COVID-19 AMALGAM

Ethics and surgery during the COVID-19 pandemic: principles are no different

B Banieghbal^I; S Al-Benna^II

^IDivisions of Paediatric, Stellenbosch University, South Africa
^IIPlastic and Reconstructive Surgery, Stellenbosch University, South Africa

Ethics can perhaps falsely give the appearance of being a complex subject, but in clinical terms it is really about forming a judgment based on the available facts of an individual case and assessing the relative risks, burdens and benefits of different courses of action. This task is done by making reference to appropriate ethical and legal frameworks.¹ While additional training may be needed to gain familiarity with these frameworks, it is not necessary for practicing healthcare professionals to be expert in these fields.¹ Surgeons need to be aware of ethical and legal issues that apply to a case as they execute the process of consultation and decision making.

The core principles of surgical ethics still apply during all phases of the COVID-19 pandemic:² respect, "the harm principle", fairness, consistency, least coercive and restrictive means, working together, reciprocity, proportionality, preser-vation of resources, flexibility, and proceduraljustice.

Their application related to principles is shown in brackets: maintaining essential services to all patients (optimal preservation of resources), diminishing adverse surgical outcomes for patients ("the harm principle"), ensuring decisions regarding prioritisation of surgery are made in a consistent manner (procedural justice, accountability, reasonableness), ensuring that decisions are communicated in a transparent and sensitive manner particularly in regard to the elderly (respect and transparency), appropriate surgical use of the overall hospital system capacity (working together, proportionality). Minimising the risk to healthcare workers (reciprocity, care provider safety, and sustainability) and, in particular for COVID-19, maximising preservation of personal protective equipment (preservation of resources) and maximising compliance with social and healthcare distancing ("the harm principle").

Failure to consider these principles can have serious consequences. In our experience, when adverse surgical outcomes occur, they are more like to lead to litigation if parties fail to communicate and understand each other's point of view.³ Many patients have access to health information from online search engines; this has a democratising effect, but it can also have negative consequences if information is variable in quality, inaccurate or difficult to interpret.⁴ It is possible that surgeons' decisions are questioned more often because of patients having access to this information. For the surgeon it has become an everyday reality that they not only need knowledge of their speciality but can practically apply the principles of ethics particularly when they conflict.

While it is naive to suppose that an individual surgeon's ethics can transform a public health system, ethics should be integrated into the everyday life of all those working in healthcare. The phrase "surgical ethics is everyone's affair" captures the idea that ethical imperatives do underpin the concept of good clinical governance in healthcare services.5 Healthcare workers, healthcare institutions and the South African government need to try and ensure that ethical 1. standards are an integral part of interactions between patients, families, and clinicians.

In the current COVID-19 pandemic, principles are predicated on balancing anticipated benefits and risks for individual patients while also considering societal needs. During the COVID-19 pandemic surgical activity has reduced and produced backlogs. This means that criteria are required to identify groups of patients most likely to benefit from a specific procedure or, conversely, most likely to suffer harm without such a procedure. In circumstances where the treatment effect is small, or evidence uncertain, alternate approaches that place less burden on healthcare resources may be used. Complex cases are best reviewed by a multidisciplinary committee that includes a specialist ethical advisor.2,6 In all these settings, clear, open and trans-parent decision-making is critical during the pandemic.

ORCID

Β Banieghbal © https://orcid.org/0000-0002-0061-9669

S Al-Benna© https://orcid.org/0000-0003-4079-9286

REFERENCES

1 Ong YT, Yoon NYS, Yap HW, et al. Training clinical ethics committee members between 1992 and 2017: systematic scoping review. J Med Ethics. 2020;46:36-42        [ Links ]

2. Oviatt CW. The ethics of surgery. JAMA. 2018;319:1388.         [ Links ]

3.Kearney L, Concannon E, Rolle C, et al. Influence of socioeconomic factors on litigation in surgery: addressing the gap in malpractice literature. J Plast Reconstr Aesthet Surg. 2020;73;376-82.         [ Links ]

4. Strzelecki A. Google medical update: why is the search engine decreasing visibility of health and medical information websites? Int J Environ Res Public Health. 2020;17:1160.         [ Links ]

5 Department of Health and Social Care. Clinical Governance Guidance. Available from: https://www.gov.uk/government/news/clinical-governance-guidance. Accessed 29 May 2020.         [ Links ]

6. Marmot M. Social justice, human rights and health equity [published online ahead of print, 2020 Apr 6]. J Public Health (Oxf). 2020;fdaa010.         [ Links ]