Physicians, not judges, should direct patient care

AMA News Wire

Physicians, not judges, should direct patient care

Jan 31, 2023

Our AMA Code of Medical Ethics reminds us that the practice of medicine is, at its core, a moral activity in which physicians bear an ethical responsibility to use sound medical judgment in caring for our patients. This demands that we always act in the patient’s best interest in directing their treatment based on evidence-based medical science, reasonably expected benefits, and informed consent.

It is against that backdrop that justices of the Wisconsin Supreme Court heard arguments recently in the matter of Allen Gahl v. Aurora Health Care Inc. The AMA’s Litigation Center and the Wisconsin Medical Society jointly filed an amicus brief late last year urging the justices to uphold a state appellate court’s decision that a physician or private hospital cannot be legally compelled to administer a particular drug or treatment determined to fall below the standard of care.

In other words, a third party cannot—and should never be—granted the authority to dictate a patient’s course of care when his or her own doctor, and established medical consensus, determines that care to be unsafe or unsupported by scientific evidence. Not in Wisconsin, nor anywhere else.

Physicians are obligated to recommend and provide interventions that are scientifically sound in light of the patient’s clinical situation and goals for care, and that in their professional judgment will offer benefit to the patient. Physicians should have the ability to reject care that is unlikely to yield clinical benefit—particularly when there is evidence that an intervention both lacks efficacy and may harm the patient.

This case arose after John Zingsheim, a 60-year-old resident of Waukesha, Wisconsin, acquired COVID-19 in September 2021. As his condition worsened, Zingsheim was first admitted to the intensive care unit, then placed on a ventilator. Gahl, his nephew who held a health care power of attorney for his uncle, contacted a physician who agreed to write a prescription for ivermectin for Zingsheim, even though he had never met or examined Zingsheim nor was he credentialed to treat patients at the hospital in question.

In tablet form, ivermectin is approved by the Food and Drug Administration (FDA) to treat strongyloidiasis and onchocerciasis in people afflicted by parasitic worms, while topical forms of the drug are used to treat head lice and certain skin conditions. It also is used off-label to effectively treat other parasitic infections as well as infestations with arthropods, including scabies mites. Multiple studies, however, have shown ivermectin to be ineffective in preventing or treating COVID-19. Both the FDA and the Centers for Disease Control and Prevention (CDC) have warned against its use for those purposes, as has its manufacturer.

Three weeks before Zingsheim was hospitalized in Wisconsin, the AMA had joined the American Pharmacists Association and the American Society of Health-System Pharmacists in calling for an immediate end to the prescribing, dispensing and use of ivermectin to prevent or treat COVID-19 outside of clinical trials. 

After physicians and administrators at Aurora Medical Center-Summit refused Gahl’s request to administer ivermectin to his uncle because doing so would be below the standard of care for COVID-19 patients, Gahl pursued legal action. The record shows that in this particular case, John Zinghsheim thankfully cleared his COVID-19 infection—without the use of ivermectin—and was later discharged from the hospital.

As the amicus brief filed by the AMA and the Wisconsin Medical Society in this matter points out, Aurora Health fully met both its ethical and legal obligations by following an evidence-based protocol, which did not include ivermectin, to treat Zingsheim’s COVID-19 infection. A legal ruling holding otherwise, the brief states, “would allow courts to compel treatments that the medical consensus finds to be substandard” and force physicians “to choose between the law and their ethical responsibilities, potentially exposing patients to harm and physicians to liability.”

Medical ethics demand that the health and well-being of patients form the basis of treatment decisions. Physicians are expected to provide patients with safe, effective, high-quality care, and patients have the right to accept or refuse any type of medical treatment or intervention. At the same time, physicians are not required to honor every request a patient—or a patient’s legal representative—makes, such as requesting a course of treatment with both medical risk and no proven medical benefit.

Of course, physicians have the right to prescribe medications for off-label uses when there is evidence of benefits that exceed risks, or within the context of a clinical trial to acquire that evidence. We physicians do this all the time, accompanied by informed consent and shared decision-making with our patients. But that’s simply not what this case is about.

The AMA has and always will oppose attempts by judges, agents of government or any other third party to interfere with the practice of sound, evidence-based medicine. In no circumstance should a physician be compelled to provide substandard care to a patient, nor be forced to choose between a legal imperative or their ethical obligations to each patient.