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February 4, 2021

When Physicians Engage in Practices That Threaten the Nation’s Health

Author Affiliations
  • 1Departments of Pediatrics and Microbiology and Immunology, Stanford University School of Medicine, Stanford, California
  • 2Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
  • 3Department of Medicine, Stanford University School of Medicine, Stanford, California
  • 4Stanford Law School, Stanford, California
JAMA. 2021;325(8):723-724. doi:10.1001/jama.2021.0122

In December 2020, less than a year after severe acute respiratory syndrome coronavirus 2 was identified as the cause of the coronavirus pandemic, an extraordinary collaboration between scientists, the pharmaceutical industry, and government led to 2 highly efficacious, safe vaccines being approved by the US Food and Drug Administration to prevent coronavirus disease 2019 (COVID-19) infection.1,2 Had the US been in its expected role as a global leader in medicine and public health, this would have been a fitting capstone of US commitment to science and how that can change the course of morbidity and mortality related to a frightening new disease.

However, a less flattering story emerged about the inadequate US response to COVID-19. A number of leaders in federal, state, and local government, guided by political exigency and recommendations from a small number of physicians and scientists who ignored or dismissed science, refused to promote sensible, effective policies such as mask wearing and social distancing. This contributed to the US having more infections and deaths than other developed nations in proportion to population size, with disproportionate effects of COVID-19 on already disadvantaged racial and socioeconomic groups.3 In contrast, countries like Taiwan, South Korea, and New Zealand, where respect for science and truth and a collaborative relationship between public health and government leaders prevailed, were far more successful at controlling the pandemic.1

Among the ways in which science-based public health evidence has been dismissed in the US is the replacement of highly experienced experts advising national leaders with persons who appear to have been chosen because of their willingness to support government officials’ desire to discount the significance of the pandemic. A leading example was the elevation of Scott Atlas, MD, a neuroradiologist, who left a position in academic medicine in 2012 to become a senior fellow at the Hoover Institution (a public policy think tank affiliated with Stanford University), to the White House Coronavirus Task Force. In his short tenure on the task force, Atlas disputed the need for masks; argued that many public health orders aimed at increasing social distancing could be forgone without ill effects; maintained that allowing the virus to spread naturally will not result in more deaths than other strategies; stated that young people are not harmed by the virus and cannot spread the disease; reportedly pressured the Centers for Disease Control and Prevention to issue guidance (later reversed) stating that asymptomatic individuals need not be tested4; and made unsupported claims about the immunity conferred by surviving infection. Nearly all public health experts were concerned that his recommendations could lead to tens of thousands (or more) of unnecessary deaths in the US alone.

History is a potent reminder of tragic circumstances when physicians damaged the public health, from promoting eugenics to participating in the human experiments that took place in Tuskegee to asserting erroneously that vaccines cause autism. It can be difficult to hold physicians accountable, especially when they are acting in policy roles in which malpractice lawsuits will not succeed. Professional self-regulation serves as the primary vehicle for accountability and is critical if trust in science and medicine is to be maintained.

To that end, action from within the medical profession is an important but underused strategy. The Hippocratic Oath binds physicians to “do no harm,” an injunction that transcends individual patient-physician encounters to situations in which physicians make medical recommendations for populations. For instance, the American Medical Association’s Code of Ethics states that physicians making media statements should ensure that the information they provide is accurate, appropriately conveys known risks and benefits, is “commensurate with their medical expertise” and confined to their area of expertise, and is “based on valid scientific evidence and insight gained from professional experience.”5 It “is ethically inappropriate for physicians to publicly recommend behaviors or interventions that are not scientifically well grounded.”5 These directives reflect an awareness that physicians’ words are often assigned great importance, even for areas in which physicians lack expertise.

There is precedent for both medical professional societies and boards of medical licensing to take action when physicians violate their ethical responsibilities in nonclinical contexts. The Federation of State Medical Boards defines competence as possessing the requisite abilities to perform effectively within the scope of professional practice while adhering to ethical standards, and defines the practice of medicine to include using the designation “Doctor” “in the conduct of any occupation or profession pertaining to the prevention, diagnosis, or treatment of human disease or condition.”6 Accordingly, many state licensing boards and professional societies have adopted policies providing for action against physicians who provide non–evidence-based testimony as expert witnesses in litigation.7 These actions could include a formal review to determine whether the physician has engaged in “unprofessional conduct,” with penalties as severe as license revocation or expulsion from professional organization membership. The same rationale supports action against physicians who violate the standards of professionalism in policy advisory roles. The argument for action is even stronger than in the expert witness context, when the physician’s words have a narrower influence and judges have a legal responsibility to exclude experts who are not qualified or who present information that does not comport with accepted scientific knowledge.7

As the Atlas example illustrates, not all physicians serving in such roles maintain active licensure, certification, or professional organization membership. However, even for situations in which the conferring organizations cannot revoke privileges, they can declare that a physician’s actions are inconsistent with the standards of professional conduct. This may have a powerful influence in undercutting rogue physicians, thereby minimizing the deleterious effects of their actions on public health.

When a physician holds a university (or affiliate) appointment, a question arises about university leaders’ role in responding to demonstrably false statements by the physician that could harm the public’s health. The most effective action is to publicly state that the university does not endorse the physician’s claims and finds them contrary to the weight of scientific evidence.

To be sure, this can be complicated. Academic freedom is a core value of the university, and public speech is an important pillar of such freedom. Academic freedom requires that faculty be free to engage in intellectual debate without fear of censorship or retaliation. Universities should be places where a diversity of viewpoints can flourish. More pragmatically, university leaders are responsible for multiple constituencies and must navigate pressures from trustees, donors, and others. In addition, there are legitimate concerns about the proverbial slippery slope when universities announce an allegiance to a particular position on a scientific or other matter.

But to take the view that respecting freedom of speech requires institutional silence when science is being subverted is to misunderstand the concept. To add speech is not to suppress it; voicing words of protest is not censorship or retaliation. Even where the First Amendment applies (eg, to officials in public institutions), courts have long held that it does not require officials to remain silent, even if their own speech expressly criticizes another speaker’s message. Furthermore, universities have not kept silent when a faculty member’s statements transgress other core values of educational institutions, such as counteracting racism and anti-Semitism. Universities have a responsibility to speak out for truth and science in support of public health. Silence is not an option, as has been tragically observed throughout history.

Faculty also can have an important independent voice within a university. For example, more than a hundred faculty experts challenged the veracity of Atlas’ claims in an open letter.8 In response, Atlas’ attorney threatened a meritless defamation lawsuit, prompting all signatories to reaffirm their commitment to the letter. Separately, the Stanford Faculty Senate voted 85%-15% to adopt a resolution: “We strongly condemn [Atlas’] behavior,” as it “violates the core values of our faculty and the expectations under the Stanford Code of Conduct, which states that we all ‘are responsible for sustaining the high ethical standards of this institution.’” The threatened lawsuit has not materialized, but Atlas’ influence in the media had remained robust despite scientific outcry (even after he resigned as White House Coronavirus Task Force adviser on December 1, 2020).

As challenging as this situation has been, it does not stand alone in history. It affirms that physicians and scientists have a professional obligation to respond when science is being misrepresented. Reasserting the scientific consensus through opinion articles, open letters, and research syntheses and commentaries in peer-reviewed journals alerts policy makers to the need for caution before acting on a single adviser’s recommendations and shapes how journalists explain matters to the public. Individuals must also honor their professional obligations as physicians and scientists when they are offered roles in public health policy. As difficult as it may be for some physicians or scientists to acknowledge that an important role exceeds their expertise, professionalism demands honesty about what they know and do not know. Without this, when the voices of physicians are coupled with the power of national leaders and provide support for misguided policies, serious public harm can result. When this happens, physicians must speak out or risk being complicit. These are some of the important lessons of the COVID-19 pandemic that should not be forgotten.

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Article Information

Corresponding Author: Philip A. Pizzo, MD, Departments of Pediatrics and Microbiology and Immunology, Stanford University, Lorry I. Lokey Research Bldg, 265 Campus Dr, G1078, Stanford, CA 94305 (ppizzo@stanford.edu).

Published Online: February 4, 2021. doi:10.1001/jama.2021.0122

Conflict of Interest Disclosures: Dr Pizzo reported that he is one of the individuals named in the lawsuit threatened by Scott Atlas, MD, for authorship on the open letter referred to in this Viewpoint. Dr Mello reported receipt of personal fees from Verily Life Sciences LLC for serving as an adviser on a product designed to facilitate safe return to work and school during COVID-19 and being one of the individuals named in the lawsuit threatened by Atlas. No other disclosures were reported.

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American Medical Association. Ethical physician conduct in the media: Code of Medical Ethics opinion 8.12. Accessed January 5, 2021. https://www.ama-assn.org/delivering-care/ethics/ethical-physician-conduct-media
Federation of State Medical Boards. Guidelines for the Structure and Function of a State Medical and Osteopathic Board. Published April 2018. Accessed January 5, 2021. https://www.fsmb.org/siteassets/advocacy/policies/guidelines-for-the-structure-and-function-of-a-state-medical-and-osteopathic-board.pdf
Kesselheim  AS, Studdert  DM.  Role of professional organizations in regulating physician expert witness testimony.   JAMA. 2007;298(24):2907-2909. doi:10.1001/jama.298.24.2907PubMedGoogle ScholarCrossref
Webeck  E. Stanford faculty votes to condemn Scott Atlas, White House coronavirus advisor and Hoover Institution fellow. San Jose Mercury News. Published November 20, 2020. Accessed January 5, 2021. https://www.mercurynews.com/2020/11/20/stanford-faculty-votes-to-condemn-scott-atlas-white-house-coronavirus-adviser-and-hoover-institution-fellow/
5 Comments for this article
Double Standard?
Steven Zeitzew, MD | West Los Angeles V.A. Healthcare Center, and Department of Orthopaedic Surgery, David Geffen UCLA School of Medicine
I advocate basing all of the treatments we recommend on the best available scientific evidence.

The authors are correct to recommend high scientific standards, but their own institution does not live up to that standard. Stanford University hosts the Stanford Center for Integrative Medicine, which one the authors is affiliated with. Integrative medicine is, by definition, an integration of alternative medicine, medical ideas not well supported by robust scientific evidence, with scientific medicine. Stanford, and virtually every other major medical school, teaches and sells unscientific medicine to patients. The Stanford Center for Integrative Medicine website makes it clear
their offerings include treatments not well supported by evidence, including acupuncture treatment for infertility (which one JAMA article showed ineffective (1)). 

The AMA ethical guidelines they cite also suggest that physicians should not sell or profit from treatments not supported by good scientific evidence.

We are entitled to differ in our interpretations of evidence. It is clear the best evidence supports masks and social distancing. The best evidence also suggests that Stanford should divest itself of the Center for Integrative Medicine and stop profiting from selling treatments not well-supported by good science. Stanford loses credibility because it offers and endorses treatment that is well known to not be supported by the best available scientific evidence, under the guise of Integrative Medicine

This article would be more persuasive if the authors explicitly supported the idea that all medical treatment recommendations should be based on the best scientific evidence, and that ethical physicians should not recommend and ethical medical schools not teach alternative medicine.

Where has the Stanford Faculty Senate been up until now? What has happened to Stanford in the quarter century since Dr. Wallace Sampson started the Scientific Review of Alternative Medicine journal?


1. https://jamanetwork.com/journals/jama/fullarticle/2681194

Hemant Hegde, MD | Eau Claire Hospital
It's about time. Thank You.
Michael Bryan, MD |
It's interesting to note that the authors write authoritatively about using science to drive decisions regarding the management of the Covid 19 pandemic yet the entire reference list are political and opinion pieces, along with references to governing body documents they feel provide them some sort of moral superiority. Where are the references to particulate size and mask efficacy with respect to viral transmissibility, and where are the epidemiology studies that support their positions? Where is the acknowledgment and analysis of the management of the pandemic in countries that are not strict adherents to the protocols that are inferred by the authors to be effective? Where are the demographic, sociologic, and logistical analyses that compare the successful management of pandemic spread to the relative geographic size, international travel policies, numbers of portals of entry, and volume of transient movement of non-tested individuals into and out of the population of the different countries who the authors cherry pick to support their opinions? I could go on, but the overwhelming gestalt of the piece is vitriol toward another physician's opinion who the authors have a declared conflict with, within their own university. I am aware it is in a section entitled "Viewpoint", but the irony of the lack of "science" in the references is hard to miss and, in my opinion, diminishes the journal as much as the authors.
The Appeal to "Authority" to Suppress Opinion
Wm Prendergast, MD | Retired physician
I second the comments of Dr. Bryan above. I would suggest that one reason no scientific articles are cited is that, as we all know if we follow this, the science on these evolving topics is hardly settled and one can cherrypick studies as needed to support one's opinion.

One error that is often made these days when supporting arguments with "science" is that writers, even well qualified scientists with impressive bibliographies, tend to confuse "science" with "scientific opinion."

We in clinical medicine ought to be pretty clear about the difference, since for the most
part we've practiced our entire careers guided by scientific opinion about science that is ever changing and rarely if ever "settled."

One clear example of this would be the evolving science of the pathogenesis and therapeutic practice in peptic ulcer disease during the 53 years since I graduated from medical school.

In view of this, I have to say I am alarmed to hear physicians, who I am sure are well meaning, taking the common approach we're hearing so much nowadays from the progressive wing of our society to demand that "authorities" "crack down" on dissident opinion and suppress divergent viewpoints.

One only has to read a little about the history of Lysenkoism in the Soviet Union to realize that this is a path we do not want to see medicine go down in the US.
Questionable Facts
Adolfo Talpalar, MD, PhD | Karolinska Institutet, Sweden
The authors select countries that show low contagion and mortality during the pandemic and authoritatively attribute such success to factors like use of face masks, lock-down, isolation, etc., whose efficacy in the long run is yet not evident. Countries like Czech Republic, Belgium, Portugal or the UK (among many others) promoted all of them, and are among the countries with highest mortality and contagion rates for number of inhabitants. How do they explain that? They can't choose example countries selectively and associate the results freely.