Most surgeons in resource-rich countries such as the U.S. have had the concept of “patient-first” ingrained in us, from the very beginning of our medical training. The theme of the most recent American College of Surgeons (ACS) Clinical Congress, For Our Patients, reflects this ethos. For most of us, the implication has always been that the patient in question is the one in front of us.
We are now in a public health crisis, where our focus, of necessity, must shift to utilitarian principles: the moral choice is what will maximize the chances of effecting the greatest good for the greatest number. In such circumstances, the needs of the patient in front of us may be secondary to the imperative to conserve resources for others in more dire straits—a situation surgeons in the U.S. are not accustomed to facing. Vital health care resources including hospital beds, personnel, and ventilators are usually tightly managed at our hospitals. Thus, any crisis that increases the demand for these resources requires a rational approach to prioritization and allocation. It is also important to note that another resource challenge has caused tremendous anxiety in recent weeks—the lack of personal protective equipment (PPE) for health care workers.
Surgeons in New York, NY, now the epicenter of the COVID-19 pandemic, and in New Orleans, LA, are forced to wear the same PPE far longer than reasonable.
In other regions of the U.S. that have yet to see a surge in the number of COVID-19 cases many health care professionals argue that regular standards should be maintained, including disposing of PPE after each case and continuing to operate on patients for whom that is the best treatment, even if it is not an emergency. The question of surgeon safety when operating on known or suspected COVID-19 patients with suboptimal PPE has not yet become an issue in most centers, given the relative paucity of cases so far. However, when it does, it will add another dimension to an already complex moral and ethical dilemma.
The desire to prioritize the patient in front of us over hypothetical patients “out there” is completely understandable; it is what we have always been trained to do. However, this default also involves a surgeon making a decision, albeit an unconscious one: to prioritize their current patient over future patients who may have greater needs. It also prioritizes patients at their institution, over patients and colleagues in regions further along the curve of COVID-19 spread. In the current climate, when we do not know how many future patients there will be, nor when regular supply chains will be restored, proactively conserving vital resources such as PPE is likely to be the path that leads to the greatest good for all the patients we serve.
