promoting effective communication and demonstrating respect for the patient as a person. However, as Emson points out, there have been problems with the introduction of living wills in the United States, which we enumerated. Accordingly, we have stressed the need for further assessment of public and professional attitudes toward the care of terminally ill patients and the need for better education of all health professionals in this field. In addition, we support the further development of palliative care services. We feel that these measures should be tried before living wills are turned into legal documents. We strongly favour improving the management of terminally ill patients, whether mentally competent or not, and we feel that dying patients should not have to be subjected to procedures that are either not clinically indicated or not desired by the patient. It is difficult to see how this can be viewed as "presumptively benevolent paternalism". Rory H. Fisher, MB Head Department of Extended Care Eric M. Meslin, PhD Clinical Ethics Centre Sunnybrook Medical Centre North York, Ont.
"Health care security"? Not in Ontario L ' ast year my father, an ophthalmologist in Sault Ste. Marie, Ont., died while waiting for coronary artery bypass surgery. Recently a young boy with tetralogy of Fallot died while waiting for needed cardiac surgery. Not long ago I received a call from a physician whose 50-yearold brother with four children urgently needs coronary artery bypass surgery; the waiting list is 6 to 9 months long. The physician 798
CAN MED ASSOC J 1990; 142 (8)
wanted to know whether I was familiar with the Heart Beat Program in Windsor, Ont., whereby patients are being treated in Detroit. According to Patrick Sullivan in his article "Health care system serves Canada well, Alberta president tells American MDs" (Can Med Assoc J 1990; 142: 237-238) Dr. Ronald Gregg, president of the Alberta Medical Association, stated last November that "medicare provides each Canadian with health care security and the peace of mind of knowing that, no matter what happens, care will be available and won't jeopardize his or her financial health". Possibly things are not as bad in Alberta; however, care is most certainly not readily available in Ontario when needed. Granted our system is running reasonably well, but I contend that it is heading in the wrong direction and needs improvement. Brian A. Shamess, MD 107-974 Queen St. E Sault Ste. Marie, Ont.
CMA's response to abortion bill I n its "Brief to the House of Commons Legislative Committee on Bill C-43, an Act Respecting Abortion", which was included with the Feb. 15, 1990, issue of CMAJ, the CMA states the following: The Bill singles out abortion as the only specified medical act to attract Criminal Code sanctions. The CMA believes that such treatment is inappropriate and that abortion should be treated and controlled under the same statutes that apply to other medical acts.
fore, it is highly appropriate for abortion to attract Criminal Code sanctions. Donald S. Stephens, MD 11 Stratford Rd. Southport, PEI
HIV testing P hysicians working with people who have AIDS generally object to the implication that there is such a thing as "AIDS testing", as suggested by the headline of Patrick Sullivan's article "Insurance company MDs
defend AIDS-testing policy before CMA council" (Can Med Assoc J 1990; 142: 379-380). Rather, there is available serologic testing for the human immunodeficiency virus (HIV). AIDS is diagnosed by specific clinical criteria as published by the US Centers for Disease Control.' Physicians or journalists talking about "AIDS testing" obscure the diagnostic process and fuel the confusion in the minds of the public between HIV testing and AIDS diagnosis. Sullivan reported the concerns of some Alberta physicians about the insurance industry's HIV testing policy, concerns that were forwarded to the CMA's Council on Health Care by the Alberta Medical Association. I share those physicians' concerns about the need for informed consent and the need for adequate counselling before and after testing, when the rate of false-positive results should be discussed. I question the comment by Dr. Peter Miller, medical director at Head Office Reference Laboratory Ltd., that "frankly, being diagnosed with cancer is just as bad", since the average time from HIV seroconversion to a diagnosis of AIDS is estimated at 7 to 10
Doctors, won't you admit yet that abortion is the only medical act other than euthanasia whose years.2 purpose is to kill people? ThereLet us aim for accuracy in
titles of CMAJ articles and in "a number of physicians" and fidiscourse with fellow profession- nally ended up in the office of a als and the public regarding this chiropractor for "allergy tests". issue. I sense some disappointment and distrust of the medical profesFrank J. Foley, MD, CCFP sion when I hear statements that Medical director doctors push pills for financial Casey House Hospice gain when treating allergies. When Toronto, Ont. eczema is repeatedly treated with steroidal creams or ointments and References the underlying cause is not delin1. Revision of the case definition of ac- eated, patients may equate their quired immune deficiency syndrome physician with a painter who for national reporting - United States. paints over a rusty spot rather MMWR 1985; 34: 373-375 2. Bartlett JG: Management of patients than repairing the defect, so the with asymptomatic HIV infection. Md rust keeps coming back no matter Med J 1990; 39: 150-155 how often the spot is painted. I believe that unless we gain public trust, patients will continue to be subjected to invalid techniques. Nonvalidated As a practising allergist I am food allergy tests as concerned as Dolovich that the public is being subjected to nonI n his second letter on this validated and questionable techtopic (Can Med Assoc J 1989; niques. I am also concerned that 141: 1222) Dr. Jerry Dolovich in the case he presented the endescribes yet another unscientific counter with a chiropractor was method of allergy detection by a the first time the mother had been chiropractor. told of the possibility that foods It is important to be aware might be contributing to the that such practices exist, but it is child's eczema. Changes in the equally important to look at the diet did lead to improvement. reasons why they do. In my earlier Should the physicians the child letter "Do you believe in aller- was taken to not have entertained gies?" (Can Med Assoc J 1988; the possibility of food allergy and 138: 889) I reported the com- consulted an allergist colleague? plaints of many patients that Instead of pointing fingers at some members of the medical others, what can we as physicians profession are reluctant to consult do so that our patients are not an allergist. Since most allergic subjected to nonvalidated techmanifestations are not life-threat- niques? Perhaps the most imporening, I wonder whether physi- tant step forward will be to incians may be casual in treating clude allergic diseases in the difallergy symptoms without bother- ferential diagnosis when dealing ing to identify the cause. When with such common distressing symptoms continue to recur upon symptoms as eczema, urticariacessation of treatment, these pa- angioedema, headaches, asthma, tients have to make repeated vis- rhinitis, conjunctivitis, abdominal its to a physician's office for re- cramps, bloating and diarrhea and newal of their prescriptions. to consider that food allergens Sometimes, out of frustration, play a significant role in the prothey explore other avenues, such duction of those symptoms. In so as a visit to a chiropractor. This doing we will not only provide a may have been the reason in the dramatic improvement in cases in case presented by Dr. Dolovich: which an allergic mechanism is the 3-year-old atopic girl with ec- the underlying cause but also mizema had previously been seen by nimize the chances of people seek-
ing out persons who use nonvalidated and unscientific modes of investigation and treatment. Jagat N. Singh, MD, PhD 1415-233 Kennedy St. Winnipeg, Man.
Hypercholesterolemia and atherogenesis r. Ronald A. Blattel (Can
Med Assoc J 1989; 140: 1006, 1008) expressed genuine scientific scepticism regarding the recommendations of various consensus reports on serum cholesterol levels and the alleged reduction in the rate of death from coronary heart disease in the Lipid Research Clinics trial.' One can appreciate the dilemma in which physicians find themselves when confronted by patients with great expectations of medical advice for an individual serum cholesterol level that a few years before would have been regarded as being within the "normal reference range". Dr. Louis Horlick (ibid: 1008-1009) countered with accusations of superficial appraisal, alleging that committees in Europe and North America had carefully scrutinized the trial results. However, careful scrutiny is not critical evaluation. After all, how many genuine scientific dissidents were invited to
participate? The results of most primary and secondary clinical prevention trials before 1984 have been considered inconclusive,2 yet Horlick, like others, has considered the results of four trials to be very convincing. There has been criticism of the first, the Lipid Research Clinics trial, which has been defended by Horlick. Like the other careful scrutineers, Horlick has failed to take into account the clinical diagnostic error for coronary heart disease, conservatively estimated at ± 30%.3 The CAN MED ASSOC J 1990; 142 (8)
799
"Health care security"? Not in Ontario L ' ast year my father, an ophthalmologist in Sault Ste. Marie, Ont., died while waiting for coronary artery bypass surgery. Recently a young boy with tetralogy of Fallot died while waiting for needed cardiac surgery. Not long ago I received a call from a physician whose 50-yearold brother with four children urgently needs coronary artery bypass surgery; the waiting list is 6 to 9 months long. The physician 798
CAN MED ASSOC J 1990; 142 (8)
wanted to know whether I was familiar with the Heart Beat Program in Windsor, Ont., whereby patients are being treated in Detroit. According to Patrick Sullivan in his article "Health care system serves Canada well, Alberta president tells American MDs" (Can Med Assoc J 1990; 142: 237-238) Dr. Ronald Gregg, president of the Alberta Medical Association, stated last November that "medicare provides each Canadian with health care security and the peace of mind of knowing that, no matter what happens, care will be available and won't jeopardize his or her financial health". Possibly things are not as bad in Alberta; however, care is most certainly not readily available in Ontario when needed. Granted our system is running reasonably well, but I contend that it is heading in the wrong direction and needs improvement. Brian A. Shamess, MD 107-974 Queen St. E Sault Ste. Marie, Ont.
CMA's response to abortion bill I n its "Brief to the House of Commons Legislative Committee on Bill C-43, an Act Respecting Abortion", which was included with the Feb. 15, 1990, issue of CMAJ, the CMA states the following: The Bill singles out abortion as the only specified medical act to attract Criminal Code sanctions. The CMA believes that such treatment is inappropriate and that abortion should be treated and controlled under the same statutes that apply to other medical acts.
fore, it is highly appropriate for abortion to attract Criminal Code sanctions. Donald S. Stephens, MD 11 Stratford Rd. Southport, PEI
HIV testing P hysicians working with people who have AIDS generally object to the implication that there is such a thing as "AIDS testing", as suggested by the headline of Patrick Sullivan's article "Insurance company MDs
defend AIDS-testing policy before CMA council" (Can Med Assoc J 1990; 142: 379-380). Rather, there is available serologic testing for the human immunodeficiency virus (HIV). AIDS is diagnosed by specific clinical criteria as published by the US Centers for Disease Control.' Physicians or journalists talking about "AIDS testing" obscure the diagnostic process and fuel the confusion in the minds of the public between HIV testing and AIDS diagnosis. Sullivan reported the concerns of some Alberta physicians about the insurance industry's HIV testing policy, concerns that were forwarded to the CMA's Council on Health Care by the Alberta Medical Association. I share those physicians' concerns about the need for informed consent and the need for adequate counselling before and after testing, when the rate of false-positive results should be discussed. I question the comment by Dr. Peter Miller, medical director at Head Office Reference Laboratory Ltd., that "frankly, being diagnosed with cancer is just as bad", since the average time from HIV seroconversion to a diagnosis of AIDS is estimated at 7 to 10
Doctors, won't you admit yet that abortion is the only medical act other than euthanasia whose years.2 purpose is to kill people? ThereLet us aim for accuracy in
titles of CMAJ articles and in "a number of physicians" and fidiscourse with fellow profession- nally ended up in the office of a als and the public regarding this chiropractor for "allergy tests". issue. I sense some disappointment and distrust of the medical profesFrank J. Foley, MD, CCFP sion when I hear statements that Medical director doctors push pills for financial Casey House Hospice gain when treating allergies. When Toronto, Ont. eczema is repeatedly treated with steroidal creams or ointments and References the underlying cause is not delin1. Revision of the case definition of ac- eated, patients may equate their quired immune deficiency syndrome physician with a painter who for national reporting - United States. paints over a rusty spot rather MMWR 1985; 34: 373-375 2. Bartlett JG: Management of patients than repairing the defect, so the with asymptomatic HIV infection. Md rust keeps coming back no matter Med J 1990; 39: 150-155 how often the spot is painted. I believe that unless we gain public trust, patients will continue to be subjected to invalid techniques. Nonvalidated As a practising allergist I am food allergy tests as concerned as Dolovich that the public is being subjected to nonI n his second letter on this validated and questionable techtopic (Can Med Assoc J 1989; niques. I am also concerned that 141: 1222) Dr. Jerry Dolovich in the case he presented the endescribes yet another unscientific counter with a chiropractor was method of allergy detection by a the first time the mother had been chiropractor. told of the possibility that foods It is important to be aware might be contributing to the that such practices exist, but it is child's eczema. Changes in the equally important to look at the diet did lead to improvement. reasons why they do. In my earlier Should the physicians the child letter "Do you believe in aller- was taken to not have entertained gies?" (Can Med Assoc J 1988; the possibility of food allergy and 138: 889) I reported the com- consulted an allergist colleague? plaints of many patients that Instead of pointing fingers at some members of the medical others, what can we as physicians profession are reluctant to consult do so that our patients are not an allergist. Since most allergic subjected to nonvalidated techmanifestations are not life-threat- niques? Perhaps the most imporening, I wonder whether physi- tant step forward will be to incians may be casual in treating clude allergic diseases in the difallergy symptoms without bother- ferential diagnosis when dealing ing to identify the cause. When with such common distressing symptoms continue to recur upon symptoms as eczema, urticariacessation of treatment, these pa- angioedema, headaches, asthma, tients have to make repeated vis- rhinitis, conjunctivitis, abdominal its to a physician's office for re- cramps, bloating and diarrhea and newal of their prescriptions. to consider that food allergens Sometimes, out of frustration, play a significant role in the prothey explore other avenues, such duction of those symptoms. In so as a visit to a chiropractor. This doing we will not only provide a may have been the reason in the dramatic improvement in cases in case presented by Dr. Dolovich: which an allergic mechanism is the 3-year-old atopic girl with ec- the underlying cause but also mizema had previously been seen by nimize the chances of people seek-
ing out persons who use nonvalidated and unscientific modes of investigation and treatment. Jagat N. Singh, MD, PhD 1415-233 Kennedy St. Winnipeg, Man.
Hypercholesterolemia and atherogenesis r. Ronald A. Blattel (Can
Med Assoc J 1989; 140: 1006, 1008) expressed genuine scientific scepticism regarding the recommendations of various consensus reports on serum cholesterol levels and the alleged reduction in the rate of death from coronary heart disease in the Lipid Research Clinics trial.' One can appreciate the dilemma in which physicians find themselves when confronted by patients with great expectations of medical advice for an individual serum cholesterol level that a few years before would have been regarded as being within the "normal reference range". Dr. Louis Horlick (ibid: 1008-1009) countered with accusations of superficial appraisal, alleging that committees in Europe and North America had carefully scrutinized the trial results. However, careful scrutiny is not critical evaluation. After all, how many genuine scientific dissidents were invited to
participate? The results of most primary and secondary clinical prevention trials before 1984 have been considered inconclusive,2 yet Horlick, like others, has considered the results of four trials to be very convincing. There has been criticism of the first, the Lipid Research Clinics trial, which has been defended by Horlick. Like the other careful scrutineers, Horlick has failed to take into account the clinical diagnostic error for coronary heart disease, conservatively estimated at ± 30%.3 The CAN MED ASSOC J 1990; 142 (8)
799
