ple may wish to donate to charity. The incomes of many organizations, including those that fund much of Canadian medical reA lthough nonprofit charitasearch (including universities and ble organizations have medical associations such as the benefited from a special Heart and Stroke Foundation and status allowing contributions to be Arthritis Society), depend the tax deductible, recently there have been major changes in these de- heavily on such contributions. Although we do not wish to ductions. imply that political parties are less Previously such donations worthy of donations, and we realwere 100% deductible; now only ize the importance of a healthy 17% of the first $250 and 29% of political system, we suggest that the balance is allowed as a credit the government consider at least to reduce the amount of federal equal income tax credits for all and provincial tax owed. Alcharitable organizations doing though this may appear to stimuwhat we believe to be work of late people to donate more than for Canadians. similar importance $250 to achieve the better rate, the credit is much less than the Colin R. Voorneveld, MD, FRCPC previously allowed deduction. Research fellow By comparison, contributions Department of Medicine to political parties have been rela- Laurence A. Rubin, MD, FRCPC tively spared. For a person living Assistant professor Department of Clinical Science in Ontario a complex formula is University of Toronto used for both provincial and fed- Toronto, Ont. eral contributions. For provincial contributions the credit is 75% of the first $200, 50% of the next $600 and 331/3% of the contributions exceeding $800, to a maxi- The bottom line mum credit of $750. The federal credit is 75% of the first $100, I found this article (Can Med Assoc J 1990; 143: 912), by 50% of the next $450 and 331/3% Dr. William Watson, offenof the contributions exceeding $550, to a maximum credit of sive. Until the last paragraph it was interesting to read about the $500. This person would have to typical demanding patient who is donate $1700 to a provincial po- confronted with a bad diagnosis: litical party and $1150 to a federal denying, petulant, trying to exerparty to receive the $750 provin- cise control *and displaying false cial and $500 federal maximum bravado. In the last paragraph, howevcredits. The same donations to charity would allow credits of er, the patient suddenly becomes only $463 and $303.50 respective- no longer nondenominational. He ly. Hence, one could expect a is Jewish, and as such Watson maximum credit of $1250 on a thinks he has alienated the patient $2850 contribution distributed to because his tests are being delayed provincial and federal political because of Good Friday. Demanding patients might be parties but only $766.50 for the same contribution to charity. alienated whether their tests are In these days of increased tax- delayed by religious holidays or ation, recently accelerated by im- by secular holidays. The only reaplementation of the goods and son I can imagine as to why Watservices tax, these differences in son thinks that Good Friday the credit regulations result in un- alienated his Jewish patient more fair competition for monies peo- than, for examp?le, Labour Day is

Unfair competition for charitable donations?

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CAN MED ASSOC J 1991; 144 (6)

if he believes that Good Friday has a special relevance related to Jews. Incidentally, I cannot refrain from wondering if Watson is just describing the accountant as "thinking of value for money on a cost-benefit basis" or is also stereotyping the Jew. The last paragraph was entirely superfluous: the article could have had the same interest for CMAJ readers without appearing racist. I am disappointed that the CMAJ editors did not apply the policy that they state for their classified ads, namely "without discrimination because of race, ancestry, place of origin, colour, ethnic origin" etc. Shirley Katz, MD 415-5845 Cote des Neiges Rd. Montreal, Que.

[CMAJ responds:] I am sorry that the final sentence in Dr. Watson's article offended Dr. Katz. However, I thought the message in what I considered an excellent piece was simple: physicians should think twice before speaking, because they may unintentionally offend a patient. And that message holds regardless of whom the patient is. In this case the patient just happened to be Jewish. I think the final sentence was important for getting that message across. Patrick Sullivan News and features editor

Genital injuries in sexual assault victims W x

rhen sexual assault cases

come to trial the medical evidence about geni-

tal injuries is considered important. Defence lawyers have often said or implied that sexual assault is unlikely to have occurred withFor prescribing information see page 656

out objective evidence of genital trauma. Our experience in the Sexual Assault Service of University Hospital, Vancouver, is that genital injuries are only a small proportion of all the injuries seen in victims of sexual assault. Among the 491 victims seen by the ser-. vice in the hospital's Emergency Department between Oct. 1, 1989, and Sept. 30, 1990, 403 (82%) had general injuries and 192 (39%) genital injuries. Objective evidence was present in 362 (90%) and 92 (48%) respectively; tenderness only was present in 41 (10%) and 100 (52%) respectively. Ellen R. Wiebe, MD, FCFP Co-director Sexual Assault Service University Hospital Vancouver, BC

Guidelines for medical practice I commend Drs. Adam L. Linton and David K. Peachey for their two recent articles on the need for clinical practice guidelines and a possible strategy for developing them (Can Med Assoc

J 1990; 143: 485-490 and 629632). I sense, however, three inherent weaknesses in their strategy, namely the interlinked issues of funding, empowerment and competition. How the proposed Committee on Guidelines for Medical Practice (CGMP) would remain well financed yet independent of any interested party defies the rule that "he who pays the piper calls the tune." It is highly unlikely that government, which picks up the (large) bills for the services provided, would allow a completely free hand in a process that would affect these large amounts. Perhaps a joint venture like the Task Force on the Use and Provision of Medical Services (the Scott Commission) would be the best (in fact, the CGMP sounds a lot -

For prescribing information see page 817

like the Scott Commission with an expanded membership and new name). Alternatively, if physicians wish to remain independent from government, then, as Brook' suggests, they should be willing to fund these activities at perhaps $100 to $200 each on an annual basis. The question of empowerment is another hornets' nest. The statement "the committee should wield considerable power" is admirable but ducks the issue of how it achieves that outcome. If the guidelines generated by this body remained voluntary, then the body would be unable to exert any coercive power, and if independent of any interested party, specifically the paymaster, it could not wield reward power. What, then, would be its source of power? It might garner some form of expert power as a body of eminent physicians, but that might not sell in Snake River. Short of some administrative backup and source of power, such bodies might well attract attention but not generate action. The consensus panels of the US National Institutes of Health have been composed of "big names," but the record of positive alterations in physician behaviour is uncomfortably thin. The record of guidelines in general is weak, albeit relatively recent.2 As several large players enter the "guidelines market" in the United States, competition for the role of the provider of the most authoritative set of guidelines will increase. How will the CGMP compete with these well-funded, well-researched and aggressively marketed imports in the age of medical free trade? Ontario does possess significant expert power in many fields, but, like any other competing industry, the resources to support these efforts must also be found. I am not despairing of what promcises to be a dlifficullt task by 1

C7

offering only sly criticism or easy answers, as there are none except that if physicians do not act others will. Denis Macdonald, MD, MBA, FRCPC 30 Whitehall Rd. Toronto, Ont.

References 1. Brook RH: Practice guidelines [C]. JAMA 1990; 263: 3021 2. Leape L: Practice guidelines & standards - an overview. QRB 1990; Feb: 42-49

Chlorpropamide or chlorpromazine? _D

r. George A. Mayer's letter (Can Med Assoc J 1991; 144: 119) brought to mind a case I attended about 10 years ago. A woman in her 20s was brought unconscious into the emergency department. Her blood glucose was undetectable, and she roused after intravenous administration of glucose. Her mother had accompanied her, bringing along the daughter's medications, which included chlorpropamide. When the mother was asked how long her daughter had been diabetic, she stated that her daughter was not diabetic but was taking chlorpromazine for a long-standing schizophrenic illness and had just had her prescription refilled. The druggist was appalled at the error that he had made. The patient recovered uneventfully. Derek A. Davidson, MD 1920 Weston Rd. Weston, Ont.

Writing prescription instructions ~r. Morton S. Rapp expresses a concern com._ mon to physicians of all kinds: the difficulty in writing D

MED ASSOCJ 1991; 144(6)

647