foundation