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When Physicians Engage in Practices That Threaten the Nation's Health

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When Physicians Engage in Practices That Threaten the Nation's Health Opinion When Physicians Engage in Practices VIEWPOINT That Threaten the Nation’s Health Philip A. Pizzo, MD In December 2020, less than a year after severe acute young people are not harmed by the virus and cannot Departments of respiratory syndrome coronavirus 2 was identified as spread the disease; reportedly pressured the Centers for Pediatrics and the cause of the coronavirus pandemic, an extraordi- Disease Control and Prevention to issue guidance (later Microbiology and nary collaboration between scientists, the pharmaceuti- reversed)statingthatasymptomaticindividualsneednot Immunology, Stanford 4 University School of cal industry, and government led to 2 highly efficacious, be tested ; and made unsupported claims about the im- Medicine, Stanford, safe vaccines being approved by the US Food and Drug munity conferred by surviving infection. Nearly all pub- California. Administration to prevent coronavirus disease 2019 lic health experts were concerned that his recommen- (COVID-19) infection.1,2 Had the US been in its expected dations could lead to tens of thousands (or more) of David Spiegel, MD role as a global leader in medicine and public health, this unnecessary deaths in the US alone. Department of Psychiatry and would have been a fitting capstone of US commitment to History is a potent reminder of tragic circum- Behavioral Sciences, science and how that can change the course of morbid- stances when physicians damaged the public health, Stanford University ity and mortality related to a frightening new disease. from promoting eugenics to participating in the human School of Medicine, Stanford, California. However, a less flattering story emerged about the experiments that took place in Tuskegee to asserting er- inadequate US response to COVID-19. A number of lead- roneously that vaccines cause autism. It can be difficult Michelle M. Mello, JD, ers in federal, state, and local government, guided by po- to hold physicians accountable, especially when they are PhD litical exigency and recommendations from a small num- acting in policy roles in which malpractice lawsuits will Department of ber of physicians and scientists who ignored or dismissed not succeed. Professional self-regulation serves as the Medicine, Stanford University School of science, refused to promote sensible, effective policies primary vehicle for accountability and is critical if trust Medicine, Stanford, such as mask wearing and social distancing. This con- in science and medicine is to be maintained. California; and Stanford tributed to the US having more infections and deaths To that end, action from within the medical pro- Law School, Stanford, than other developed nations in proportion to popula- fession is an important but underused strategy. California. tion size, with disproportionate effects of COVID-19 The Hippocratic Oath binds physicians to “do no harm,” on already disadvantaged racial and socioeconomic an injunction that transcends individual patient- physician encounters to situations Multimedia in which physicians make medical rec- [T]o take the view that respecting ommendations for populations. For freedom of speech requires institutional instance, the American Medical Associa- tion’s Code of Ethics states that physi- silence when science is being subverted cians making media statements should is to misunderstand the concept. ensure that the information they pro- vide is accurate, appropriately conveys groups.3 In contrast, countries like Taiwan, South Korea, known risks and benefits, is “commensurate with their and New Zealand, where respect for science and medical expertise” and confined to their area of exper- truth and a collaborative relationship between public tise, and is “based on valid scientific evidence and in- health and government leaders prevailed, were far more sight gained from professional experience.”5 It “is ethi- successful at controlling the pandemic.1 cally inappropriate for physicians to publicly recommend Among the ways in which science-based public behaviors or interventions that are not scientifically well health evidence has been dismissed in the US is the re- grounded.”5 These directives reflect an awareness that placement of highly experienced experts advising na- physicians’ words are often assigned great importance, tional leaders with persons who appear to have been even for areas in which physicians lack expertise. chosen because of their willingness to support govern- There is precedent for both medical professional so- ment officials’ desire to discount the significance of the cieties and boards of medical licensing to take action pandemic. A leading example was the elevation of when physicians violate their ethical responsibilities in Corresponding Scott Atlas, MD, a neuroradiologist, who left a position nonclinical contexts. The Federation of State Medical Author: Philip A. Pizzo, MD, in academic medicine in 2012 to become a senior fel- Boards defines competence as possessing the requi- Departments of low at the Hoover Institution (a public policy think tank site abilities to perform effectively within the scope of Pediatrics and affiliated with Stanford University), to the White House professional practice while adhering to ethical stan- Microbiology and Immunology, Stanford Coronavirus Task Force. In his short tenure on the task dards, and defines the practice of medicine to include University, Lorry I. force, Atlas disputed the need for masks; argued that using the designation “Doctor” “in the conduct of any oc- Lokey Research Bldg, many public health orders aimed at increasing social dis- cupation or profession pertaining to the prevention, di- 265 Campus Dr, G1078, tancing could be forgone without ill effects; main- agnosis, or treatment of human disease or condition.”6 Stanford, CA 94305 (ppizzo@stanford. tained that allowing the virus to spread naturally will not Accordingly, many state licensing boards and profes- edu). result in more deaths than other strategies; stated that sional societies have adopted policies providing for jama.com (Reprinted) JAMA February 23, 2021 Volume 325, Number 8 723 © 2021 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Stanford University Medical Center User on 05/03/2021 Opinion Viewpoint action against physicians who provide non–evidence-based testi- First Amendment applies (eg, to officials in public institutions), courts mony as expert witnesses in litigation.7 These actions could in- have long held that it does not require officials to remain silent, even clude a formal review to determine whether the physician has en- if their own speech expressly criticizes another speaker’s message. gaged in “unprofessional conduct,”with penalties as severe as license Furthermore, universities have not kept silent when a faculty mem- revocation or expulsion from professional organization member- ber’s statements transgress other core values of educational insti- ship. The same rationale supports action against physicians who vio- tutions, such as counteracting racism and anti-Semitism. Universi- late the standards of professionalism in policy advisory roles. The ties have a responsibility to speak out for truth and science in support argument for action is even stronger than in the expert witness con- of public health. Silence is not an option, as has been tragically ob- text, when the physician’s words have a narrower influence and served throughout history. judges have a legal responsibility to exclude experts who are not Faculty also can have an important independent voice within qualified or who present information that does not comport with a university. For example, more than a hundred faculty experts chal- accepted scientific knowledge.7 lenged the veracity of Atlas’ claims in an open letter.8 In response, As the Atlas example illustrates, not all physicians serving in such Atlas’ attorney threatened a meritless defamation lawsuit, prompt- roles maintain active licensure, certification, or professional orga- ing all signatories to reaffirm their commitment to the letter. Sepa- nization membership. However, even for situations in which the con- rately, the Stanford Faculty Senate voted 85%-15% to adopt a reso- ferring organizations cannot revoke privileges, they can declare that lution: “We strongly condemn [Atlas’] behavior,” as it “violates the a physician’s actions are inconsistent with the standards of profes- core values of our faculty and the expectations under the Stanford sional conduct. This may have a powerful influence in undercutting Code of Conduct, which states that we all ‘are responsible for sustain- rogue physicians, thereby minimizing the deleterious effects of their ing the high ethical standards of this institution.’”The threatened law- actions on public health. suit has not materialized, but Atlas’ influence in the media had re- When a physician holds a university (or affiliate) appointment, mained robust despite scientific outcry (even after he resigned as a question arises about university leaders’ role in responding to de- White House Coronavirus Task Force adviser on December 1, 2020). monstrably false statements by the physician that could harm the As challenging as this situation has been, it does not stand public’s health. The most effective action is to publicly state that alone in history. It affirms that physicians and scientists have a pro- the university does not endorse the physician’s claims and finds them fessional obligation to respond when science is being misrepre- contrary
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