Is it unethical for doctors to stop masking?

A JAMA Health Forum viewpoint ignores the facts: no evidence justifies the practice & there are downsides

This week, a viewpoint appeared in JAMA Health forum. It argues that patients, particularly disabled and immunocompromised patients, should be able to request health care providers wear masks, and providers should not be permitted to decline that request.

Doctors have a duty not to harm their patients, and ergo, should wear masks when requested. It then discusses ways state medical boards and other groups can police this policy.

There are 6 errors in the piece.

First, let’s assume the authors are correct: If health care providers wear surgical masks, that protects immunocompromised and disabled patients.

If this is true, then why should patients have to request it? Do I have to request a surgeon use sterile instruments? Do I have to request my blood transfusion be screened for HIV? If the assumption is true, masking should be mandatory, not up to patents to request.

Second, the assumption is false. There is no good evidence that making health care providers who feel well wear flimsy surgical masks lowers iatrogenic spread to patients. To prove this claim, you would have to run a cluster randomized trial. Randomize wards, units or offices, to the masking policy, and others to no masking. A third arm could test the author’s preference of masking when requested.

Then, follow patients and staff over the next 14 days to see if there are fewer cases of all respiratory viruses; follow for 90 days and look at all cause mortality. Basically, no such study exists, and I would bet $1000 it will be staggeringly null. Even running the power calculation will reveal how silly the entire premise is.

Third, the authors do not consider downsides to masking. Each week, most of my patients tell me that they are sick of masking. They often ask permission to take off their mask, or take it off before I enter. My colleagues read this JAMA HF piece, and sent me a steady stream of angry text messages saying patients want to see faces, and that the authors are out of touch with reality. The authors may argue that is why patients should have to request masking— to allow those who are willing to take the risk, but its a slippery slope. Zealous policy makers will be quick to reimplement universal masking. My hospital— SFGH— has never stopped masking, and not masking is a misdemeanor offense in SF. You can shit on the sidewalks in SF, but you can’t unmask in hospitals.

Fourth, the authors’ argument exploits disabled people to further the wishes of the pathologically anxious. The authors are careful to make their essay seem as if it is about immunocompromised and disabled people, but in 2023, I have not seen any good evidence that current circulating strains are worse for immunocompromised people than healthy people. In fact, COVID is not filling the ICU with ARDS, and is largely relegated to a seasonal cold and flu illness. The authors exploit disabled people, and ADA regulations, when their policy will be preferentially used by anxious people.

Fifth, masking is a political symbol. Views vary by political party. The specific policy the authors recommend has no evidence. Wearing a MAGA hat is a political symbol. It also has no evidence it helps disabled or immunocompromised patients. Can a patient request a provider wear a MAGA hat? What if it actually makes them more comfortable? They feel more relaxed knowing that their provider does not demonize Mr. Trump. Of course, most sensible people would say such a policy is absurd. But the truth is there is little difference between a flimsy, spun plastic surgical mask worn in a room for 15 minutes and a MAGA hat in slowing respiratory viruses— and if the authors believe otherwise— they have the burden to demonstrate that.

Sixth, the authors exploit morality and ethics to cover up ignorance and lack of evidence. The entire essay is about ethics, but it should be about evidence. I find the most obnoxious trend among many far left political doctors to be how quickly they turn arguments about evidence into arguments about morality. They did it for masking toddlers, and booster mandates— and now they are back, hoping to condemn us into a perpetual masking (upon demand) society.

In conclusion: the essay is poorly reasoned, and empirically unsupported. It reflects poorly on JAMA Health Forum to publish it. We will be writing a letter to the editor.

My view is simple: masking is over. Patients are free to ask their doctor to mask or wear a MAGA hat, and doctors should be free to say yes or decline. Some might do both— to keep patients happy— and others might do one or the other. Using medical boards to police this foolish and a waste of resources. Pretending the article is about disabled people, immunocompromised adults, and morality rather than discussing the evidence to me, and the fact that a tiny subset of Americans remains pathologically anxious, reflects poorly on the authors and journal.

UPDATE: Oh, I see now this is their thing