Last week, a friend sent me an article by Avery Wilks of Charleston's Post and Courier ("SC Doctor Discipline Board Silent as COVID-19 Misinformation Debate Rages," 26 Feb, 2022) about a topic that has been of great interest to me over the past couple of years. In the article, Wilks discusses the fact that there have been no South Carolina physicians disciplined by the S.C. Board of Medical Examiners for 1) prescribing unproven, off-label treatments for COVID-19, or 2) discouraging patients from getting COVID vaccines. He said that this is a "good thing" according to conservative politicians and physicians who want to empower physicians to prescribe alternative treatments like hydroxychloroquine (HCQ) and ivermectin for COVID; that this is concerning to physician groups who want medical boards to take a stronger stand against COVID misinformation; and that it is frustrating for patients who wonder if their complaints to the medical boards are being taken seriously. One patient featured in the article complained to the South Carolina Board of Medical Examiners that his physician had 1) repeatedly downplayed the threat of COVID-19, 2) had prescribed him HCQ, and 3) told him that COVID-19 vaccines were "made to kill people and thin the earth's population."
Let’s take a step back and look at these issues, though. They are not always black-and-white. It’s way too easy to want to punish people who disagree with you or give a free pass to people who agree with you. These issues require an objective look beneath the surface rather than a knee-jerk emotional response. To do this, we need to understand that the ethical practice of medicine involves contractual obligations to our patients but also to our profession and our society, and in many cases these days to our employers (for the growing number of physicians employed by corporations). The final analysis often falls somewhere in the middle. All it requires is thinking for oneself.
One of the better known codes of ethics for the medical profession is the one endorsed by the American Medical Association (which is the basis for the South Carolina Code of Medical Ethics as written in Chapter 81, Article 6 of the South Carolina Code of Laws). This code calls for physicians to provide competent medical care with compassion and respect for human dignity and rights. It calls for us to uphold standards of professionalism and to be HONEST in all professional interactions. It says that a physician should respect the law, but to strive to change the laws when they are contrary to the best interest of our patients. The code calls for doctors to continue to study, apply, and advance scientific knowledge; maintain a commitment to medical education; and make relevant information available to patients, colleagues, and the public, when indicated. We are free to choose the environment in which we practice, whom to serve, and with whom to associate. We are also charged with a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. Above all, our responsibility to our patients is paramount.
In the Post and Courier article, one Upstate physician was quoted as saying, "the main thing for me is that the CDC, the FDA, Dr. Fauci, they shouldn't interfere in the doctor-patient relationship. It's up to the discretion of the physician to choose what's in the best interest of the patient." Whoa! This is not only arrogant and paternalistic, but is also a blatant mis-characterization of how medicine is practiced in the United States...at least the way I was taught. I have been in private practice for 25 years, and never--including the years of the pandemic--have the CDC, FDA, or Tony Fauci, EVER interfered with the relationship I have with my patients. None of those entities "tell" me how to treat my patients. Standards of care are not dictated by one man or by one agency, but are formulated through careful, and evolving, scientific data. That is why we commit to CONTINUING education, so that we follow the advancement of our knowledge on a subject in order to know all of the treatment options. Then we present them to our patients. This requires a critical and objective appraisal of ALL available science, as well as the current standards of care and potential adverse effects of treatment. It affords us the ability to block out the noise of our own political, religious, ethnic, and social beliefs, and concentrate on tailoring a treatment plan to the values, beliefs, and medical needs of our patients within the bounds of what we feel is medically, ethically, and morally appropriate. The doctor-patient relationship is a team effort, not a dictatorship, and for one man to think that he, and he alone, holds the discretion above all else for determining what is in his patient's best interest is taking the term "relationship" out of the equation and may be ignoring best practices. After researching the physician quoted in the article, it seems that he is chiefly concerned with being able to decide what’s in his patients’ best interest based on his own religious and political philosophy. In my opinion, an infectious disease should not be made to be a political football. SARS-CoV-2 is no more of a democratic virus than influenza is a republican virus.
That being said, there is nothing inherently unethical about politics, religion, and other issues coming into play in someone's medical practice. There are well-documented studies demonstrating that a physician's political leanings, religious preference, race, ethnicity, and gender, all may come into play within his or her practice of medicine, especially those that involve hot-button issues such as gun safety and abortion. Only when those factors interfere with presenting all available data, and representing that data honestly to the patient based on known standards of care, does it cross the ethical line. Even so, there is also nothing automatically unethical about prescribing off-label treatments. If a physician knows that there are anecdotal studies showing that some people may benefit from a medication, but that the preponderance of evidence shows no benefits, and he or she knows the side effects of the medication in question, and presents all of that information to his or her patient, allowing them to make an autonomous decision, then that physician should absolutely NOT be punished for prescribing his or her patient HCQ or Ivermectin. By the same token, there is also nothing wrong with a physician deciding that he or she should not prescribe HCQ or Ivermectin to his or her patients because it showed no benefit in the studies, or if there was a concern about risks of the treatment outweighing the benefits.
Recently, South Carolina's Attorney General wrote an opinion stating that South Carolina state law protects doctors who prescribe off-label treatments as long as they have informed consent to do so. As long as they have informed consent, and not someone's biased slant on it, I agree with this one hundred percent. Prescribing off-label has been around for decades. Sometimes it helps, and sometimes it doesn't, but as long as the patient knows what they're getting into, it is certainly something that doesn't deserve punishment by the state licensing agency. Now, the issue of prescribing a treatment that has not been shown to have benefit, and exactly how professional that is, is another story. If there are better treatments available, it might in some instances be considered unethical to prescribe unproven therapies in place of more beneficial ones—especially when the better treatment is not offered or either therapy is falsely portrayed. Some doctors want to prescribe alternate medications like HCQ and Ivermectin, but are prohibited by their employers. This is well within the purview of the hospital systems and other employers to do, since the doctor has entered into a contractual agreement with that hospital or clinic, and they must, therefore, abide by their rules. After all, the physician works for—and represents—them.
A state legislator from Aiken County applauded the Attorney General's opinion, and stated that "doctors should practice medicine and we should stay out of their way." Maybe he should have added, "if they agree with my political party's stance on the type of medicine they are practicing." Some legislators in Tennessee have threatened that they may try to disband the Tennessee Board of Medical Examiners after the board agreed to discipline doctors who spread misinformation about COVID-19 vaccines. The Tennessee legislature passed three bills preventing the Tennessee Board of Medical Examiners from disciplining doctors because of how they treated or what they said about COVID-19 without going through the Joint Government Operations Board. They also demanded that the Board remove the policy from their web site. So much for the government staying out of the way of a board of physicians disciplining unethical members of their own profession! Let's not leave the doctors alone to police themselves professionally. We are against government interference...unless we're for it.
My question here is, who are they protecting? Not the patients, that's for sure, and definitely not the public. They seem to be protecting an ideology of some sort. They use the guise of "protecting the doctor-patient relationship" and "not having government interference," when that is all very convenient, since the same folks advocate for being paternalistic and ignoring standards of care when it suits. They also support government interference when it suits. It's not just a red issue or a blue issue. Both sides do it. The double standards make my head spin. With regard to COVID-19, doctors have a contractual obligation not only to our patients and profession, but to society, though our state licenses. We have a duty to commit to the common good of society, especially in times such as these past two years during a pandemic caused by a novel coronavirus. Spreading misinformation about the virus, downplaying its severity, and telling blatant lies about COVID vaccines is not only contrary to our patients' best interest, it is shirking our responsibilities: to be honest in all of our professional interactions, to study and apply scientific knowledge, and to contribute to the betterment of our community and public health. Again, I ask…who is being protected by allowing the spread of lies and conspiracy theories to go unchecked?
What if your doctor discouraged you from receiving necessary cancer chemotherapy, stating that it was a ploy by medical elites to thin the herd? What if your doctor told you it was okay to drive drunk since relatively few people die when they choose to drive drunk? What if your doctor said that seatbelts don't work, because people still have accidents when they're wearing them? You'd think he or she was crazy. At the very least, they'd be professionally irresponsible and dishonest. That is the same thing as doctors downplaying the impact of COVID-19 and lying about the vaccines, and those folks should be subject to discipline by the SC Board of Medical Examiners, in my opinion. That is our duty as outlined in the state constitution. Both the state code and the AMA code of ethics charge us to “report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.” This is why I support the Federation of State Medical Boards and a group of physicians who have formed an organization known as "No License for Disinformation," who agree that physicians knowingly and willfully spreading false information about COVID-19 vaccines should be punished by their state medical licensing boards. As of the end of February, twelve states have taken action against doctors for disinformation they have spread during the pandemic.
The problem is not politics or religion in medicine. The problem is not formulating standards of care or whether or not to listen to the advice of experts. Those have been and always will be factors in the medical profession. The problem is when we let our biases cloud our judgement and prevent honest, objective appraisal of data, resulting in the unethical and unprofessional practice of medicine. Even though the pandemic is at a lull right now, these issues will still be with us and are important as we move toward the future. The integrity of the medical profession, the credibility of physicians and medical researchers, and the future of pandemic responses (among other things) are all at stake. We have a duty to protect our patients, our profession, and our society. We should stand up for them. South Carolinians deserve the best we have to offer.
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