Ethics for surgeons during the COVID-19 pandemic.

Editor

Ives and Huxtable in their commentary on surgical ethics during the COVID-19 global pandemic conclude that society will accept that during this crisis available healthcare resources must be directed at the pandemic and surgeons will work flexibly for the benefit of patients and to support their colleagues. I also would agree the COVID-19 pandemic is a devastating global healthcare emergency with seismic impact on how modern surgical services function. Surgeons will face unique specialty-specific challenges[3,4] during this pandemic, including personal risks of intra-operative infection and professional challenges of prioritising who receives limited surgical care. Surgeons are also conscious that significant collateral damage will arise during this battle from delays to urgent surgical treatment and from backlogs of postponed surgical procedures[3,4].

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) transmission has caused a global pandemic, from asymptomatic or mild illness to sudden hypoxaemic respiratory failure, multisystem organ failure and death. Globally, millions have been infected and hundreds of thousands have died, amongst them many frontline healthcare workers and surgeons. Epicentres, even in well-resourced healthcare systems, have been overwhelmed and have diverted all available resources to the pandemic. Surgeons, as all healthcare workers, have selflessly placed themselves at risk to deliver emergency care.

The four fundamental principles of medical ethics are considered to include: Beneficence, Nonmaleficence, Autonomy and Justice. The primacy of patients welfare is perhaps the foundation of medical ethics, and assurance of those values form the bedrock of professional codes, but during a pandemic some individuals best interests must come secondary to society's greater good. The principle of autonomy gives control of choice to patients but does not entitle everyone to any requested treatment, regardless of medical advisability or competing claims for scarce resources. Social justice in healthcare demands we consider the available resources and the needs of all patients while taking care of individuals. In epicentres even well-resourced healthcare systems are overwhelmed by demand and have insufficient for all in need, and finite resource has had to be directed to those most likely to survive. In a pandemic choices may be restricted or even withheld, which creates a dichotomy for the surgeon as patient advocate and public servant. These grave decisions should not be taken in isolation but working in partnership, being open, and recognizing the uncertainty that exists.

Surgeons worry that whilst healthcare resources are directed against the pandemic, this may cause unintended negative consequences through delays to surgical treatment. However, as surgeons we are distinguished by our ability to offer good judgement in the face of uncertainty. We must strive to do the right thing, advocate for our patients, and use the best principles of medical ethics to guide us to make the best of the available choices for our patients during the COVID-19 pandemic, and of course in the aftermath.