First, Do No Harm
As physicians we took an oath to do no harm. The public is being harmed by misinformation aimed through marketing attempts to eliminate the risk involved in taking something with unknown results. Governments depend on scientists for the truth but often over rule them to give the public a false sense of security to alleviate panic. A global pandemic should have been easier to navigate through the use of modern science but instead unleashed a mania of misinformation not backed up by facts. If we are going to subject any patient to any risk we have to be truthful and clear on what those risks are.
On Sunday, May 24, The Guardian ran a story highlighting one of the many sources of information about Covid-19 and its treatment that is at odds with mainstream science.(1) Supporters of President Donald Trump are citing some of these sources as scientific support for his purported use of hydroxychloroquine to protect himself against Covid-19 infection. The particular source cited in this issue of The Guardian is Dr. Jane Orient, executive director of the American Association of Physicians and Surgeons (AAPS). In a perfect world, science would never take political sides. All governments would look to scientists for the truth and that is what the scientists would deliver. It’s a Utopian ideal that will never become reality. Governments have overruled scientists for centuries and there is no reason to think that will change. Copernicus, for example, withheld publication of his theory of the heliocentric universe for nearly three decades for fear of running afoul of Church doctrine. Nearly a century later, Galileo did, in fact, endure the wrath of the Church (which was co-equal with government of the time) when he embraced the notion of earth revolving about the sun. He was tried by the Roman Inquisition, found “suspect of heresy” and sentenced to house arrest for the remainder of his life.
Fast forward to the twenty-first century. A global pandemic featuring a novel RNA virus unleashed on an immunologically naïve population has upended life as we know it for a sizable portion of earth’s human inhabitants. How fortunate we are to live in the modern world…a world where we don’t have to blame pestilence on unseen demons or the sins of our ancestors or other things beyond our control. We have modern science! We know that observation and experiment and meticulous examination of facts will lead us to answers we can believe. Or do we?
But let’s get back to the President and his use of hydroxychloroquine (HCQ). It’s unclear upon whose advice the Chief Executive is taking HCQ or even if he truly is. But Dr. Jane Orient has certainly stepped forward to defend the decision. She speaks on behalf of the American Association of Physicians and Surgeons (AAPS), which by her own acknowledgement (2) does not typically involve itself in medical issues. Yet, they have spoken out unabashedly on this issue. They claim to have compiled “all” the relevant studies testing HCQ against Covid-19 and their results demonstrate this very inexpensive and widely available drug is more than 91% effective against SARS-CoV-2 with a demonstrated mortality of 0.5%.(3) It is also interesting to note that none of the studies were independently peer-reviewed, none were blinded nor were they compared against untreated controls. This is not the first time the AAPS has disagreed with mainstream medical thought. They have argued that HIV was not the cause of AIDS, that childhood vaccines are linked to autism, and that government efforts to discourage tobacco use was misguided and harmful. This is not science. This is marketing. I have included some references below that demonstrate a considerably more objective look at the clinical use of HCQ for treatment of Covid-19. (4,5,6,7,8,9,10)
Now, before my detractors begin to call for my head on a pike, let me say that I’m not advocating for a prohibition against treatment of active cases of Covid-19 with HCQ. Off-label prescription of medication happens day in and day out in our world. What I am advocating for is truthfulness. If we elect to prescribe a medication for an indication for which there is no substantial supporting evidence, we are obligated by our oath to make that clear to the patient. And why is that? It’s because the risk is born by the patient. Potentially harmful, even fatal reactions can and do happen with any drug. Sometimes those untoward reactions are entirely new and unexpected. Sometimes the reaction is rare, but well-known, as in the case of cardiac rhythm disturbances associated with HCQ. Another very important, although often overlooked risk is that of an unjustified sense of security. If patients are given the impression that they’re taking a medication that protects them against infection, what risk might they take or what risk might they subject others to if they become infected and assume it can’t be Covid-19?
If we’re going to subject any patient to any risk, we are morally obligated to be entirely truthful. It is not truthful that solid evidence supports use of HCQ in cases of Covid-19. It is not truthful that use of HCQ in Covid-19 is without risk. It is not truthful, nor have there been any studies attempting to demonstrate that HCQ can prevent Covid-19 infection. Shame on any physician who fails to make that clear. Primum non nocere…first, do no harm. Non-maleficence is built into the physician’s oath. If we don’t honor that obligation, we’re no better than the politicians.
- N Engl J Med 2020; doi:10.1056/NEJMoa2012410
- JAMA 2020; doi:10.1001/jama.2020.8630
- BMJ 2020; 369: m1849
- BMJ 2020; 369: m1844
- JAMA Cardiol 2020; doi:10.1001/jamacardio.2020.1834
- JAMA Cardiol 2020; doi:10.1001/jamacardio.2020.1787
- Ann Intern Med 2020 doi:10.7326/M20-1998
To read more of Dr. Randy Cook's blog "The Script Pad" go to https://mymdcoaches.com/blog. Dr. Cook is also host of MD Coaches, LLC's weekly Rx for Success Podcast found at http://rxforsuccesspodcast.com.
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