OLYMPIA — Doctors and clinics across the state are mailing thousands of letters urging patients to join in their initiative battle against trial lawyers and so-called "jackpot" jury verdicts in medical-malpractice cases.

The mass mailing was timed to hit patients' mailboxes just before they start receiving absentee ballots for the Nov. 8 election.

Many doctors argue that it is not only their right, but also their responsibility, to lobby patients on controversial public-policy issues.

"Doctors are absolutely convinced that their ability to provide care for patients is in significant jeopardy here," said Dr. Kenneth Isaacs, a neurologist from Walla Walla and outgoing president of the Washington State Medical Association. "They want to make sure patients know what's at stake before they vote on this issue."

But some medical ethicists say the letters are improper.

"Discussion of politics at that level should really not be part of the doctor-patient relationship," said Dr. Wylie Burke, chairwoman of the Department of Medical History and Ethics at the University of Washington.

Some law firms also have sent letters warning clients that the doctors and their allies are trying to bar the courthouse doors to injured patients.

But officials with the trial lawyers' campaign, citing "campaign strategy," would not say whether they have launched a coordinated letter-writing effort similar to the doctors'.

Doctors and trial lawyers are embroiled in a high-stakes political war over a pair of ballot measures.

Initiative 330, backed primarily by doctors and hospitals, would cap jury awards for noneconomic damages — also known as pain and suffering — and limit attorney fees in malpractice cases.

Trial lawyers are pushing Initiative 336, which wouldn't limit malpractice awards and instead is aimed at cracking down on negligent doctors.

The two sides are pouring millions of dollars into television and radio ads, but both also are waging aggressive mail campaigns.

Late last month, Isaacs sent letter-writing packets to thousands of doctors, hospitals and clinics.

The packets included a CD with three different versions of pro-I-330/anti-I-336 campaign letters. Doctors were instructed to personalize one version and send copies to their patients. This week, the doctors are supposed to mail out follow-up postcards, again urging patients to vote for I-330 and against I-336.

Tom Curry, executive director for the medical association, said doctors have different comfort levels when it comes to pushing I-330. He pointed out that doctors gathered more than 125,000 signatures for I-330, well over half of what was needed to qualify the measure for the ballot.

Curry said some doctors simply leave campaign material in their waiting rooms, while others will bring up the issue in the examining room.

"It varies from doctor to doctor," Curry said.

The American Medical Association's code of ethics encourages physicians to be politically active, especially when it comes to health-care reform. The code also says it's "natural" for physicians to express their views to patients. But, it adds, "Under no circumstances should physicians allow their differences with patients ... about political matters" to interfere with care.

Earlier this year, a disagreement over I-330 drove a wedge between a Richland obstetrician and one of his patients. In that instance, after the patient refused to sign an initiative petition, the doctor told her he could no longer be her care provider.

The incident drew criticism from Burke and Dr. Thomas Gallagher, a UW internist who has done extensive research on doctor-patient relationship issues. They said the medical association's letter-writing campaign raises similar concerns.

Burke and Gallagher pointed out that doctors are in a position of power in their relationship with patients. The problem with lobbying patients on issues like I-330, Gallagher said, is that patients who disagree might worry, "How would that affect the kind of care I get?"

Burke said she thinks it's fine for doctors to educate patients on important public-policy issues that relate specifically to the individual patient's health. And she said she has no problem with doctors speaking out publicly in favor of I-330, such as on TV commercials.

"The problem I have with doctors lobbying individual patients is that there is a lot of potential self-interest in I-330 for the doctors," Burke said.

But Isaacs, the Walla Walla neurologist, disputed Burke's assertion that doctors are acting out of self-interest in lobbying patients on I-330. He said doctors are convinced that problems in the medical-liability system are a threat to health-care access and that they have a "duty" to inform patients.

Besides, Isaacs added, "Obtaining a medical license shouldn't go hand in hand with forfeiting your First Amendment rights."

Ralph Thomas: 360-943-9882 or rthomas@seattletimes.com