Individual vs. Population Interests
It is clear that we need to collectively limit face-to-face encounters, and do our part to flatten the epidemiological curve to protect our collective patient populations, providers and society at-large. Demonstrably worsened clinical outcomes among patients with cancer who contract COVID-19 underscore this risk.11Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a 133 nationwide analysis in China. Lancet Oncol. 2020;21(3):335-337. We also know that delaying head and neck cancer evaluation and management will undoubtedly impact oncologic and functional outcomes, and patients and providers alike will bristle when facing such postponements.
The principles of medical ethics, broadly speaking, require us to consider patient preference, maximizing benefit, minimizing harm, and being deliberative and fair.22Beauchamp and Childress, Principles of Biomedical Ethics, Fourth Edition. Oxford. 1994. The challenge of the current COVID-19 pandemic is that honoring these principles as resources become scarce or non-existent will lead to intrinsic conflict. There will be instances when we cannot grant specific individual requests or focus on a specific patient’s needs in a manner that supersedes the obligation to protect populations and to conserve resources necessary for others. This highlights the tension between “clinical ethics” and “public health ethics.”33Kass NE. An ethics framework for public health. Am J Public Health. 2001; 91(11): 1776–1782. The former, which is familiar to most clinicians, focuses on the primacy of the doctor-patient relationship in formulating evidence-based and individualized treatment paradigms designed to maximize the best outcome for a specific patient. In contrast, public health ethics concentrates on the needs and interests of populations, even if that might negatively impact specific individuals.
Such a paradigm shift might be difficult for individual head and neck cancer providers to accept, and explains the intense challenges facing us all. When we shift from a clinical ethics framework to a public health framework, it is important that we do not force individual clinicians to ration at the bedside, but rather, institutions that are charged with caring for communities must take the lead. Our oncology community will need to discern when the needs of populations outweigh the needs of individuals, potentially leading to treatment delays or non-standard treatment paradigms.
Since surgical manipulation of the upper aerodigestive tract now poses new risks and requires additional resources, the weighting of treatment choices will change. Specifically, when non-surgical modalities are superior to surgery, the choice is easy. In cases in which these choices are either neutral or preference-sensitive, non-surgical approaches should be recommended. However, for conditions in which surgery is clearly preferred or is the sole option, proceeding with an operation might carry considerably more risks and tradeoffs than in the pre-COVID-19 era. Relative urgency related to estimated tumor progression and risk of delay is another metric for triage. This is not to state that such tradeoffs cannot be justified, but rather than clinicians will need to recognize that choices for individual patients will be made based upon the needs of others in ways we do not normally consider. Complicating the situation, we will also need to factor in the finite availability of non-surgical resources and the limited number of skilled personnel necessary to deliver the selected care safely and appropriately. Non-surgical modalities also require repeated and uninterrupted visits over extended periods of time that serve as a potential vector to other populations of clinical staff and oncology patients seeking similar non-surgical therapies.
This does not obviate our ethical responsibility to our patients, though. Even though we might not be able to provide the same level of care or be able to see patients face-to-face, this does not prevent us from maintaining productive doctor-patient relationships. Patients and survivors are often intensely vulnerable and they deserve support, counseling and reassurance for cancer control and symptom management as much as ever. Utilization of virtual care can be invaluable to counsel our patients and ensure they do not feel abandoned.44Shuman AG. Navigating the ethics of COVID-19 in otolaryngology. Otolaryngol Head Neck Surg 2020 (Epub).