Moral Plurality and the Two Big C’s

“Why are you bringing all these cancer patients into the hospital and putting us all at risk?” asked one of my non-IO colleagues. An undiagnosed COVID patient brought in that day for an extended procedure resulted in losing six staff to a week-long quarantine.

Treating cancer patients during the COVID epidemic poses moral and ethical conflicts. The concept of moral plurality embraces the idea of “two rights”, rather than right vs. wrong.  Patients with cancer need diagnostic and therapeutic procedures to stay alive. Contact with the health system increases risk of viral transmission for patients, providers, and their families/caregivers.

Across the country, interventional oncology practices are postponing non-urgent elective procedures.  Determination of what qualifies as non-urgent should be made on a case-by-case basis based on several factors including the indication for the procedure (e.g. cancer-mediated symptoms, rate of tumor progression), alternative treatments, patient co-morbidities, risk for COVID-19 infection and complications, and institutional resources, such as availability of PPE.

Asymptomatic patients with a low burden of a low-grade tumor and normal organ function can continue imaging surveillance for several months with little risk of an adverse outcome. Patients who are symptomatic or have a heavy tumor burden that threatens survival should undergo therapy if hospital resources allow. Vascular access, biopsy, and image-guided therapies should be performed on an outpatient or observation status to minimize contact with the inpatient population and staff. Our outpatient IO facility schedule remains packed despite the drop-off in hospital census.

If the community is early on the curve of the epidemic, with low prevalence of infection and ample resources, consider accelerating treatment plans to get cancer patients in and out before resources become stressed and exposure risk increases. I compressed a month’s worth of scheduled cases into a several 10-hour days before our recovery room and observation unit were repurposed by the hospital for COVID management. Follow-up in the Interventional Oncology Clinic is now done by telemedicine, with imaging and laboratory testing done local to the patient.

Physicians are bound by the Belmont Principles of autonomy, justice, and beneficence. Some patients fear their cancer more than the virus, some the other way around. One day I am dissuading a patient who wants an ablation that can wait; the next I am trying to convince a patient who needs embolization to come in to the hospital. The principle of patient autonomy competes with the principle of utilitarianism, which prioritizes the greatest good of the greatest number.

Sadly, our ability to guide our patients through these difficult decisions is diminishing. The autonomy of physicians and patients is being usurped by hospitals commandeering our resources and forcing us to justify every elective case. Telling a cancer patient to stay home because your hospital refuses to allow you to treat them is the worst feeling.

The COVID epidemic is challenging all of us personally and professionally. Deaths from coronavirus now exceed deaths from cancer. The right to cancer care is competing with the rights of the greater community. Our patients need us to help them navigate this shifting landscape so those needing treatment have access to care, while reassuring those who can defer.

1 Comment

Beautifully said

April 17, 2020 05:39 PM by Karen Brown, MD

Thank you, Mike.  Perfectly encapsulates situation we have all been struggling with. I have had similar "Why are we bringing patient in for this procedure?" questions from fearful staff. Hope to post this for everyone to read as it so clearly answers that question.  

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