Give Hydroxychloroquine a Chance

Controversy swirls around whether hydroxychloroquine and azithromycin ("H&A") should be used to treat people who have the Wuhan virus.  Setting aside for now all the qualifications that for good reason are used whenever discussing the question (qualifications like "after consultation between the patient and the doctor" and "administered according to a well established protocol"), the core issue is whether or not to use a treatment that has shown positive results for some and has not shown obviously negative results for any.

Given the standard medical diktat that the first obligation of a health care worker is to do no harm, there is a case to be made that H&A treatment should be withheld until properly designed clinical trials have established to a high level of certainty that the treatment has a significantly more positive effect on patient health than it does negative.  There are, however, two good reasons to challenge this well established approach in our current circumstance.

The first reason is that the current circumstances are abnormal.  Virtually everybody understands this, so there is no need to discuss it in detail.  Suffice it to say that the widespread suspension of people's rights to move about freely has already established the unusual nature of the world in a pandemic.  If things are bad enough to justify keeping people homebound, they are bad enough to bend the rules regarding use of medicine.

The second reason — less often discussed — is that the right to live our lives as we wish ought to be sufficient justification for overruling the historically well established medical directive that the caregiver should do no harm.  As positive and humane as that medical directive has been over the ages, it has also accrued power and authority into the hands of the professional caregiver.  In fact, it is only in modern times that the doctor and the patient have worked together to make a treatment choice.  In earlier days, folk medicine and home-grown cures were employed to treat commonly occurring ailments, whereas resort to a specialist was confined to those maladies that only the specialist knew anything about.

But it is a new world now.  The computer age has opened the door to medical understanding for anybody willing to do a little online surfing.  In all likelihood, this growing accessibility to medical knowledge greatly increased the modern regard for joint decisions between patient and doctor, an arrangement that has to some degree eroded the traditional authority of the medical specialist (witch doctor, neurosurgeon, whatever).

To this day, most people who need medical treatment for something that is not life-threatening continue to bow to the authority of a doctor — a sensible choice since the doctor usually is much better informed about the condition and its treatments than is the lay person.  But when a person is confronted with the prospect of a terminal illness, there is suddenly great incentive to find out as much as possible about the disease and treatments.  That incentive is in fact even greater for the patient than it is for the doctor.  People are still free to concede to the judgment of the doctor, but no longer should they be obliged to do so.

Ironically, the phenomenon that may have done the most to establish this new mindset is the question of who should decide whether or not an abortion should be committed.  To honor the importance of transparency, I must admit that I am opposed to abortion because a fetus is a person yet to be born — but clearly, the thinking of those who argue for a woman's "right to choose" expects that the judgment of the patient will trump that of the doctor.

So now returning to the question of H&A treatment for the Wuhan virus, there seems to be no compelling argument for denying a virus-sufferer access to it.  If a woman can choose to have an abortion, surely a patient dying from the Wuhan virus can choose to have the H&A treatment.

Turning now to the question of anecdotal versus clinical trial evidence that H&A treatment helps patients and has no serious side-effects, there is no question but that clinical trial evidence (which we don't yet have) would be superior.  At the same time, it is important to recognize that anecdotal evidence also is evidence — and at present, it is the best evidence we have.

A nasty problem exists here: the word "anecdotal" carries a negative connotation.  It implies that people recovering from the Wuhan virus with unexpected frequency after having received H&A treatment is mere perception and is, therefore, not science.  This is wrong.  Anecdotal evidence is not hearsay evidence; it is evidence from direct observation.  Anecdotal evidence compiled by somebody with an agenda other than saving lives might be readily dismissed, but doctors who are in the business of treating Wuhan virus patients are motivated to find what works best.

The French doctor Didier Raoult has conducted a small-scale experiment using the H&A treatment, the results of which suggest that it is effective.  Without doubt, the study was not controlled to the degree generally expected when trying to establish the efficacy of a new drug, but this was inevitable, since Dr. Raoult's primary concern was for his patients rather than research.  Does this mean that his study is flawed?  Yes, but all studies are.  Does it mean that his study is so flawed that it should be ignored entirely?  No, not unless someone presents a reasonably strong case as to why his work should be dismissed.

After all, even the studies performed by professional researchers trying to establish the efficacy of some new medicine are inevitably flawed.  They are flawed because they have to rely on sampling procedures and inferential statistical tests.  Any honest scientist will readily admit that selecting a perfectly representative sample from a population is impossible because there is no way of knowing what attributes, and how many of them, must be perfectly represented in the sample taken from the larger population.

Historical evidence indicates that the more intensely controlled a study and the larger the number of cases it uses, the more reliable it is likely to be.  This is not a rejection of smaller, less well controlled studies.

To give an example, President Jefferson sent Lewis and Clark on an expedition to the west coast so as to find out what conditions exist in the vast territory of the Louisiana Purchase.  Relative to the task at hand, this was a small and poorly controlled study of the newly purchased land.  It discovered that west of the Mississippi, there existed a great and relatively dry plain extending to a zone of high mountains that had to be surmounted before reaching the biotic abundance of a Pacific coastal zone.  What a pity it would have been if President Jefferson and the rest of the country rejected the findings of Lewis and Clark because their investigation was insufficiently thorough, their sample size too small, their method of measuring things not as refined as was being done back in Massachusetts and Virginia.

Controversy swirls around whether hydroxychloroquine and azithromycin ("H&A") should be used to treat people who have the Wuhan virus.  Setting aside for now all the qualifications that for good reason are used whenever discussing the question (qualifications like "after consultation between the patient and the doctor" and "administered according to a well established protocol"), the core issue is whether or not to use a treatment that has shown positive results for some and has not shown obviously negative results for any.

Given the standard medical diktat that the first obligation of a health care worker is to do no harm, there is a case to be made that H&A treatment should be withheld until properly designed clinical trials have established to a high level of certainty that the treatment has a significantly more positive effect on patient health than it does negative.  There are, however, two good reasons to challenge this well established approach in our current circumstance.

The first reason is that the current circumstances are abnormal.  Virtually everybody understands this, so there is no need to discuss it in detail.  Suffice it to say that the widespread suspension of people's rights to move about freely has already established the unusual nature of the world in a pandemic.  If things are bad enough to justify keeping people homebound, they are bad enough to bend the rules regarding use of medicine.

The second reason — less often discussed — is that the right to live our lives as we wish ought to be sufficient justification for overruling the historically well established medical directive that the caregiver should do no harm.  As positive and humane as that medical directive has been over the ages, it has also accrued power and authority into the hands of the professional caregiver.  In fact, it is only in modern times that the doctor and the patient have worked together to make a treatment choice.  In earlier days, folk medicine and home-grown cures were employed to treat commonly occurring ailments, whereas resort to a specialist was confined to those maladies that only the specialist knew anything about.

But it is a new world now.  The computer age has opened the door to medical understanding for anybody willing to do a little online surfing.  In all likelihood, this growing accessibility to medical knowledge greatly increased the modern regard for joint decisions between patient and doctor, an arrangement that has to some degree eroded the traditional authority of the medical specialist (witch doctor, neurosurgeon, whatever).

To this day, most people who need medical treatment for something that is not life-threatening continue to bow to the authority of a doctor — a sensible choice since the doctor usually is much better informed about the condition and its treatments than is the lay person.  But when a person is confronted with the prospect of a terminal illness, there is suddenly great incentive to find out as much as possible about the disease and treatments.  That incentive is in fact even greater for the patient than it is for the doctor.  People are still free to concede to the judgment of the doctor, but no longer should they be obliged to do so.

Ironically, the phenomenon that may have done the most to establish this new mindset is the question of who should decide whether or not an abortion should be committed.  To honor the importance of transparency, I must admit that I am opposed to abortion because a fetus is a person yet to be born — but clearly, the thinking of those who argue for a woman's "right to choose" expects that the judgment of the patient will trump that of the doctor.

So now returning to the question of H&A treatment for the Wuhan virus, there seems to be no compelling argument for denying a virus-sufferer access to it.  If a woman can choose to have an abortion, surely a patient dying from the Wuhan virus can choose to have the H&A treatment.

Turning now to the question of anecdotal versus clinical trial evidence that H&A treatment helps patients and has no serious side-effects, there is no question but that clinical trial evidence (which we don't yet have) would be superior.  At the same time, it is important to recognize that anecdotal evidence also is evidence — and at present, it is the best evidence we have.

A nasty problem exists here: the word "anecdotal" carries a negative connotation.  It implies that people recovering from the Wuhan virus with unexpected frequency after having received H&A treatment is mere perception and is, therefore, not science.  This is wrong.  Anecdotal evidence is not hearsay evidence; it is evidence from direct observation.  Anecdotal evidence compiled by somebody with an agenda other than saving lives might be readily dismissed, but doctors who are in the business of treating Wuhan virus patients are motivated to find what works best.

The French doctor Didier Raoult has conducted a small-scale experiment using the H&A treatment, the results of which suggest that it is effective.  Without doubt, the study was not controlled to the degree generally expected when trying to establish the efficacy of a new drug, but this was inevitable, since Dr. Raoult's primary concern was for his patients rather than research.  Does this mean that his study is flawed?  Yes, but all studies are.  Does it mean that his study is so flawed that it should be ignored entirely?  No, not unless someone presents a reasonably strong case as to why his work should be dismissed.

After all, even the studies performed by professional researchers trying to establish the efficacy of some new medicine are inevitably flawed.  They are flawed because they have to rely on sampling procedures and inferential statistical tests.  Any honest scientist will readily admit that selecting a perfectly representative sample from a population is impossible because there is no way of knowing what attributes, and how many of them, must be perfectly represented in the sample taken from the larger population.

Historical evidence indicates that the more intensely controlled a study and the larger the number of cases it uses, the more reliable it is likely to be.  This is not a rejection of smaller, less well controlled studies.

To give an example, President Jefferson sent Lewis and Clark on an expedition to the west coast so as to find out what conditions exist in the vast territory of the Louisiana Purchase.  Relative to the task at hand, this was a small and poorly controlled study of the newly purchased land.  It discovered that west of the Mississippi, there existed a great and relatively dry plain extending to a zone of high mountains that had to be surmounted before reaching the biotic abundance of a Pacific coastal zone.  What a pity it would have been if President Jefferson and the rest of the country rejected the findings of Lewis and Clark because their investigation was insufficiently thorough, their sample size too small, their method of measuring things not as refined as was being done back in Massachusetts and Virginia.