Ethical Dilemmas Associated With the COVID-19 Pandemic: Dealing With the Unknowns and Unanswerables During Training.

The coronavirus disease-2019 (COVID-19) has and will continue to influence every aspect of cardiology, cardiothoracic surgery, and society at large. Hospitals have experienced significant changes in their clinical volume and case mix. Most encounters that can be done virtually have transitioned to telemedicine (1). The strain of the pandemic on the health care system has rendered necessary reallocation and rationing of both material and human resources (2). In the process, the pandemic also has raised numerous complex ethical considerations, such as allocation of scarce resources, worker protection, and equity. Trainees and early career (EC) professionals, who are already experiencing a challenging period of personal and professional transition, are especially vulnerable. These dilemmas add a layer of difficulty and uncertainty when learning during a pandemic about what are already complex decision-making ethical processes, such as determining elective versus emergent surgical indications; implantation, management, and deactivation of various cardiac devices; ensuring responsible utilization of advanced therapies, such as heart transplantation and mechanical circulatory support; and navigating end-of-life care (3). In the absence of an appropriate framework or vocabulary for navigating these moral dilemmas, confusion or even injury may occur, which can have lasting implications throughout their careers. This paper aims to address 3 major ethical dilemmas that may arise for trainees and ECs during COVID-19—allocation of scarce resources; worker protection and personal protective equipment; and end-of-life decisions and training in ethics and palliative care—and propose potential solutions and next steps.

Dilemma 1: Allocation of Scarce Resources

Until recently, rationing has been a relatively unfamiliar concept to most of us, and especially to most trainees. However, the pandemic has raised many challenging ethical questions regarding scarcity (2). Optimal cardiac care is deeply affected by dynamic changes in number of intensive care unit beds, ventilators, mechanical circulatory support circuits, activity of transplant centers, and qualified care teams. Inability to easily assess and refer patients, travel limitations, and COVID-19 testing requirements due to the pandemic has led to increased barriers to referrals and access to expert, high-volume centers (3). Given limited resources now, our treatment paradigm must consider a different set of questions. How should we prioritize care when we cannot provide it for all? Should it be based on the order of arrival, prognosis, social utility, or other characteristics? If centers face shortages of shared resources such as ventilators and blood products, they may need to curtail elective procedural volume (e.g., diagnostics, structural heart interventions, cardiac surgery for nonemergency cases) for potentially a prolonged duration of time (2). Also, how do we talk about prognosis when someone has not made reasonable progress toward recovery on scarce, life-saving devices? If centers face shortages of equipment, the cardiovascular community may need to consider withdrawal of devices in certain patients to increase availability for other patients.

E.O. Wilson once said, “We have created a Star Wars civilization, with Stone Age emotions, medieval institutions, and God-like technologies” (4). The pandemic is the moment to reconcile these gaps and to reflect on our utilization of technology (5). Trainees and early-career cardiologists should take this opportunity to both personally and collectively grapple with these questions, as they will help forge the ethos that will guide the rest of our careers. They can attend, organize, or request lectures to learn more about various allocation policies. Triage teams comprised of multidisciplinary members in cardiac surgery, interventional cardiology, critical care, and advanced heart failure may have important roles in facilitating urgent care of acutely ill patients (6,7).

Dilemma #2: Worker Protection and Personal Protective Equipment

The pandemic also introduces challenges regarding protection of our workforce as well as their families. Redistribution of house staff to various roles (e.g., triage, intensive care unit, procedural teams) depends on many factors, such as stage and scope of training that determines skillset and degree of autonomy. It is also fraught with ethical dilemmas. Some view redistribution of trainees to the front lines as a justifiable call-to-arms. However, some perceive trainees as a vulnerable population given their limited wages, above-average work hours, and position within the hospital hierarchy. Thus, it can be viewed as an exploitation of trainees who may have little choice in the process. Furthermore, it warrants recognition that trainees may require an extension in training duration to make up for time lost either with their removal from subspecialty rotations participating in the care of patients with COVID-19, or if they become infected and ill with the virus. As a system, efforts to reduce circadian disturbance, >24-h call schedules, and redundancies in workforce and overall work hours can help protect trainees (8). Furthermore, programs need to remain flexible and cognizant of the potential logistical challenges faced by trainees, such as difficulty meeting board case-volume requirements; delays in licensing examinations, interviews, and the overall job search process; as well as general financial and psychosocial difficulties.

This issue is compounded by variable availability and policies regarding the use of personal protective equipment (PPE), which is rationed in most settings, forcing many health care workers to decontaminate, reuse, self-supply, or forgo its use (9). The American Medical Association Code of Medical Ethics states that physicians have an obligation to act in the best interests of patients and to do no harm, even at greater risk to their own safety (10). In a pandemic, however, health care workers also may act as vectors, propagating harm to other patients, colleagues, and members of society. Protecting health care workers ensures they can perform their duties toward patients in a safe, ethical, and responsible manner to society at large (11).

Dilemma #3: End-of-Life Decisions and Training in Ethics and Palliative Care

The challenges presented by the pandemic add complexity to already difficult decision-making processes in end-of-life care. Limitations on visitors due to infection control measures for COVID-19 have negatively affected comfort and decision-making among patients and their caregivers. The paucity of experience with COVID-19, lack of evidence-based guidelines, which are constantly evolving, and concern for potential medico-legal liabilities limit the extent to which trainees can provide clear guidance regarding therapy or prognosis.

These circumstances highlight the need for ethics and palliative care skills among frontline cardiac providers for current and future pandemics. Since the Accreditation Council for Graduate Medical Education began to require teaching of ethical and professional behavior in 2007, many institutions have generated their own curricula with some success (12). In cardiology and cardiac surgery, we have seen an increase in ethics-related conversations, with a focus on medical futility, discordant or withdrawal of care in patients with end-stage heart failure, and more recently, on device-based therapies such as left ventricular assist devices and transcatheter valve replacement (13). Yet, as stated in the 2016 report from the American College of Cardiology (ACC) Palliative Care Working Group, a survey of all ACC members revealed only 10.5% having received any formal instruction on the topic during training (14).

Though much progress is needed in development and integration of ethics and palliative care education into cardiac surgery and cardiology curricula, existing online resources that could be adapted into curricula include the ACC’s Essentials for Cardiovascular Care for Older Adults program (15) and communication guides such as Vital Talk (16) and the Serious Illness Conversation Program by Ariadne Labs (17). This content offers readily applicable skills and frameworks to trainees to be able to approach, effectively communicate, and care for patients to determine preferences and goals, which are of great relevance during the COVID-19 pandemic to facilitate shared decision-making and patient empowerment. Collaboration with specialty palliative care consultants should be considered.

The Importance of Guidelines for Trainees

A guideline lifts the moral accountability of each decision out of the hands of the few at the bedside and distributes it among a collective conscience. We suggest trainees become familiar with guidelines put forth by institutions or national societies and, to the extent possible, become involved in their creation and revisions. These dynamic conversations will introduce trainees to ethical principles, because adequate policies balance principles of maximization of benefit, equal treatment of all patients, promotion of instrumental value without discrimination, and priority to the sickest and help trainees to be better advocates for patients and themselves (2,18,19). Furthermore, participating in this process as part of triage teams and frontline clinicians will provide trainees an opportunity to understand the rationale, to provide direct feedback based on personal experiences, and ultimately gain a greater sense of agency. Combined with palliative care and communication skills, trainees will be able to better navigate themselves and their patients through these challenging times.

As a community, we are only in the beginning stages of learning about, addressing, and coping with the pandemic. Trainees in cardiac care face unprecedented changes to their training environments, compounded by a myriad of ethical challenges given scarcity of resources, variable occupational risk, and clinical decision-making. Although it is difficult to predict how our fields will change as a result of the pandemic, with thoughtful planning and increased education, we can hope to emerge from the pandemic with a stronger bioethical foundation.