US doctors debate refusing treatment to malpractice lawyers

BMJ 2004; 328 doi: (Published 24 June 2004) Cite this as: BMJ 2004;328:1518
  1. Fred Charatan
  1. Florida

    Animosity between doctors and medical malpractice lawyers has reached such a pitch in the United States that the American Medical Association last week debated a motion proposing that doctors should refuse medical treatment to such lawyers, their families, and employees except in emergencies.

    Although the motion, brought by Dr Chris Hawk, a surgeon from South Carolina, was lost, some doctors felt the fact that it was proposed at all shows how bad relations between the professions have become. Doctors are angry, among other things, at the effect that malpractice awards are having on their insurance premiums.

    Dr Clinton “Rick” Miller, a prominent neurosurgeon from New Hampshire, is one doctor who supports the idea of refusing treatment except in emergencies. In his 25 year career he has never been sued for malpractice. Nevertheless, last year he paid $84 151 (£46250; €70000) in medical liability insurance premiums. He said that his take home pay after taxes was $64 000. “That's less than my malpractice premium,” said Dr Miller. “This puts in perspective how desperate the situation is.”

    He has said publicly that he would not treat Tim Coughlin, president of the New Hampshire Trial Lawyers Association (except in an emergency), because Coughlin lobbied the legislature against limits on malpractice suits.

    In an angry exchange of views in the Portsmouth Herald last December Dr Miller took issue with Coughlin's opposition to legal reform, claiming that Coughlin's articles in the newspaper “impugn[ed] the integrity and good intentions of both the medical community and the insurance industry.”

    The American Medical Association says that the size of malpractice insurance premiums has now r eached crisis point in 20 states. Many doctors believe that lawyers encourage patients to take them to court. According to the Physician Insurers Association of America, 70% of malpractice cases were dropped or dismissed in 2003, and a jury verdict for the plaintiff was reached in only 1% of cases.

    Dr Donald J Palmisano, the association's president, said: “The AMA is disheartened that the medical liability environment in Massachusetts [the 20th state defined as in crisis] has deteriorated to the point where physicians are restricting services and patients are losing access to care. Until lawmakers enact proven reforms, our nation's crisis will only get worse.”

    Dr Hawk, the surgeon who proposed last week's motion and chairman of the association's Council of Scientific Affairs, first suggested not treating lawyers who brought malpractice cases in a speech to the South Carolina Medical Association convention last March.

    When he repeated the proposal at the association's convention last week, however, he was denounced by 16 doctors, even after he had asked that it be withdrawn.

    One correspondent emailed: “What Dr Hawk is proposing is egregious, both hypocritically and Hippocratically.”

    Several neurosurgeons in Florida's wealthy Palm Beach county have scaled back their practices because of their concerns that emergency cases put them at higher risk of medical malpractice lawsuits. Only four neurosurgeons now handle emergency calls at the 13 hospitals in the county, increasingly leaving emergency rooms with no one available.

    The American Medical Association has made medical liability reform its top priority. Congress has tried to pass meaningful reforms, pre-empting the role of the states. Last May the US House of Representatives passed the Health Act of 2004, by 229 votes to197. It caps non-economic damages at $250000 (£136000; €206000) and would allocate damages in proportion to a party's degree of fault. But the legislation is stalled in the US Senate.

    Dr Arthur Caplan, director of the Center for Bioethics, University of Pennsylvania, told the BMJ that “it is unethical to withhold treatment on the basis of a profession or an opinion.” He added that doctors treat enemy combatants, including terrorists.

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