POST 87. December 12, 2020. CORONAVIRUS. “…Rudolph W. Giuliani, the latest member of President Trump’s inner circle to contract Covid-19, has acknowledged that he received at least two of the same drugs the president received. He even conceded that his “celebrity” status had given him access to care that others did not have.”

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“Ben Carson, Chris Christie and Donald J. Trump are not the sturdiest candidates to conquer the coronavirus: older, in some cases overweight, male and not particularly fit. Yet all seem to have gotten through Covid-19, and all have gotten an antibody treatment in such short supply that some hospitals and states are doling it out by lottery….

Mr. Giuliani’s candid admission once again exposes that Covid-19 has become a disease of the haves and the have-nots. The treatment given to Mr. Trump’s allies is raising alarms among medical ethicists as state officials and health system administrators grapple with gut-wrenching decisions about which patients get antibodies in a system that can only be described as rationing.

“We should not have Chris Christie and Ben Carson — and in the case of Carson with intervention by the president — get access,” said Arthur Caplan, a medical ethicist who works with drug companies on how to ration scarce medicines, referring to the secretary of housing and urban development’s admission that the president “cleared” him for the therapy. “That is not the way to secure public support for difficult rationing systems.”..

In an interview on Wednesday, one prominent businessman, who spoke on condition of anonymity to avoid harming his reputation, described his aggressive efforts to track down the Regeneron treatment — including calling friends who were hospital executives and hospital donors — after he tested positive last week.

Eventually he was directed to an emergency room in his city, which was expecting him. He was given an infusion of the drug on Monday. He is feeling much better, he said….

Once state and local health agencies determine which hospitals or medical facilities should get the drugs, they are shipped out by a third-party distributor. Then it is up to health care providers to figure out what to do with them. Dr. Peter L. Slavin, the president of Massachusetts General Hospital, said in an interview Tuesday that access there would be by lottery.

“The notion that we are going to be able to treat a significant percentage of the people who qualify for the drug with the drug — it’s not going to happen,” he said.” (A)

(October, 2020)

“As the symptoms of Covid-19 took hold, President Trump got an infusion of an experimental antibody cocktail and was whisked by helicopter to Walter Reed National Military Medical Center. When his oxygen levels dipped, he was quickly put on a steroid normally given to patients with severe cases of the disease. At every step of the way, the president has had a team of expert physicians carefully monitoring his care.

That experience is a world away from the stressful waiting game most patients wade through after a positive test.

They are told to stay home and monitor their symptoms. If they do become severely ill, there is only a remote chance they will get access to the antibody cocktail, which was developed by Regeneron Pharmaceuticals and is being tested in clinical trials. The company said Monday that the president was among fewer than 10 people who have gotten access to the drug through a compassionate use program.

“Covid is all about privilege. The more privilege you have, the more you can ignore some of the rules of Covid. Where one person would need to be in the hospital, another person can have the hospital come to them. That’s privilege,” said Lakshman Swamy, an ICU physician at Cambridge Health Alliance in Massachusetts.

If the president’s privileged treatment is understandable given his prominence, the contrast is no less stark for millions of Americans who have faced down Covid-19 in their homes or local hospitals, where barriers to cutting-edge care do not simply melt at the mere mention of their names or job titles.

“That’s the most heartbreaking thing about this virus,” Josh Barocas, an infectious disease physician at Boston Medical Center, a safety-net hospital that treats a largely underserved population. “A portion of the people who are severely symptomatic don’t have access to health care … and they are the population that is just being decimated by this.”

In many ways, it’s not a disparity that’s exclusive to Trump. High-profile individuals — in particular, professional athletes — have had frequent access to testing with fast-turnaround results. For much of the rest of the population, however, confirming a case of Covid-19 has meant waiting in line for a test, and waiting even longer for results.

Many patients are worried about losing their jobs because of a positive test, or afraid to go into the hospital because no one else will be available to care for their children if they’re admitted. So they stay home and try to ride it out.

For ordinary patients, there is no such thing as a precautionary hospitalization. Unlike the president, they would not be admitted based on concerns about what could happen if they are not in close proximity to doctors and state-of-the art equipment. They are only hospitalized if signs of severe infection emerge…

But ordinary patients don’t necessarily get the everything-but the-kitchen sink care received by the president. In addition to remdesivir and the antibody cocktail, the president’s physicians have also said he was given the steroid dexamethasone after a temporary drop in his oxygen levels. It is unclear whether the president was actually sicker than his doctors had portrayed at that point. But for most patients, the steroid is only given if they are severely ill and already on a ventilator or otherwise receiving supplemental oxygen.” (B)

“The medical team in charge of Trump’s care have prescribed the President an experimental antibody cocktail, an antiviral drug, and a steroid usually administered to patients with severe cases of COVID-19. The comprehensive nature of Trump’s treatments and the conflicting reports about his health have led medical experts to raise concerns about a new risk: “VIP syndrome.”

“VIP syndrome,” coined in 1964 by Walter Weintraub, a doctor at the University of Maryland School of Medicine, describes a phenomenon in which the medical treatment of a famous, powerful, or influential patient—a very important person, or VIP—faces challenges caused by the person’s fame, power, or influence.

Doctors might make decisions they wouldn’t normally make because they are more willing to accede to the famous person’s demands or are more concerned than usual that the VIP avoids feeling pain or recovers quickly.

“[VIP syndrome] often pressures the health care team to bend the rules by which they usually practice medicine,” according to a 2011 paper in the Cleveland Clinic Journal of Medicine.

Complications can arise when doctors embark on medical treatments that diverge from the standard course of care that may turn out to be detrimental to the patient’s health.

“A VIP draws special attention based on his or her status in society and level of importance as perceived by the health care professional providing treatment,” according to a 2007 article in the peer-reviewed medical journal Intensive Care Medicine. “The special handling of the VIP patient…induces the potential for inappropriate and ineffective care.”

To be clear, there is no firm evidence that VIP syndrome is a factor in the President’s care, but experts have offered it as a possible explanation for the mixed messages from Trump’s medical team.”  (C)

“So overall I think the care of President Trump raises many questions. One, it’s possible he’s a whole lot sicker than what we’re led to believe, or he’s had this virus for longer than we think he has. But the other possibility is that he is receiving VIP Medicine, which means more drugs sooner and new combinations. And it sounds like that ought to be better for patients, but so often it isn’t, and it can be detrimental.

So I’m concerned for the president, I’m concerned for his medical care. And I guess I’m concerned about the message that it sends to the broader public. That just because there are therapies that might work doesn’t mean that we know that they do work. And potentially there’s a reason why we’re not offering a bunch of therapies to someone who still has the odds in his favor. Because even though he’s 74, and even though he’s overweight, most people who fit those criteria with SARS-COV-2 do fully recover. And that’s not a situation where you want to try kitchen sink medicine, that’s a situation where you want to stick to well accepted evidence based practices.

It’s one thing to go with the expanded access route when someone’s on death’s door. It’s another thing entirely to do it early when somebody has the odds on his side of doing well. So VIP Medicine, it isn’t always what’s best for people. And I think the president’s case may be an example of that.” (D)

“You are a bioethics fellow at a major hospital. How are VIPs treated differently than the rest of us? Lecturer Joseph Dunne

Medical centers try and do the same things they always do when anyone comes in—which is to provide the best medically indicated care possible for the patient at hand.

I can assure you that hospitals don’t have super-secret machines hidden in the back or technology saved for just such people! The only difference in treatment, if there is any, comes instead with more practical measures like locking or restricting the patient’s chart access—to protect against snoopers and gossipers—and providing additional security personnel to protect the vulnerable patient.

What are the ethical pressures physicians face when treating VIPs?

It’s this scenario: “Doctors save lives. So when we bring you our VIP, you should save their life, right? Don’t you know how important they are!?”

I am not a physician, but there seems to be an intense pressure facing the physician treating the VIP to “do everything possible” and simply make them well again because of how necessary or integral they are to the function of whatever important institution(s) they are connected with.

Do these pressures change the medically indicated care plan?

Pressures typically apply to not-purely-medical things like requests for the most experienced medical personnel, access to window rooms (or requests against them so no one can see in) and heightened 24/7 monitoring. Pressures to treat VIPs don’t typically affect what is medically indicated—if at all.

If a prominent person comes in for a myocardial infarction (heart attack), then they will be treated, medically speaking, in the same way as other patients suffering from that issue. That’s because there’s not much that can be done outside of routine medically indicated care for the issue….

The only deviation from this general trend is when the medical care may involve novel  treatments, meaning not yet approved by the FDA, for novel conditions—for example, new treatments for COVID-19. Where there is no clear routine or medically indicated care yet, physicians will typically exercise their best judgment under the developing umbrella of justifiable treatment options — some of which can be more or less risky, more or less efficacious, and more or less scarce. Physicians would most likely begin by utilizing the less risky, more efficacious and less scarce options and see if those work first.

In philosophy, people are considered morally equal. So why does a VIP get scarce COVID treatment when my grandma doesn’t?

The worry is that social inequality, in some sense, trumps—pun not intended—medical equality. Is this justified or is it a moral calamity?

Here’s one reason to think that it’s not unjustified: Suppose a hospital system gets a limited supply of COVID vaccines and has to figure out how to distribute them. Who should get them first? You might think that we should give them to people based purely on who is the most vulnerable (older, obese, etc.). But most hospitals won’t distribute the vaccine like this — in fact, they have been recommended not to by the NIH and CDC via the National Academies of Sciences, Engineering and Medicine.

Instead, hospitals will likely give those scarce vaccines to their own staff who work primarily with COVID patients, with their most vulnerable employees getting the vaccine first…” (E)

“In a video shot moments after his return, Trump addressed the American people as if he had already beat the disease. “Don’t let it dominate you,” he said, not wearing a mask, despite almost certainly still being infectious. “Don’t be afraid of it, you’re going to beat it, we have the best medical equipment, we have the best medicine.”

Trump has certainly had the most advanced medicine. He was treated with at least three drugs – an experimental monoclonal antibody from Regeneron, antiviral remdesivir and steroid dexamethasone – which are usually reserved for patients with “severe” Covid-19 or a “life-threatening” condition.

Average Americans will not have access to Regeneron’s antibody cocktail, and certainly not at the dose Trump took, which was three times greater than what is being studied. Regeneron’s chief scientific officer, George Yancopoulos, acknowledged this special treatment.

“If I had to treat one patient, I’d give the high dose,” Yancopoulos said, according to Science magazine. “From a societal point of view and the need to treat as many people as possible, I’d give the lower dose.”

Remdesivir has been in short supply for months. It only became available for hospitals to buy from the distributor, rather than the US government, the same day Trump is believed to have received his first positive Covid-19 test. Dexamethasone is normally reserved only for severely ill patients.

All of this special treatment underlines the inequality in America’s medical system – regular people have to jump through bureaucratic hoops and pay exorbitant prices for healthcare. But special treatment is not necessarily healthy for the patient it is bestowed on either.

Doctors at the Cleveland Clinic, where the institution’s academic esteem attracts royalty and political luminaries from around the world, set out principles to care for VIP’s. The first one is “don’t bend the rules” of clinical practice.

“In other words, suspending usual practice when caring for a VIP patient can imperil the patient,” wrote the group of physicians. Cleveland Clinic doctors continued: “Usually, the VIP is relieved if the physician states explicitly, ‘I am going to treat you as I would any other patient.’”” (F)

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(A)Trump and Friends Got Coronavirus Care Many Others Couldn’t, By Sheryl Gay Stolberg, https://www.nytimes.com/2020/12/09/us/politics/trump-coronavirus-treatments.html?referringSource=articleShare

(B) ‘Covid is all about privilege’: Trump’s treatment underscores vast inequalities in access to care, By CASEY ROSS, https://www.statnews.com/2020/10/06/covid-is-all-about-privilege-trumps-treatment-underscores-vast-inequalities-in-access-to-care/

(C) What is ‘VIP syndrome’? Trump’s COVID-19 diagnosis underscores challenge of treating famous patients, BY NAOMI XU ELEGANT, https://fortune.com/2020/10/05/trump-covid-what-is-vip-syndrome/

(D) Just because drugs might work doesn’t mean they do work, says Vinay Prasad, by Greg Laub, https://www.medpagetoday.com/infectiousdisease/covid19/88978

(E) Is Very Important Patient treatment justified?, https://umdearborn.edu/news/all-news/articles/very-important-patient-treatment-justified

(F) ‘You over-treat or under-treat’: the problem of VIP patients like Trump, by Jessica Glenza, https://www.theguardian.com/us-news/2020/oct/07/trump-vip-patient-special-treatment-coronavirus