Patients waiting lists and the COVID-19 pandemic: A moral dilemma.

Introduction

Health services in low-income or developing countries have emerging ethical problems regarding the allocation of available resources. Questions concerning the adequate allocation of government resources occasionally surface because of various needs imposed on health systems. For example, In Brazil, several patients wait for laboratory or radiographic examinations in long queues for elective surgeries or organ transplants. However, according to Smethurst and Williams, "waiting lists are politically sensitive," and "essentially long waiting lists deter referrals," this problem has been frustrating most patients. In our country, outpatient referral rates have not decreased, although the waiting lists are increasing daily.

With the outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, many developed countries have become mindful of this problem, thereby causing them to think of an ethical way of dealing with scarce resources. As Buckwalter and Peterson stated, "Patients needing lifesaving treatment may quickly outpace a hospital's resource capacity. When this happens, decisions about how to allocate scarce resources must be made."

As stated by Drake et al. "Although advocated by some, utilitarian philosophy is not an adequate ethical approach for planning. Maximizing positive outcomes must be considered, and additional guidance based on respect for persons, and non-maleficence (avoiding harm) included." The authors also remark that "maximizing the number of patients receiving care overall does not justify disregarding care for vulnerable individuals or communities."

In addition, scarce resources should be distributed to patients suffering from other illnesses, chronic or acute, and in need of immediate treatment. During the coronavirus disease (COVID-19) pandemic, several patients with diseases that may have been more severe than COVID-19 ended up being neglected or received fewer resources for treatment than expected, such as colorectal cancer many other diseases. In a 35-item survey distributed worldwide to members of surgical societies with interest in colorectal cancer care, the authors found some factors are significantly associated with delays in procedures like endoscopy, radiology, and surgery. These factors were: "suspension of multidisciplinary team meetings; staff members quarantined or relocated to COVID-19 units; most units fully dedicated to COVID-19 care, and personal protective equipment (PPE) not readily available." However, 48,9% of the survey respondents reported a change in the initial surgical plan, and 26,3% reported a shift from elective to urgent operations. Another worldwide survey on proctological practices conducted by Gallo et al. showed that 119 participants (11%) tested positive for SARS-CoV-2, and the participants from Asia reported a higher proportion of unaltered practice (17%). At the same time, those from Europe had the highest proportion of completely stopped practice (20%). It is noteworthy that a total of 550 (52%) respondents stated that elective oncological surgery reduced, whereas 286 (27%) surgical procedures were stopped. According to the waiting list, in South America (including Brazil), 30.9% of procedures were rescheduled in 1–3 months. Disturbingly, among respondents from the South American continent, only 14.7% were tested for SARS-CoV-2 before surgery, posing an evident risk of contamination for surgeons and the entire staff. In addition, in the same region, only 66.2% of the respondents had readily available PPE.

Nevertheless, the authors stated, "Surprisingly, PPE was deemed readily available by only 71% of respondents worldwide, ranging from <33% in Africa and South America to >80% in North America." This result may reflect resource management policies that do not always meet risk prevention. To date, there is no scientific evidence on the spread of SARS-CoV-2 and the poor distribution of available resources allocated to public health in developing countries.

The problem of transplants

In July 2019, Brazil had 35,519 people on the waiting list for an organ transplant. Data from July 2020 showed that this number increased by approximately 30% (46,131 people waiting in the same queue). In April 2021, a balance sheet released by the Brazilian Association of Organ Transplants revealed a 34% drop in kidney, liver, heart, and pancreas transplants. According to the survey, 410 transplants were performed in 2020 compared to 617 in 2019 in the same period. In January 2020, the Ministry of Health announced its intention to reduce the number of patients on the waiting list for surgeries in the country to zero. Ophthalmologic procedures were the most demanded; for managing cataracts and their consequences and retinal diseases, followed by herniorrhaphy and cholecystectomy.

The Ministry of Health aims to clear the waiting list of patients requiring procedures that are not urgent and of medium complexity. Elective surgeries are part of the daily care offered to the population in hospitals across the country. Data recorded in the SUS information system showed that in 2018, 2.4 million elective surgeries were performed throughout the country. Until October 2019, this number reduced to 2 million procedures in all Brazilian states. However, with the worsening of the COVID-19 pandemic, the number of elective procedures has drastically reduced.

The problem of intensive care unit vacancies

During the COVID-19 pandemic in Brazil, the problem of intensive care unit (ICU) vacancies became more evident due to the lack of hospital beds, artificial respirators to maintain life support. In addition, the suspension of elective surgeries further increased the number of patients on the waiting lists. However, the scarcity of resources has limited the number of ICU vacancies for patients with COVID-19 who are critically ill, making it difficult for everyone to access intensive care services.

There are several criteria required for the selection of people seeking health services in low resource settings as shown below:

medical and scientific objectivity;

included in the waiting list;

screening;

randomization; and

social criteria.

These criteria seem logical and tend to enhance the sense of justice and fairness; however, they demonstrate a sense of utilitarianism that often ignores the individual's rights and the rights of doctors to choose management based only on medical and scientific criteria.

Moreover, a choice based on these criteria has the power to strengthen an existing structure of social injustice in each society. Regardless of the criteria, both the individual right and social justice of the patient will be compromised.

It seems contradictory to talk about individual rights when we want to achieve greater social justice. However, the concept of equity involves respecting the rights of each individual. So then, we get closer to the idea of justice for all.

It is also important to point out that the criteria described above have virtues and weaknesses. One of the weaknesses is that the criteria are contradictory, as earlier mentioned, and meet more established relations within the community than with individuals. In addition, regarding relations between doctor and patient, they are of little or no satisfaction.

When applied in developing countries, the principles of medical ethics and bioethics require an accurate reflection and respect to the cultural characteristics of each country. Bioethical principles are always followed in the strict sense because they ultimately suffer the influence of economic burdens. Therefore, ethics based on universal principles have difficulties to be applied or incorporated in a context of inequality that exists in complex societies as in the Third World.

The problem of economic influence

An example of the economic influence over applying bioethical principles appears when many patients have to wait for surgery in public hospitals of low-income countries like Brazil. Although the waiting lists may seem fair in the context of community relations, they might generate conflict between doctors and their patients. These conflicts become intense when the patient's condition aggravates, such as those affected with COVID-19 having severe respiratory distress and immediately need an ICU bed and mechanical ventilatory support. Such patients cannot be on hold on an ICU waiting list. The medical decision needs to be immediate.

Moreover, severity criteria are not always clearly chosen when two patients in similar conditions are in the same queue for an ICU bed. For example, what are the required selection parameters? What is the patient's oxygen saturation? Does he have some previous comorbidities, such as diabetes, obesity? What is the patient's age?

The Brazilian Constitution guarantees all citizens universal access to medical treatment through the Unified Health System (SUS). This system, created in 1990, was based on the British model of medical care. Although it might be imperfect, it is a sound system, and it is much better than the previous policy implemented.

However, the resources earmarked by the Brazilian State (12% of Gross Domestic Product – GDP - approximately $ 27.5 billion in 2007) to health are scarce (US$ 120 per capita), which implies that the queues for medical care are enormous. Therefore, after the first consultation, patients who need surgical management are referred to a waiting list, which could require several years, depending on each case.

We can cite, for example, the waiting time for a simple tonsillectomy in the ENT Department of the Clinics Hospital of the Faculty of Medicine of the University of Sao Paulo will require three years. At the end of 2007, there were 800 children in a queue waiting for a tonsillectomy procedure. The hospital had only six surgeries of this type a week, either due to the lack of operating rooms or anesthetists. Children with recurrent tonsillitis or severe respiratory conditions must remain in the queue in order of entry rather than symptom severity. Doctors observed these developing problems with their pediatric patients and questioned the state system regarding the ethical aspects of a child waiting to undergo surgery for an extended period. The same problem occurs in other specialties, with patients in long queues waiting to undergo inguinal hernia surgery or kidney transplants.

Similarly, we believe that these problems observed in Brazil also occur in other low-income or developing countries and might occur in some developed countries. In a modeling study using Hospital Episode Statistics data (2014–2019), Fowler et al. showed that 547 534 patients with a pooled mean age of 53.5 years expected to undergo surgery between March 1, 2020, February 28, 2021. Until May 31, 2020, 749 247 surgical procedures were canceled. Assuming that elective surgery is reintroduced gradually, 2 328 193 patients will be awaiting surgery by February 28, 2021. As the authors stated, "safe delivery of surgery during the pandemic will require substantial resources costing 526.8 million Euros."

This fact explains why medical ethics and bioethics in this new century must include discussing crucial public health aspects and efficient procedures in developing and developed countries. Moreover, it should be more applicable in a crisis such as that triggered by the COVID-19 pandemic.

The protocol for hospitalization in the ICU of the Ministry of Health in Brazil

This protocol establishes some severity criteria for admission to the ICU for patients with COVID-19 based on gasometry findings, need for mechanical ventilation, and involvement of other organs.

These criteria are as follows:

Gasometry: PaO2 <60 mmHg; PaO2/FiO2 <200 mmHg; pH <7.3 and PCO2 >50 mmHg;

Invasive mechanical ventilation; Sepsis or septic shock;

Acute organ dysfunction (acute kidney failure, kidney failure, decreased consciousness)

Although it is fair, the challenge with this type of selection criteria is to establish equal parameters for different individuals. Less aggressive forms of disease could result in more severe conditions in individuals with other health problems. For example, patients with immunosuppression or comorbidities such as diabetes and obesity may have a worse clinical response than patients who do not have these conditions. Besides, these selection criteria do not consider the patient's age, placing young and elderly patients on the same level of assessment. This type of selection criteria could be unfair for both the youngest (with longer life expectancy and a greater chance of success for intensive care) and older ones (with lower life expectancy), but not with a "less valuable" life, as might be.

Therefore, objective criteria may be technically fair but not morally fair. Furthermore, they affect doctors' autonomy, placing the obligation to decide who will live and who will die in their hands. Unlike the respect for the patient's autonomy, we believe that the doctor's autonomy should depend on offering the best scientific knowledge and technical abilities to save everyone and not decide which patient "deserves" a better chance to live. It may not be kind for a doctor who has been taught and trained to save lives to make such choices.

Surgical strategies and telemedicine

As stated by Ielpo et al., "healthcare systems adopted specific measures to preserve hospital capacity including the postponement of non-oncological elective procedures." The authors added, "several surgical societies globally recommended a safe approach even in emergency surgery, with the implementation of non-operative management whenever possible." Some of these recommendations are as follows:

Use of minimally invasive surgery;

Use of ultrafiltration systems of carbon dioxide filtering; and

Evacuation during laparoscopy.

Although there is no evidence that SARS-CoV-2 could be spread by aerosolization by both pneumoperitoneum and smoke during minimally invasive surgery, the hypothetical risk exists. However, it is essential to emphasize that the most sophisticated filtering systems are not available in all countries when choosing the surgical modality to be applied.

In a limited resource country (as in Brazil), given the lack of ultrafiltration systems, paucity of PPE, shortage of surgical workforce, and the impossibility of routine testing of all patients, a trend toward a more conservative attitude indeed occurred during the COVID-19 pandemic, increasing the number of patients included in the waiting lists.

It is noteworthy that the survey organized by Ielpo et al. revealed that the majority of respondents (51.0%) reported that they only screened patients with respiratory symptoms or suspected of having SARS-CoV-2 infection before surgery for acute appendicitis; 37.4% of all patients before surgery were routinely screened, whereas 11.6% of respondents declared that they do not test under any circumstances. Thus, in Brazil, the most frequent trend has been to test patients only in the presence of respiratory symptoms. This type of attitude may be different regarding other types of non-elective surgery; however, it is required to test all patients before elective or non-elective surgeries.

Whenever possible, it is important to use protective equipment in the operating room, as reported by 56.3% of the respondents, such as an FFP2/FFP3 face mask and goggles.

In addition, personal attitude and surgical approach were critical. For example, some authors found that 39.0% of respondents changed their standard surgical approach from laparoscopy to open surgery (36.6%) or the reverse (2.4%) during the pandemic."

The use of telemedicine in some settings is a reality. In many countries, regular government updates have discouraged patients from using public transport and hospital visits unless necessary. There are different usage models of telemedicine today (store and forward; real-time; remote/self-monitoring; and the so-called m-Health). In our opinion, the real-time model (synchronous telehealth) could be beneficial in both elective and non-elective surgeries at the pre or postoperative follow-up. However, there are some challenges, mostly in rural communities with limited software (as in large part of Brazil) due to its reliance on stable external and internal infrastructure for uninterrupted use, a set bandwidth, and network capability for performance-based stream for videoconferencing, and broadband access.

The need for a protocol based on disease severity for elective surgeries

Unlike protocols for admission to ICU beds, to the best of our knowledge, there are practically no protocols for attending patients in queues for elective surgery. Regarding orthopedic surgeries, Massey and collaborators developed a protocol that considered the need for surgeon safety, patient safety, non-dissemination of the virus, and the resources needed to perform various surgeries. It is a very detailed protocol, establishing priorities in each type of surgery and possibly performing some procedures on an outpatient basis.

As declared by the authors, "the use of the term 'elective' has fallen victim to scrutiny, with notable room for subjective interpretation among surgeons. When considering which surgeries to delay and which ones to prioritize, there are several factors to consider." These factors are different for each surgical specialty; thus, every department must develop its protocols at these very crucial times. By establishing defined criteria, the possibility of doing justice for all patients is enhanced. In addition, surgeons would not submit to unsolvable ethical dilemmas.

It is possible that, as Black states, "it is challenging to eradicate waiting lists, but we may make them less unfair and cause so much anguish and suffering." However, the same author proposes some attitudes to minimize the effects of those lists, such as: pooled or shared waiting lists, more significant use of daycare, shifting care from inpatient to outpatient settings and from hospitals to primary care, establishing elective-only surgery facilities, pre-admission assessment clinics, issuing reminders to reduce non-attendance rates and specialized, single-procedure surgical centers.

the use of priority scoring systems,

staff substitution, better management of theater time,

The use of telemedicine would be helpful in some instances, decreasing the pressure on the health system in these pandemic times. Measures cited above and alternatives like telemedicine become urgent with the increase in the number of infections caused by SARS-CoV-2.

Final considerations

Waiting lists for elective surgery, an ICU bed, and an organ transplant are moral problems for all physicians. Establishing fairer criteria and providing alternatives to reduce waiting for lines in times of crisis like the one we are experiencing may not be the complete solution to this problem. Nevertheless, it is much better than simple omission.

Credit author statement

Ivan D. Miziara: Wrote and designed the text.

Carmen Sivia MG Miziara: This author helped with study design, manuscript preparation and revised the final text.

Declaration of Competing Interest

None.