HCQ, Politics, and Professionalism

By now, everyone and their mother has seen the censored Breitbart video of “America’s Frontline Doctors” standing in front of the Supreme Court and vaunting a hydroxychloroquine cocktail as “a cure” for COVID.  To many, the overtly political display seemed over-the-top and proof that the stuff could only be snake oil.  It also didn’t help that the doctor who promoted its benefit with the most swagger had apparently made prior claims about the demonic origin of certain diseases.

But I will take sides here and defend those who wish to prescribe that cocktail, that they may be able to do so without fear of ignominy.  If my arguments are taken to be political, so be it. 

Whether “it works” is beside the point

The main argument against the use of the cocktail is that “it doesn’t work” or that it has not been proven to work.  Therefore physicians should be discouraged—or perhaps even prevented—from using the drug.  

By “it doesn’t work,” opponents of hydroxychloroquine (HCQ) mean that randomized controlled trials of the drug for the treatment of COVID-19 have been negative.  That was the point articulated by Dr. Fauci yesterday on MSNBC: 

The scientific data, the cumulative data on trials, clinical trials that were valid, namely clinical trials that were randomized and controlled in the proper way, all showed consistently that hydroxychloroquine is not effective in the treatment of coronavirus disease or COVID-19.

There are 2 objections against this position, one minor and one major.  

The minor objection is that the exact cocktail touted by HCQ proponents—a combination of HCQ, Zinc, and azithromycin (or doxycycline)—has not yet been tested in the context that matters, i.e., early in the course of the illness.  There have been trials of HCQ alone, and (as far as I know) a trial of HCQ plus azithromycin in hospitalized patients, but no trial of the actual combo in the outpatient setting.  So, in theory at least, the jury is still out.  

Of course, one can very plausibly make the case that, given all the negative trials, it is unlikely that yet another trial of HCQ would be positive. That’s a valid point but it remains at the level of opinion.  The chance that the cocktail works may be slim, but there are clearly medical conditions where agents are not effective singly but are effective in combination (for example the combination of ampicillin and a beta-lactamase inhibitor for gram positive infections).  There is sufficient bio-plausibility for the combination of HCQ, Zinc, and azithromycin that one ought to at least admit that it “could work.”

The major objection is that, pace Dr. Fauci, whether the cocktail “works” or not is irrelevant.  

It’s irrelevant because the relevant question for a clinician is not whether a drug has been shown to be superior to placebo in a randomized trial. The relevant question is this: Is it a good idea (is it wise) to give *this* patient *this* drug combo at *this* time for *this* condition?  That’s really the question that matters first and foremost.  

The results of clinical trials bear on the answer, of course, but only in a secondary way.  A positive trial can give you confidence that the drug will be helpful for Mrs. Jones, but it cannot assure it. Vice versa, a negative trial can greatly reduce the expectation that a treatment will work, but it cannot exclude the possibility of benefit in the particular patient. What if clinical trials excluded patients like Mrs. Jones?

The COVID context is particularly important here. For better or for worse, people are terrified of the virus. A physician serving a patient with early symptoms of the disease has to take care of that person. If the choice is between telling a patient “Look, I think you have COVID. Here’s a cocktail of medicine that will help you,” or “Look, I think you have COVID. There’s no treatment available at this stage but if you get worse you can always go to the hospital,” I hope everyone can see that the first option is far from being an obviously egregious malpractice.

And it bears remembering that randomized controlled trials typically compare a given treatment not to “usual care” which, in this case, would be no treatment (compounded by a great degree of isolation: self-quarantine) but to placebo care, with all the attention and benefits that giving placebos in the context of a clinical trial entail.  It is not all that obvious that if HCQ “fails” in a placebo-controlled clinical trial that it would equally fail in the real world. 

Now some might retort that, if a simple placebo effect is a reason to prescribe HCQ, then doctors could just as easily prescribe, say, Mucinex for COVID-19, making the same claims as they would for hydroxychloroquine and reap the same benefits. But that doesn’t hold. If psychological expectations play a role in the placebo effect, then it’s obvious that—for better or worse—Mucinex would probably fail where HCQ “might work.”

All this is to say that there is no real “scientific standing” to discourage or prevent the use of an HCQ-based treatment in the early stages of COVID-19. There can be legitimate professional disagreement, but that’s about it.

What about those “cure” claims?

Obviously, none of this should lead one to endorse the false claim that HCQ cocktail “cures” COVID-19.  Nothing can claim to cure COVID-19. COVID-19 is by-and-large a self-limited illness. It’s the body that cures itself.  Admittedly, some patients can have a very hard time curing themselves and will either fail and succumb to the virus or survive but with significant long term consequences.  By helping the body fight the virus off, perhaps HCQ can help avoid these dreadful complications in some cases.  But there is no question of “cure” in this case.

That leaves us with the question of how “reasonable” doctors should deal with colleagues who make HCQ claims that are “over-the-top.” 

By now, blue checkmark MDs are calling for the medical profession to “reckon with” these outspoken physicians. “Their words seed distrust in medicine. And, right now, it [sic] could kill someone,” says a professor about the rogue doctors, many of whom may not even be practicing physicians, or are unlikely to have ever treated an actual COVID patient.  

Here again, context matters. As mentioned above, the doctors on camera in front of the supreme court are clearly engaged in a political action. Are they taking advantage of the pandemic to try to sway public opinion in favor of Donald Trump, using their white coats as a proxy for trustworthiness? Or are they acting out of genuine concern for the medical field, seeing that if the “other side” has its way, the ability of other doctors to practice independently will be severely compromised?  Who knows?

The main problem is that we are all victims of the terrible consequences of government licensing of the medical profession. That’s where the politicization of medicine begins.

Because licensing laws have “equalized” physicians and lumped us all together, we have lost the ability to peacefully form our own “schools,” of associating with those who share similar principles, of distinguishing ourselves from those who don’t, and of self-policing (by ostracism).  

We are afraid that the behavior of some will reflect badly on all physicians but we have no mechanism to “save the profession” because licensing has done away with professionalism to begin with: no one is held accountable to principles that they have professed publicly.  All that we have are technical requirements by which doctors can be granted the privilege to practice or have it taken away by brute force—oftentimes for very unjust reasons.

So here, I’m actually willing to give the HCQ tea party some slack. I find it ironic that self-righteous accusations of unprofessionalism are leveled against them simply for exaggerating the benefit of a rather benign treatment when, as a “profession,” we have made it completely acceptable the support or engage in such practices as abortion, euthanasia, and assisted suicide.  Until I start hearing more complaints from physicians about those medical behaviors, I will save my outrage for another day.