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Background The COVID-19 pandemic has strained healthcare systems by creating a tragic imbalance between needs and resources. Governments and healthcare organizations have adapted to this pronounced scarcity by applying allocation guidelines to facilitate life-or-death decision-making, reduce bias, and save as many lives as possible. However, we argue that in societies beset by longstanding inequities, these approaches fall short as mortality patterns for historically discriminated against communities have been disturbingly higher than in the general population. Methods We review attack and fatality rates; survey allocation protocols designed to deal with the extreme scarcity characteristic of the earliest phases of the pandemic; and highlight the larger ethical perspectives (Utilitarianism, non-Utilitarian Rawlsian justice) that might justify such allocation practices. Results The COVID-19 pandemic has dramatically amplified the dire effects of disparities with respect to the social determinants of health. Patients in historically marginalized groups not only have significantly poorer health prospects but also lower prospects of accessing high quality medical care and benefitting from it even when available. Thus, mortality among minority groups has ranged from 1.9 to 2.4 times greater than the rest of the population. Standard allocation schemas, that prioritize those most likely to benefit, perpetuate and may even exacerbate preexisting systemic injustices. Conclusions To be better prepared for the inevitable next pandemic, we must urgently begin the monumental project of addressing and reforming the structural inequities in US society that account for the strikingly disparate mortality rates we have witnessed over the course of the current pandemic.

The experience of cancer has always been fraught with uncertainty. These new treatments provide an illusion of certainty because of their genetic basis, which hides the inherent uncertainty in the behavior of cancer and its response to treatment. Unfortunately, the onslaught of much complex information does not provide greater certainty but does make the journey potentially more complicated. 20Cancer medicine continues to be rife with uncertainty. While genomic information in cancer may answer many questions and is guiding treatments, it also creates new uncertainty, albeit in different forms. New issues arise as new therapies present new problems.Precision medicine is a perfect example. The processing of this information and patients' experiences in this new technological age of big data, social media, and the Internet hinges on communication. We know that poor communication affects patient outcomes; however, we also know that communication is the key for satisfactory patient care and the skills to do it well can be learned. 21,22 Psycho-oncology is the area of oncology that studies responses of patients and caregiving staff to cancer treatment. How does an oncologist present a new therapy based on genomic information? How much detail is good for which patient? How do you respond to the range of responses from anger to fear, to stoicism? How do you help the patient understand the value of a new targeted therapy in his/ her own context of illness and values? This is simply a new layer of the usual communication problems in oncology, which are the delivery of bad news, discussing unpredictable and burdensome treatment responses, and sustaining hope despite a life-threatening situation. 23 However, precision medicine in oncology now adds a new set of communication issues to this agenda. 24It is essential that psychosocial investigators address these issues because psychosocial research is far behind the science of genomics and that of digital information. We must study patients' responses to targeted therapies, understand how to assure informed consent, and spread awareness that ethical issues are associated with these treatments that may delay end-of-life care planning. Psycho-oncology must step up to the plate with medical oncology and take the lead in creating new research and educational efforts that contribute to the science of care in the genomic era.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has raised a variety of ethical dilemmas for health care providers. Limited data are available on how a patient’s concomitant cancer diagnosis affected ethical concerns raised during the early stages of the pandemic. METHODS: We performed a retrospective review of all COVID-related ethics consultations registered in a prospectively collected ethics database at a tertiary cancer center between March 14, 2020, and April 28, 2020. Primary and secondary ethical issues, as well as important contextual factors, were identified. RESULTS: Twenty-six clinical ethics consultations were performed on 24 patients with cancer (58.3% male; median age, 65.5 years). The most common primary ethical issues were code status (n = 11), obligation to provide nonbeneficial treatment (n = 3), patient autonomy (n = 3), resource allocation (n = 3), and delivery of care wherein the risk to staff might outweigh the potential benefit to the patient (n = 3). An additional nine consultations raised concerns about staff safety in the context of likely nonbeneficial treatment as a secondary issue. Unique contextual issues identified included concerns about public safety for patients requesting discharge against medical advice (n = 3) and difficulties around decision making, especially with regard to code status because of an inability to reach surrogates (n = 3). CONCLUSION: During the early pandemic, the care of patients with cancer and COVID-19 spurred a number of ethics consultations, which were largely focused on code status. Most cases also raised concerns about staff safety in the context of limited benefit to patients, a highly unusual scenario at our institution that may have been triggered by critical supply shortages.

PURPOSE: As the role of clinical ethics consultation in health care advances, there are calls to standardize the process of consultation. The Ethics Committee at Memorial Sloan Kettering Cancer Center (MSK) hypothesized that the process of requesting an ethics consultation could be improved by instituting an electronic health record (EHR) order for consultation requests. This report summarizes the impact of adopting an EHR order for ethics consultation requests at MSK. METHODS: This retrospective review of all clinical ethics consultations requested at a tertiary cancer center from May 2017 to February 2020 spans 17 months before and after implementation of an electronic order for consultation requests. Summary statistics are presented using Pearson chi-square analyses with a significance level of 0.05. RESULTS: There was a significant increase in the total number of consultation requests placed after implementation of the EHR order (n = 165, 0.08% of total patients) compared with before (n = 108, 0.05% of total patients; P = .007). The number of consults requested by providers from inpatient ( P = .02) and outpatient ( P = .04) settings significantly increased. The proportion of consults placed by medical versus nonmedical providers remained unchanged ( P = .32). CONCLUSION: In this large single-institution retrospective study, implementation of an EHR order for ethics consultation requests was associated with a significant increase in the number of consultation requests. Implementation of an electronic order may decrease barriers to ethics consultation in diverse practice settings. Further longitudinal, multicenter studies are needed to assess strategies to improve access to clinical ethics consultation for oncology patients.