- •What constitutes urgent?
- •Which patient should come first?
- •How should we ration scarce resources, such as testing kits and personal protective equipment (PPE)?
- •What is our duty to provide care in the face of inadequate PPE?
- •Is it reasonable to refuse being redeployed to a high-risk unit?
- •When, if ever, is it permissible to deny provision of life-saving care that is usually readily available?
- •How should we prioritise restoration of services and procedures as capacity is reinstated?
The Ethical Framework
|Minimize harm (non-maleficence/ beneficence)||Society should take steps to protect the public from harm and minimize physical, psychological, social, and economic impacts of a pandemic||Ensure there exists reserve capacity in critical care settings to accommodate any surge related to future waves of disease transmission||Cardiac surgery volumes should be balanced by weighing patient acuity and waiting lists against the need for critical care beds and ventilators|
|Fairness (distributive justice)||Persons matter equally and should have equal access to resources. However, those with greater needs and who stand to gain the most (utility), as well as services that provide the greatest benefit to the greatest numbers (efficiency), should be prioritized. Care must be taken to avoid placing undue burden on particular segments of the population or further perpetuating systemic or structural inequities||Surgeries, invasive and noninvasive interventions, as well as diagnostic testing, that are likely to benefit more people to a greater degree are prioritized over procedures that will benefit fewer people to a lesser degree||The resource investment required to operate high-volume ambulatory heart failure clinics should be balanced against those required for aggressive therapies, such as mechanical circulatory support or cardiac transplant, which greatly benefit a few|
|Respect for persons (autonomy)||Autonomous, informed choice, as well as cultural safety, privacy, and confidentiality, must be respected and promoted||Explore individual patients’ perspective, including goals and assessment of quality of life||Those patients who do not want to attend a recommended procedure or test due to concerns over COVID-19 transmission and infection should not be prejudiced against either for acute care during the pandemic, or for regular care once the pandemic abates|
|Proportionality||Decisions should be proportional to balance potential benefits of an activity against risks of harm. These calculations must be evidence-based and data-driven, wherever possible||Risks of exacerbating nosocomial COVID-19 spread and precipitating an unmanageable increase in pressure on healthcare resources should be considered||Exposing an elderly patient or a patient with significant comorbid disease burden to a COVID-rich environment, where adequate risk mitigation cannot be achieved, must be balanced by the potential benefit of the proposed procedure or test|
|Reciprocity||Those who are asked to take increased risks, or face undue burdens, should be supported in doing so, and harms mitigated as much as possible||Patient and provider safety should be considered when deliberating on available treatment options||Decision to perform an aerosol-generating medical procedure is balanced by sustainable access to PPE|
|Flexibility||Plans should be iterative and adapt to new evidence and public health directives||Proposals increasing access to services and associated communications must acknowledge the possibility of, and be responsive to, the ebb and flow of future COVID-19 surges||Patients and providers must be prepared for services to be abruptly altered, and the resultant reduction may not be consistent across all therapeutic areas|
|Procedural justice||Decisions should be accountable to a fair and transparent process throughout the planning and implementation stages. Stakeholders should be engaged, and decisions should be applied in a consistent manner with open communication||The decision on how to reintroduce service capacity and where resources will be allocated should be deliberate and informed by all stakeholders||The allocation of operation and procedural room access should be governed by an established set of principles|
- Supplemental Table S1
- Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic.J Am Coll Cardiol. 2020; 75: 2871-2872
- Principles for allocation of scarce medical interventions.Lancet. 2009; 373: 423-431
- Safe reintroduction of cardiovascular services during the COVID-19 pandemic: from the North American society leadership.Can J Cardiol. 2020; 36: 971-976
- The untold toll—the pandemic’s effects on patients without COVID-19.N Engl J Med. 2020; 382: 2368-2371
- Cardiac surgery in Canada during the COVID-19 pandemic: a guidance statement from the Canadian Society of Cardiac Surgeons.Can J Cardiol. 2020; 36: 952-955
See page 1316 for disclosure information.