The ethics of prescribing during a pandemic

In times of disaster, marginalized groups often become even further marginalized. Both those of lower socioeconomic status and those with disabilities often are left out of emergency planning, as is evidenced by the current COVID-19 pandemic. From access to testing to ability to acquire needed goods and services to triage policies being adopted from community to community, those with lower SES or who suffer from disabilities seem to be an afterthought, if considered at all. For those with invisible disabilities, the lack of consideration and inclusion in the emergency response to the pandemic has been sharply illustrated by ill-informed, knee jerk proclamations by Donald Trump that “hydroxychloroquine and azithromycin, taken together, have a real chance to be one of the biggest game-changers in the history of medicine.”

Trump’s ill-informed and unsubstantiated pronouncement began a cascade not dissimilar to the recent panic buying and stockpiling of toilet paper and hand sanitizer with clinicians reportedly writing prophylactic prescriptions of hydroxychloroquine for friends and family and pharmacies denying or limiting access to the drug that many, particularly those with autoimmune conditions, depend on regularly.  This kind of reaction and response sends a message that people who rely on this medication daily are not valued and are not as important to society as those who are infected or may become infected with COVID-19.

Emergencies and emergency preparedness certainly call for a reallocation of resources and a redefining of priorities, but this should not come at the expense of those who are already at high risk.  Many of those who take hydroxychloroquine on a daily basis suffer from autoimmune conditions such as lupus or rheumatoid arthritis.  Those with autoimmune conditions are considered to be at higher risk for contracting COVID-19, yet health care providers from pharmacists to dentists to physicians are seemingly willing to further compromise the health of those with already compromised immune systems to protect themselves and their loved ones.  Such responses are in direct conflict with the concept of professionalism espoused in codes of ethics.  The AMA Code of Ethics states, “The relationship between a patient and a physician is based on trust, which gives rise to physicians’ ethical responsibility to place patients’ welfare above the physician’s own self-interest or obligations to others . . .”. Similarly, the Code of Ethics for Pharmacists asserts that “A pharmacist places concern for the well-being of the patient at the center of professional practice.” Additionally, the ADA Principles of Ethics & Code of Professional Conduct “calls upon dentists to follow high ethical standards which have the benefit of the patient as their primary goal.”

How, even in an emergency, can a blatant disregard for patient health if not outright discrimination be acceptable is unclear.  While desperate times may call for desperate measures, maintaining trust and transparency are critical to the management of any public health emergency. When those for whom society holds in high regard, such as health care providers act in disregard of the social contract, confidence in the professionals relied on most during a pandemic is greatly diminished.

Nanette Elster is a bioethicist.

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