by Buzz Hollander, MD
Everyone has a right to their opinion. The question is: does everyone have a right to voice their opinion? Increasingly, in these strange times, it seems that we physicians have the right to voice only certain opinions, when it comes to discussing Covid-19.
Wanting to hit the mute button on physicians who choose to challenge the public health narrative, especially in regard to vaccination for Covid-19, is understandably tempting. We carry a bit more authority than lawyers or statisticians when we share our thoughts about medical matters; and quite a few physicians seem to have little interest in toeing the party line. However, appealing as it might be to silence these voices, succumbing to the temptation of censorship might end up costing our society more than it gains.
Imagine this: you’re a physician in charge of opening an intensive care unit in New York City for Covid-19 patients in March 2020 as the disease is tearing through the city. You notice that the standard protocols your hospital follows for intubated patients seem to be failing, perhaps injuring, your patients with Covid-19. Rumblings from Chinese intensivists, and publications from Italian physician Luciano Gattitoni, imply that intubation and ventilator management should be reconsidered in this new disease. Your hospital is reluctant to change their well-established protocols. Most of your intubated patients are dying. What do you do?
Dr Cameron Kyle-Sidell experienced this dilemma — and then posted a video on YouTube on March 31, 2020, watched nearly a million times, in which he described his experiences caring for Covid-19 patients in respiratory failure. In the video, Kyle-Sidell shared that existing treatment protocols for patients with severe pneumonia did not seem to apply to Covid-19 patients with dangerously low oxygen levels — they could be intubated later, and their lungs were less stiff and required lower ventilation pressures, than typical severe pneumonia patients. His warning was part of an alarm that was raised by others, as well, which did indeed lead to a rapid shift in management of severely ill Covid-19 patients. He also ended up stepping down from his leadership of the ICU due to disagreement with hospital management; and some of those hundreds of thousands of viewers of his YouTube video concluded that his perhaps poorly-worded comparison of Covid-19 lung disease to high altitude sickness was cause to consider the pandemic a hoax.
Was Dr Kyle-Sidell a hero for sticking his neck out and challenging the prevailing dogma, in a sincere attempt to improve outcomes for severely ill Covid-19 patients? Or should his video have been censored, and perhaps his medical license threatened, for questioning the conventional narrative in ways that could be co-opted by conspiracy theorists?
Scenario two: an Israeli soldier comes into your ER in early February 2021, complaining of chest pain and a rapid heart rate, and is diagnosed with myocarditis. He was vaccinated against Covid-19 with the Pfizer mRNA vaccine four days prior. You report it to local media as a possible vaccine adverse reaction, and the news is widely circulated as one of the first reports of this now well-recognized potential complication of the mRNA vaccines, most notably in young men.
Was it right of the Terem Emergency Medical Clinic to publicize a severe reaction to a Covid-19 vaccine, especially before causation had even been established, before there was enough data to even estimate its frequency? Was the risk of worsening vaccine hesitancy worth the benefit of sounding an alarm that ultimately led to real scrutiny and validation of this concern and efforts to quantify its relevance to public health?
Finally, a third scenario: you are a family and ER physician in rural British Columbia whose clinic begins to distribute some 900 doses of the Moderna Covid-19 vaccine in March 2021. You claim to observe two cases of anaphylaxis, a vaccine-associated death, and three more severe adverse reactions to the vaccine, and write an email to your colleagues in the area suggesting a pause in the vaccination program. When this leads only to a professional rebuke and a gag order, you write a public letter to the British Colombia Provincial Health Officer, and soon find yourself removed from your position at the ER.
The physician involved, Dr. Charles Hoffe, went on to postulate that the mechanism of injury of the mRNA vaccines was the formation of “microthrombi” – tiny clots – and that by using the commonly available d-dimer lab test for clotting he has found 62% of the vaccinated patients he has studied to have elevated d-dimers, and considers them at high risk of related disease within the next three years.
Was Dr. Hoffe rightfully relieved of his ER duties? Should his videos have been taken down, or was a thorough debunking adequate?
Dr. Hoffe is, of course, by no means the only physician accused of promoting misinformation about the Covid-19 vaccines. Dr Ryan Cole, the Mayo-trained Idaho pathologist who recently was appointed to his Idaho regional health board, has expressed his opinions in multiple interviews that vitamin D rather than vaccines is the better option to prevent Covid-19, claiming that he sees evidence in his pathology lab of long-term auto-immune disease from the mRNA vaccines. Perhaps most publicly, well-published cardiologist, Dr Peter McCullough, has been sued by Baylor University, where he was co-chair of the internal medicine department, for continuing to carry out interviews denigrating vaccine safety and promoting the use of ivermectin as an alternative to vaccination under the banner of his employer, which parted ways with him earlier in the year.
As a society, how should we respond to physicians who publicly question the narrative forwarded by our health institutions? Doctors like Hoffe, Cole, and McCollough only make my job harder when I am trying to engage a vaccine-reluctant patient in an open discussion about the risks and benefits of these new vaccines, and I start hearing about d-dimers and auto-immunity. I can object, true, and remind the patient that none of these claims really have biologic plausibility nor published data on their behalf, and have been convincingly debunked; and they aren’t seen by the rest of us caring for hundreds or thousands of vaccinated patients— but sometimes I get that look that says, “And how did your Mayo fellowship go? How about that prestigious chairmanship at Baylor?”
That is just my experience on the scale of an individual practitioner. On the greater scale, people with impeccable credentials and a clear understanding of scientific principles and terminology can do great harm when they choose to cast improbable aspersions on the vaccines. It’s hard to know where “I read something on the internet that caused me to doubt these vaccines” ranks among causes for vaccine hesitancy. I suspect, though, that it’s high, when I read polls like this, which show a strong association between where people get their news and how likely they are to get vaccinated.
Doctors Get Ready
This, then, is the milieu into which the Federation of State Medical Boards released their statement in late July, entitled, “SPREADING COVID-19 VACCINE MISINFORMATION MAY PUT MEDICAL LICENSE AT RISK.” Its central sentence reads as follows:
“Physicians who generate and spread COVID-19 vaccine misinformation or disinformation are risking disciplinary action by state medical boards, including the suspension or revocation of their medical license.”
The three major boards from primary care specialties followed suit in September with a similar statement. Board certification could be jeopardized by providing “misinformation” over the Covid-19 vaccines, going on to say:
“We are particularly concerned about physicians who use their authority to denigrate vaccination at a time when vaccines continue to demonstrate excellent effectiveness against severe illness, hospitalization and death.”
For a physician to practice medicine in the U.S., a medical license is required. Losing your medical license is akin to losing your livelihood. Board certification in an area of speciality can be required by one’s employer. These are not trivial threats.
Normally, the function of state medical boards is to protect patients from abusive, impaired, or grossly incompetent physicians. A surgeon operating under the influence of alcohol would be an extreme example. More topically, if a board is informed that a doctor is telling their elderly diabetic patients to avoid Covid-19 vaccination at all costs since the shots are dripping with graphene oxide, the board reasonably would take action, given the physician’s egregious parting with standard of care. Policing what a physician says about medicine and health outside of their clinic, however, is not a typical use of the power of these boards.
While I find the language of these statements from our professional organizations chilling, I don’t doubt the good intentions behind them. The concern for physicians doing broad harm by seeding doubts about vaccine safety or efficacy is real. The question is: will suppressing their voices via threats or censorship turn out to be more problematic than simply allowing them to speak their minds?
The Price of Silence
The first problem is a practical one. Physicians are often the canaries in the coal mine, seeing problems before a study can be completed, or expert consensus can be formed. Discouraging physicians from speaking out against, or even calling into question, accepted beliefs and protocols is akin to throwing water on the fires of scientific advancement.
From the examples I gave, I think it’s clear that we want Dr Kyle-Sidell to speak his mind, even if it makes for some uncomfortable narratives. The ER doctors in Israel, publicizing the post-vaccine myocarditis, are perhaps a more complex case. One could argue private communications with colleagues would have been more appropriate in the setting of witnessing a single reaction, in order to better assess if they were seeing a true safety signal or only an outlier reaction. Having a public conversation about a significant vaccine adverse reaction is no friend to vaccination rates. However, discretion is the enemy of speed. Rapid recognition of events too rare to be picked up even in large controlled trials is essential to ensuring the safety of these vaccines, which are, after all, a relatively new medical technology. Dr Hoffe and his sensationalistic claims about the dangers of the mRNA vaccines are clearly baseless to my eyes; but, what if he had been right?
Trust Is in the Eye of the Beholder
The second problem is a related, possibly greater, one: who is the arbiter of “misinformation?” Per the Oxford Reference, misinformation involves “the dissemination of false information with the deliberate intent to deceive or mislead.” What is false today in science can be true tomorrow; and rational scientists and physicians can disagree vehemently with each other about many subjects. We have seen this often in the realm of Covid-19 vaccinations, with spirited arguments among experts and institutions over the degree of waning protection of the vaccines, the need for vaccine boosters, and whether those with prior infection should be required to be vaccinated.
We simply lack a central authority whom we can trust to determine scientific veracity. There is no more authoritative national institution during a pandemic than the Centers for Disease Control and Prevention. To give but one example — and there are many to choose from — the CDC, as well as the World Health Organization, insisted month after month on ignoring the growing drumbeat of evidence that SARS-CoV-2 was primarily spread via aerosol transmission. Meanwhile, an aerosol scientist at Virginia Tech, Dr. Linsey Marr, was prominent among scientists who gave interviews and publicly posted their explanations of the primacy of aerosols in the spread of Covid-19, and was a key part of the movement that eventually unseated the conventional perspective that SARS-CoV-2 transmission relied on large droplets. Should she have been censored, or her research position threatened, for contradicting the CDC? In retrospect, it rather seems the CDC was perpetuating false information, and the resulting slow uptake of ventilation over barrier shields and disinfectant bombs was a costly mistake by any measure.
“Let the boards decide what’s really false” is also an unsatisfying answer. Board sanctions are fraught with their own failings and politics. It’s tempting to think that some physicians will be in obvious need of censorship, and the boards will know to leave the rest alone. However, the line between “completely crazy” and “faintly plausible” can be blurry, as can be the distinction between a whistleblower and a bad-faith actor.
Consider this example: a healthy 14 year old boy with a confirmed prior Covid-19 infection who received a first Pfizer shot, and his parents are now concerned about the safety of a second shot. This is a cherry-picked hypothetical, in that adolescent boys with prior infection are the one and only example in which the risks of vaccination almost certainly outweigh the benefits, at least in terms of hospitalization risk. It’s relevant, though, in that this boy would be required by the state of California to get his second shot if he wants to attend in-person school. This hypothetical patient carries about a 1/7500 annual risk of hospitalization with Covid-19 without any prior immunity; that same boy with natural immunity after a laboratory-confirmed case of Covid-19 would only have about a tenth that risk, and this recent pre-print from Israel crudely implies additional modest (perhaps 30-50%) improvement in protection with that first Pfizer shot. Whether you believe the rate of hospitalization for vaccine-induced myocarditis to be 1 in 5,000 or 1 in 15,000, clearly the hospitalization risk is several times higher if one opts to choose the second shot rather than forego it. I am quite comfortable that the current scientific literature is clear on this subject. I would feel less comfortable that my state medical board would choose not to censure me in the current ideological climate were I in the crosshairs of an investigation.
Currently, a physician in neighboring Maui is under investigation by the Hawaii state medical board. It appears pediatric cardiologist Dr Kirk Milhoan has found himself in hot water for offering Covid-19 treatment programs that stray from CDC recommendations, as well his membership in the group, Pono Coalition for Informed Consent, which questions the safety of the Covid-19 vaccines. In a video with the founder of the Pono group, Dr Milhoan displays a disturbingly poor grasp of basic statistics in discussing the death rates of vaccinated and unvaccinated Covid-19 patients in the UK; and states that for those younger than 40, he is “…personally more of a fan of natural immunity.” I can’t abide the misuse of statistics, and ignoring the real hospitalization risk of healthy young adults (around 3% for healthy, non-immune people in their 30s diagnosed with Covid-19) has led to a lot of full hospitals and poor outcomes. I have a hard time defending Dr Milhoan’s opinions. I still choose to defend his right to speak them.
When discussing his case, the executive officer of the Hawaii Medical Board, Ahlani Quiogue said, “Licensed physicians have an ethical and professional responsibility to practice medicine in the best interest of their patients. Thus, providing misinformation may jeopardize their license.” Back to our hypothetical example, I would argue that encouraging a 14 year old boy with a confirmed prior case of Covid-19 to get a second Pfizer vaccination would clearly violate this code – it would not be in the patient’s best interest to get that second shot. However, I suspect the board would not see things that way.
What’s the Value of Trust?
The other practical point to consider when publicly quieting physicians who question vaccination is whether we actually are achieving a net reduction in harm. Those members of the public whose antennae are raised to any evidence that the government does not truly have faith in the quality or safety of these vaccines pay close attention to this sort of news. If those already inclined to doubt the party line about the importance of vaccination are convinced that their own physician might be afraid to speak the truth about the subject, how can their physician talk them out of their vaccine hesitance? When YouTube takes down Dr Pierre Kory’s congressional testimony on ivermectin, the presumption of those who support ivermectin is that Big Tech is hiding something.
It’s impossible to know whether the loss of trust suspicious patients experience with news of censorship exceeds any benefit from silencing the doubts of a small minority of physicians. A large study in Denmark and the US actually tried to address a related question around the value of transparency in reporting news around the Covid-19 vaccines. Conclusions were mixed; yes, straightforward negative reports (i.e., on post-vaccine myocarditis) reduced vaccine acceptance, but also increased trust in public health authorities.
Only the sunniest optimist would believe Covid-19 will be the last pandemic we will face in our lifetimes. The next might be worse. The public buy-in needed for a coordinated response might be essential. Frittering away trust in our public health authorities via censorship is a potentially costly unforced error.
It Was the First Amendment for a Reason
Finally, there is the unquantifiable aspect of this argument: the legal and ethical problems with curtailing free speech. I’ll leave it to scholars of jurisprudence to delve into the legality of these sorts of pronouncements, but let’s just agree it’s complicated, and prone to end up in protracted court battles. What’s more, distinctions between what constitutes protected speech, and commercial speech, and professional speech which can be regulated by a governing body, are hard to understand for us simple physicians.
How complicated? The American Association of Naturopathic Physicians advised its members to be wary of promoting supplements as possible aids in preventing or treating Covid-19 due to the risk of attention from the FDA and FTC in their roles regulating “commercial speech.” Vitamin D was given as an example. While I see the evidence on behalf of supplemental vitamin D for either treating or preventing covid-19 to be rather lean, I allow that a case can made on its behalf. I find it hard to justify cease-and-desist letters from the FDA for promoting the use of such a benign (and potentially useful) supplement. It seems to be okay that Dr. Anthony Fauci said, “I would not mind recommending, and I do it myself, taking vitamin D supplements”; but not so okay if you make the same recommendation on a website, which includes a link to a pharmacy, that sells vitamin D supplements. Complicated.
As to the ethical aspects, we might do well to remember that there’s a good reason freedom of speech is considered one of the unquestionable foundations of this country. Supreme Court Justice Benjamin Cardoza wrote of free speech in the 1930s that it “…is the matrix, the indispensable condition of nearly every other form of freedom.” When physicians and other professionals can’t speak their minds about what they sincerely believe to be true and necessary for others to know, something important has been lost from our society.
Instead of taking away some people’s voices, perhaps we can simply amplify or hone others. Our public health institutions like the CDC should strive to consistently speak the truth in ways that display transparency, humility around uncertainty, and respect for opposing viewpoints. This is not too much to ask. If people had more cause to trust the CDC, they might have less cause to believe those who contradict it.
For the concern that vaccine misinformation might sway those still on the fence about vaccination, perhaps promoting positive content could serve as an alternative to silencing negative voices. I shopped for an e-bike last month, and now I cannot even read a medical article online without it being framed by ads for that same e-bike. Surely, since Big Tech tracks everything we do, they know that I spent much of last week reading about Dr. McCullough’s vaccine conspiracy theories in between looking for positive slants on how the Pittsburgh Steelers can fix their miserable offensive line. It cannot be that hard to insert a pro-vaccine post from Steeler legend Jerome Bettis into my Twitter feed (and perhaps a thread thoughtfully countering Dr McCoullough’s claims, as well).
Similarly, medical boards don’t need to very publicly threaten their members’ licenses or board certifications if they speak out against vaccination or any form of the public health party line. Contacting physicians and having a conversation with them might help in some cases; some doctors are just under informed, statistically impaired, or in the thralls of poor mentors. If a physician is unchastened and continues to post information the board deems inappropriate, they could publicly post a (thoughtful and non-judgmental) response to the physician’s claims. The goal should be more conversation, not less.
It’s tempting for physicians to nod heads in agreement that physicians like Dr. Hoffe, Cole, or McCullough deserve their reprimands, since they appear to have lost their way from sound scientific reasoning. However, the same people might feel less comfortable if those in positions of authority start telling them to stop posting on their social media accounts that a woman in Texas has a right to receive an abortion. We don’t always get to pick who makes the rules.
Such is the great risk of starting down the slippery slope of curtailing the freedom of speech of physicians. We never know quite what could be waiting for us when we reach the bottom.
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Buzz Hollander MD is a family physician on the Big Island of Hawaii with no ideological axes to grind. He tweets @buzzhollandermd.