Ethical Issues
Not only should the planning for the management of a pandemic focus on
trying to reduce the spread of the virus or on treating the sick, but
also on providing ethical considerations that allow establishing certain
limits16. In this sense, and in a situation like the
one experienced in Spain beginning in March 2020, it is totally
necessary to ask certain questions such as:
- Should critical care resources be allocated according to the needs
caused by the pandemic or according to specific criteria independent
of the pandemic situation?
- Is it ethically permissible to use exclusion criteria for scarce
resources such as ECMO based on concepts such as objectivity, equity,
or transparency of the system?
- Is it ethically permissible to withdraw care from a patient in a
critical care unit in order to reallocate resources to another person
with a greater chance of benefiting from those resources?
- If new resource allocation standards for critical care and/or ECMO
therapy are implemented during the crisis, should clinicians who do
not support such implementation be relocated to non-clinical roles, or
should it be accepted as a conscience clause that they be released
from their obligation to participate in clinical care?
The aforementioned issues have sparked enormous controversy in Spain,
not only on a medical level but also among public opinion and the media,
and the contest has finally moved to the political scene. The
controversy has focused on patients older than 75-80 years, many of whom
were not transferred from their retirement homes or residences to
hospitals or once admitted to hospital centers, did not have access to
critical care beds or ECMO support. The controversy is not over, and it
even seems inevitable that it will have judicial ramifications.
The other major ethical concern that involves us, as cardiac surgeons,
is the need to continue our surgeries in the event of a pandemic, as a
shortage of beds and respirators is expected in the Intensive Care
units. In this scenario, it seems reasonable to cancel elective
surgeries, but not urgent ones, since the decision to reserve a bed for
a critically ill COVID-19 patient and not offer cardiac surgery to a
potentially more recoverable patient is a truly conflicting, complicated
decision. In the COVID-19 era, the “Heart Team” perhaps becomes more
essential and can serve to face certain indications with a more open
mind or a more groundbreaking approach that facilitates controversial
decision-making by a team and not by one individual.
Focusing on ethical considerations regarding ECMO support during the
pandemic, we believe it is essential to keep at least the following
points in mind:
- Define and maintain predetermined consensus criteria for the
allocation of ECMO in case of a possible shortage.
- Regularly reevaluate all aspects of a patient’s treatment plan,
including the need to continue or end ECMO therapy.
- Invoke distributive justice only in circumstances where the shortage
of devices prevents providing care to every patient.
- In ethically compromising scenarios, it is advisable to seek the
opinion of the hospital’s ethical and/or medicolegal
committees15.