key: cord-0891451-20tkajox authors: Holt, G. Richard title: Contemporary ethical considerations in clinical otolaryngology date: 2020-07-29 journal: Laryngoscope Investig Otolaryngol DOI: 10.1002/lio2.438 sha: cd95cdc7427de74254a052a98d99a652975bbc50 doc_id: 891451 cord_uid: 20tkajox The practice of otolaryngology has been significantly challenged by the constraints of the novel virus pandemic, but the specialty has continued to provide clinical care for patients in a manner consistent with ethical principles and moral leadership. Continued attention to maintaining the ethical foundations for appropriate informed consent, provision of remote health care through telemedicine, and strengthening the patient‐physician relationship while role modeling the highest level of professionalism will continue to be challenging for the specialty throughout and beyond the pandemic temporal boundaries. These contemporary elements of ethical clinical care, examined in the context of disruption of the traditional practice of otolaryngology, are foundational to the duties and responsibilities inherent to the profession of medicine. LEVEL OF EVIDENCE: 5 Of the numerous topics in bioethics under wide contemporary discussion, three have inter-related considerations for otolaryngologists owing to the impact of the SARS-CoV-2 public health emergency. The pandemic will likely have some lasting effects on the practice of medicine, so it is important to recognize and consider the potential ethical consequences that must be understood, managed, or mitigated as we attempt to provide the best standard of care under the constraints of this global emergency. The ethical issues involved in informed consent, provision of distant health care through telemedicine, and professionalism and maintenance of the patient-physician relationship are all coherent and fundamental to an otolaryngologist's responsibilities in the performance of ethical patient care. These elements represent important trusts that exist between patient and otolaryngologist, and have without question been challenged under the recent, and current, restrictions to the practice of medicine. They will be examined in the context of the ethical principles of autonomy, beneficence, nonmaleficence, and social justice and viewed through the lens of duty and honesty. At no time in one's practice will empathy and altruism likely be more important to this specialty than at this time in the contemporary history of medicine. The most important element of ethical clinical care of importance to otolaryngologists under current discussion during the pandemic is maintaining and ensuring the primacy of the patient-physician relationship as a fundamental part of professional obligation. Professionalism embodies the essence of medicine-all ethical actions are directed toward a duty to patients and profession, with responsibility and accountability having been inculcated into our moral fabric over the course of our lives. Individuals enter the profession of medicine with a commitment to public service in the broadest sense, and with the understanding that it is a profession of virtues (compassion, keener consideration, there are three professions which depend on a formal and socially codified relationship with a person-medicine, law, and the clergy. Without a patient, medicine does not exist; therefore, the patient-physician relationship is at the heart of the profession. In his recent commentary, Dr Andrew Shuman has nicely identified the types of stewardship expected of otolaryngologists during the pandemic, including safety, distributive justice, and non-abandonment, all of which support the responsibilities of a patient-otolaryngologist relationship. 6 He identifies the dual importance of individual patient care and care related to population medicine. There is, indeed, a moral cost to both the otolaryngologist and the patient when "traditional" medical care is significantly disrupted. As otolaryngologists examine how to move forward in caring for their patients, the opportunity to examine and reorient their focus on the patient, using empathy to better understand the patients' perspectives on their illnesses and how they can best be served, should not be lost. Mutual trust, honesty, and effective communication are the cornerstones to the patient relationship, which in turn, is the cornerstone of the profession. Effective communication is an exchange of information and thoughts that foster better understanding for clinical care-listening well is an important contribution by the otolaryngologist to the exchange. Informed consent is, in its best form, a series of conversations between patient and surgeon with the intent of exploring the potential risks, benefits, alternatives, and consequences of a particular procedure or set of procedures. 7 The informed consent process is a unique combination of evidence, experience, communication skills, honesty, respect, empathy, concern, questions and responses, and many other intangible elements that eventually lead to a formal agreement between patient and surgeon that may or may not have incontrovertible legal standing. Its importance to both patient and surgeon cannot be overstated. Any external factor, such as a public health emergency of pandemic magnitude, can raise concerns by the patient regarding potential risk for viral exposure and hospital acquired infection. A patient's belief that the informed consent is as complete as possible is of primary importance; namely that the surgeon is knowledgeable, to the best possible degree, of all of the elements of the surgical procedure, based on education, training, and life-long learning. Yet, in the presence of a pandemic caused by a novel virus, much is unknown about surgical procedures and risks to the patient in the perioperative period, and the climate remains somewhat uncertain in this regard. Some surgeons have recommended adding an "additional, enhanced discussion of potential risks and benefits of proceeding with versus delaying an operation during COVID-19 pandemic," as well as optional discussions of the various risk scenarios of nosocomial infections. 8 Uncertainty on many levels continues to be a concern for both patient and otolaryngologist, particularly with surgical procedures of some urgency. Understanding the ethical implications of caring for patients with head and neck cancer is particularly important, with a need to evaluate the impact of SARS-CoV-2 on such critical issues as goals of care, standards of care, the patient's risk, the provider's risk, and duty to treat, as described by Gordin and colleagues. 9 Federal, institutional, and specialty clinical guidelines have been developed over several months in a collegial effort of unity heretofore not seen by most otolaryngologists. For the most part, these guidelines are directed toward risk management, patient and provider safety, and best practices. Although ethical considerations are always important in guidelines, it is salutary to identify those ethical principles that may be at risk for subjugation during a public health emergency. One of the first to be affected-patient autonomy-was the result of selfisolation and quarantine orders from national and state governments. Otolaryngology patients no longer had the freedom to see their physician in the clinic for routine care, were forced to cancel or reschedule their surgical procedures for an indefinite period of time, and at least initially, may have been unable to contact their provider for medicine renewals or new concerns. As patient care guidelines for otolaryngology have become more clear and refined, courses of action for patient self-determination, while still somewhat restricted, have become more actionable. It is very important for otolaryngologists to understand the frustrations that patients experience when their health care is nearly completely out of their control. New surges of viral infection have the potential for reverting back to more restrictive patient contact guidelines, which can be both confusing and frustrating for patients. Informed consent has recently been, and continues to be to some degree, primarily about paternal considerations of beneficence and non-maleficence. Patients initially shared the confusion and lack of credible information about this novel virus with the physicians whom they trusted to care for them. As the otolaryngology specialty began to sort through available data, patient care guidelines were designed and initiated to protect patients from the risks of viral infection, which were at once benevolent and prevention from harm. In effect, patients had to trust their otolaryngologists to look out for their best interests, not to place them at risk, and to care for their disorders in the best possible manner, under the prevailing circumstances. Patient selfdetermination remains intact with respect to the informed consent for procedures, but the "informing" portion of the process needs to include known risks, while still acknowledging the uncertainty of the virus' impact on perioperative health. Most importantly, the patient looks to the otolaryngologist for honesty, transparency, and empathy. where we connect with the patient through a laying on of hands, and verbal and nonverbal interaction. Although effective in many ways, telemedicine is not bedside medicine-therefore, it is important to convey one's concern and empathy in whatever ways possible during a virtual visit. In other words, put oneself in the patient's position and interact with them in the manner one would wish to be interacted, for the constraints of this pandemic have already taken a toll on patients. There is a significant ethical issue of social justice in telemedicine. Unfortunately, there seems to be a "two-tiered" stratification of patients-those who have internet access and smart phones/computers, and those who do not. For the latter, most do have a tele- The practice of otolaryngology has been significantly challenged by the constraints of the novel virus pandemic, but the specialty has con- The author declared no potential conflicts of interest. 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An assessment of telemedicine eligibility among otolaryngology diagnoses Telemedicine in otolaryngology outpatient setting-single Center Head and Neck Surgery experience Online Ahead of Print. How to cite this article: Holt GR. Contemporary ethical considerations in clinical otolaryngology