The Dubious Wisdom of Rationing

It may be worth noting that America's poor are not the only people affected by rationing of medical treatment {Cover, July 31}. Thousands of elderly people have become victims as well.

Medicare, by its Prospective Payment System, conducts "back door" rationing by restricting the number of days a patient may stay in the hospital. Maureen C. Kelley National Journalism Center Washington

Does it make sense and, more important, is it morally defensible, to advocate rationing without first asking whether we have done all we can to make the current system more effective and less costly, short of instituting rationing. The de facto rationing we now have is deplorable and needs to be addressed, but it should not be institutionalized by making it national policy.

How can rationing be advocated when 1) perhaps one third of U.S. health care expenditures are being wasted on ineffective or unproven technologies and procedures, 2) malpractice and defensive medicine cost the nation at least $15 billion annually, 3) administrative and bureaucratic expenses are estimated by some to exceed 20 percent of the total costs for health care, 4) health insurers do not pay for most preventive services, and 5) many diagnostic tests and procedures are performed unnecessarily, thus wasting billions of dollars?

Seymour Perry, MD, FACP

Professor and chairman Department of Community and Family Medicine Director, Program on Technology and Health Care Georgetown University

Expanding Prescription Privileges

An article on prescription privileges {Medical News, July 24} stated that both psychiatry and psychology are based on "talk therapy," implying that both professions do the same thing except that psychiatrists prescribe drugs.

To the physician, diagnosing and using medications to treat mental illnesses such as depression, obsessive-compulsive disorder or schizophrenia require the same level of knowledge and skill as diagnosing and treating heart disease, diabetes or rheumatoid arthritis. Deciding whether to use a drug, choosing the best drug to use, setting the proper dose, monitoring the drug's effects -- both good and bad -- and quickly discontinuing or altering treatment when things don't go as planned is what physicians are uniquely trained to do.

By the time a psychiatrist begins medical practice, he or she will have managed the care of 200 to 300 patients with a range of physical and emotional illnesses; this care includes performing an examination, rendering a medical diagnosis, providing medication or other treatment and monitoring the effect of treatment, all under the supervision of senior physicians.

There is more to practicing medicine than matching an illness in Column A with a drug in Column B. Allowing others to use medication without the benefit of a medical education and medical judgment developed through years of clinical training significantly increases the chance for wrong decisions and harm to patients. Melvin Sabshin, MD Medical director American Psychiatric Association Washington

Medicines prescribed for the mind invariably affect the body. Illnesses in the body often affect the mind. For example, a patient taking lithium, a commonly prescribed medicine for manic depression, must undergo regular blood tests to monitor the level of the drug, as well to determine thyroid and kidney function and salt balance. Inadequate monitoring can lead to toxicity.

Many illnesses, including drug intoxication, Grave's disease and AIDS, can manifest first by changes in behavior and thinking. An ability to understand the interaction of psychological and physiological processes is fundamental to good medical care and is the foundation on which the license to prescribe medications rests. Without this understanding, prescribing medications is unethical and possibly dangerous.

Anne C. Mazonson, MD,

Chief resident

Department of Psychiatry and Behavioral Sciences

George Washington University Medical Center