Apples to Oranges: Ethical Considerations in COVID-19 Surgical Recovery.

As the COVID-19 pandemic approaches peak incidence in many areas, recovery and emergence plans including the re-initiation of surgical cases are underway. The first challenge for hospitals and health care systems involves scheduling the hundreds of postponed surgical procedures. Presuming all of the previously scheduled operations are medically necessary, the difficulty lies in deciding which procedures are most time-sensitive and deserve priority.[1] The cornerstone of case risk stratification has been based on data-driven medical decision-making coupled with surgeon judgment.[2] However, as the manifestations of the pandemic persist, we are pushed away from familiar algorithms into uncharted waters where multiple ethical challenges exist due to a paucity of data.

It is clear that dichotomizing surgical cases (“elective” vs “non-elective,” “essential” vs “non-essential”) is an oversimplification. The prime example of this false dichotomy is cancer surgery, which does not fall squarely into one particular category. Several surgical societies have made recommendations regarding postponing some cancer surgeries by extrapolating from existing guidelines and best evidence.[3] However, surgical delay has its consequences. In many cases, patients with aggressive disease biology have been initiated or maintained on systemic therapy in lieu of surgery. In other situations, patients who have completed a planned course of systemic therapy have continued on nonstandard plans of additional systemic therapy due to lack of surgical resources and to support efforts to conserve personal protective equipment. Although the goal is to provide ongoing disease control during this surgical delay, these treatment plans carry the risk of overtreatment, adverse events, worsening immunosuppression, and resistance. Prolonged utilization of chemotherapy in patients can sometimes provide radiographic control, but this does not always translate into pathological control. It is therefore imperative that the status of a patient's condition needs to be dynamically assessed for changes, both from a disease and symptomatic standpoint, during the decision-making process.

Challenges to recovery and emergence exist beyond cancer patients, as all surgical specialties are faced with the need to prioritize and schedule previously delayed surgeries. Although all medically necessary operations have an impact on the patient's life expectancy or quality of life, the constraints of available block time, resources, and staff put hospitals in a unique position where decisions across specialties are required. Tough choices will need to be made. How should cases with potentially but not definitely life-limiting diagnoses (ie, expanding aneurysms) be prioritized against operations for patients who are acutely symptomatic (ie, a patient who is repeatedly admitted for bowel obstructions due to a ventral hernia)? Should a patient needing a hip replacement for immobilization due to chronic pain have surgery before another needing a thyroid lobectomy for a small papillary thyroid cancer? Surgeons have rarely had to compete to this extent with other surgeons for limited operating room resources. Further complicating matters involves the consideration of patient demographics, comorbidities, and considerations related to quality of life in the decision-making process, further increasing the surgeon's moral distress.

Unfortunately, there is no single scale that can cross-compare all of these considerations for these diverse groups of patients. The most significant consideration should be the impact of the illness or disease on an individual patient if a hospital is seeing stable or declining numbers of new COVID-19 infections without immediate resource availability concerns. At the beginning of the COVID pandemic, physicians were forced to move from individualized patient-centered to public health ethics, which is, by its nature, more paternalistic.[4] This shift was not easy, but was necessary to weigh the risks to the community in the face of scarce resources. As surgeons shift back to patient-centered ethics, they should refocus on balancing non-maleficence, beneficence, and patient autonomy against institutional constraints. Last but not least, we need to share with patients the possible uncertainty of long-term operative outcomes during the COVID-19 era to engage them in shared decision-making, weighing the risks of infection against the benefits of surgery and adding in consideration of consumption of resources beyond the individual surgeon in this unprecedented time of public health stress.