The ethics of neuro-oncology in the era of COVID-19: lessons to be learned.

The COVID-19 pandemic has required us to consider our roles as surgical oncologists within the scope of a new threat: to our system, to our patients, and to ourselves as health care workers. The pandemic has limited any chance of considering things as business as usual. The elective surgery schedule has been eliminated. Urgent surgery at my institution now means admitting a patient the night prior for placement on an urgent surgery queue. Surgery times have ballooned with the need for our anesthesia colleagues to take severe precaution during the process of intubation. Any consideration of surgery has required balancing the risks of waiting with the risks of going forward.

A few weeks ago, soon after the start of our pandemic response, while waiting to start a craniotomy for a woman with progressive seizures who I feared harbored a transforming low-grade glioma, my colleague from anesthesia, a friend of many years, asked me if it was right for us to be operating. Should we be treating someone with a cancer instead of preserving these necessary resources for patients with COVID? As pressingly, should we be asking our anesthetists to take the risk required of them for us to do something we felt it necessary to be done?

Embedded within her second question is the implicit fact that, while we are both physicians, she is on the front line in a manner that I am not. When I have considered what risk means in this pandemic, it has been to worry about the risks of exposure that my patients face coming to and being in hospital to receive their care, and about the risks of immunocompromise that accompany the adjuvant treatments that they often require. My own risk is likely no greater than the risk that any of us face during the time of pandemic driven by a virus that is easily transmitted and too often deadly.

But this more personal question should not be used to avoid the ethical weight of her first question: should we as a health system invest resources toward caring for patients with cancer at a moment when the demand on those resources is so great? While the ethics of our health care system are built on the four principles of autonomy, beneficence, non-malfeasance, and justice, in reality we rarely have to consider the lattermost of these in our daily roles as physicians in North America. It is only under duress, for example, at this time of pandemic during which our health care system is so severely taxed, that the principle of justice challenges its three usually sovereign sisters.

Yet the presence of issues of justice in our approach to cancer care is not novel. Our decision to invest in cancer care has always been a decision made inherently at the cost of other investments. I have often wondered, for example, what it means to care for a patient with glioblastoma in a world in which children die of malnutrition or go blind because of vitamin deficiency, and in a nation in which race and economic status are determinants of access to health care, time to necessary services, and outcomes of health and survival. These problems not faced were previously kind enough to stay hidden while I made decisions with my patients with cancer—while we decided on surgery, while we made arrangements for chemotherapy and radiation, while we offered a drug at tumor recurrence thousands of fold more expensive than vitamin A or an ACE inhibitor. It is worth noting the human cost of these decisions.

Strangely, the pandemic has required me to consider my role in our health care system within a framework of questions that I have avoided in the past. What does justice require of us? What does it require of me? What does it mean for me to offer expensive, technologically and medically advanced but palliative treatment patient by patient, when simple measures that could cure or prevent devastating disease on a large scale are deferred for lack of resources? I don’t have good answers for these questions. That the questions exist doesn’t diminish the meaningfulness and importance of the work, patient by patient, that I do. But I suspect that the manner in which these questions have surfaced for me will mean that I will never quite be able to return to business as usual once this pandemic has passed.

As cancer care providers, we are fortunate to have the health care system that we have. It allows us to offer everything we have to our patients as they encounter the greatest challenges of their lives. But COVID-19 has shown the ethical foundations of our system to be deeply flawed. We must own its flaws as well as its strengths. We have often earned the right to consider ourselves stewards of autonomy, beneficence, and non-malfeasance. We must remember that we are as bound by our duty as stewards of justice.