Consistency as an Ethical Tenet
The multidisciplinary nature of head and neck cancer care is both an
advantage and vulnerability in the COVID-19 era. Multiple treatment
paradigms and the networks of clinicians create systemic redundancy and
options, all of which are welcome. However, this also can create
conflicting, disparate perspectives and approaches, both at
societal/national levels and for individual care teams.
Major ethical concerns arise when dissimilar treatment approaches are
offered to similar groups in different locations. Even if a provider or
group is consistent in their practice and treatment algorithms for a
specific, discrete population of patients, other providers might employ
consistent but fundamentally different approaches, thus creating
different care approaches that are inconsistent with ethical principles
of justice and fairness.
The solution to this dilemma is to ensure consistent evidence-based
approaches as best as possible, considering the systematic issues.
Within our sphere of influence, it is essential that we form consensus
approaches to head and neck cancer management. Also, given that resource
allocation and safety will impact care decisions, these best consensus
approaches may require revision. At the institutional level, this
requires providers to collaborate and consider how best to maintain care
paradigms. For example, it would be inappropriate for individual
surgeons to decide to operate on all oropharyngeal cancers without
proactively unifying the broad approach with radiation and medical
oncology colleagues, whether they are part of the same institution or
part of a broader referral network. Individual patients can and should
still be discussed in multidisciplinary tumor boards, but this does not
replace a more cogent and cohesive approach to disease management.
Limited capacity for treatment (regardless of modality) will also impact
decisions. Scarce resource allocation with regard to ventilators and ICU
beds for patients with COVID-19 is in the spotlight, but the principles
similarly apply to cancer care resources if and when they are also
insufficient.11Emanuel EJ, Persad G, Upshur R, Thome B, Parker
M, Glickman A, Zhang C, Boyle C, Smith M, Phillips JP. Fair Allocation
of Scarce Medical Resources in the Time of Covid-19. N Engl J Med.
2020 (Epub). The selection of ablative and reconstructive procedures
that avoid the use of ICU beds is an example. In short, this requires
explicit, consistent, evidence-based and objective standards,
transparency, and involvement of all necessary stakeholders. Such
protocols must responsibly utilize and preserve vital resources, and
frame treatment that aligns as much as possible with current best
practice.
Some populations have been victims of cultural, racial, geographic and
economic discrimination for generations and societal stress points such
as pandemics can worsen both explicit and implicit biases.22Spector-Bagdady
K, Lombardo PA. U.S. Public Health Service STD Experiments in
Guatemala (1946-1948) and Their Aftermath. Ethics Hum Res. 2019;
41(2):29-34. Health care providers must deliberately partner with
underrepresented groups to assure that the risks of care disparities are
minimized in the face of crisis.