Even Rudy Giuliani himself admitted it. “If it wasn’t me, I wouldn’t have been put in a hospital, frankly,” Guiliani, Trump’s personal lawyer and close confidant, told WABC radio earlier this month of his treatment for Covid-19.
The more decision points there are, the more it can be possible for privileged patients to find vulnerabilities they can exploit to their advantage.
Ben Carson, secretary of housing and urban development, also spoke forthrightly about his privileged care after contracting the virus. He noted that while in the hospital, "President Trump was following my condition and cleared me for the monoclonal antibody therapy that he had previously received."
Another key Trump ally, former New Jersey Gov. Chris Christie, also received emergency access to the experimental monoclonal antibody therapy. He was granted compassionate use access to the Eli Lilly version after reportedly having been denied access to the similar Regeneron treatments when he wouldn’t enroll in a clinical trial because he stood a chance of receiving a placebo.
As hundreds of thousands of Americans get ill, suffer debilitation and die from Covid-19, it is crucial that treatments and therapies be distributed on an equitable basis to those most deserving. Watching these men with political connections get advantages they don’t deserve reveals some of the unfairness embedded in the U.S. health care system. We must do better to ensure that Americans get the care they deserve and don’t lose faith in medical institutions.
Unfortunately, the system providing access to important health care services, including access to investigational drugs under compassionate use, has many individual components that people with celebrity, means and connections can exploit to their advantage. Relying on the rectitude, awareness and wherewithal of doctors, drug companies, health care facilities and the like not to give special preferences at each step in the process hasn’t been sufficient to eliminate all the vulnerabilities.
The example of the compassionate use drugs like those Christie received demonstrates the vulnerabilities of the current stepwise process. The process begins with physicians making a request to the drug manufacturer when a patient needs an experimental drug and participation in a clinical trial is not an option. The manufacturer reviews the request against its approval criteria and supply quantities, which are often limited because the drug hasn’t been approved for mass production. If the manufacturer approves the request, the treatment center evaluates the case to make sure it meets its clinical and ethical requirements, and then, with the informed consent of the patient, the treatment can be made available.
In theory, the physicians, treatment sites, pharmaceutical companies and patients themselves should be guards against undue influence based on celebrity, position and connections. In practice, Covid-19 is demonstrating how fair access to investigational drugs under compassionate use is not guaranteed.
Physicians can be aware that providing their patient with a scarce investigational drug means another patient doesn’t get it, including those who are likely to benefit more. In those cases, they balance moral obligations to their individual patients with their obligations to broader patient populations. But physicians have an ingrained fidelity to their patients such that they give preference to those in their care. And while fame and power shouldn’t factor in, external pressures to favor certain people can be more than anyone’s moral authority can withstand.
Thus, when Giuliani enters the hospital for Covid-19 treatment, his celebrity can bring him an advantage in terms of greater attention, more attending physicians and ultimately requests for investigational drugs and other services.
Treatment centers, such as hospitals, can also face enormous external pressures that corrode fairness. While Trump’s “clearance” — whatever that consisted of — for Carson’s monoclonal antibodies shouldn’t affect the protocols for determining whether the housing secretary was a good candidate and the one most qualified for treatment, it can be difficult to withstand presidential pressure.
The more decision points there are, the more it can be possible for privileged patients to find vulnerabilities they can exploit to their advantage — in Christie’s case, having two different drug companies to appeal to. Christie’s stature was not enough for Regeneron to approve his request for its monoclonal antibodies after he refused to enroll in its clinical trial for fear of receiving the placebo, as pharmaceutical companies limit the supply of drugs they allocate under compassionate use because supplies are needed for clinical trials. But, apparently, Christie’s fame was enough for Eli Lilly, which did provide him access to its compassionate use program. (Eli Lilly and Christie representatives have declined to comment.)
Patients who are less connected and savvy often don’t know that they’re competing with others to obtain investigational drugs. But when they do, they should be expected not to claim preference or exploit vulnerabilities in the system to gain advantage over others. Giuliani is proof that patients can know their status gets them advantages and gleefully take advantage of them.
Thankfully, in part because of some high-profile cases highlighting advantages some people had over others before Covid-19’s spread, we are beginning to identify some solutions. Some of these cases led to a novel collaboration in 2015 between the New York University School of Medicine Division of Medical Ethics and Janssen Pharmaceuticals called the Compassionate Use Advisory Committee.
The committee comprised a diverse group of experts from medicine, bioethics and patient advocacy. Members reviewed requests for compassionate use access to an experimental cancer drug without any identifying patient information and only having details pertinent to the fairness aspects of the decision, which included clinical profiles, availability of trials, treatment center capabilities and patient consent. Thus, Trump would not be able to “clear” access to compassionate use for Carson through this committee. The success of the pilot has led to its expansion into several therapeutic areas at Janssen.
The intention of these pilot programs is to provide a model for fair compassionate use drug allocation that other pharmaceutical manufacturers can adopt. As more companies adopt this process, more doctors, treatment centers and patients will be exposed to fair processes and, ideally, assimilate them.
The public knows the special treatment Trump’s friends are receiving is wrong, yet they are to a degree inured to it because it’s so common. We shouldn’t accept this. We shouldn’t wink at a Carson or a Giuliani bragging about their rapid and unfettered access. Instead, the public ought to loudly condemn them and demand fairness in access to compassionate use drugs. We’ll know the public has been successful when Giuliani, Carson and Christie are made to get in line with the rest of us, and when no one expects anything different.