Dr. Collins' corona choices

Dr. Collins, in his interview regarding coronavirus, suggested that cost should not be a factor in saving lives. We should not put a price tag on saving lives, at least as I understood what he said.

But that was when the cost was in dollars.

When he was asked about hydroxychloridine, he said it should not be authorized even on an emergency basis-- because there are side effects. In other words, side costs. So cost should not be a factor when the cost is dollars. But it’s OK for cost should be a factor when side health effects – i.e. side effects being marginal costs – exist.

This seems to be an inconsistency that arises from a Hippocratic orientation – first do no harm – versus an economic orientation – opt for benefits that exceed costs.

This is directed to Dr. Collins, but I could not find a way to contact him directly.

Hello, George, and welcome to the forum!

Dr. Collins has not (in my recollection) interacted here on the public forum - at least not in recent years. That doesn’t mean he couldn’t or wouldn’t - but as you can imagine he’s a very busy man, and now more than ever! All that said, you also won’t be surprised that many here can give answer on his behalf since he has more than a few who know him well here.

In that spirit, I listened to the same interview and heard what you heard. My takeaway, though, was not that Dr. Collins is unfairly or disingenuously holding back on something that he knows will help the public. Quite far from it: he’s refusing to sign off on something that has not yet been shown to be an effective public response. It is his job to be conservative in this regard as you don’t want millions in the public to become your guinea pigs on whom you discover that your “cure” ends up being even worse for them than the thing they were afraid of in the first place. […and there is plenty of room for this situation to be worse, as hard as that may be to believe if you are one of the suffering ones.] It is easy and quite understandable for some desperate folks to latch onto anecdotal “evidence” that some wonder drug “helped” somebody feel better or even get better. But the scientific mind (and many of us have that kind of mind around here!) knows good and well how untrustworthy such anecdotal evidence is. You’ll hear from the few across a nation how something apparently “worked” because that is the kind of news we all latch onto and love to spread. But you won’t hear from the potentially many many more for whom the same thing did not work, or worse yet - caused them unnecessary problems! There just is no substitute or shortcut around the science to keep us from fooling ourselves in this way. And it isn’t that Dr. Collins or other scientists are insensitive to the plights of the desperate. Many such people can volunteer to participate in trials to find these sorts of things out scientifically. It takes a long time to properly test a vaccine, and they are making faster than usual progress on that given our present urgency; but even so, such tests still take many months.

Regarding the price tag on human life, I think Dr. Collins has an expected blend of Christian compassion and realism that does not shut its eyes to evidence and obligatory medical policy. He commiserated with the undesirable positions of medical staff that are forced into decidedly non-ideal choices - nobody wants to crassly put a price tag on human life. And yet I get the sense that he also knows the realities that medical technologies, labors, and materials are finite things so that there are limits to what we can expend whether we like it or not. Obscenely great expenditure on behalf of a few may mean obscene neglect for many others. In that way, there is a practical “price tag” on life that has always existed - as is well known to engineers or others who design any systems that have bearing on saving lives. [Think of automobile design - and how driving around in virtually armored “tanks” would save a few lives from traffic fatality - and yet we (rightly) don’t find such expense to be “worth it”, as it would cost way too much in so many other ways.]

So while some might wish he (Dr. Collins) was quicker to sign off on this or that hopeful drug, I thank God that we have at least a few good competent individuals still left in our present federal government who insist on holding to truth despite pressures from populist crowds, and even pressure from their own bosses to proclaim more confidence in something than is warranted.

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Greetings and welcome, @GeorgeE. If you go to Dr Collins’ NIH blog, I do see that people post personal notes which I suspect he reviews. https://directorsblog.nih.gov/2020/04/07/dealing-with-stress-anxiety-and-grief-during-covid-19/

It is my understanding that many hospitals do have protocols for use of hydroxychloroquine and azithromycin, but only in those who are ill, and inpatient. https://www.newsweek.com/fda-says-hydroxychloroquine-chloroquine-can-used-treat-coronavirus-1494925

That does not confirm that they are effective.

That’s a strange interpretation of “side effects” in the context of medicine. Usually, side effects mean potential damaging effects to patients, hence the “do no harm” conflicting with the “do good” of bioethics.

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George, welcome to the forum. From interaction with others, I believe your question is common when generalized to other medication issues also especially regarding “alternative medicine.”
For example, what is wrong with homeopathic drugs? They are essentially placebos consisting on no active ingredients and either just water or a drop of water dried after being placed on a tablet.
Well, what is wrong is that they may give the false impression of treatment where none exists, thus depriving the patient of a valid treatment and thus can do harm.They drain health care dollars which are limited into useless areas and thus deprive others as well as the patient of care through the waste of resources. From a non-therapeutic standpoint, they enrich charlatans and victimize the innocent.
Now, there is the argument that homeopathic drugs may benefit by replacing harmful treatment, which is true, but also points out to need to apply rigorous scientific examination to all treatments.

Hope that helps. In this case, the need to study the drug combination is needed, because using it not only could kill,some patients, as the promotion of arrhythmia is a real danger in a disease that causes cardiac myopathy, but also that it could delay development of other more effective treatments. Both could increase death and suffering.

On the other hand, if I were to be hospitalized, would I want it used on me? I think I would consent to entering a controlled study using it, but would hesitate if it were something they just said “let’s try this drug because some people have a good feeling about it.”

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JPM, thanks for responding. However, this is what’s called a strawman argument while not responding to the point of my comment!

Lumping an FDA approved pharmaceutical in with alternative and homeopathic medicines is disingenuous. Then making the case against homeopathies is a rhetorical placebo – nothing to prove or refute the argument purportedly addressed, while using a lot of words to make the appearance.

Following this is the statement that the drug combination needs to be studied – something I’d not expect if hydroxychloroquine were truly a placebo! – while ignoring the cost of rejecting a true in fear of accepting a false. Next is an at-best false dilemma, the suggestion that the maker of Plaquenil has other candidates waiting to be tested.

JPM, I sincerely hope you do not become hospitalized, but if you do, and agree do enter a controlled study, would you be indifferent about being assigned to the control group? And would you really reject treatment if your doctors said they were aware of successful off-label results? I take you at your word, but hope for your best.

Christy – Agreed, speaking of side effects as costs is not something you hear every day! And agreed, side effects typically mean, as you say, “potential damaging effects to patients.” Notice that side effects excludes additional beneficial effects – you never see lists of possible side effects including things like “this rash medicine may possibly also improve your eyesight and hearing.” No, side effects are limited to things that are damaging. Think about that word “damaging.” From the perspective of the patient, is “damaging” a benefit or a …? Hope this helps!

Yes, Randy, hospitals are administering those drugs. That was not the issue I addressed, however.

The fact that hospitals are administering those drugs supports the concept that pursuing a strategy where do-good exceeds cause-harm (rather than a strategy of never risk causing any harm) is a sound one.

Agreed, having a protocol does not confirm drug effectiveness. Outcomes confirm effectiveness.

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The efficacy of an off-label use of a drug must be put through research and testing before it can be signed off on. He was speaking to the general populace, and “side effects” is the word choice he decided to use here, but he went on to discuss how it has not yet had enough evidence in cases for this use.

I don’t see how being concerned for the severity of these effects when there’s not enough data to back up its success is in any way a contradiction to “do no harm.” It sounds to me like he IS concerned and this is a very standard ethical consideration in medicine.

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Wow!! Quite a response. I’ll just walk passed the condescension and chuckle a thank-you for your time!

If I said “that Dr. Collins is unfairly or disingenuously holding back on something that he knows will help,” that was not my intent. Rather, it was my intent to ask about what appear to be different and/or inconsistent principles that are no doubt sincerely held.

Your own statement, “not yet been shown to be” reflects a standard for showing that you share with Dr. Collins – a standard that is valid even if it is not the only valid standard available. Your way of seeing is valid, but there may be other valid ways of seeing. I understand – we all get caught up in our profession’s way of seeing, and often discount other ways because of that.

The statement “you don’t want millions in the public to become your guinea pigs” is telling. A few days ago, there were reportedly some 41,000 hospitalizations, growing a few thousand daily. Not quite “millions.” As for doctors in those hospitals treating their patients as “guinea pigs” if they supervise the use off-label drugs – well, that’s not something I worry about. The doctors who have taken care of me over the years aren’t perfect, but they’re capable and caring. I don’t need to disparage them to feel good about what I do.

Your belief that the news media only reports successes is … charming.

I’m glad that you recognize healthcare has financial costs and constraints. As I recall, Dr. Collins said in the interview that this should not be the case in the US, perhaps just for coronavirus. As for shutting one’s “eyes to evidence and obligatory medical policy,” again, this presumes principles and standards for what one considers evidence and obligation. And no doubt you and he are sincere and resolutely believe you see things just as they are. Like everyone believes!

This assumption underlies your comments on auto design. You may be surprised that there was a time when we (or perhaps your parents) did drive around in “virtually armored ‘tanks’ .” Whether it’s right or wrong to find the expense unworthy – you seem to assume it’s universally right – the reason for redesign was not to save money; it was to reduce gas consumption and to improve air quality – things valued more by decision-makers than “a few lives from traffic fatality.”

I’m glad that you count yourselves among “at least a few good competent individuals still left in our present federal government…” But more likely there are a lot of good competent individuals in the present federal government (and in hospitals, going back to your earlier comment) – it’s just that they don’t fit into your tribe. Pity.

One of the potential side effects of hydroxychloriquine is death by cardiac arrest. It’s not an “economic orientation” or a violation of the Hippocratic oath that doctors do a cost/benefit analysis and weigh “do good” with “do no harm.” That’s basic medicine. I don’t think it is analogous to put “costs” to health in the same category as “costs” to the economy. The question is “Should we recommend the use of a drug that has unproven benefits and known lethal side effects in some cases?” The answer is “No, not until we know more about whether the potential benefits justify the potential risks.” That seems pretty straightforward to me from an ethics point of view.

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No, it was not. It was an analogy showing how a treatment that is worthless has real costs in terms of human life, that can be appled to hydroxychloroquin as well. If I did not respond to your point, that was due to difficulty in understanding what your point was. I assume that is was in this sentence:

In other words, it seems you agree that you have the factor in the non-monetary costs when you propose a treatment. And I interpret Dr. Collins’ words as saying we have no evidence that the benefit of this particular treatment exceeds the harm it may cause at the present time. I have trouble understanding what you are asking as that seems in agreement. Care to restate your question?

One of the potential effects of treatment with chloroquine or hydroxychloroquine is to make viral illnesses worse. In fact, that’s the only effect on viral illnesses that has actually been demonstrated.

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Live and learn

It’s not 1918 and we have a much more advanced medical technology. In this the first phase of the pandemic we need to continue these primitive distancing and containment methods. In the second stage we should be able to use our advanced medical abilities to effectively mitigate this pandemic. It is very possible that the virus like measles another airborne virus will wane during the warmer summer months due to transmissibility and seasonal immunity. In the upcoming second phase of the pandemic we should have identified from available medications that are already fda approved with known effects to treat the high risk patients intervening at an early stage preventing progression to the more severe conditions. Whatever the treatment It is known that viruses must be treated early to prevent the disease progression especially for the most at risk to experience more severe conditions. Early treatment for viruses such as the flu is necessary for the use of antiviral agents. We need to expeditiously and aggressively use this time in the first stage of the pandemic to actively explore these potential early intervention treatments. It is likely that once a patients ARDS symptoms appear it will be difficult to treat with any medication or therapeutic plasma /antibodies.

The current strategy for treatment and standard of care must be improved. There are currently upwards of 150 studies in the works in the US evaluating drugs and various therapies. We don’t need a treatment to cure this disease we only need a drug or more likely a cocktail of drugs to prevent patients going into the most severe forms of the disease needing ICU and assisted ventilation while improving overall outcome. Ideally we will have a take two and call me in the morning regimen available especially for those in highest risk groups that come down with the virus early in its course. The severe effects seen in some patients are primarily not due to the viruses direct damage but by the patients immune response and inflammation generated in response to the virus. Many times infected patients rapidly go from a stable condition to becoming unstable needing ventilation and experiencing organ failure. It is obvious that doctors must have a regimen for early intervention to prevent the onset of severe symptoms.

It seems to me that the people who are saying, “Some older and/or already unhealthy people need to be sacrificed for the good of the economy, that’s an acceptable cost” are the same people saying, “Some people who have severe side effects to an untested drug regimen need to be sacrificed, just in case it helps some people, that’s an acceptable cost.”

Then there are others who say neither of those scenarios are acceptable. I don’t see the inconsistency.

That observation wasn’t with regard to official news media outlets - which, it cannot be doubted, love to delve into tragedy and failure of all sorts. It was more a reflection on our personal preference for what we like to “noise abroad” of our own experiences. I think we have a bias towards remembering and sharing our apparent successes. If I try some remedy and it appears to work for me, it’s news that I’m most eager to share. And then I’m probably less likely to recall other instances where this same remedy (now invested with my hopes) may have failed. And in this age of social media and self-publishing, all this kind of bias becomes part of our world of news and personal influence.

Sorry about tones of condescension. It is condescension towards my own tendencies too as much as anyone else’s.

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I don’t see any inconsistencies. The cost in lives is not the same as cost in dollars. You can say that we shouldn’t spare any costs in getting good medicines to people while at the same time determining which medicines are good. If we don’t know the risk-benefit ratio for a medicine then it would be improper to push it.

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Christy. For myself I do know, that almost all drugs have dangerous side effects and contraindications often including death. Consider many of the cancer drugs which often essentially are cytotoxic. In fact consider that many over the counter drugs can have severe side effects or contraindications. The pharma industry and the FDA put these drugs through a somewhat rigorous testing regimen to identify safety and efficacy. Often in this testing and early in the release of the drug side effects and contraindications are identified sometimes much later! These are often mentioned in the fine print on commercials. ( may cause death)The FDA takes these side effects versus the benefit in weighing the drug suitability for use. This is the risk/benefit of the drug. All drugs have this risk benefit statistical analysis. What I am saying is that the standard of care for Covid is clearly not working now and we are losing to many patients to this virus. We have to figure out a regimen of FDA approved drugs that we already know their side effects and contraindications to intervene early In the progression to save lives. I know that people are talking about Chloroquine here but I am actually referring to a larger number of potential FDA approved drugs treatments to intercede early in the disease to reduce onset of the severity. There are a good number of fda approved drugs in trial to evaluate this risk/ benefit vs Covid 19. The FDA approved drugs will have well understood side effects and contraindications. We have a lot of very smart doctors around the country and we need them to be able to respond to their patients needs at the clinical level. I have seen many doctor communications where like in any war are figuring out the rules of engagement and looking for ways to improve standard of care treatment. As is the case with all viruses I am sure we need to intervene early as possible to prevent those at most risk categories from developing the severe conditions which is too late and difficult to treat. Personally, if I were in a high risk category I would rather take my chance with an early intervention with a drug with known side effects as long as I know that I don’t have a comorbidity contraindication to that drug than wait to see if I develop severe symptoms. Wouldn’t you?

Early automobiles were relatively heavy with metal, to be sure, but not necessarily safer. And (as I think you are suggesting) there were other motivations in play for the young and exploding technology - originally an exclusive toy of the rich. Those “tanks” may have been heavier - but the only safety they had going for them compared to today’s vehicles would have been that they couldn’t go as fast. Apart from that - they were death traps, not just for the people in them, but the pedestrian populace still adjusting to their presence as well. No seatbelts, air bags, etc. And other less obvious features now help protect us in the modern auto. E.g. the made-to-collapse engine compartment that serves as a cushion between a solid frontal collision and the passenger compartment. In such an event, the last thing passengers would want is for their vehicle to be an entirely rigid structure - thereby transferring the entirety of the impulse straight onto the unfortunate occupants. If you’re going to have a wreck, you definitely want it to be in a modern car - not an old one. The much higher speed of the modern car would be the only factor that reduces the safety advantage the modern has over the old. But our infrastructure and behaviors also changed to accommodate those higher speeds.

Not sure what you even meant by the above. First - competent or not - I’m not even in government. Second, right now competence in government is golden wherever it can still be found - in any tribe. And there are times when I want to be able to lean on that competence. If any particular tribe reduces its own store of competency by its policies and attitudes, so much the worse for that tribe and …so much the worse for all of us whether we are members of that “tribe” or not.

[And I should hastily add, that as “golden” as competence is, there is something more valuable (and maybe tragically more rare) yet: integrity. If one or the other had to be missing, we would sadly have to let the competence go - better the bumbling, ineffectual good heart than the intelligent, highly effective devil. Education for the former may be easier to come by than reform for the latter.]

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Sure. But I don’t think it is wise or good practice to just throw drug cocktails at patients with a wish and a prayer. Lots of trials and experimental treatments are currently being investigated in studies with patients. Nobody is saying don’t look for those possibilities because…side effects. They are saying if we don’t know yet that there is any benefit at all to using a certain drug, maybe don’t imply it’s some kind of magic bullet. My friend has taken chloroquine for decades for lupus and now can’t get her prescription filled. That’s not cool either.

“Let your conversation be always full of grace, seasoned with salt, so that you may know how to answer everyone.” -Colossians 4:6

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