The Doctors Take On Bush

By Philip Elmer-DeWitt.

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.

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."

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."

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.

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.

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.

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.

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."

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."

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.

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.

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 decisions to physicians and their patients.

With reporting by Barbara Dolan/Chicago, Melissa Ludtke/Boston and Dick Thompson/Washington