This has led to claims that powerful doctors can abuse the process to punish other doctors for reasons unrelated to medical issues (termed "sham peer review").

A federal judge wisely ruled that the administration could not punish doctors who recommend the benefits of marijuana to their patients.

Professionals in medicine need them, too, he said, not only to punish bad doctors, but to reassure good ones that they remain proficient in their skills.

Now, some advocates are trying to swing the pendulum in the other direction, by pressing authorities to punish doctors for not using pain medicine aggressively enough.

The American Medical Association is also asking the trade commission to let local medical societies punish doctors for fee gouging.

Families have sued doctors for "medical battery" for forcing life support or resuscitation on unwilling patients, and some states punish doctors who disregard advance directives.

That act was intended to thwart drug abuse and trafficking, not to punish doctors who prescribed medicines in accord with state law.

The death toll was much higher in Argentina and Chile, where efforts to punish doctors who aided the torture of political prisoners have been largely unsuccessful.

Mr. Dukakis's advisers and supporters say he never intended to punish doctors, and that he has been working hard to improve relations with them.

For-profit managed care companies punish doctors financially if they provide too much care, which becomes an impediment to pain control and palliation.