I appreciate Dr. Kapusta's response to my editorial [1]. My thesis is that physical and emotional stresses in the workplace can confound, as well as create, a "present illness." The illness of work incapacity is an issue for most patients and a challenge to manage. Available redress for work incapacity is all too often iatrogenic. However, I stopped short of suggesting ways out of the quagmire. Dr. Kapusta urges me to do so. In this brief response, I can only sketch some possible solutions.

I must disagree with Dr. Kapusta; the workers' compensation system in the United States is already "no-fault." Workers are indemnified for any injury that arises from or in the course of employment and occurs by accident, even if the injured worker was responsible. The trade-off is that indemnification is the "exclusive remedy"; generally, the worker can not sue his or her employer.

Three other features are problematic and beg reform. Two pertain to workers' compensation, the third to all disability schemes.

1. Workers' compensation exists because the injured worker is deemed to be particularly worthy. Social Security schemes are meager in comparison. Access to the greater largesse pivots on the definition of "injury." The notion of violent injuries, common to the early statutes, has proved to be no match for epistemologic elan; the inguinal hernia and the extruded nucleus pulposus became "ruptures," and sophists are now transforming arm pain and psychological stress. Rather than rejoin the battle to define injury, I would abandon workers' compensation entirely in favor of a single tier of disability insurance. Equally pressing is the provision of employment in which job autonomy, job sharing, and compassion supplant the "bottom line." More Americans might then have other options than to find their illness disabling.

2. Workers' compensation indemnifies all treatment aimed at putting things as right as possible. If the claimant refuses, the veracity of symptoms is questioned before the advisability of the intervention. No wonder "injured workers" are subjected to so much more than are other patients and to so little avail. "Maximum medical improvement" is not an end point—it is a process. Abandon any other notion.

3. Our nation has taken impairment rating for disability determination as gospel. This notion holds pathoanatomy as a reasonable surrogate for disability. It's not! Short of the catastrophic, impairment is a barely discernible influence. Yet, "contracted examinations" and "independent medical examinations" abound. The entire process is Kafkaesque. Impairment rating should be relegated to history. Because medical documentation is a minor factor, a panel of peers could be empowered to determine disability.

The United States deeply fears rewarding anyone who is undeserving, anyone who truly could work. How do we catch the scoundrel? The solutions promulgated a century ago operate in the United States today. We squander wealth to avoid bestowing a pittance on the unworthy. Common decency calls for us to do better. Legislators need to understand the medical hazards of the unhappy workplace, redundancy, and displacement. They must realize that an Orwellian society swimming in bureaucratic make-work is a public health hazard. Until such leadership emerges, I'll duck the solution and simply offer the wisest counsel I can muster for any of my patients who face the illness of work incapacity.