As a bioethicist, I’m disturbed that the person highly likely to be the next President of the United States is receiving substandard treatment for hypothyroidism. Hillary Clinton’s health records were just released to the public, which was not a HIPAA violation but standard protocol for Presidential candidates as health and fitness for office are released to the voting public.
Unfortunately, it was revealed that Hillary Clinton is not being properly treated for hypothyroidism. Instead of being prescribed the standard of care — levothyroxine sodium — she is being prescribed desiccated thyroid hormone — which is an antiquated and less stable form of thyroid hormone replacement, as any board-certified endocrinologist or physician with demonstrable training knows. Here’s the report from the Daily Mail that makes public her doctor’s report:
Levothyroxine sodium has been the standard of care for many years, so it is not easily explained why Ms. Clinton’s internal medicine physician would not follow the standard of care. The most recent clinical practice guidelines from both the American Association of Clinical Endocrinologists (AACE) and the American Thyroid Association (ATA), strongly recommend against the use of desiccated thyroid hormone. See Recommendations 22.1 and 22.4 in the joint ATA/AACE “Clinical Practice Guidelines for Hypothyroidism” (https://www.aace.com/files/final-file-hypo-guidelines.pdf) and Recommendations 1a and 12 in the ATA “Guidelines for the treatment of hypothyroidism” (http://online.liebertpub.com/doi/full/10.1089/thy.2014.0028 )
The site, “Quackwatch”, managed by Dr. Steven Barrett, even has a warning about physicians who prescribe desiccated thyroid hormone: http://www.quackwatch.org/01QuackeryRelatedTopics/armour.html
There are only two reasons why a physician would prescribe desiccated thyroid hormone to a hypothyroid patient in the year 2015 (as opposed to the year 1915):
- The physician is not aware of the standard of care, and offered it as an option. Although it’s true that physicians with no special training or board certification in endocrinology manage many hypothyroid patients, clinical practice guidelines put out by specialty organizations exist for the purpose of educating and updating these colleagues about the acceptable and recommended standards of care. Internal medicine practitioners, such as Ms. Clinton’s physician, have a legal and ethical duty to stay up to date and proficient in standards of care for multiple common conditions. Since hypothyroidism is one of the most common conditions seen by internal medicine practitioners, prescribing a medication that is below the standard of care – particularly to the former Secretary of State and potentially future POTUS, is ethically concerning. If Ms. Clinton was offered desiccated thyroid hormone as an equal alternative to levothyroxine – either by her internist or a different physician — then she was unable to provide informed consent.
- The patient has declined the standard of care. Many hypothyroid patients search the Internet or popular health books about treatments. Unfortunately, purveyors of misleading information that desiccated thyroid hormone is “natural” and therefore better for you, is a common false message patients will find. Many physicians spend considerable effort to educate (or de-program) hypothyroid patients that desiccated thyroid hormone is below the standard of care, but some patients insist on it against medical advice. Or, a patient may refuse to switch to the standard of care if desiccated thyroid hormone was prescribed by a different physician. In these cases, it is ethically permissible to prescribe (or renew) desiccated thyroid hormone because it is, at least, better than nothing. Not providing thyroid hormone replacement would lead to severe hypothyroidism, which could mean loss of decision-making capacity in the short term, and myxedema coma in the long term.
This situation leads to wider, unintended consequences for thousands of hypothyroid patients, which I call the “Oprah Problem”. Oprah Winfrey’s 2007 diagnosis of what was probably Hashimoto’s thyroiditis led to her promoting non-standard therapies on her show, endorsed by factitious experts with no training in thyroidology (See: http://www.newsweek.com/why-health-advice-oprah-could-make-you-sick-80201). Patients assume that women with the power and stature of Oprah Winfrey or Hillary Clinton must be receiving the very best care in the United States and may request the same non-standard therapies. This results in pointless harm. Unfortunately fame is often a barrier to good care for reasons having to do with “VIP Syndrome” – when physicians become star-struck, and are reluctant to refer their famous patients to more experienced physicians.
Considering Hillary Clinton’s long dedication to American healthcare, she deserves, at least, the prevailing standard of care, not a level of care that is so far below the community standard.