The Absurdity of Medical Freedom
Archie Cochrane (1909-1988) was one of the fathers of evidence-based medicine and the namesake of the Cochrane Collaboration. His professional life was profoundly influenced by his experience as a World War II prisoner of war. While serving as a physician in the British Army, he was captured during the Battle of Crete in May 1941. He spent the rest of the war as a medical officer in POW camps. Eventually, he was placed in charge of caring for Allied prisoners suffering from tuberculosis.
The resurgence of tuberculosis during the war was a public health catastrophe. At that time there were no effective antibiotics for tuberculosis. The options available to Cochrane consisted of either bed rest or an intervention such as pneumothorax or thoracoplasty. Bed rest does have a physiologic basis (lying flat reduces the oxygen tension in the lung apices). As for the other treatments, no one knew if they really worked. These therapies were based on opinion—and the impulse to do something to help a dying patient.
Cochrane suspected that interventions like pneumothorax might have hastened the death of some of his patients. He was torn between the emotional satisfaction of ordering an intervention and the distress of not knowing if he was doing more harm than good.
He was also struck by the obvious paradox: Although he was locked within the walls of a prison, he had nearly complete freedom to do whatever he thought was best for his patients. This situation brought to his mind a pamphlet he had read extolling the virtues of medical freedom:
"I found it ridiculous. I would willingly have sacrificed all my medical freedom for some hard evidence telling me when to do a pneumothorax."For a physician who believed that treatment should be guided by evidence, the concept of medical freedom was simply absurd. Cochrane recognized that clinical freedom was worthless if all it meant was the freedom to choose from a list of ineffective and possibly dangerous therapies.
In 2019, the emergence of a novel coronavirus provided the perfect opportunity for a resurgence of the medical freedom movement. Suddenly we found ourselves confronted with a deadly disease for which science had few answers and no magic bullets. The whole world was placed in a situation similar to Professor Cochran’s tuberculosis ward, where the compulsion to do something was overwhelming. Many clinicians turned to unproven remedies like ivermectin. This was an understandable response, and early data did point to a possible in vitro mechanism of action. However, as evidence accumulated that ivermectin was ineffective—and that many of the early studies were fraudulent—the medical freedom movement simply doubled down.
When the majority of physicians declined to participate in the ivermectin craze, legislatures in dozens of states introduced laws to promote off-label prescribing. The State of Tennessee decided to completely bypass physicians and make ivermectin an over-the-counter drug.
The medical freedom movement is not a harmless fad. It is a strain of anti-intellectualism that has plagued our nation since its inception. It resisted public health measures during the 1918 influenza pandemic. It fought against the fluoridation of water through the 1950s, and it helped spawn the vitamin and supplement industry that fleeces Americans of tens of billions of dollars every year for worthless pills and powders. Perhaps its most insidious accomplishment has been the undermining of public trust in immunizations.
The medical freedom movement has flourished amid the uncertainties of the COVID-19 pandemic, and its advocates now dominate a large swath of the political spectrum. Over the past 2 years, groups promoting medical freedom were able to introduce—and sometimes enact—laws to subvert the public health response to COVID-19. Their most recent victory in South Carolina was the passage of House Bill 3621, which prohibits public employers from requiring COVID-19 vaccination. It also prohibits privately owned facilities from requiring proof of vaccination as a condition of entry.
Respect for patient autonomy is a core principle of medical ethics. Patients with decision-making capacity should always have the freedom to make decisions regarding their personal healthcare, even when their choices conflict with our clinical recommendations. However, this freedom must be balanced with respect for the rights of others, and each person’s responsibility to live in harmony with their neighbors. To live in a society where people are “free” to be vectors of disease, where physicians are “free” to spread misinformation, where immunocompromised persons are “free” to stay home because healthy people can’t be inconvenienced—well, that is a perversion of freedom. As John Milton wrote, “None can love freedom heartily but good men; the rest love not freedom, but license.”
Lack of medical freedom has never been an impediment to the advancement of science. The twentieth-century conquest of infectious diseases is a testament to the true drivers of progress: Public health, vaccinations, and evidence-based medicine. We should cherish the freedom to enjoy the additional years of life and health that resulted from the scientific advancements of the modern age. And we must remain ever vigilant for those who would destroy these achievements with their absurd conception of freedom.
Cochrane, Archibald and Max Blythe. One Man’s Medicine: An Autobiography of Professor Archie Cochrane, BMJ Books, 1989.
Murray JF, Schraufnagel DE, Hopewell PC. Treatment of Tuberculosis. A Historical Perspective. Ann Am Thorac Soc. 2015 Dec;12(12):1749-59.