Arnold-Relman is the man who decides what will appear in the New England Journal of Medicine. The man who writes the editorials that continually have him embroiled in controversy. The man who called the ethical foundation of medicine outdated, who has challenged doctor's conflicts of interest, who has questioned whether capitalism should rule medicine.

He hasn't written an editorial he'd retract, he says with frankness bordering on the glib. Not yet, he laughs.

Crimson: In march nearly 2000 physicians-intraining struck eight hospitals in New York City claiming that patients were dying needlessly because of staff and equipment shortages. Do you support such strikes and if not, what other ways would you suggest for the strikers to bring about the enforcement of standards in patient care they feel are lacking?

Relman: I think that withholding services is a totally inappropriate technique for physicians to use because they can only damage people who they're supposed to be serving. A strike is a legitimate social technique when it's a weapon against an employer but when physician strike, who are their Employers? The city of New York is not going to be hurt financially or economically by the strike. The people who are going to be hurt are the people who need the services in the hospital...I'm in total sympathy with their objectives if they are as stated to improve the quality of care in hospitals which are probably not very organized and not very well maintained. But that's not the way to do it.

Crimson: What is the way?

Relman: One way is to withhold professional approval of such hospitals as teaching hospitals. The city would respond I think, to pressure from the accrediting bodies which decide whether hospitals should be approved for teaching or not. Simply to walk off the job is nothing for a doctor to do. A doctor doesn't have any right to walk off the job.

Crimson: I think the striker's argument would be slightly different. They see no other way to bring dangerous conditions to the attention of the public. They are not trying to hurt the city, they were not striking for more money. They were simply striking for attention.

Relman: I don't wish to tell the interns and residents of New York what to do, but I do wish to suggest that withholding professional services is not the best way to call attention to your situation. If I were a patient in one of those hospitals. I would not appreciate what the residents did even though they say they were doing it in my interest.

Crimson: About one-eighth of all doctors in the United States are now part of physician's unions. Are you in favour of such unions?

Relman: I'm totally opposed to them. Unionization is for workers in an industry. Medicine is not an industry. Medicine is not a business. Medicine is a profession and the economics and ethics are entirely different. It's very sad to see that medicine is being treated more and more by both the profession and the public as a business. But I think that it's not in the best interests of the public...in the long run.

Crimson: What are you blaming this condition on?

Relman: I think there are many reasons. The main reason I think is simply the tremendous economic burden that health care now carries. Health care is the second largest industry in the country. There are tremendous pressures on the part of government to control the costs, there are temptations to the profession to profit from the enormous amount of money that's being spent on health care and I think that there are many people who view it simply as another business. But it isn't.

Crimson: Advances in technology have virtually transformed medicine several times since 1945 yet you have said that we overuse technology that are of marginal benefit to the patient and drive costs up unnecessarily. What can we do to stop this?

Relman: I think there are two general approaches that have to be taken. One is that government and the insurance companies and all third parties that pay for health care have to remove the perverse economic incentives that stimulate doctors to overuse medical technology. Doctors are only human and theyrespond to economic incentive just as any other human being would and the system that we now have...encourages overutilization of intensive, elaborate procedures...Any procedure that is recognized as safe and is believed to be effective is accepted by the profession and will be reimbursed. And usually the more expensive and more elaborate and more technical, the more it's reimbursed for...If the money is there to pay for them and the patient likes the idea of having these elaborate tests done and the doctor is trained to do them, they're gonna be done.

Secondly, the profession has to pull up its socks and take more responsibility for monitoring what it does. The profession has to be more critical of itself, it has to set up more rigorous systems for evaluating its own technology, making rigorous decisions about what's justified and what isn't.