Bioethics Forum Essay
Ethical Responsibility in Publishing Research Results on Covid-19 Treatments
The Covid-19 health crisis warrants relatively prompt dissemination of outcomes from clinical trials, given the steep slope of the infection curve and the dire predictions regarding both patient care and resource utilization. It thus stands to reason that researchers are motivated to turn around data rapidly, consistent with serving the common good in times of extreme need. This process, however, has its limits when underpowered studies with limited data yield conclusions with broad-reaching implications.
There is little doubt about the urgent need for treatment. But premature publication of definitive recommendations based on inappropriate conclusions grounded in scant, hastily-acquired data serve only at best to confuse and at worst mislead at a time when tensions are high and need for help is great. One recent study, “Hydroxychloroquine and Azithromycin as a Treatment of COVID-19: Results of an Open Label Non-randomized Clinical Trial,” published in the International Journal of Antimicrobial Agents and receiving attention all the way to the White House, raises such concerns.
In this investigation, 36 adult patients who tested positive were studied over a two-week period at a hospital in Marseille, France. Twenty patients received 200 mg of hydroxychloroquine sulfate three times per day for 10 days while 16 patients served as control subjects. Six of those randomized to the active treatment also received 500 mg of azithromycin on day 1 and then subsequently 250 mg per day for four additional days at the authors’ discretion, depending on clinical presentation “to prevent bacterial super-infection.”
The results show that at day 6, all of those treated with combination hydroxychloroquine and azithromycin were cured, compared with 57.1% of those receiving hydroxychloroquine only and 12.5% in the control group. The recommendation issued by the authors was thus that “COVID-19 patients be treated with hydroxychloroquine and azithromycin.”
Publication of recommendations based on studies such as this is highly problematic. An investigation with only 20 treated patients (after six dropped out) is significantly underpowered and greatly subject to sample size error. Further, the reason for the addition of azithromycin is poorly described and subject to question. It is one thing to call results promising; it is another to issue definitive treatment recommendations. Hydroxychloroquine exists in limited supply, and poorly grounded recommendations touting effectiveness by health care providers and President Trump only exacerbate this shortfall. This is even more troubling with regard to azithromycin, where overuse may lead to resultant potential shortages of an important antibiotic needed to treat bacterial infection as well as the downstream effect of increasing the number of strains of drug-resistant pathogens. The FDA recently cautioned against the use of hydroxychloroquine because of reports of cardiac arrhythmias and even death in the wake of its unmonitored use.
It is ironic that the authors of this study state, “For ethical reasons and because our first results are so significant and evident we decide to share our findings with the medical community, given the urgent need for an effective drug against SARS-CoV-2 in the current pandemic context.” The true ethical responsibility of researchers is to produce and to publish data and subsequent recommendations based on robust methodology and stringent review. Some investigators may be altruistically motivated to rapidly disseminate hopeful conclusions. Nevertheless, the responsibility we hold to our patients and, especially during the pandemic, to society at large depends on good judgment and fiduciary concern rather than on haste to demonstrate beneficial outcomes.
Michael A. Erdek, MD, MA, is an associate professor at Johns Hopkins University School of Medicine and the Berman Institute of Bioethics. Twitter: @MichaelErdek
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