As Covid-19 has swept across the world, a common refrain has been to listen to the experts – those with experience, competence and mastery. Now that there are more than 60,000 confirmed cases of coronavirus in the UK and many more with symptoms, our doctors and nurses have been forced to become experts. They’ve seen the virus spread, spotted patterns in outcomes and communicated with colleagues around the world.
Covid-19 is novel and it defies comparison to other illnesses, so unlike with more well-understood diseases, no one has more knowledge than those learning on the frontline. Despite their knowledge, NHS England guides prevent them from prescribing treatments that they think are effective, including those used abroad. Its obtuse attitude may go some way to explaining why case fatality rates in the UK are four times higher than in the United States, despite similarly limited testing in both countries. The NHS hierarchy should be removed from the experts’ way; patients and doctors should have the right to try.
The NHS Covid-19 clinical management guide says: “there is no current evidence from randomised controlled trials to recommend any specific anti-Covid-19 treatment”. This reasoning is used to limit specific anti-Covid-19 treatment to clinical trial participants. British doctors wishing to provide more treatment report feeling scared for their professional positions and that “professors of rheumatology and consultants in respiratory medicine can only object anonymously”.
Although randomised controlled trials (RCTs) have been started, the findings may not be available for several months. Doctors may pass patients into trials, but the use of treatments is relatively unusual compared to other countries. Given the speed of change that we have seen even in the last month, the results could be too late to be useful for most patients. Moreover, as hundreds die each day, the trial results have already come too late for many.
The NHS clinical management guide is right to say that there isn’t evidence from randomised controlled trials, however the conclusion that they’ve drawn is wrong. In the current crisis conditions, we should allow treatments recommended by clinicians and carry out observational trials as time goes on.
While RCTs are the gold standard, there are other types of studies and sources of knowledge which can be used to make urgent decisions. In fact, our entire society was locked down because of the virus spreading in our midst, without perfect evidence from RCTs.
Factories are shuttered, office workers are on zoom and children are out of school. These policies haven’t been tested in any trial, however it’s obvious that reducing human contact reduces infections, so we implemented them anyway. Similarly, we didn’t need an RCT to show that patients with coronavirus-caused respiratory failure need a ventilator – we just started ventilating. In both cases, urgency and the extreme potential cost of inaction allowed us to lower our evidence standards.
We made the right decisions to socially distance and ventilate without RCTs because we recognise that not doing these things is, in itself, a decision. There is a sense in the NHS guide that waiting for results from RCTs is an ethically superior choice because it avoids the risk of people being given ineffective treatments. However, restraining practitioners from action is a decision – and one that could be having awful consequences. Any cost-benefit analysis shows it to be a critically mistaken choice. Inaction is sometimes the right thing, however that choice should only be taken by the actual experts – in this case, the front-line clinicians.
The UK’s chief medical officers wrote a letter on the 3 April seeking RECOVERY trial volunteers, stating: “Use of treatments outside of a trial … is a wasted opportunity to create information that will benefit others”. However, clinicians across the world have been using a variety of treatments outside of RCTs and have shared their outcomes publicly; medicine has never innovated faster.
It makes a striking contrast to UK authorities, which are still denying the effectiveness of masks even after the WHO, the US surgeon general and international experts have recommended them. Expert knowledge and communication have clearly been used to choose the specific treatments trialled in RECOVERY, so experts acting outside of clinical trials cannot be a waste.
Imperfect trials have even been used to create treatment guidelines in other countries, such as South Korea, also based on the experience of the SARS outbreak. It’s unethical to deny these same treatments to consenting British clinicians and patients without extremely good reason. Even the current RECOVERY RCT does this to the control group patients (who receive placebos). At least those individuals will have consented, unlike other patients denied treatment.
Last week a nurse I am living with saw a cancer patient wait seven hours for a top priority ambulance because the service was overwhelmed. “It’s like a war – a war against the virus,” she said. Her analogy is good. As the fog of war gives us imperfect information, so does a pandemic. However, as the virus advances, we must allow frontline experts to block it with treatments and PPE.
If the virus were a human enemy, it would say that it was “just the flu”. It would dismiss evidence for treatments and insist on denying their use to expert practitioners. Politicians, practitioners and the public must urgently overrule the virus and the NHS hierarchy. We must give patients and doctors the right to try.