key: cord-320634-x7a3k5xu
authors: Salna, Michael; Argenziano, Michael; George, Isaac
title: Reply: A problem of “ethic” proportions
date: 2020-08-11
journal: J Thorac Cardiovasc Surg
DOI: 10.1016/j.jtcvs.2020.07.030
sha: 
doc_id: 320634
cord_uid: x7a3k5xu

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The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

• Life-years gained • Fiduciary duty to patient Emerging data • Other patients life-years lost • Resource utilization REPLY: A PROBLEM OF "ETHIC" PROPORTIONS Reply to the Editor:

As healthcare providers, we must care for those who are sick. Our industry is not afforded the luxury of capping production or stopping the assembly line when conditions become overwhelming. Naturally, this means compromises must be made, operations delayed, staff reassigned, and, potentially, prioritization of care when hospitals begin to exceed capacity. Resources are finite, and in times of pandemic, procedural justice guided by utilitarianism, collectivism, and common sense must prevail.

Makhdoum and colleagues 1 present a thoughtful letter on the philosophical perspectives surrounding critical care and cardiac surgical case prioritization. The crux of the argument is "there are no simple solutions" to, in the words of Dr Rajagopal, this "wicked" and highly complex problem. 2 The question arises, what is the role of utilitarianism in cardiac surgery-a field rife with acuity and where "elective" perhaps could be redefined as "electively acute"? As Makhdoum and colleagues 1 point out, modest delays are permissible, but there is always a price to pay. Head and colleagues 3 reported a 1.1% death rate per 1000 patient-weeks while awaiting surgery. However, this cost becomes affordable to society when the alternative is almost certainly 100% fatal in a patient with Coronavirus Disease 2019 (COVID 19) and acute respiratory disease syndrome requiring intensive care unit (ICU) care.

Medical decision making is rooted in individualistic clinician beliefs and often does not fully consider resource allocation at a societal level. This, of course, makes sense. Surgeons primarily have a fiduciary responsibility to their patients, even after the first clinic visit. How could we defer surgical revascularization for patient X seen in the office with his family for the benefit of an unidentified statistic (ie, a patient in the emergency department with worsening COVID acute respiratory disease syndrome)? The fact is that those "statistics" are known to their friends and families and so operating on, and subsequently using an ICU bed for, a known patient could indirectly worsen outcomes for another. This puts surgeons in unfamiliar territory-a shift from a prioritization of their patient to that of society.

The arithmetic guiding these decisions, stemming from arguments over cost-effectiveness and quality-adjusted life year maximization, can be debated infinitum. Ultimately, to maximize gain and minimize harm, we need agreed-upon decision-making algorithms and risk stratification tools to weigh predicted resource consumption against anticipated gain. The Society of Thoracic Surgeons online calculators have made inroads into this challenge with predicted ventilator durations, continuous venovenous hemofiltration probability, and so forth, but the job is far from over. In our article, 4 we sought to establish qualitative thresholds by which surgeons could more objectively decide whether to operate on a given patient during a given phase of the pandemic. However, this type of heuristic is still limited by its unit conversion. What proportion of "resource consumption" to "life years gained" is ethically acceptable? Common units are needed to make this kind of comparison. Bolstered with more objective data that will likely emerge from this pandemic, perhaps more sophisticated heuristics can be developed balancing potential "life years gained" against potential "life years lost."

Another surge will come. It may not be a "second wave" of COVID-19 that overwhelms ICU capacity, but our healthcare system will inevitably be tested again in the future. To prepare, we must harness the data emerging from this pandemic to advance our surgical triaging skills and develop more robust tools to more objectively work through issues of ethical proportionalities. Clinical wards once uncomfortable caring for patients requiring nonrebreather masks managed dozens of ventilated patients, providers who had never set foot in an ICU mastered ventilator optimization to reduce peak and plateau pressures, and mammography technicians learned to use chest radiograph machines. These are only a handful of examples of the rapid evolution that took place within our institution. As a specialty that prides itself on innovating outside its comfort zone, maybe now is the time we as cardiothoracic surgeons learn to play a bigger role in incorporating the economics and ethics of whom we operate on when the system is strained and take more effective ownership over the challenges to come.

Wicked problems and proportionality: is the lesser of two evils the best we can do?

Commentary: Implications of COVID-19 for cardiac surgery: priorities and decisions

Adverse events while awaiting myocardial revascularization: a systematic review and meta-analysis

The rapid transformation of cardiac surgery practice in the COVID-19 pandemic: insights and