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.