BOOK AND MEDIA REVIEWS
THE DIAGNOSIS AND TREATMENT OF MEDICARE By Andrew J. Rettenmaier and Thomas R. Saving, 179 pp, $25.95. Washington, DC, American Enterprise Institute, 2007. ISBN-13 978-0-8447-4251-9.
THIS BOOK IS OF INTEREST TO HEALTH CARE POLICY MAKERS as well as physicians who seek to better understand the crisis in Medicare funding and its potential solutions. The book will be useful background to anyone who wants to explain the crisis in understandable terms to consumers, patients, or one’s own family. Andrew Rettenmaier and Thomas Saving, of the Washington think tank the American Enterprise Institute, are economists who have precisely spelled out for laymen why Medicare funding, as we know it, is unsustainable. Saving also speaks with the authority of serving as a public trustee of the Social Security system. Over the course of 14 chapters, the authors carefully spell out the historical roots of Medicare, the current crisis, and why it will be virtually impossible for Medicare to continue to provide first-dollar coverage for retiree health expenses over the next 20 years. They strengthen our understanding that current law does not support cost sharing by consumers in most parts of the Medicare program and that there are few limits on payment of all claims submitted by clinicians and little accountability for the appropriateness of the services. Physicians and other clinicians are paid (though some would say not enough) for almost any service provided in good faith. Additionally, most patients have no direct financial responsibility to restrain demand for any service, leading to few incentives to control costs. Since cost and coverage are the 2 key drivers of health care policy, the authors spend more than half of the book exploring various proposed models of economic impact and proposed solutions. Several chapters aid and assist us in understanding generational transfer of tax income from current workers to current retirees and the implications that a large increase in federal tax burden will be necessary unless the current model is changed. Rettenmaier and Saving also take the necessary pains to explain several aspects of how age-adjusted utilization by the average Medicare recipient has increased over the 4 decades of the program. Other chapters explain how means-testing and increasing eligibility would not fully solve the funding problem, in the light of even conservative estimates of the impact of the Baby Boom generation on Medicare spending. There is probably no serious political will to adopt rationing of access to care for chronic diseases. Saving and Rettenmaier believe that prepayment of Medicare premiums is a key way to accrue dollars to cover calculated unfunded obligations. They believe this model will pre©2007 American Medical Association. All rights reserved.
serve generational equity without burdening a younger workforce with the increasing needs of a large retiree population after 2020. While this may be an acceptable strategy, my sense is that other think tank leaders would suggest it is not the only solution. Some would argue that the impact of giving Social Security benefits to millions of illegal immigrants is another example of needed equity. The impact of immigration on Medicare may deserve further analysis in terms of these funding projections. Conservative scholars and public policy researchers have rallied around the prepublication manuscript with effusive praise. My concern is that leaders in more moderate or liberal think tanks may not be as generous. The authors do not develop a serious discussion of the relative merits of Medicare managed care as one of several tools that may be applied to finding realistic solutions. Additionally, there are other drivers of cost that they do not discuss in terms of how those may be better managed by our society. For example, others have pointed out that endof-life care and the care of expensive chronic diseases drive a large portion of cost. (Individuals receiving such care comprise 10% of the population that generates 50%-70% of medical costs.) Additionally, the behavioral aspect of chronic diseases has been shown to exacerbate costs, particularly relating to management of depression associated with chronic physical disabilities. In summary, I found the book a worthy read with thoughtful solutions. Some readers may come away with the strong sense that there is a large kernel of truth in the authors’ analysis. The real-world solutions, however, may need a better balancing of the economists’ approach with an evidencebased medical management model to control costs in a caring, humanistic paradigm. Prentiss Taylor, MD Rush University Chicago, Illinois
[email protected] Financial Disclosures: Dr Taylor reported that he is an employee of United Healthcare and that he holds stock in UnitedHealth Group. Disclaimer: The opinions presented are those of the author.
CONSENT TO TREATMENT: A PRACTICAL GUIDE By Fay A. Rozovsky, 4th ed, 1298 pp, $269. New York, NY, Aspen Publishers, 2007. ISBN-13 978-0-735-56204-2.
FIRST PUBLISHED MORE THAN 20 YEARS AGO, ROZOVSKY’S CONsent to Treatment was quickly recognized as a major contribution to the field of health law and bioethics. It provided Book and Media Reviews Section Editor: John L. Zeller, MD, PhD, Contributing Editor. (Reprinted) JAMA, October 3, 2007—Vol 298, No. 13 1569
BOOK AND MEDIA REVIEWS
a detailed, accessible, comprehensive guide to the law of consent to medical treatment, along with its exceptions or qualifications. By its expanded second and third editions, it had become a relevant classic. It is often considered the definitive guidebook for practitioners working at the intersection of medicine and law on issues related to informed consent and has been cited in many court decisions, including those of the US Supreme Court. This, its fourth edition, continues the success of previous editions and adds material on pressing medical-legal topics of recent concern, particularly effective communication and consent. The volume provides realistic, practical advice about topics such as risk management and clinical documentation. Its chapters on consent in women’s health, experimental research, human research, minors, prisoners, patients with AIDS, elderly individuals, mentally incapacitated individuals, autopsies, and organ transplantation are now updated with the latest citations to cases, statutes, and national regulations; yearly supplement updates continue to be made available to the reader. The goal of the fourth edition is to go beyond traditional legal concepts by integrating throughout the volume an expansive, rich, and relational notion of effective communication as a vehicle of proper informed consent. As Rozovsky points out, Consent is a process, not a form. It is a communication process at the core. . . . The law provides a framework for the consent process. It leaves to care providers, health lawyers, and risk managers the opportunity to build a strong process on this legal framework (p 18).
The new materials on practical interpersonal communication strategies (eg, a “communications time out”), approaches to expectation setting, the role of family in the consent process, linguistic and cultural competency, cultural advance directives, and continuum of care perspectives all help to achieve this goal. Tactics to overcome challenges to effective communication and quality informed consent are provided in new materials on payfor-performance, consent in the medical office, Medicare Part D and consent, and consent in patients undergoing compulsory treatment. The notion of consent as a patient safety tool is developed in new material on managing information overload and disclosure of adverse outcomes within the context of medical disciplinary actions and on theories of liability exposure. This work can also help resolve lingering debates in the legal theory of informed consent, specifically the question of what standard (objective or subjective) should be applied in determining the disclosure of risks and alternatives to patients. Jay Katz’s classic The Silent World of Doctor and Patient points to this tension between a legal system that thinks in terms of what a “reasonably prudent” person would expect vs what specific meaningful considerations obtain for the “individual patient” in question, even if idiosyncratic.1(pp75,76) Katz, siding with the subjective stan1570
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dard of materiality, reminded us that new skills would be necessary: . . . how to inquire openly about their patients’ individual informational needs and patients’ concerns, doubts, and misconceptions about treatment—its risks, benefits, and alternatives. Guarding self-determination requires assessing whether patients’ informational needs have been satisfied by asking them whether they understand what has been explained to them. Physicians should not try to “second guess” patients or “sense” how they will react. Instead, they need to explore what questions require further explanation. Taking such unaccustomed obligations seriously is not easy.1(p78)
Indeed, the very question of materiality and what should be told to, rather than discussed with, a patient forgets that “Autonomous decision making requires two-way conversation.”1(p79) With Rozovsky’s process-oriented, holistic, and dialogical approach to informed consent, the subjective vs objective standard of materiality is overcome: the “reasonable man” standard is not denied as much as it is generalized to its reasonable particulars. Rozovskywrites that Consent to treatment . . . is a communications process shaped by a variety of standards. Consent information provided to patients does not remain static. Instead, it changes in response to modifications in the standards that determine what is considered necessary to disclose to patients, the range of treatment alternatives, and related information (pp 1-14).
The book’s primary audience is health care practitioners, both legal and medical. In addition, its varied chapters could be useful reading for teaching ethics courses to medical students and for residents in forensic psychiatry. A great advantage of the work is the dramatic incorporation of material on consent into a single volume that is at once comprehensive, with analytically rigorous case and legislation analyses, and yet easy to read. It consistently slices across complicated topics with a pragmatic no-nonsense approach to help the practitioner make difficult clinical decisions and to formulate and enforce voluntary and lawful policy. This approach is greatly facilitated by an unambiguous and useful format, exemplified by the many well-organized checklists and flowcharts scattered throughout the chapters. Looking back 30 years to a time when informed consent could be likened to a “fairy tale” in practice, the fourth edition of Consent to Treatment is a testament to the evernarrowing gap between mythic ideals and the reality of striving to increase patient self-determination.2 In this fourth edition, Rozovsky provides novel and relevant material, and the book continues to be a seminal integrative tool of scholarship and daily practice for physicians, risk managers, and medical lawyers representing patients and clinicians. Omar Sultan Haque, MTS Harold J. Bursztajn, MD Program in Psychiatry and the Law Beth Israel Deaconess Medical Center Department of Psychiatry Harvard Medical School Boston, Massachusetts
[email protected] ©2007 American Medical Association. All rights reserved.
BOOK AND MEDIA REVIEWS Financial Disclosures: Dr Bursztajn reported serving as a consultant to patients, physicians, and institutions and as a testifying expert in informed consent. No other disclosures were reported. 1. Katz J. The Silent World of Doctor and Patient. New York, NY: Free Press; 1984. 2. Katz J. Informed consent—a fairy tale? law’s vision. Univ Pittsburg Law Rev. 1977;137:39.
BONE MARROW AND STEM CELL TRANSPLANTATION Edited by Meral Beksac (Methods in Molecular Medicine), 234 pp, $129. Totowa, NJ, Humana Press, 2007. ISBN-13 978-1-5882-9595-8.
RENEWING THE STUFF OF LIFE: STEM CELLS, ETHICS, AND PUBLIC POLICY By Cynthia B. Cohen, 320 pp, $35. New York, NY, Oxford University Press, 2007. ISBN-13 978-0-1953-0524-1.
THIS REVIEW CONCERNS 2 BOOKS ON STEM CELL TRANSPLANtation: one on the molecular methods for various protocols and the other on public policy as it relates to embryonic stem cell transplantation. Both relate to different aspects of stem cell transplantation, from basic biology to public policy. Bone Marrow and Stem Cell Transplantation is part of a continuing series in the Methods of Molecular Medicine handbooks. It has contributions from experts from around the world. The book is devoted to molecular biology protocols for a wide array of stem cell testing, not only for treatment of disease but primarily for research studies. The reference text is a compilation of protocols, starting with protocols for HLA typing including polymerase chain reaction (PCR) priming, sequence-specific oligonucleotideprimed PCR, and other sequencing-based methods. It includes protocols for detecting and identifying non-HLA polymorphisms, which only recently have become recognized as affecting transplantation outcomes. Other protocols relate to typing for epithelial cell receptors in relation to tissue regeneration, with emphasis on the emerging role of NOD2/CARD125 genes. Protocols are discussed for lymphoid and epithelial cell tracking as ways of determining chimerism of donor cells in host tissues, either for repopulation of a previously myeloablated bone marrow or for regeneration of injured tissue. There are also procedures for identifying and tracking natural killer cells and their receptors (important for posttransplantation immunity) and other protocols for in vivo bioluminescence tracking, a cutting-edge research technique. Other procedural items relate to measurement of chimerism for timing of donor lymphocyte infusions after transplant as host/donor cell chimerism changes over time and for prediction of rejection, albeit rare in stem cell transplantation. Still other protocols relate to detection of minimal residual disease after transplantation, tumor cell contami©2007 American Medical Association. All rights reserved.
nation within stem cell products, and the emerging role of proteomics during and after stem cell transplantation. As such, this book is a complement to existing texts of clinical stem cell transplantation,1,2 with a focus on the molecular biology protocols. The protocols are, however, framed with enough allusions to clinical implications to make it readable by molecular biologists and clinicians alike. Readers of JAMA may enjoy this book for opening their eyes to the realm of studies now possible with newly developed molecular biology protocols. Scientists and researchers will enjoy it for the hands-on tools described in sufficient detail for them to import to their own sites for immediate experimentation. Renewing the Stuff of Life: Stem Cells, Ethics, and Public Policy is about embryonic (not hematopoietic) stem cell transplantation and provides essential background information needed to understand the public controversies regarding embryonic stem cell transplantation. It is a thorough, scholarly review of the types of pluripotent stem cells and their potential uses, including creation of human-nonhuman chimeras for research relating to diseases such as amyotrophic lateral sclerosis, Parkinson disease, and many others. The book focuses on the moral significance of early embryos, from which cells are obtained. The Western and Eastern religions are juxtaposed in their philosophies about the meaning of life and death, and the author relates these philosophical nuances to geographic policies in the West and the East, in particular the United Kingdom, Germany, and Japan. All of this background in the science, morality, and political ramifications is then used to explore the situation in the United States, which is unique in its division between public and private philosophies and funding. The moral reasoning that led to the funding compromise on human stem cell research within the US National Institutes of Health is fully described in its religious and political context. It is certain that embryonic stem cell research will increase, if not in this country then in others. It is certain that this type of research will provide enormous technological possibilities. However, it is not certain that this type of research will be accepted in particular countries without immense public debate. This book provides the framework by which the public can intelligently engage in the debate and direct the future application of embryonic stem cell transplantation. Bijay Nair, MD Paulette Mehta, MD Department of Hematology/Oncology University of Arkansas for Medical Sciences Central Arkansas Veterans Healthcare System Little Rock
[email protected] Financial Disclosures: None reported. 1. Mehta P, ed. Pediatric Stem Cell Transplantation. Sudbury, MA: Jones & Bartlett Publishers; 2004. 2. Atkinson K, ed. Clinical Bone Marrow and Blood Stem Cell Transplantation. Cambridge, England: Cambridge University Press; 2004. (Reprinted) JAMA, October 3, 2007—Vol 298, No. 13 1571
