Given the many ethical issues that have arisen in the response to and the management of COVID-19 patients, the American College of Surgeons (ACS) Committee on Ethics has prepared some guiding principles to help our Fellows and their institutions in their decision-making process. These guidelines provide a framework for discussion and do not supersede or supplant thoughtful recommendations coming from institutional bioethics committees. Rather, they should be viewed as an adjunct where such committees exist, and as a resource where they do not. In this initial installment, we examine ethical issues caused by the triaging challenges, moral distress, and financial burden created by this global pandemic.
We will discuss additional ethical challenges in subsequent issues of the newsletter.
The COVID-19 pandemic has resulted in numerous governmental and institutional recommendations and admonitions to stop or limit nonurgent operations, thereby putting surgeons’ duty to their patients in conflict with public health and institutional goals—and resources. Although rationing may be the ultimate effect of having limited resources, prioritizing and triaging are probably more acceptable terms in less severe circumstances. In truth, the intensity of the term being used may well depend on the degree of shortage any individual institution is facing.
How are surgeons to approach such surgical prioritizing? The American College of Surgeons has published a document that proposes a hierarchy for prioritizing operations, and additional guidance will be forthcoming from the College. This approach may be applicable to many areas of surgery, and specialty surgical organizations are developing additional specialty-specific guidelines that will provide greater detail. Across the nation, hospitals and surgical practices are facing unprecedented uncertainties and limitations, and guidelines for prioritizing cases vary both between institutions and within a single institution.
Surgeons should be in communication with their institutions’ surgical and administrative leadership and bear in mind that information regarding COVID-19 and resource availability is constantly changing, and consequently, rules that applied yesterday may be completely inadequate for tomorrow’s circumstances. Convening a surgical review committee, composed of surgery, anesthesiology, and nursing personnel to provide defined, transparent, and responsive oversight is important. This committee can lead the development and implementation of guidelines that are fair, transparent, and equitable for the hospital, system or local/regional issues that are rapidly evolving.
The level of distress in the world has risen for all people as the coronavirus pandemic has gradually spread across the globe. In the last few weeks, the volume of COVID-19 cases in the U.S. has risen dramatically such that many hospitals now are trying to care for large numbers of patients with the virus while shutting down much of the elective medical and surgical care they offer.
Throughout the U.S., more people are being told to stay home and respect strict social distancing precautions. While these changes have caused tremendous disruptions to routine life, it is likely that physicians, especially surgeons, are facing significant moral distress.
Most physicians who have been educated and practice in well-resourced environments are used to making decisions based on what is best for each individual patient. This patient-centered ethics approach pays great attention to principles of beneficence (taking steps to benefit patients) and respect for the autonomous choices of individual patients. Surgeons, who can only operate on one patient at a time, are particularly focused on patient-centered ethics.
We now increasingly are being forced to shift to a public health ethics model. It is no longer a matter of what will be best for each individual patient, but rather, what is best for the group. This shift to public health ethics is one that is familiar to surgeons who have practiced in severely resource-challenged environments—such as those surgeons who have responded to natural disasters or served in war zones—but it is an approach to which many of us are unaccustomed.
As surgeons increasingly are forced to think about how to make decisions about scarce resources such as operating rooms, intensive care unit beds, or ventilators, our moral distress is likely to increase. However, it is essential to realize that in periods of absolute scarcity of resources, public health ethics is the far more responsible framework to adopt. As difficult as it may be for us to consider the welfare of the community over the welfare of each patient, this approach is essential at the present time so that we can be as helpful as possible in getting through this public health crisis.
In the interest of public health, national societies including the American College of Surgeons have put forth recommendations to postpone performing elective and semi-elective surgery. These delays affect the patient, the surgeon, and the hospital. Some surgeons are driven to complete these cases by several motivating factors. First, we do not want to disappoint our patients or incur their frustration or anger. Second, we worry that a delay may result in a poor long-term outcome for which we may be held personally or legally responsible. Third, cancellation of our clinics and surgical cases may result in a significant adverse financial impact for surgeons, our teams, and the hospitals and institutions where we practice.
Concerns about the financial impact of diminished or delayed surgery can manifest in several ways. Hospitals, surgery centers, and other facilities may pressure surgeons and other health care professionals to continue performing elective procedures despite public health interests. Some hospital executives worry that revenue lost from canceled surgery will compromise their institution’s missions and ability to provide care in the future.
Similarly, individual surgeons and medical groups worry about lost revenue. Most surgeons are compensated either completely or at least in part based on their productivity. As we witness the impact of this pandemic on the stock market, we also must acknowledge the potential financial impact on our fellow surgeons. The burden of financial toxicity is discussed with reference to our patients, but we must acknowledge the concern for a significant financial impact on providers and their families. Surgeons remain the backbone of our health care system and are often involved in the care of the sickest patients.
During this pandemic, people will continue to need emergency surgery and the surgeon’s support will be needed in intensive care units across the country. Health systems, and federal and state governments should begin developing comprehensive solutions to address the financial impact on hospitals, physicians, and other health care providers that result from canceled operations, so that these perceived financial risks do not influence some surgeons to continue to perform elective operations. It is critical that we cease elective surgical care to minimize exposure for our patients and health care personnel and to ensure our health systems remain viable and can achieve their missions.
We cannot ignore the rate of transmission and the devastating impact of COVID-19, even if most surgeons are in areas with few COVID-19 cases. We need to be proactive in helping to suppress the spread of the virus despite the potential financial impact of canceling elective cases. If we do not act, the global burden will be far worse, and the recovery delayed.