PERSPECTIVE ON HEALTH CARE : Hippocratic or Hypocritic Oath? : Doctors should refuse to sign gag orders from health maintenance organizations limiting what patients can be told.

Late last year, David Himmelstein, an associate professor at Harvard Medical School and a primary care physician at Cambridge Hospital, received a letter from U.S. Healthcare eliminating him from its provider network.

The largest HMO on the East Coast gave no reason for the firing, but Himmelstein had publicly criticized for-profit HMOs. Only three days before the firing, he appeared on Phil Donahue’s show and argued that U.S. Healthcare and other for-profit HMOs jeopardize patients’ health by rewarding physicians for denying needed care and forcing them to sign gag clauses like the one included in U.S. Healthcare’s standard contract. “Physician,” it reads, “shall agree not to take any action or make any communication which undermines or could undermine the confidence of enrollees, potential enrollees, their employers, their unions, or the public in U.S. Healthcare or the quality of U.S. Healthcare coverage. . . . Physician shall keep the proprietary information and this agreement strictly confidential.” In other words, if a physician tells a patient anything an HMO doesn’t approve of, he or she can be fired.

In the current health care climate, where maximizing profit seems to be the only bottom line, such HMO policies are routinely preventing physicians from giving patients information about their diagnoses, prognoses and treatment options. Consider the following hypothetical examples of what could happen to patients when their physicians are muzzled:

* A 49-year-old woman has a mammogram. The test reveals a suspicious shadow. The woman’s doctor would like to order another test to make sure the troubling finding is just a machine error, not a cancerous mass. But the HMO won’t pay for it. If the doctor tells her patient to pay for a second mammogram herself, this sensible advice could be construed as a criticism of the quality of care her HMO provides. So the doctor minimizes the findings. Come back for a checkup in six months, she tells her patient. Sadly, that six months could prove to be critical if the woman does indeed have breast cancer.

* A 60-year-old man needs a trans-urethral resection--an operation to relieve the obstruction to urine caused by an enlarged prostate. His surgeon would like to use a new laser technique that produces less blood loss, pain, risk of infection or impotence. But the patient’s HMO will only pay for the more invasive procedure that carries many more risks. If the surgeon tells his patient about the new surgery and suggests the patient appeal to the HMO for permission to use it, he could be fired.

* A 35-year-old woman has just suffered her first bout of severe depression. Her doctor would like to prescribe Zoloft, a class of medication that has few side effects and no risk of death from a self-administered overdose. (Depressed patients are often suicidal.) But the HMO has cut a deal with a pharmaceutical manufacturer to purchase Elavil, a type of drug that has many side effects and a very a high risk of death from an overdose. The physician would like to suggest that the patient purchase Zoloft herself. But again, he is silenced by the contract he has signed.

Well-informed patients clearly make far better health care decisions. Because of the complexity of and rapid advances in medical knowledge, even the most savvy health care consumer will always rely on information provided by his or her physician. If physicians cannot speak honestly with their patients, the latter cannot hope to control their health care fates. In such an environment, it is foolish for patients to believe that their doctors have told them the whole truth. That’s why such pernicious policies must be stopped.

In California, representatives of Consumers for Quality Care, a consumer watchdog group, and the California Nurses Assn. have filed a ballot initiative that would ban such gag orders. But patients and doctors shouldn’t wait until November to act. HMO patients should ask their physicians whether they have signed a gag order. (If the doctor refuses to say, he or she probably has.) Doctors should be encouraged to oppose this practice through their professional associations, legislation and public education. And many more should follow the courageous example of Dr. Himmelstein. When he received his U.S. Healthcare contract in l994, he sent it back with the gag clause crossed out and has not hesitated to speak out about against managed care abuses. HMO gag orders contradict the fundamental tenet of medicine’s Hippocratic Oath: “I will prescribe for the good of my patients according to my ability and my judgment and never do harm to anyone.” How can doctors who have sworn to uphold that oath take another pledge that puts their patients at such risk?