reorganization and in the important choice of the physician who will lead the program. I am convinced that we need a national program; I am equally sure that it must be a program driven by medical concerns to meet the requirements of medical practice today. The Canadian blood program is funded by the citizens of this country and must be responsible to them. It should not be mired in bureaucracy and administrative politics. Clearly now is the time for change. Let us hope that the right changes will be made this time. Gail Rock, PhD, MD 270 Sandridge Rd. Ottawa, Ont.
Dr. Morgan and Ms. Cohen point out clearly that the Canadian blood supply system is one of the safest and most efficient in the world but that the rapid advances in transfusion medicine have produced a situation that calls for a radical change in outlook. As a former medical director of the Calgary Centre of the CRCS Blood Transfusion Service and a successor of Dr. Andrew Kaegi I know that the bureaucratic maze that administers the blood transfusion system in Canada urgently needs reorganization. A tremendous contribution could be made by the medical directors of the 17 transfusion centres across Canada, but at present their views are not allowed the weight they deserve. It is a matter of great personal regret that I am no longer privileged to attend their meetings. Canada can justifiably be proud of the level of expertise in transfusion medicine possessed among them. They all have many years' experience in the practical management of transfusion services, and many of them are internationally recognized as experts. Unfortunately, as Morgan and Cohen point out, the medical
directors' views cannot be made known or acted upon because of the top-heavy committees through which decision-making must slowly wend its way under the present system. If a council of medical directors, under experienced chairmanship, were to report directly to the Canadian Blood Committee an enormous number of difficulties would be removed. The complexity of transfusion medicine today demands some such dramatic initiative. The CRCS still has great prestige among the public and should certainly continue to be involved in such areas as donor recruitment, but it cannot keep up with the rapid technologic advances. A reorganization, possibly along the Dutch lines, whereby the CRCS maintained its involvement with donor recruitment but the provision of blood transfusion services were part of the national effort in health care delivery would enable us to meet the increasing demands upon the service while maintaining the historical connection with the CRCS. We have a blood transfusion service in Canada that has served us well in the past and could, with appropriate reorganization, continue to serve us well in the future. Those of us who now work in the field of transfusion medicine outside the CRCS recognize that reform is necessary and hope that Morgan and Cohen's article will stimulate productive debate on this vital issue. Jeremy W. Culver-James, BM, BCh, FRCPC Division of Hematology Department of Laboratory Medicine University of Alberta Hospitals Edmonton, Alta.
Because it appeared to be impossible to get a decision from the CRCS to establish an autologous blood transfusion program for children, we developed at the Alberta Children's Hospital a process for the recruitment of patients, phlebotomy and storage of blood independent of the CRCS donor program. In response to the question "Is the Red Cross capable of meeting the administrative standard required . . .?" we suggest that there is no agreement on the administrative standard. If the standard is to meet the lowest common denominator of phlebotomy, use time-honoured tests and provide blood products at times of regional or national crisis, then the CRCS is providing an effective service. If the standard is to introduce and maintain progressive forms of phlebotomy and blood product management, then we should accept Dr. Raymond Guevin's opinion that "decisionmaking is secondary to preserving the organizational structure." The CRCS is not able to adapt to rapid change. The decisionmaking structure will not permit the introduction of innovative programs. Perhaps expectations of the CRCS system are unrealistic and we should be looking to other organizations for introduction and assessment of new programs. Gerald V. Goresky, MD, FRCPC Director Stuart G. Neil, MB, ChB, FRCPC Assistant director Department of Anaesthesia Alberta Children's Hospital Calgary, Alta.
As physicians responsible for an Bill C-43 and the CMA autologous blood transfusion program for children we sympathize A s one of his last acts of business, outgoing CMA with Dr. Gail Rock's frustration president Dr. Marcien autoloin attempting to introduce wrote a letter Aug. 1, Fournier gous transfusion and directed do1990, to Minister of Justice Kim nation. CAN MED ASSOC J 1991; 144 (3)
275
Campbell, exhorting her to withdraw Bill C-43, an Act Respecting Abortion. I take exception to this. Setting aside the relative merits or flaws of the bill, I am disappointed that Fournier saw fit to use the word "extremist" to describe citizens who choose to defend unborn human beings. He used this term three times in a seven-paragraph letter. Moreover, as head of the CMA Fournier was particularly unsuited to tell the justice minister anything about the bill, since he headed a delegation that refused to appear, as requested, to give information before the AllParty Committee on Bill C-43 on Mar. 27, 1990. This request to appear a second time undoubtedly was the result of the CMA delegation's disappointing first appearance, on Feb. 6, when its ill-considered and unreferenced brief was read from start to finish, which left insufficient time for the committee to even scratch the surface of its list of questions. Finally, Fournier is in error when he closes his letter by claiming to represent "our 46,000 physician-members and the patients we serve" on the question of abortion. How would he know? The CMA has not surveyed its members since 1982. CMA executives dismissed the 1989 Canadian Physicians for Life (CPL) survey results, yet they have haughtily ignored requests to do their own new poll, unless they consider their survey of 800 abortionists to be representative. Is it possible that the CMA hierarchy is afraid of the results it may get, since its 1982 poll did not give majority support for unrestricted access to abortion? By opposing such a weak abortion law as Bill C-43 Fournier rejects even the faintest legal restraint on abortion in Canada. Whatever his personal views on the subject, he does not (and, as president, did not) have the au276
CAN MED ASSOC J
1991; 144 (3)
thority to claim to represent Canadian physicians in this matter. Paul J. Ranalli, MD 403-2115 Finch Ave. W Downsview, Ont.
[The CMA responds.] The term "extremist" was used in Dr. Fournier's letter to describe physicians and nonphysicians at the extreme ends of the opinion spectrum on this issue. It was not used in any pejorative sense. Fournier, serving as the CMA's principal spokesman, enunciated policy and positions approved by the association's governing bodies: the General Council and the Board of Directors. He was serving in the same capacity as the leader of the CMA delegation that appeared before the House of Commons Legislative Review Committee when it was reviewing Bill C-43. The opinions expressed by Fournier in the letter to Kim Campbell before the committee and the mass media were those of the association and did not necessarily reflect his personal views. The CMA declined an invitation to appear before the committee a second time because it had nothing more to say. A CMA request that any new questions be sent to it yielded no new policy areas but, rather, technical questions that could best be answered by technical experts. The CMA brief was read to the committee to ensure that it was on the record, to meet bilingualism requirements and to ensure that members of the committee (who, experience has shown, do not always read briefs in advance of the meeting) were exposed to overall CMA policy and positions on the subject. The committee hearing was not disappointing. Originally scheduled for 1 hour by the committee it lasted about 13/4 hours minus 15 minutes for a House of
Commons vote. There were two complete rounds of questions for committee members plus supplementary questions. There was no apparent sign of unasked questions when the chairman adjourned the meeting. The CMA offered to and did respond to members of Parliament's requests for more information or answers by mail and telephone subsequent to the meeting. No subject or CMA brief has been subjected to as extensive a review during the past 25 years. The policy and positions received overwhelming support from General Council and the Board of Directors before and after the policy had been approved. The CMA policy is not established by membership referendum. We remind readers that the CMA helped the CPL to conduct its survey by providing address labels according to its needs. The CMA has consistently supported the right of the CPL, other organizations and individual physicians to voice their views on this subject. The only negative comment or criticism voiced by the CMA on the CPL survey was that it was not conducted on a scientifically valid, random-sample basis. Therefore, it was prone to bias and distorted response rates. For the same reason, the CMA has consistently refused to release any data from its review of the opinions of the 800 "abortionists" referred to by Dr. Ranalli. The CMA's information collecting was not a scientifically valid survey. It was done only to support the CMA's opinion that a sizeable number of physicians who performed abortions would discontinue doing so if Bill C-43 was passed into law; as Fournier's letter stated, "Bill C-43 may provide legal entitlement to abortion but it will do so at the expense of access to the service . . ." Experience has proven the CMA's opinion to be correct. The CMA's policy does not
Dr. Morgan and Ms. Cohen point out clearly that the Canadian blood supply system is one of the safest and most efficient in the world but that the rapid advances in transfusion medicine have produced a situation that calls for a radical change in outlook. As a former medical director of the Calgary Centre of the CRCS Blood Transfusion Service and a successor of Dr. Andrew Kaegi I know that the bureaucratic maze that administers the blood transfusion system in Canada urgently needs reorganization. A tremendous contribution could be made by the medical directors of the 17 transfusion centres across Canada, but at present their views are not allowed the weight they deserve. It is a matter of great personal regret that I am no longer privileged to attend their meetings. Canada can justifiably be proud of the level of expertise in transfusion medicine possessed among them. They all have many years' experience in the practical management of transfusion services, and many of them are internationally recognized as experts. Unfortunately, as Morgan and Cohen point out, the medical
directors' views cannot be made known or acted upon because of the top-heavy committees through which decision-making must slowly wend its way under the present system. If a council of medical directors, under experienced chairmanship, were to report directly to the Canadian Blood Committee an enormous number of difficulties would be removed. The complexity of transfusion medicine today demands some such dramatic initiative. The CRCS still has great prestige among the public and should certainly continue to be involved in such areas as donor recruitment, but it cannot keep up with the rapid technologic advances. A reorganization, possibly along the Dutch lines, whereby the CRCS maintained its involvement with donor recruitment but the provision of blood transfusion services were part of the national effort in health care delivery would enable us to meet the increasing demands upon the service while maintaining the historical connection with the CRCS. We have a blood transfusion service in Canada that has served us well in the past and could, with appropriate reorganization, continue to serve us well in the future. Those of us who now work in the field of transfusion medicine outside the CRCS recognize that reform is necessary and hope that Morgan and Cohen's article will stimulate productive debate on this vital issue. Jeremy W. Culver-James, BM, BCh, FRCPC Division of Hematology Department of Laboratory Medicine University of Alberta Hospitals Edmonton, Alta.
Because it appeared to be impossible to get a decision from the CRCS to establish an autologous blood transfusion program for children, we developed at the Alberta Children's Hospital a process for the recruitment of patients, phlebotomy and storage of blood independent of the CRCS donor program. In response to the question "Is the Red Cross capable of meeting the administrative standard required . . .?" we suggest that there is no agreement on the administrative standard. If the standard is to meet the lowest common denominator of phlebotomy, use time-honoured tests and provide blood products at times of regional or national crisis, then the CRCS is providing an effective service. If the standard is to introduce and maintain progressive forms of phlebotomy and blood product management, then we should accept Dr. Raymond Guevin's opinion that "decisionmaking is secondary to preserving the organizational structure." The CRCS is not able to adapt to rapid change. The decisionmaking structure will not permit the introduction of innovative programs. Perhaps expectations of the CRCS system are unrealistic and we should be looking to other organizations for introduction and assessment of new programs. Gerald V. Goresky, MD, FRCPC Director Stuart G. Neil, MB, ChB, FRCPC Assistant director Department of Anaesthesia Alberta Children's Hospital Calgary, Alta.
As physicians responsible for an Bill C-43 and the CMA autologous blood transfusion program for children we sympathize A s one of his last acts of business, outgoing CMA with Dr. Gail Rock's frustration president Dr. Marcien autoloin attempting to introduce wrote a letter Aug. 1, Fournier gous transfusion and directed do1990, to Minister of Justice Kim nation. CAN MED ASSOC J 1991; 144 (3)
275
Campbell, exhorting her to withdraw Bill C-43, an Act Respecting Abortion. I take exception to this. Setting aside the relative merits or flaws of the bill, I am disappointed that Fournier saw fit to use the word "extremist" to describe citizens who choose to defend unborn human beings. He used this term three times in a seven-paragraph letter. Moreover, as head of the CMA Fournier was particularly unsuited to tell the justice minister anything about the bill, since he headed a delegation that refused to appear, as requested, to give information before the AllParty Committee on Bill C-43 on Mar. 27, 1990. This request to appear a second time undoubtedly was the result of the CMA delegation's disappointing first appearance, on Feb. 6, when its ill-considered and unreferenced brief was read from start to finish, which left insufficient time for the committee to even scratch the surface of its list of questions. Finally, Fournier is in error when he closes his letter by claiming to represent "our 46,000 physician-members and the patients we serve" on the question of abortion. How would he know? The CMA has not surveyed its members since 1982. CMA executives dismissed the 1989 Canadian Physicians for Life (CPL) survey results, yet they have haughtily ignored requests to do their own new poll, unless they consider their survey of 800 abortionists to be representative. Is it possible that the CMA hierarchy is afraid of the results it may get, since its 1982 poll did not give majority support for unrestricted access to abortion? By opposing such a weak abortion law as Bill C-43 Fournier rejects even the faintest legal restraint on abortion in Canada. Whatever his personal views on the subject, he does not (and, as president, did not) have the au276
CAN MED ASSOC J
1991; 144 (3)
thority to claim to represent Canadian physicians in this matter. Paul J. Ranalli, MD 403-2115 Finch Ave. W Downsview, Ont.
[The CMA responds.] The term "extremist" was used in Dr. Fournier's letter to describe physicians and nonphysicians at the extreme ends of the opinion spectrum on this issue. It was not used in any pejorative sense. Fournier, serving as the CMA's principal spokesman, enunciated policy and positions approved by the association's governing bodies: the General Council and the Board of Directors. He was serving in the same capacity as the leader of the CMA delegation that appeared before the House of Commons Legislative Review Committee when it was reviewing Bill C-43. The opinions expressed by Fournier in the letter to Kim Campbell before the committee and the mass media were those of the association and did not necessarily reflect his personal views. The CMA declined an invitation to appear before the committee a second time because it had nothing more to say. A CMA request that any new questions be sent to it yielded no new policy areas but, rather, technical questions that could best be answered by technical experts. The CMA brief was read to the committee to ensure that it was on the record, to meet bilingualism requirements and to ensure that members of the committee (who, experience has shown, do not always read briefs in advance of the meeting) were exposed to overall CMA policy and positions on the subject. The committee hearing was not disappointing. Originally scheduled for 1 hour by the committee it lasted about 13/4 hours minus 15 minutes for a House of
Commons vote. There were two complete rounds of questions for committee members plus supplementary questions. There was no apparent sign of unasked questions when the chairman adjourned the meeting. The CMA offered to and did respond to members of Parliament's requests for more information or answers by mail and telephone subsequent to the meeting. No subject or CMA brief has been subjected to as extensive a review during the past 25 years. The policy and positions received overwhelming support from General Council and the Board of Directors before and after the policy had been approved. The CMA policy is not established by membership referendum. We remind readers that the CMA helped the CPL to conduct its survey by providing address labels according to its needs. The CMA has consistently supported the right of the CPL, other organizations and individual physicians to voice their views on this subject. The only negative comment or criticism voiced by the CMA on the CPL survey was that it was not conducted on a scientifically valid, random-sample basis. Therefore, it was prone to bias and distorted response rates. For the same reason, the CMA has consistently refused to release any data from its review of the opinions of the 800 "abortionists" referred to by Dr. Ranalli. The CMA's information collecting was not a scientifically valid survey. It was done only to support the CMA's opinion that a sizeable number of physicians who performed abortions would discontinue doing so if Bill C-43 was passed into law; as Fournier's letter stated, "Bill C-43 may provide legal entitlement to abortion but it will do so at the expense of access to the service . . ." Experience has proven the CMA's opinion to be correct. The CMA's policy does not
