LETTERS to the EDITOR

Fee-for-service

I read Dr. Fleischman's "Our Generation" article "We must return to fee-for-service" in Contemporary Ob/Gyn [2004;49(June):32] with great enthusiasm. He has said things that my husband and I have often talked about (we are both physicians) over the past few years. I whole-heartedly agree with everything said. Physicians are horrendously underpaid, our overhead expenses are through the roof, and lawsuits are out of hand. Why haven't doctors put their foot down and refused horrific payments and bundling? In Pennsylvania, a TAH/BSO, culdoplasty, Burch, abdominal sacral colpopexy and paravaginal repair—a 6-hour surgery—reimburses about $850.

Lawyers, greedy patients, and cheap insurance companies aside, perhaps the biggest obstacle is that doctors do not stick together. One of the reasons we can't negotiate higher fees is that there is always another doctor down the street who will do "X" for $50 less. There is always a doctor, especially when paid enough, who will testify against another doctor—this is wrong and some make a lot of money doing this. Doctors need to unite. Many of our physician-friends in Manhattan do not accept any insurance and they are able to repay their medical school loans. Everything is paid for via fee-for-service or on an out-of-network basis. As Dr. Fleischman pointed out, if only one group does it, patients will just go elsewhere. If doctors in Connecticut united and did this, we would probably be better off.

I am a third-year urogynecology fellow at Magee-Womens Hospital and will be moving to Connecticut in September to join another urogynecologist in practice. How can we facilitate change in Connecticut?

Lara J. Burrows, MD
Pittsburgh, Pa.

Author's reply:

As far as "uniting," there are significant barriers (i.e., the FTC) to contend with. However, we are seeing the formation of larger groups in Connecticut. The largest, Women's Health Connecticut, comprises about 140 ob/gyns.

Consider getting involved with the CT section of ACOG. We meet fairly regularly and could use some new energy.

I am confident that the market will force those frightened to change to move toward fee-for-service.

Steven J. Fleischman, MD
New Haven, Conn.

The FDA and Plan B

The July 2004 issue of Contemporary OB/GYN contains a strident editorial by Drs. Lockwood and Greene ["Playing politics with women's health: The FDA and Plan B," pp. 11-15] castigating the FDA for its "Not Approvable" letter in response to Barr Pharmaceuticals' request for OTC status for its "emergency contraceptive," Plan B. In bold red letters, the authors ask "Whether someone is pro-life or pro-choice, how can he or she oppose a measure that would reduce the need for abortions?"

Sadly, such a statement demonstrates the authors' appalling ignorance of the scientific basis for a scientist's or medical doctor's moral and ethical reservations about the "morning after pill." Medical science has acknowledged for decades that the development of a new human being begins when 23 chromosomes from the mother unite with 23 from the father. The US Government and the medical establishment later saw fit to define "pregnancy" as beginning with implantation, not fertilization. This "redefinition" of when a pregnancy begins as opposed to when a new life actually begins then conveniently allows the "EC" to be labeled a "contraceptive" since two of its acknowledged mechanisms of action are prevention of ovulation if taken before ovulation has occurred, or prevention of implantation, if ovulation, but not implantation, has already occurred.

If a woman chooses to place value on a newly created human being from the moment of fertilization and does not limit the sanctity of that new life to only its postimplantation existence, then the "morning after pill" to her can sometimes work as a true contraceptive (when it prevents ovulation and therefore also fertilization) but can also work as an abortifacient (when it prevents implantation of a new human being in development). To say it "reduces the need for abortion" is therefore at best misleading and at worst deceptive to anyone who values a new human life at any stage of its development after fertilization.

If the authors could at least acknowledge that there are millions of women—and men—who view the sacredness of life in this way, they would understand the absurdity of their red-letter statement, which says to them, "reduce the need for abortions by killing this little new life before it implants, which is not really an abortion by our definition of when a pregnancy begins." These men and women reject the notion that it is a "kinder and gentler" abortion just because it is done earlier in the developmental phase than a traditional surgical or medical abortion. They refuse to acknowledge that for some people, there are absolute truths and one of them is the sanctity of life no matter how small or helpless it might be.

Finally, the authors state they find it "offensive" that "religious ideology and partisan politics have been introduced into the decision-making process regarding a public health issue." They say this is an intrusion of religious ideology into "what should be a scientific and empirical examination of the evidence by an objective, secular, and unbiased expert government advisory committee." History saw an ugly example of what an "objective, secular, and unbiased" government could do in Nazi Germany when human beings were dehumanized and mentally "defective" and handicapped people were rounded up and killed to ease their "burden" on society in the name of eugenics. Far-fetched? What about our own national eugenics policy of rounding up as many defective and handicapped fetuses as we can with amniocentesis and killing them with "therapeutic" abortions? Where do a thoughtful and moral people draw the line? And if they don't draw it somewhere, are we really willing to let a secular government advisory committee draw it for us?

Alan G. Moore, MD
The Woodlands, Tex.

Dr. Lockwood's and Dr. Greene's reply:

We thank Dr. Moore for his passionate commentary on our editorial concerning the decision by the acting director of the FDA to overrule his advisory panel and staff by declaring "non-approvable" the manufacturer's proposal to make "Plan B" available over-the-counter. First, his implication that we, and our colleagues on the FDA panel, were unaware of the contragestive effects of this agent is inaccurate. Indeed, at the FDA hearing we and others challenged the company's assertion that Plan B exerted no contragestive effects and urged appropriate labeling of the drug so that those with a fundamental belief that all life is sacred and begins at conception could make informed decisions about the product.

Dr. Moore asserts that "Medical science has acknowledged for decades that the development of a new human being begins when 23 chromosomes from the mother unite with 23 from the father." We would contend, however, that when "life" begins is more a religious than a scientific argument. As Dr. Sandel has argued, a single-cell zygote has the potential to become a person, but it is not a person.¹ When a two-cell embryo in the IVF laboratory stops developing, we do not sign a death certificate. We also do not record that event as a spontaneous abortion in that woman's obstetrical history. Indeed, the early human blastocyst's inner cell mass remains totipotential (any cell can form an individual) until the formation of a bilaminar embryonic disc in the second week post-conception. Thus, the American Fertility Society and Australian and United Kingdom government commissions and committees have defined a "pre-embryonic"stage of human development during which research is permissible and such pre-embryos are not maintained after this time limit.² To put this simply, a multi-cell embryo can be frozen and thawed and grow up to be a 3-year-old child. A 1-month-old fetus cannot. If all of the multi-cell embryos that stop developing every day in IVF laboratories all over this country were considered "deaths" of "people," then we would have a major public health emergency. But that is not the case. Most Americans recognize that the idea of when "life" begins is much more nuanced than Dr. Moore suggests. Although a human zygote is accorded a degree of respect that a mouse zygote is not, it is not yet a "person" either. We suggest that, as with the multi-cell embryo in the IVF laboratory, such an early embryo cannot be considered to have been "aborted" if it did not implant.

The religious arguments about the origins of life are fascinating. Different religions hold different positions as to when life begins. For Orthodox Jews, abortion is acceptable before 40 days post-conception. For Roman Catholics, the thesis that the soul enters the body at conception is a relatively recent concept. It arose through the work of French theologians in the early 19th century who were building a case that Mary was born without original sin. These individuals reflected the growing "Marianist movement" and their arguments culminated in promulgation of the dogma of the Immaculate Conception of Mary in 1854 by Pope Pius IX (Pio Nono). In the United States, following the tradition of British Common law, abortion was legal until the early- to mid-19th century. Catholic physicians such as Dr. Gunning Bedford, one of the founders of the NYU School of Medicine, were instrumental in agitating for anti-abortion laws. Indeed, they were often opposed by mainstream Protestants, in part for nativist reasons and in part for progressive ones. Thus, the concept that life begins at conception is a very modern one, not universally held, and based on subjective criteria.

While we appreciate the depth of his feelings, we do take exception to Dr. Moore's equating with Nazi ideology our contention that "scientific and empirical examination of the evidence by an objective, secular, and unbiased expert government advisory committee" is the best way to assess the safety and efficacy of drugs. We could just as easily equate admission of religious arguments into federal advisory panel deliberations with the first step in a theocracy not much different than the one espoused by Islamic fundamentalists. That is not to say that religion has no place in society. Our Founders sought freedom of religion not freedom from religion, but they were dead set against government support or control of religion and vice versa. James Madison argued that separation of church from state was a practical necessity because³:

(1) "Who does not see that the same authority which can establish Christianity, in exclusion of all other religions, may establish with the same ease any particular sect of Christians, in exclusion of all other sects?"

(2) "The free exercise of religion implies the right to believe in no religion at all, so even the most permissive tax to support religion might violate some conscience."

(3) "Civil magistrates can properly neither judge religious truth nor subordinate religion to public purposes."

With all due respect, Dr. Moore, we think our Constitution is a far better defense than religious orthodoxy against Nazi ideology.

Charles J. Lockwood, MD
New Haven, Conn.
Michael F. Greene, MD
Boston, Mass.

REFERENCES

1. Sandel MJ. Embryo ethics—the moral logic of stem-cell research. N Engl J Med. 2004;351: 207-209.

2. Ethics in Obstetrics and Gynecology. The American College of Obstetricians and Gynecologists, 2002, page 69.

3. Ketcham RL. James Madison: A Biography. Charlottesville, Va: University Press of Virginia; 1990:164.

 

Letters to the Editor. Contemporary Ob/Gyn Aug. 1, 2004;49:25-28.