2014 ATA Thyroid therapy guidelines: 2. Ethics

American Thyroid Association-Ethics

Here I move on to part 2 of my summary of ATA thyroid therapy guidelines, where they try to defend the ethics their own stance (Jonklaas et al, 2014). Their self-righteous, defensive and arrogant reply to question 11 deserves its own post. (“WE” = Endocrinologists and other doctors who treat hypothyroidism. Anything in quotation marks is directly from their article.)

PARAPHRASE RESUMES:

Q11. How do we maintain our professional ethics while treating hypothyroidism with levothyroxine?

A: We are charged with assessing your risk/benefit ratio. Ethically, we can’t give you “a therapy that is known to have no therapeutic benefit.”

We ethically can’t give you hormone pharmaceuticals such as desiccated thyroid because “Offering patients formulations of THs [thyroid hormones] or other preparations that are known to be inferior to the standard of care, potentially futile, or even harmful contravenes the Principles of Beneficence and Non-Maleficence.”

We must “protect clinicians from deviating from practice to satisfy inappropriate patient demands.”

Even if patient autonomy is a value, we can never “cater to patient preferences” if it means agreeing to a request for “inappropriate therapies.” (See an article we’ve cited, titled “Sick autonomy” by Tauber, 2003, which explains that we have responsibility for you and you are not independent of us. If you think we are being paternalistic toward you, read the other article we’ve cited, titled “In defense of paternalism” by Loewy, 2005, which explains that you have the right to select your goal, but it’s our job to advise you whether it’s feasible and how to attain it. It’s our moral role to lead you in helping you choose a good health goal, and if we simply present you with options we are not only abandoning you to unwise autonomy but actually violating your autonomy.)

“There are limits to what practitioners may offer if patients are demanding therapies that are outside the standard of care or potentially harmful.”

We must protect “patients who do not have full decision-making capacity from pointless harm.”

We declare that you do not have full decision-making capacity if you can’t demonstrate appreciation of our rationality and see the risks the way we do: “If there is inability of autonomous patients to demonstrate understanding, appreciation, rationality, and expression of a choice, this indicates there is a barrier to decision-making capacity, and thus, valid informed consent cannot be claimed.”

Therefore, even a consent form can’t enable us to morally justify prescribing anything other than Levothyroxine. Fully informed consent is not ethically obtainable because you are obviously not informed enough or rational enough if you disagree with our expert opinion.

It is never good enough for you as a patient to express that you want to “feel better” or that you “prefer” a form of thyroid therapy, even if you think it is more “natural.”

If you make a request for a “natural” thyroid therapy, you demonstrate a lack of scientific understanding of the bioidentical nature of synthetic hormones, which incapacitates you from having valid decision-making capacity.

What you really need is to be more deeply educated about the beneficial properties of synthetic levothyroxine medication and how it restores natural function.

If you still won’t comply with our guidance, we will resort to more extreme measures to protect you from yourself. We even ethically required to take measures to limit your rights and freedoms if we suspect that you are putting others at risk by refusing our recommended treatment. For example, we can take away your driver’s license: “Failing to fulfill the Duty to Warn, for example, by notifying third parties or authorities when severely hypothyroid patients are driving and are known threats to public safety or even child safety (if driving children), is a violation of Non-Maleficence.”

In addition, we will do anything in our power to ensure that everyone who treats thyroid patients abides by our standard of care so that you have no way out except to comply with our care.

We believe that doctors who treat hypothyroidism outside our standards of practice must be punished, and we should even take their licenses away.  We have the ethical duty do this if we value professional competence and intellectual honesty.

It is deceitful to all patients for a doctor to claim that they are an expert in treating hypothyroidism when they have no formal training or accreditation or certification in the area, when all they have done is study a lot of thyroid medical literature and learn by clinical practice.

Even if they as a doctor do have formal training and licensing in the area of thyroid therapy, they are misusing their medical knowledge if they “personally profit, deceive patients, or purvey nonstandard, risky innovative therapies in hypothyroidism.” Doing so is “violating basic standards of care,” so we have our eyes on them!

We cite as examples “Two recent judgments in high-profile medical negligence cases” —Michael Kamrava and Conrad Murray, in 2011. (Conrad Murray was convicted in Michael Jackson’s death.) 

These two examples “involved practitioners acceding to patients’ demands for unsound medical therapies. In these cases, the physicians abandoned primary obligations to beneficence and non-maleficence, and treated the patients as their customers. In one judgment, the practitioner was stripped of his medical license; in the other, he was convicted of involuntary manslaughter for iatrogenic harms caused by a therapy the patient demanded.”

(We won’t tell you this, but you’ll find out by looking them up that these cases have no connection to thyroid disease or thyroid therapy. Anyway, we’re making a philosophical point, and these are useful examples to warn all doctors who might be tempted to help you “feel better” by prescribing a competing bioidentical thyroid hormone source we don’t approve of.) 

END OF PARAPHRASE.

Ethics should involve two-way dialogue, and this argument is so offensive that I’m going to respond to this section right away.

A RESPONSE

American Thyroid Association-StandardCare

You, the ATA (and all who follow your authority), have taken away our autonomy and rights when it comes to our freedom to choose an alternative thyroid hormone pharmaceutical. You briefly acknowledge that patient autonomy is a value, but then you trample on our autonomy. You have replaced our autonomy with your medical power.

You, the ATA, claim that you are legally and morally charged to uphold your profession’s narrow ethical standards against patients’ unreasonable “demands” and “preferences” (you won’t even give us the honor of using the word “choices”).

You, the ATA, imply that any requests patients make for other therapy options and broader, individualized thyroid care are unreasonable.

You, the ATA, then make your own “demands” on us — we, your patients, must understand and appreciate the science behind our thyroid therapy.

You deeply insult us by saying that we are not even capable of giving informed consent because we can’t possibly understand how thyroid hormones work if we voluntarily give our consent to a change of pharmaceutical source and ratio of hormones.

You have created an unequal and unfair playing field by saying that we are immediately ethically out of bounds as soon as we interpret the scientific evidence differently from the way you do.

You do not show an attitude of a scientific, evidence-based inquirer willing to engage in ethical two-way dialogue or learning; there is only room for one-way indoctrination.

You, the ATA, practice scientific dishonesty when you embed unfounded attacks against competing thyroid hormone medications into your statements that demean your patients’ requests. By claiming that an entire class of pharmaceuticals are “formulations of THs [thyroid hormones] or other preparations that are known to be inferior to the standard of care, potentially futile, or even harmful,” you imply that you have proven them to be such.

Show us your long list of double-blind randomized controlled studies over decades (since thyroid therapy is lifelong), replicated by others, that conclusively prove that any and all other thyroid hormone pharmaceutical or combinations are “known to be inferior” to levothyroxine monotherapy.

No, you can’t, because you have never been bothered to systematically substantiate your own attacks with evidence against their safety and equal effectiveness, evidence that passes your own high standards for medical research.

Saying you “know” this is your opinion, not evidence, and you’re using your authority to slide these unscientific opinions into your arguments. You make it seem as if they are well-established facts that are beyond even the reach of human consensus, like knowing the law of gravity. It’s pure slander and defamation.  Meanwhile many people who disagree with you “know” other thyroid hormone preparations to be superior for some patients, as well as effective and safe. 

It is so disappointing to see you lose your credibility in this way, by so unscientifically demeaning all other thyroid hormone therapies but your own “preference” (can we even call your standard of care your voluntary and informed “choice,” when your medical discipline coerces and constrains you to use levothyroxine alone?)

Throughout this document, I see over and over a defense of a favorite paradigm and set of assumptions. Fear of permitting alternatives is justified by ignorance and disdain for the history of thyroid therapy. I see a refusal to learn and do fair, open-minded research on the problems with your favorite therapy and benefits of other therapies.

Moreover, you say that consent for therapy must be voluntary and not coerced, yet you coerce us. You say that if we as patients do not comply with your “standard of care,” you can openly threaten to punish us with the means you have within your power.

In many regions of Canada, doctors are in short supply, and many can’t afford to go doctor-shopping. To add to the power imbalance, those of us who suffer the most from your “standard of care” may be too handicapped and restrained by our fatigue, brain fog, depression, and poor health to advocate with much energy to improve our poor thyroid therapy. We have to put up with your coercion and suffer.

You also threaten to punish any other doctors who don’t follow your ways. You appear to be determined to cut off all avenues for more effective care so that we will have no alternative but to submit to your “standard of care.” Doctors also have to put up with this ideology and shut up, or their careers will suffer. That is not ethical.

What you seem to be doing is offering our medical systems and impressionable doctors ways of justifying their narrowing of our therapy options so that they have the convenience and reduced cost of simplifying our thyroid care. You are giving them self-defense mechanisms. They can hide behind your guidelines document and shield themselves from damage to their careers and from any sense of guilt or doubt that they may be harming us.

And somehow, such narrow, self-righteous zeal to indoctrinate, defame, coerce, and punish is supposed to prove that you are ethical, respectful, and benevolent toward all thyroid patients?

We are supposed to believe that you have the professional and moral objectivity and scientific data to determine that no other thyroid hormone preparations can ever be equally safe and equally beneficial?

TO BE CONTINUED…

  • Tania S. Smith

REFERENCES

Jonklaas, J., Bianco, A. C., Bauer, A. J., Burman, K. D., Cappola, A. R., Celi, F. S., … Sawka, A. M. (2014). Guidelines for the Treatment of Hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement. Thyroid, 24(12), 1670–1751. https://doi.org/10.1089/thy.2014.0028

 

 

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