Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review

Abstract

At the time of writing of this article, there have been over 110 million cases and 2.4 million deaths worldwide since the start of the Coronavirus Disease 2019 (COVID-19) pandemic, postponing millions of non-urgent surgeries. Existing literature explores the complexities of rationing medical care. However, implications of non-urgent surgery postponement during the COVID-19 pandemic have not yet been analyzed within the context of the four pillars of medical ethics. The objective of this review is to discuss the ethics of elective surgery cancellation during the COVID-19 pandemic in relation to beneficence, non-maleficence, justice, and autonomy. This review hypothesizes that a more equitable decision-making algorithm can be formulated by analyzing the ethical dilemmas of elective surgical care during the pandemic through the lens of these four pillars. This paper’s analysis shows that non-urgent surgeries treat conditions that can become urgent if left untreated. Postponement of these surgeries can cause cumulative harm downstream. An improved algorithm can address these issues of beneficence by weighing local pandemic stressors within predictive algorithms to appropriately increase surgeries. Additionally, the potential harms of performing non-urgent surgeries extend beyond the patient. Non-maleficence is maintained through using enhanced screening protocols and modifying surgical techniques to reduce risks to patients and clinicians. This model proposes a system to transfer patients from areas of high to low burden, addressing the challenge of justice by considering facility burden rather than value judgments concerning the nature of a particular surgery, such as cosmetic surgeries. Autonomy can be respected by giving patients the option to cancel or postpone non-urgent surgeries. However, in the context of limited resources in a global pandemic, autonomy is not absolute. Non-urgent surgeries can ethically be postponed in opposition to the patient’s preference. The proposed algorithm attempts to uphold the four principles of medical ethics in rationing non-urgent surgical care by building upon existing decision models, using additional measures of resource burden and surgical safety to increase health care access and decrease long-term harm as much as possible. The next global health crisis will undoubtedly present its own unique challenges. This model may serve as a comprehensive starting point in determining future guidelines for non-urgent surgical care.

Psychological distress among elderly surgical patients who had their surgery postponed during the COVID-19 pandemic

“…Strict lockdowns, social isolation and lack of support in addition to fear of contracting the COVID-19 infection from both community and within hospitals while seeking treatment compounded to the existing reasons for deteriorating mental health (Arjomandi Rad & Vardanyan, 2020 ). Postponement of their surgeries caused further harm ‘downstream’ in the consequence of waiting for a new date and managing the disease at home (Brown et al, 2021 ). Even so, with a lengthy waitlist despite resuming elective surgeries, patients continue to experience clinical depression that could lead to disruption of their daily activities (The Lancet R, 2021 ).…”

Navigating our way through a hospital ransomware attack: ethical considerations in delivering acute orthopaedic care

“…With little guidance on how to manage during these situations, the department relied on experience as well as advice published regarding surgical prioritisation during the COVID-19 pandemic to aid in decision making 7 8 16. Only those patients requiring operations that were deemed emergent or urgent were taken to the operating room (OR).…”

“…Given the devastating impact that COVID-19 has had globally, much has been published recently about the ethical challenges faced by surgical departments during a pandemic 6–8. However, there is no published literature examining the challenges encountered during a ransomware attack and how to navigate through such an event.…”

Impact of the COVID-19 pandemic on delays in surgical procedures in Germany: a multi-center analysis of an administrative registry of 176,783 patients

“…While general and nonspecific recommendations to protect patients, particularly cancer patients, from COVID-19 infection were available early [ 4 , 5 ], detailed and specific recommendations for organizing, selecting, and performing surgical procedures, including ethical considerations, were not published until later in the COVID-19 pandemic [ 6 ]. Early recommendations and guidelines for patient selection regarding performance, deferral, or cancellation of a surgical procedure specifically addressed elective procedures [ 7 , 8 ].…”