The article highlights various implications of the unproven treatments suggested by patients and how physicians can respond to such requests.

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Key takeaways

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Remember the early days of the pandemic, when clinicians knew little about COVID-19? There was a palpable level of fear in providers and patients as ERs and refrigerated trailers serving as temporary morgues filled up.

Two years later, with vaccines and therapeutics, it’s easy to forget how fear bred desperation, which drove many patients to seek unproven treatments such as hydroxychloroquine and ivermectin. Among the many lessons of the COVID-19 pandemic is one on communication specifically, how doctors can respond to such requests. 

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Ethical implications of unproven treatments

Basil Varkey, MD, is a retired pulmonologist and professor emeritus of medicine with the Medical College of Wisconsin. These days, he peer-reviews articles and serves as section co-editor for Current Opinion in Pulmonary Medicine. One of his chief interests is clinical ethics, which he wrote about in a 2021 Medical Principles and Practice review.

In an exclusive interview, Varkey was unequivocal about the ethical implications of denying requests for unproven treatments.

He quoted:

“I really don’t see much of an ethical dilemma at all.  If you break it down, the physician, as a professional, is bound to serve the best interest of the patient. And if a physician, with his knowledge and background, feels that a particular treatment is unproven and not in the best interest of the patient, then it should not be prescribed.”

This is aligned with the AMA’s Code of Medical Ethics, which specifies that doctors should prescribe “based solely on medical considerations, patient need, and reasonable expectations of effectiveness for the particular patient.”

Varkey said that refusing to prescribe an unproven treatment doesn’t conflict with patient autonomy, one of the fundamental principles of medical ethics outlined in his Medical Principles and Practice review. “Autonomy obliges the physician to disclose medical information and treatment options that are necessary for the patient to exercise self-determination and supports informed consent, truth-telling, and confidentiality,” he wrote.

Absent from that description is a requirement to acquiesce to every patient's demand. “Patient autonomy is not in the choice list of treatments,” he said.

He advised that doctors consider what the patient is asking for and whether there’s any merit to the requested treatment. If the answer is no, then ask yourself, Is there a possible downside to the treatment? If the answer is possible yes, patient autonomy doesn’t factor in. Of course, the implications of requests for unproven treatments expand beyond the realm of ethics.

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Legal implications of unproven treatments

While a doctor may deny access to unproven treatments, courts have sometimes intervened, as they did throughout the pandemic, in some cases forcing hospitals to deliver them. Such a case was highlighted by a March 2022 New England Journal of Medicine Perspective.

In that case, the wife of a Texas man with COVID-19 who was on a ventilator and in an induced coma found a doctor unaffiliated with his hospital who was willing to prescribe ivermectin. She filed a court petition to force the hospital to provide the drug but lost. However, similar suits in other states succeeded, as the NEJM perspective noted.

This variability in outcomes stems from the “pliable” nature of the law as it pertains to prescribing, physician licensing, the doctor-patient relationship, and hospital credentialing. It’s normal for patients to have multiple doctors, but this can prompt them to doctor-shop for a physician willing to prescribe the treatments they seek.

However, hospital-credentialing requirements may bar the willing doctor from prescribing. When this conflict occurs, physicians and hospitals have two options, according to the NEJM article. Doctors can weigh the outside doctor’s input and decide on the prescription, or hospitals can transfer the patient elsewhere. If the impasse persists, the perspective notes that several courts have deferred the judgment of hospitals. While this may be some consolation to doctors, court battles are probably far from their minds at the point of care.

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Handling patient communication

Varkey advised that if a patient wants an unproven treatment you’re unwilling to prescribe, you should try to remain emotionally detached.

“It became a bit easier for me as I got more grey hair,” he said. “Early on, you react to it. But as you get older and more experienced, you can put yourself more in the patient’s and the family’s situations and you’re much more tempered in your reaction and advice.”

In the case of COVID-19, putting yourself in patients’ and families’ shoes requires comprehending the sometimes extreme uncertainty and anxiety that accompany a positive COVID test. To help, the AMA developed a patient care module to facilitate empathic listening.

“In this current era of COVID-19 with unprecedented levels of uncertainty and anxiety, it is even more crucial that clinicians employ empathetic listening to understand and allay patients’ fears and concerns,” the AMA wrote.

This is no easy task, Varkey said—but it’s essential. "But when you choose the profession of taking care of people as a physician, you sometimes are going to be in difficult situations.”

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This story is contributed by Joe Hannan and is a part of our Global Content Initiative, where we feature selected stories from our Global network which we believe would be most useful and informative to our doctor members.