ACADEMIA Letters

The COVID-19 Wars: Physician vs. Clinician

Barbara Lewis, Brooklyn College of CUNY
William Lewis, WashU, St. Louis (class of 2023)

Introduction
In his paper, Organizational Agility, Visionary Leadership in the Age of VUCA, HersheyFried-
man uses the military idiom, VUCA, that has been adopted by the corporate world referencing
the “vulnerability for obsolescence”: volatile, uncertain, complex, and ambiguous. Friedman
depicts and cautions against this inflexibility found throughout most organizations, industries,
and academic institutions that resist change and, therefore, face collapse. An analogous situ-
ation transpired during the global pandemic triggered by Covid-19. Author Susan Dominus
in her New York Times Magazine article The Covid Drug Wars That Pitted Doctor v Doctor
(8/8/2020), debates the dispute that emerged between the bedside physicians treating critically
ill Covid-19 patients and the research clinicians. Their opposing perspectives on the morality
of using treatments for which there is no evidence-based medicine (EBM) to confirm their ef-
ficacy, spawned battles. In this paper, we will draw comparisons between the rigid approach
demanded by medical research protocols versus the agility needed to combat a pandemic,
rapid in growth, “deadly, contagious and entirely novel” (Dominus).

”Fighting the Last War”

“Warfare demonstrates the importance of using new approaches in fighting battles” (p. 26)
states Friedman depicting several instances in which wars were fought with outmoded meth-
ods. From Waterloo muskets to the Crimean War rifles, improved firearm proficiency from

Academia Letters, August 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Barbara Lewis, barbaraj@brooklyn.cuny.edu

Citation: Lewis, B., Lewis, W. (2021). The COVID-19 Wars: Physician vs. Clinician. Academia Letters,
Article 3085. https://doi.org/10.20935/AL3085.

1
one hit in 469 to one hit in 16 (Friedman, p. 16 refers to White, 2012 p. 324). The technolog-
ical growth in weapons was exponential between World War I and World War II so trenches
and mustard gas below were ineffective whereas planes with bombs became the enemy above.
This was an enemy undetected until the last moments and approximated a lightning-fast virus
descending upon an unaware public. Dominus provides documentation for this viral Covid-19
war that she outlines which “pitted” physicians against one another.

Covid-19 War: Agility and Instantaneous Responses Are Vital

Considerably high mortality rates for hospitalized Covid-19 patients pressured physicians des-
perate for treatment options. Ideally, medications, even those approved to treat other illnesses
(off label), would have been tested through RCTs (double-blinded, randomized, controlled
trials meaning that neither the patient nor the doctor knows which test group they are in).
Considered the standard in research, these tests prevent bias in judgement polluting results.
But there was no time for this. The morgues were filled, and refrigerated trucks were parked
in New York neighborhoods collecting bodies.
Dominus relates an interaction between a research team member and a pulmonary-critical
care doctor who judged his patient needed a higher dosage of the trial medication and, there-
fore, would be removed from the trial. Angry words were exchanged after which the lead re-
searcher stated in a subsequent meeting that “Relying on gut instinct rather than evidence..[was]
witchcraft” (Dominus, p. 2). That is the derivation of the infamous blow repeated in the
Covid-19 research community. The outbreak was overwhelming to the health care system
with a virus unknown and deadly. Global doctors sought information from social media
platforms and WhatsApp groups to garner some understanding of treatment. Nothing was
peer-reviewed because this novel virus was too new.
A cardiologist in California was alarmed at how physicians in NY were treating patients
using off-label treatments declaring, “it felt it wasn’t even World War I medicine…It was
almost like civil War-level medicine, reported Dominus (p. 4). Constructing a timeline re-
garding the various drugs utilized and their benefit or risk to the patient, Dominus interviewed
frustrated physicians who proclaimed, “There is no proof that anything works…Everything
is experimental” (Dominus, p. 6). They were conducting guerrilla warfare without science to
guide them.
Another story transcribed by Dominus depicted the excited response to hydroxychloro-
quine, declared as a lifesaver but later revealed to create heart problems for some patients.
Physicians were “panic-prescribing” (Dominus, p. 9) without any EBM. With the broad dis-
pensing of hydroxychloroquine, there was no way to enroll subjects in an RCT as treatment

Academia Letters, August 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Barbara Lewis, barbaraj@brooklyn.cuny.edu

Citation: Lewis, B., Lewis, W. (2021). The COVID-19 Wars: Physician vs. Clinician. Academia Letters,
Article 3085. https://doi.org/10.20935/AL3085.

2
with this theoretical miracle drug because they began a protocol immediately upon verifica-
tion of infection. In contrast, by June 2020, Britain had conducted a large RCT and found this
drug was not a useful treatment. How was Britain able to do so while the US was stymied?
In Britain, high-level medical officials sent messages throughout the country requesting that
physicians not use off-label meds without an RCT in place, whereas in the US, federal agen-
cies had done the opposite, easing restrictions regarding off-label usage in the panic to provide
defenses to fight the pandemic.
An NYU bioethicist acknowledged that “the commitment to long-shot efforts to rescue
patients was stronger than the commitment to science” (Dominus, p. 11) thus delaying RCTs.
More strife transpired regarding the aggressive use of anticoagulants, as well as corticos-
teroids, with the ethical dilemma of not providing enough of this class of drugs to some of the
test subjects to prevent their deaths. The position of the bedside doctors as they were fight-
ing the rapid onset of conditions that this disease generated, became “life and death. Fear.
Ignorance. You were seeing human behavior in survival mode, a classic reaction to threat”
(Dominus, p. 15).

Responses
This dire situation prompted experimentation with medicines and dosages that may be harmful
to the patient but so is an RCT if the patient is in the control group and is receiving a placebo,
not the medicine being tested, or a different dose of the existing medicine. Many physicians
were practicing “kitchen sink therapeutics” (labeled by Griffin in TWIV episode 656) so that
anything was attempted. But as the COVID-19 evolution of treatments reveals, some of the
protocols did much harm rather than any good. Professionals were in clinical equipoise in
that they did not know which treatment would be better for patients, but they were urgently
seeking some approach to combat the flow of patients and deaths.
The Stanford Encyclopedia in The Ethics of Clinical Research article by A. London, Social
Value, Clinical Equipose, and Research in a Public Health Emergency, identifies the “funda-
mental ethical concern raised by clinical research is whether and when it can be acceptable to
expose some individuals to risks and burdens for the benefit of others”. This was the trigger
that set the two groups of Covid-treating physicians (those bedside and those researching the
treatments for the virus) on the warpath with the battle cry of “witchcraft” leveled against doc-
tors attempting any available treatment to prevent another death without having the certainty
and guidance provided through EBM. Griffin (TWIV episode 656) labeled the interaction as
skirmishing when a cease-fire was required. He describes an interaction directed at a steroid
prescribing physician who was accused of “killing the patient.”

Academia Letters, August 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Barbara Lewis, barbaraj@brooklyn.cuny.edu

Citation: Lewis, B., Lewis, W. (2021). The COVID-19 Wars: Physician vs. Clinician. Academia Letters,
Article 3085. https://doi.org/10.20935/AL3085.

3
 London projects that “testing potential new treatments can take 10-15 years” (London,
p. 3). With a novel virus that grows exponentially globally and with mind-boggling rapid-
ity, how can any testing get up and running quickly enough to benefit the millions battling
the illness? Additionally, the article underscores a physician may not “compromise patients’
medical interests when conducting therapeutic studies” (London, p. 11). There are stringent
regulations designed to protect the subjects, but the nature of these studies clearly places some
in a more dangerous position with the philosophy that the study provides for the greater good
rather than the individuals’ benefit. Is this immoral: placing some at risk, or not proceeding
with studies and placing all future persons contracting the illness at risk? Is there an ethical
delineation between actively causing harm versus allowing harm to occur? Although testing
might not actively cause harm, it may reduce a subject’s ability to be cured, thus harm occurs.
For Covid-19 treatment options, there has been little time to generate RCTs. Is it ethical
to withhold a possible treatment if the patient is in the control group? Physicians need the
science behind the treatment, but with a new novel virus, how do we create guidance while
still addressing immediate and catastrophic patient needs?
This is the “parachute” dilemma that D. Griffin discusses in his podcast See It Can Be Done
(episode 656 TWIV). Withholding a medication may pose a serious ethical problem for the
physician if their judgment is telling them that the medication is necessary. Yet administering
it will remove the patient from the test subject pool. The concept of an RCT of a parachute led
to the naming of this dilemma - the absurdity of designating a pool of randomized subjects
who would consent to be in the placebo parachute users’ group dropping from a height without
a parachute most likely guaranteeing death. Worrell warns of the “fetishization” of random
testing and that sometimes it is not necessary and even detrimental (episode 656 TWIV).

Conclusion
The moral dilemma created by a new novel, fast-spreading, virus is unique in our present his-
tory with the last occurrence a century ago. Will we be fortunate to not face this again for
another 100 years? Some scientists predict that these events will be arriving more frequently
as we claim more of the earth from indigenous species and zoonotic diseases will continue to
plague us. We need to prepare for these wars and have an agreement between treating physi-
cians and research clinicians as to how to plan and test possible treatments. Friedman stresses
adaptability and improvisation, testing multiple options simultaneously to deploy remedies
more rapidly. Discord and clashes are counterproductive. The exchange of global informa-
tion expedited by the internet, as it was during this pandemic, enables the world’s scientific
community to conjoin and share information across borders. This should not be politically

Academia Letters, August 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Barbara Lewis, barbaraj@brooklyn.cuny.edu

Citation: Lewis, B., Lewis, W. (2021). The COVID-19 Wars: Physician vs. Clinician. Academia Letters,
Article 3085. https://doi.org/10.20935/AL3085.

4
motivated, as is war, but rather, a collaborative endeavor that will allow humans to cohabitate
with indigenous life on our planet.

References
Dominus, S. (2020, August 8). The covid drug wars that pitted doctor v. doctor. New York
Times Magazine. https://www.nytimes.com/2020/08/05/magazine/covid-drug-wars-doctors.
html

Fuller, J. (2020, January 6). Evidence based medicine. Philosophers on Medicine. https://
jonathanfuller.ca/podcast/2020/1/6/evidence-based-medicine

Friedman, H. (2020, November 11). Organizational agility, visionary leadership in the age
of VUCA. SSRN https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3728372

Griffith, D. (2020, August 23). Episode 656. See it can be done! This Week in Virology.
podcast. https://www.microbe.tv/twiv/twiv-656/

Worrall, J. (2020, August 23). Evidence based medicine. Philosophers on Medicine. podcast
https://www.microbe.tv/twiv/twiv-656/

London, A. J. (May 20, 2018). Social value, clinical equipoise, and research in a public
health emergency. Clinical Research. Section IV. Stanford Encyclopedia. https://plato.
stanford.edu/entries/clinical-research/

Academia Letters, August 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Barbara Lewis, barbaraj@brooklyn.cuny.edu

Citation: Lewis, B., Lewis, W. (2021). The COVID-19 Wars: Physician vs. Clinician. Academia Letters,
Article 3085. https://doi.org/10.20935/AL3085.