Ethical issues in the COVID-19 pandemic
In 2014, the American College of Chest Physicians published a Consensus Statement reporting on ethical considerations in the care of critically ill patients during pandemics [11]. Pandemics, such as the one caused by the COVID-19 spread, jeopardize ethical decision-making. Hence, planning for the management of pandemics should not be only focused on approaches to reduce the spread of virus or to treat ill patients, but should also provide ethical guidance to set some ethical boundaries. We would like to suggest a few: pandemic policies should reflect the broad consensus that there is no ethical difference between withholding and withdrawing care;
critical care resources should be allocated based on specific triage criteria, irrespective of whether the need for resources is related to the current pandemic or an unrelated critical illness;
it should be ethically permissible to use exclusion criteria for critical care resources, since the advantages of objectivity, equity and transparency generally outweigh potential disadvantages;
policies permitting the withdrawal of critical care treatment to reallocate to someone else based on higher likelihood of benefit should be ethically permissible;
specific groups of people, such as healthcare workers, should not receive exclusive access to scarce critical care resources when crisis standards of care are in place;
hospitals should make plans to assist with moral distress in healthcare providers involved in providing mass critical care;
critical care clinicians who are unable to accept implementation of crisis standards of care should be transferred into support or non-clinical roles during disaster response, if possible, but not be absolved of their obligation to participate in the response;
hospitals should aim to protect their workers and encourage healthcare providers/workers to create personal/family disaster preparedness plans.
The point 4 has been recently addressed by the Italian Society of Intensive Care (SIIARTI) in a document published online in March 2020 [4], in which the Scientific Society presented clinical ethical recommendations for the admission to ICUs, under the exceptional circumstances of an imbalance between needs of a population and availability of resources. The Authors examined a scenario in which criteria for admission to the ICU may be solely based on the principle of distributive justice. Hence, the ethical principle guiding the intensivists in a resource-limited healthcare system should be to allocate resources to those with a greater life expectancy rather than on a first-come, first-serve basis. A second approach could be giving priority to those who are sickest and therefore in greatest need. During the system of triage established in the Napoleonic army, for instance, soldiers who were ‘dangerously wounded’ received care before the less severely wounded. The dying were left untreated [12].
Luckily, at present in Italy, it has not been necessary to apply this concept, thanks to a relevant increase in the intensive care beds and human resources put in place by the national healthcare system.
Another ethical concern revolves around the need to carry on with surgery, in our cases with cardiac surgery, in case of a pandemic. As we have already reported, one of the main issue in the course of a pandemic is the possible shortage of ICU beds and ventilators. In this scenario, it is surely necessary to cancel elective, but not emergency surgeries.
Let us suppose for the sake of a dramatic example that we only have 1 ICU bed with a ventilator and are faced with 2 patients, one of whom is suffering from COVID-19 interstitial pneumonia needing assisted ventilation and a younger one, needing emergency coronary artery bypass grafting. The decision-making then becomes complicated.
In this view, the hospitals need to be organized into a hub-and-spoke system. The ‘Hub’ has to carry on with cardiac surgery, whereas the ‘spoke’ has to temporarily stop their activity.
Moreover, even hub hospitals have to provide 2 different routes for COVID-19-positive patients with respiratory failure and for COVID-19-negative patients needing emergency cardiac surgery. Finally, there will be a subset of COVID-19-positive patients requiring emergency cardiac surgery. In this case, there is an ethical commitment to provide these patients with cardiac surgery, but reduce OR personnel to a required minimum, pre-determining requirements for enhanced personal protection, and assessing all the team adopted protective measures for themselves, and assessing adequacy of post-procedural sterilization as suggested by the American College of Cardiology [13].
The advent of heart team, mimicking teams in the field of oncology, is becoming more and more useful in choosing the right approach for the right patient, given the overlap of transcatheter and surgical approaches [14]. We believe that a heart team is imperative in the era of COVID-19. In fact, in cases where a transcatheter approach can be employed for the patients, without the need of ICU bed and ventilator, the balance between risks and benefits must be evaluated by a team rather than by an individual.