<p>Once loyal, the medical establishment is fuming over issues
ranging from the abortion gag rule to fetal research
</p>
<p>By Philip Elmer-DeWitt--Reported by Barbara Dolan/Chicago,
Melissa Ludtke/Boston and Dick Thompson/Washington
</p>
<p> Doctors tend to be pretty conservative people, professionally
and politically. Most counsel moderation, make good money
(average yearly income: about $160,000) and look with disfavor on
various schemes to nationalize health care. Not surprisingly,
they often vote Republican.
</p>
<p> But ask a doctor today how he or she feels about the
current Administration and you could easily get an earful. "I'm
frustrated," says Dr. Sherman Elias, director of the division
of reproductive genetics at the University of Tennessee. "We're
mad," says Dr. Carol Kurz, an obstetrician-gynecologist at a Los
Angeles hospital. "The Bush Administration has overstepped its
bounds," says Dr. Allan Rosenfield, dean of the School of Public
Health at Columbia University. "And medicine is strongly and
unanimously opposed to it."
</p>
<p> What's ailing these doctors? In three words: the gag rule.
Two months ago, the Supreme Court upheld a Reagan
Administration ban on abortion counseling at federally funded
clinics and thus permitted the type of government meddling that
makes doctors most uncomfortable: restricting, based on
political rather than professional considerations, what they can
say to patients. Ever since, the medical establishment has been
running a high fever, dashing off angry letters, signing
petitions and marching in street demonstrations like any other
disaffected interest group. "This is a bald-faced issue for
doctors," says Dr. Marjorie Braude of the American Medical
Women's Association. "It's asking us to commit malpractice."
</p>
<p> This is not the first time the Bush Administration has run
afoul of doctors. Two years ago, Louis Sullivan, the Secretary
of Health and Human Services, angered medical researchers by
extending a Reagan-era ban on federal funding for experiments
involving fetal-tissue transplants, an important field that
shows promise for treating many human disorders, including
diabetes and Parkinson's disease. Ignoring the recommendations
of a scientific panel, Sullivan argued that encouraging
fetal-tissue research would lead to more abortions. A measure
that would overturn the ban passed the House last week by nearly
enough votes to override a Presidential veto. A similar
provision is expected to be introduced in the Senate in August.
</p>
<p> An issue even closer to most doctor's hearts--and
pocketbooks--is the Medicare fee schedule proposed in late
May. The Administration was directed by Congress to overhaul the
fees physicians are paid to treat the 34 million elderly and
disabled patients eligible for Medicare. The idea was to shift
some payments from high-paid specialists to lower-paid general
practitioners. But the new Administration rules went even
further, cutting future Medicare payments by $3 billion and
lowering reimbursements to some groups--notably internists--that Congress had intended to help. To make matters worse, the
government issued new rules last week that will sharply restrict
the circumstances under which doctors may send Medicare and
Medicaid patients to clinics and out-patient services in which
they have a financial stake. These investments, which have
yielded rich dividends for physicians during the past decade,
will now have to be restructured or withdrawn altogether.
</p>
<p> But it was the gag rule that really got doctors steamed.
The Supreme Court case centered on the Public Health Service's
Title X program, created during the Nixon Administration to
provide family-planning services to low-income women. The
original act stated explicitly that federal funds were not to
be used to finance abortions, but in 1981 the guidelines were
changed to make it clear that pregnant women should be advised
of their full menu of medical options, including prenatal care,
foster care, adoption and abortion.
</p>
<p> Then in 1988 the Reagan Administration revised the rules:
doctors and nurses were prohibited not only from counseling on
abortion but even from pointing patients to Yellow Pages
listings of clinics that would offer such advice. If a woman
asked about terminating her pregnancy, doctors were instructed
to recite these words: "The project does not consider abortion
an appropriate method of family planning and therefore does not
counsel or refer for abortion." The directive did not take
effect immediately because it was challenged in several state
courts, but the Supreme Court cleared away those obstacles when
it declared the gag rule constitutional on May 23.
</p>
<p> The next day, the American College of Obstetricians and
Gynecologists issued a bulletin to 600 key members, headlined
ALERT--IMMEDIATE ACTION NEEDED and calling for a lobbying
campaign in Congress. By mid-June the group had pulled together
a coalition of 21 national organizations representing 425,000
health-care professionals. Coalition activists hand delivered
letters to every member of Congress, cornered the leadership of
both Houses and pressed for a meeting with the President. Even
the conservative American Medical Association--one of the most
powerful lobbies in Washington--raised its voice in protest.
"We are convinced," said A.M.A. executive vice president James
Todd, "that political medicine is harmful to the health of all
Americans."
</p>
<p> For doctors, already beset by nit-picking insurance
companies, shrinking Medicaid payments and malpractice lawyers,
the gag rule seemed the final intrusion--one that was doubly
galling because it came from an Administration many had
supported. Says Alan Altman, a gynecologist in Brookline, Mass.:
"((The government)) bothers me in the pocketbook, it bothers me
in the delivery room, but it has never before bothered me in the
consultation room." Dr. Laura Sirott, a Pasadena, Calif.,
obstetrician-gynecologist who describes herself as a past
supporter of Bush, complains that the gag rule violates a
patient's right to be fully informed. "This is absurd. I don't
think abortion should be a political issue."
</p>
<p> There are practical considerations as well. Although the
gag rule includes an exception for life-threatening pregnancies--in which case women can be referred for ``emergency care"--it is not at all clear what doctors are supposed to tell women
with diabetes, congenital heart disease or multiple sclerosis.
These illnesses could make pregnancy risky, but are not
necessarily life threatening. If a woman with AIDS or Tay-Sachs
disease is in danger of bearing an abnormal child, a doctor who
did not give her that information and describe all her options
could be liable for malpractice or "wrongful life." In June a
Massachusetts woman infected with German measles while pregnant
was awarded $1.3 million because her doctor failed to test
adequately for the disease and then did not give her information
about either her child's risk of serious malformation or her
option to terminate the pregnancy.
</p>
<p> President Bush seems to be hearing the doctors'
complaints. After initially threatening to slam a fast veto on
any attempt to reverse the gag rule, the Administration has
started backpedaling. Faced with reports from Bush's own
pollsters that his abortion policies were starting to cost him
support among Republican and independent women voters, the
Administration indicated late last month that it was rethinking
its position on the gag rule.
</p>
<p> Would a victory for the doctors signal a new era of
medical activism? Probably not. It is possible that the
coalition whipped up to defeat the gag rule could strengthen
efforts to revise the Medicare schedule or liberalize
fetal-tissue research, but neither of those issues generates the
same kind of deep emotions. Most doctors would prefer to leave
politics to the politicians, if they would just leave medical
