In an Oct. 18 article(www.nejm.org) in the New England Journal of Medicine, the executive leadership of five key physician organizations -- the AAFP, the American College of Physicians, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics and the American College of Surgeons -- call for an end to legislation that crosses traditional boundaries and intrudes into the realm of medical professionalism, saying that "legislators should abide by principles that put patients' best interest first."
"Critical to achieving this goal is respect for the importance of scientific evidence, patient autonomy and the patient-physician relationship," say the five organizations, which represent the majority of physicians providing clinical care in this country.
"Examples of inappropriate legislative interference with this relationship are proliferating as lawmakers increasingly intrude into the realm of medical practice, often to satisfy political agendas without regard to established, evidence-based guidelines for care," say the organizations, who add that four types of laws are of particular concern. These include laws that
- prohibit physicians from discussing with or asking their patients about risk factors that may affect their health or the health of their families as recommended by evidence-based guidelines;
- require physicians to discuss practices that may not be necessary or appropriate at the time of a given encounter with a patient, according to the physician's best judgment;
- would require physicians to provide -- and patients to receive -- diagnostic tests or medical interventions not supported by evidence, including tests or interventions that are invasive and are required to be performed even without a patient's consent; and
- limit the information physicians can disclose to patients, consultants in patient care, or both.
- In a New England Journal of Medicine article, the AAFP and four other physician organizations have called for an end to laws that interfere with the patient-physician relationship and that are not grounded in science and evidence.
- The organizations identify four types of laws or legislative proposals that are most concerning, giving an example of how each type of law has played out.
- The AAFP and the other organizations say the laws have succeeded in devaluing the patient-physician relationship.
The organizations give an example of each of the four types of intrusive law. For example, the organizations cite a 2011 Florida statute that "substantially impaired physicians' ability to deliver gun-safety messages to patients."
The law, known as the Firearm Owners' Privacy Act, prohibited physicians and other health care professionals from routinely asking patients if they owned firearms and recording the information in the medical records of patients.
"Practitioners who violated the law were potentially subject to severe disciplinary action, including fines and loss of licensure," the organizations say.
They point out that U.S. District Judge Marcia Cooke issued a permanent injunction in June, barring the law's enforcement. In her opinion, Cooke said, "the state, through its law, inserts itself in the doctor-patient relationship, prohibiting and burdening speech necessary to the proper practice of preventive medicine, thereby preventing patients from receiving truthful, non-misleading information."
Cooke also said "the law chills practitioners' speech in a way that impairs the provision of medical care and may ultimately harm the patient."
Nevertheless, according to the article, Florida is continuing to push for the law. Florida Gov. Rick Scott recently announced that the state is appealing Cooke's ruling.
The authors of the article also cite a New York statute requiring physicians to discuss practices that may not be necessary or appropriate at the time of a specific encounter with a patient. The New York law, which took effect in 2011, requires physicians and other health care professionals to offer terminally ill patients "information and counseling regarding palliative care and end-of-life options appropriate to the patient."
These include the patient's prognosis, risks and benefits of various options, and a patient's legal rights to pain and symptom management. However, the Medical Society of New York and others have criticized the bill for "failing to recognize the complexity and uncertainty involved in end-of-life discussions among patients and their families and physicians."
"This an area in which one size does not fit all and in which physicians are best able to determine what discussions with patients and families are necessary or appropriate at a given time," the organizations say. "Yet failure to comply with the law can result in fines of up to $5,000 for repeat offenses and a jail term of up to one year for willful violations."
As an example of laws that mandate diagnostic tests that may be neither medically indicated nor desired by the patient, the article cites a Virginia measure that would require women to undergo ultrasonography before having an abortion.
In addition, the article notes that four states -- Pennsylvania, Ohio, Colorado and Texas -- have passed legislation making it difficult for physicians to obtain information about the chemicals used in fracking, a process that involves injecting toxic chemicals into the ground.
"In Pennsylvania, physicians can obtain information about chemicals used in the fracking process that may be relevant to a patient's care, but only after requesting the information in writing and executing a nonstandardized confidentiality and nondisclosure agreement drafted by the drilling companies," the article states.
The organizations say laws of these types have effectively reduced health care decisions "to a series of mandates," devaluing the patient-physician relationship.
"Legislative mandates regarding the practice of medicine do not allow for the infinite array of exceptions -- cases in which the mandate may be unnecessary, inappropriate or even harmful to an individual patient," the article says.
The organizations do not discount the role of government, saying, for example, that "federal, state and local governments have long played valued and important roles in our nation's health care."
"Various levels of government are appropriately involved in providing essential health care services, licensing health care professionals, protecting public health, determining the safety of drugs and medical devices, and investing in medical education and research," the article says.
The organizations assert that objections to "legislatively mandated health care decisions does not translate into an argument that physicians can do whatever they want."
The health care needs of individual patients and the broader society are best served when physicians' actions and physician-patient interactions are dictated not by legislation but by "the fundamental principles of respect for autonomy, beneficence, nonmaleficence and justice," the organizations conclude.