Patient Power

Correspondence with Annals of Surgery

What follows is my correspondence with Annals of Surgery concerning a letter I co-authored with Paul Hsieh, M.D. that we submitted for publication. — Brian

From: Annals of Surgery <nevar[~at~]surgery.wisc.edu>
To: [Brian T. Schwartz]
Sent: Tuesday, July 22, 2008 12:15:52 PM
Subject: Annals of Surgery

Ref.:  Ms. No. ANNSURG-D-08-00648
Single-Payer Health Care: Immoral and Deadly
Annals of Surgery

Dear Dr Schwartz,

Your manuscript has been reviewed, and the editorial comments are attached for your information.

We would be happy to evaluate a revised version of this manuscript in which reviewer questions and concerns have been addressed. Please include a written description of changes and highlight these changes for reviewers in your paper (please do not use tracked changes for this purpose). Please understand that there is no guarantee that a re-review will result in acceptance.

To submit a revision, go to http://annsurg.edmgr.com/and log in as an Author.  You will see a menu item called Submission Needing Revision.  You will find your submission record there. Please be sure to include all parts of the submission including tables and figures.  Remember that tables should be submitted in a document format compatible with MS Word and that figures must be submitted in high resolution TIFF, EPS, or Powerpoint file formats.

We look forward to hearing from you.

Yours sincerely

Layton F. Rikkers, MD
Editor in Chief
Annals of Surgery

Reviewers’ comments:

This is a very biased and vitriolic letter. There certainly is a broad range of opinion as to the best system of health care for the United States and open discussion is to be encouraged. However, to call a single payer system, that serves much of the Western world with equal or better results than we achieve in the United States, “immoral” and “deadly” is inappropriate and serves no purpose. Prior to consideration for publication, this letter needs to be toned down several notches.

Thank you for taking the time to review our letter in response to “Fact and Fiction: Debunking Myths in the US Healthcare System,” by Sarpel et al., and for sharing the reviewer’s comments with us.  We are certainly happy to make modifications that would suit the journal’s needs.

The only specific part of the letter the reviewer cites is the submitted title: “Single-Payer Health Care: Immoral and Deadly.”  We have made the following changes:

1.  We modified that title so that it now reads, “Single-Payer Health Care: Immoral and Hazardous to Patients’ Health.” 

2.  We removed “deeply” from the last sentence of the first paragraph.

3.  We have also, in the final paragraph, added “as we contend” to qualify the phrase “deadly and immoral.”

We kept “immoral” in the title because it captures a main point of our letter.  We don’t use it as rhetoric or personal attack.  Sarpel et alexplicitly assume a moralpremise as a foundation for their advocacy of single-payer health care.  Our letter challenges this premise, and we find nothing unreasonable about characterizing it as immoral if we disagree with it. 

To clarify that we are challenging a moral premise and making a moral argument — rather than using “immoral” in a “vitriolic” rhetorical sense — we have made the following changes:

4.  First paragraph:
Original: “This faulty premise underlies all forms of socialized medicine…”
Revised: “This faulty moral premise underlies all forms of socialized medicine…”

5.  Second paragraph:
Original: “The only proper role of government is to…”
Revised: “The only moral and proper role of government is to…”

We regard the moralevaluation of policy proposals as an integraland legitimate part of any public policy debate.  For example, one could legitimately argue whether a particular country’s policies with respect to, say, organ transplantation or euthanasia were moral or not.  Given that the initial article based their health care policy on a particular ethical and moral basis, we wished to offer a different starting moral principle and argue for an alternate health care policy as a result.  Neither articles are necessarily “biased,” to use the reviewer’s term.  They just present different points of view, and do so explicitly.

If the editors believe that certain changes in wording would be appropriate, we would be happy to consider them.  The debate about the morality of single-payer care is crucially important for the future of American medicine.  We hope the journal will allow this debate to be played out on its pages.

Sincerely,

Brian T. Schwartz, Ph.D.
Paul Hsieh, M.D.

Ref.:  Ms. No. ANNSURG-D-08-00648R1
Single-Payer Health Care: Immoral and Hazardous to Patients’ Health
Annals of Surgery

Dear Dr Schwartz,

Thank you for submitting your manuscript to Annals of Surgery.  It has been reviewed by members of the Editorial Board, and I am sorry to inform you that it was not accepted for publication. Reviewer comments are attached for your information.

Due to limited publication space, we regret that we are unable to accept many fine manuscripts.  However, please be assured that we greatly appreciate your considering Annals for your work.

Yours sincerely,

Layton F. Rikkers, MD
Editor in Chief
Annals of Surgery

Reviewers’ comments:

Reviewer #1: This represents a quite biased political statement rather than a constructive discussion of an important national issue. It sheds little light on an extremely controversial topic and detracts from reasonable discussion because of its tone. The manuscript has been minimally altered and is not acceptable for publication in the Annals of Surgery.

Dear Ms. Nevar,

Can you forward this letter to Dr. Rikkers? It concerns our submission to Annals (Ms. No. ANNSURG-D-08-00648R1).

Thank you,

Brian T. Schwartz, Ph.D.

————————————

Dear Dr. Rikkers,

We are disappointed that the Editorial Board chose not to publish our letter in response to the article by Sarpel et al in support of single-payer health care. We are concerned that the reviewer’s vague criteria were impossible to satisfy, and that the evaluation is based on our viewpoint rather than the quality of our arguments.

We would appreciate if you reconsidered the letter for publication.

Short of gutting our arguments, we fear that there were no possible further revisions that would have satisfied the reviewers concerns. The reviewer’sfirst comments specifically addressed only two words, “immoral” and “deadly.” In our revision we made explicit that were making a moralargument, and were not using the term “immoral” as a personal attack. (We explain this in the accompanying letter. Did the reviewer have access to this?). We also qualified our use of the term “deadly,” which referred not to our own statement, but that of the Canadian Supreme Court. We also removed the word “deadly” from the title.

Beyond these changes and those summarized in the letter accompanying the revision, we could not figure out what, if anything, would satisfy the reviewer. To our understanding, the review contained no objective criteria that could be met. In the letter accompanying the revisions we explicitly asked for specific suggestions, but received none. This made it impossible to submit a satisfactory revision.

In both reviews, the reviewer referred to our letter as “biased.” Yet, as I wrote in the first letter, “neither articles are necessarily ‘biased,’ to use the reviewer’s term. They just present different points of view, and do so explicitly.”

The reviewer also indicated a preference for the point of view we were critiquing. From the first review: “…to call a single payer system, that serves much of the Western world with equal or better results than we achieve in the United States…” This statement assumes as true the point our letter attempts to refute.

We are concerned the reviewer evaluated the letter according to his or her political beliefs, and not according to the merits of the arguments we presented.

We would prefer to think that our letter received a fair review and consideration for publication. As it stands, we cannot convince ourselves of this. We would greatly appreciate your feedback to help us understand better.

Thank you for your time.

Brian T. Schwartz, Ph.D.
Paul Hsieh, M.D.