© 2003 American Thoracic Society
ATS, American Bar Association, and AsbestosTo the Editor:Dr. Thomas Martin, immediate past president of the American Thoracic Society (ATS), wrote, on April 23, 2003, to the President-elect of the American Bar Association (ABA), Mr. Archer. His motive for doing so is not clear. The wording of his letter, particularly the statement, "The ATS has the following concerns ..." intimates that he is communicating concerns shared by a general consensus of the Society at large. His letter has been circulated to members of the ABA. It is being portrayed by members of the Bar as an official opinion of the Society and is being utilized as such in asbestos litigation. ATS has a development process for official ATS documents that was last updated December 2002 (1). This process requires a minimum of six recommendations for potential reviewers selected by the Documents Coordinator and the ATS Journal Editor, if not initiated by the Assembly. Dr. Martin's letter abrogates the ATS process for development of official documents. It is my opinion that Dr. Martin's unilateral action was an improbity of his fiduciary responsibility to the Society at large. His statements should have been proffered, if proffered at all, with the codicil that they represent only the personal opinion of one who also happened to be, at the time, President of the ATS. The last official statement of the ATS regarding asbestos diseases was published in 1986 (2). It is my understanding that a Committee, chaired by Dr. Guidotti, has undertaken a revision of the 1986 official statement. If so, then why would Dr. Martin deem it necessary to usurp the Committee by an action of primacy? His letter reveals his knowledge of the existence of the Committee's forthcoming revision. A simple statement to that effect would have sufficed. Dr. Martin stated, "Significant asbestosis can be present with an X-ray profusion less than 1/0 or even with a normal x-ray." He then stated that impairment therefrom could be manifest by a decrease in the diffusing capacity (DL) without any other physiological abnormality. Further, he stated that the DL is standardized, referring to the 1987 ATS recommendations (3), and that it is available at any lung center. Perhaps, in an ideal world, that would be accurate. Apparently, however, Dr. Martin is unaware that the ATS published an update in 1995 (4) within the first two pages of which it is clearly stated that "considerable test variability can be expected." A conclusion of the Committee was that "... the potential for large variations in measured DLCO, predicted DLCO, and percent predicted DLCO still exists." Further, there are many confounders—that is, emphysema (4), recent cigarette smoking (5), acute and chronic alcohol ingestion (4), gastroesophageal reflux disease (6), elevated carboxyhemoglobin (7), and others—that affect the DLCO. Pulmonologists know that a ventilatory function study does not definitively diagnose any disease. The DLCO, without rigorous elimination of confounders and additional objective medical evidence, does not permit the assignation of an impairment to the solitary disease state of asbestosis. Without entering into a detailed discussion, Dr. Martin's assignation of similar importance to the FVC demonstrating "impairment from asbestos ... when the X-ray is normal" is equally as ludicrous. Dr. Martin also addressed "pleural scarring" and referenced Lilis and colleagues (8). He used the terminology of "diffuse pleural thickening" and "circumscribed pleural scarring." He did not distinguish the difference, in lay terms, among them. Instead, he combined the effect of both as a reduced FVC. He is not an NIOSH-certified B reader and may not have thought it necessary to make this distinction. Be that as it may, on balance, an individual with only circumscribed (plaques) pleural thickening usually has lung function tests within the normal range and exertional dyspnea is usually absent (9). In summary, it is my opinion and firm belief that no individual of the Society's hierarchy should express personal opinions that have not been clearly and emphatically stated to be their own. Dr. Martin's letter is one that should have resided many nocturnal hours beneath his pillow before the dawning sun was ever permitted to shine upon it.
Morgantown, West Virginia FOOTNOTES Conflict of Interest Statement: J.J.R. has no declared conflict of interest. REFERENCES
From the Author: Dr. Renn expresses concern that I used my position as President of the American Thoracic Society (ATS) to express my personal opinions to the American Bar Association (ABA) about the evaluation of patients with asbestos-related diseases, but his concern is unfounded. The letter that I wrote to the ABA, and a second letter written by the current ATS President, Homer Boushey, Jr., M.D., to members of Congress, have been posted on the ATS Website for ATS members to read for their own information (1, 2). With the office of President of the ATS comes the responsibility to represent the ATS in many different ways. As President, one recognizes that the ATS has a diverse membership, which includes internationally recognized specialists in virtually all of the areas of pulmonary and critical care medicine (3). By including internationally recognized experts on ATS committees and task forces, and by encouraging a wide range of Assembly activities, the ATS gains strength from the broad expertise of our members. Our membership provides the ATS with the intellectual resources needed to develop and express public positions even when the ATS President is not an expert in a specific area. Adam Wanner, when he was ATS President, referred to this as "distributed leadership," and saw this as a major strength of our organization (4). The asbestos issue cited by Dr. Renn is a case in point. An ATS working group consisting of internationally recognized experts and chaired by Tee Guidotti, M.D., is finalizing a new ATS Statement on asbestos-related diseases, which we expect to be published in the American Journal of Respiratory and Critical Care Medicine in 2004. The membership of this committee can be viewed on the ATS Website. Early in 2003, members of this group learned that the ABA was drafting a position on new asbestos legislation under consideration in Congress. Because they believed that the ABA position was based on outdated information, and because of the upcoming ATS Statement on asbestos-related disease, they encouraged me as ATS President to communicate with the President of the ABA by letter. Members of the ATS asbestos committee helped to draft the ATS letter to the ABA and approved the wording of the final draft. Gary Ewart, the head of our ATS office in Washington, DC, and an expert on legislative affairs, also reviewed the letter and provided a valuable perspective on the legislative initiative underway in Congress. In this letter, we informed the ABA that the medical information that they were using was not current and that the ATS was finalizing a new statement on the medical aspects of asbestos-related lung disease. This letter was sent to the President of the ABA in April 2003. In June 2003, the ATS was asked by Congressional committees to comment on the new asbestos legislation under consideration. Dr. Guidotti and members of the asbestos writing committee reviewed the legislation and drafted a document with comments on the medical issues involved. ATS President, Homer Boushey, sent this document to Congress with a cover letter to the committees involved. Through this mechanism, the ATS had thoughtful and professional input about the medical aspects of asbestos-related lung disease. This may influence the development of the new asbestos-related legislation. Commenting on the medical aspects of asbestos-related lung disease is fraught with difficulty because individual physicians and scientists inside and outside the ATS have been involved on both sides of asbestos litigation. By drawing on the work of a committee of internationally recognized experts who are producing an updated consensus document on asbestos-related lung disease, I used "distributed leadership" to speak with authority on an important topic that affects the health of the public. This ATS process enables us to serve our members and patients around the world.
Immediate Past President American Thoracic Society FOOTNOTES Conflict of Interest Statement: T.R.M. has no declared conflict of interest. REFERENCES
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