key: cord-0958099-gzzjx0na
authors: nan
title: Urologic Oncology: News and Topics: Ethics of Urologic Care in the Time of COVID-19
date: 2020-04-23
journal: Urol Oncol
DOI: 10.1016/j.urolonc.2020.04.018
sha: f707a07f696f145a04f9ba5af9f60f0df61ab1cb
doc_id: 958099
cord_uid: gzzjx0na

nan

The ongoing COVID-19 pandemic is characterized not only by the morbid and mortal spread of the novel coronavirus SARS-CoV-2, but also by novel responses to that infection within healthcare systems worldwide. The rapidity of these responses, which have hastened to keep up with the contagiousness of the virus and the shifting geography of its associated hot-zone epicenters, has left doctors and patients alike on profoundly unsteady footing. The foundations of our clinical practices, including the commitment to therapeutic alliance and a determination to maximize medical benefit while minimizing harm to our patients, remain firm. However, how to best operationalize those cornerstones of our profession in the current, virulent environment is an open question, which continues to be posed online, in print, in conversations, and in individual consciences.

Urologic oncology is a particularly challenging area in this regard, as the diagnosis and treatment of genitourinary cancer is seldom emergent or imminently life-threatening, but frequently urgent, with the possibility that delayed management may significantly compromise quality and quantity of life. At a time when governmental regulatory bodies have suspended "elective" surgeries, the degree to which the procedures that are used to evaluate and address urologic malignancies should be considered elective is uncertain. Various medical professional groups and healthcare institutions have composed guidelines to prioritize certain procedures, but these are contested and even their authors confess them to be of limited utility, rendered obsolete by the evolving urgency of the pandemic almost as soon as they are promulgated [1] . Therefore, urologists in clinic and hospital spaces everywhere must be equipped with the tools necessary to decide, independently of the organizations with which they are affiliated, how to adhere to the professional obligation to provide the best possible care for their patients. These decisions are as much moral as they are medical: the raison d'etre of the field of bioethics is to grapple with the tension between rival values, to make the best possible choices in the face of uncertainty. Although bioethics is a standard part of medical school curricula and included in the American Urological Association Core Curriculum for resident training, it is seldom explicitly used as a tool for urologic decision-making: a PUBMED search for "'urology' and 'bioethics'" resulted only in discussions of assistive reproductive technology and genitoplasty. This paper aims to provide an organized framework for thinking through the ethical dilemmas that arise in provision of these and other forms of urologic care during the current pandemic crisis.

The most commonly applied and validated tool for medical ethical reasoning is that of Beauchamp and Childress' Principles of Biomedical Ethics, which describes 4 values, or principles: respect for autonomy, non-maleficence, beneficence, and justice. To utilize these in decision-making, each principle is located and specified to whatever extent it is pertinent to the moral question, and the relevant principles are balanced against each other in a process of deductive reasoning that connects the situation to its proper outcome [2] . While this principlism can be a useful methodology for resolving problems of medical ethics, like other clinical decision-making instruments it has significant limitations and does not always apply to the diversity of patients and situations. These inherent flaws are a consequence of the cultural context in which the principles, and indeed the discipline of bioethics itself, developed: that of mid-20 th century Western biomedicine, a time of supreme confidence in the ability of antibiotics and vaccines to eliminate infectious disease from the collection of human ills.

In that halcyon moment, when antibiotic resistance was just a small cloud on the horizon, smallpox was nearly eradicated and the polio vaccine promised to do the same in relatively short order, dilemmas that might arise with pandemic infection did not concern the fledgling field of bioethics, which developed instead around cases focused on subacute and chronic clinical conditions. Many of the classic dilemma-cases, which derived from real-life medicolegal conflicts in the United States and continue to be used for didactic purposes in that country and others, focus on problems of informed consent by individual patients or their proxy decision-makers. Although Beauchamp and Childress suggest that the 4 principles are of equivalent value, in the United States (with its fetishization of individualism [3]) there is a powerful and persistent tendency to privilege the principle of autonomy above all others. A common critique of conventional principlist bioethics notes that different nations and cultures may consider another principle to be the higher-order good.

This criticism is particularly apt when considering the ethical dilemmas that arise from a disease as encompassing as COVID-19, which has spread to every continent except Antarctica [4] . A scourge that affects patients of all ages, nations, cultures, and creeds is a salutary opportunity to reconsider our established values and their relative goodness, and the bioethical discourse around COVID-19 reflects this. Faced with widespread lack of preparedness for the strain of the disease on existing healthcare facilities and unfortunate shortages of essential medical resources, especially ventilators, respirators, and other personal protective equipment, bioethics scholars and committees in the United States have shifted their emphasis from the principle of autonomy to justice, calling for aggressive transparency and consistency in the allocation of scarce resources: "everybody has to feel that they have equal opportunity. . .for the required healthcare if they get sick. This has to be asserted, because that makes people support rationing rules" [5] .

The other principles − non-maleficence and beneficence − also merit increased consideration when making decisions about COVID-19 care, but have thus far received less widespread attention, perhaps because they are more challenging to specify and describe in this context. When so much is unknown about the biology of a disease and its best treatments, only retrospect will reveal what therapies are more harmful than beneficial. In medias res, beneficence tempts doctors, patients, and politicians to promote and utilize unproven medications at the risk of causing ancillary and otherwise avoidable harms, as exemplified by the enthusiastic uptake of hydroxychloroquine therapy. In the rush to populate the empty field of COVID-19 therapeutics, established ethical structures for the protection of research subjects are being circumvented, sometimes with the imprimatur of regulatory bodies (as in the "compassionate use" expansion of access by the US Food and Drug Administration) but also more problematically in community settings without the understanding or agreement of those subjected to experimental treatment [6] .

In contrast, for the various clinical conditions that occupied urologists before this pandemic and which continue to plague patients, requiring our attention and care, we have ample data with which to negotiate the balance of harm and benefit, risk and reward. And unlike COVID-19, the overwhelming majority of urologic complaints are not contagious, with their direct medical impact limited to the affected patient. Only very rarely does the management of patients directly implicate and endanger the health of those with whom they interact (as in the case of brachytherapy for prostate cancer, which can expose those around the patient to radiation) and we know how to minimize and mitigate those externalized costs. Absent these distinctive characteristics of pandemic infection, for non-COVID conditions one may reasonably choose to maintain the primacy of the autonomy principle, according to which individuals are empowered to choose and to act according to their idiosyncratic wills.

However, to do so rightly it is imperative to go beyond this simple, "every will is. . .a law unto itself" understanding of autonomy [7] . Feminist bioethicists have criticized this concept as inaccurately abstracted from the social contexts which structure and restrict individual actors, but to date their alternative "relational autonomy" model has gained little traction in clinical contexts [8] . The current pandemic has made manifest the inadequacy of the traditional, atomistic autonomy concept, as every individual at every moment now embodies a dual potential as both a victim and vector of COVID-19 disease, a potential that highlights the interconnectedness of every person on a biological as well as social level. In this "patient as victim and vector" view, individuals' interest in treatment of their urologic disease is necessarily moderated by a concomitant interest in avoiding infection with and transmission of COVID-19 to their companions [9] . Intersectionality is a helpful analytic prism through which to view these competing autonomy interests, as both COVID-19 and prostate cancer disproportionately affect African American patients [10] .

SARS-CoV-2 is a rapidly moving target, and the risk of infection and of transmission to and from each person will continue to vary, changing over time and space with interventions of social distancing, diagnostic testing, cohorting and isolating the infected, and with differential access to protective equipment for reduction of disease spread. By specifying the principles of autonomy, nonmaleficence, beneficence, and justice to the immediate, ever-changing context in which we are providing care, and by appreciating patients' interests and agency from their perspective as both a victim and vector of disease, we are better equipped to grapple with the difficult judgment calls ahead.

Week Old COVID-19 Urology Guidelines Already Outdated. Medscape

Principles of Biomedical Ethics

Keeping out coronavirus in the frozen Antarctic

Who Gets a Ventilator? Rationing Aid in COVID-19 − An Ethicist's View. Medscape

COVID-19 Patients Given Unproven Drug in Texas Nursing Home in 'Disconcerting Move. NPR

Grounding for the Metaphysics of Morals (1785)

Relational Autonomy: Feminist Perspectives on Autonomy, Agency, and the Social Self

The Patient as Victim and Vector: Ethics and Infectious Disease

The Concept of Intersectionality in Feminist Theory