key: cord-1036801-kslq16jv authors: Rajagopal, Keshava title: Reply: Hamlet, the cardiac surgeon date: 2020-08-07 journal: J Thorac Cardiovasc Surg DOI: 10.1016/j.jtcvs.2020.06.123 sha: 84f5b397fad475107fa1104b4a62c9b28169d309 doc_id: 1036801 cord_uid: kslq16jv nan REPLY: HAMLET, THE CARDIAC SURGEON Reply to the Editor: ".for there is nothing either good or bad, but thinking makes it so." -Hamlet, Act 2, Scene 2 Thank you to Dr Fremes and his colleagues for their insightful remarks regarding what they termed the "wicked" problem of how to allocate cardiac surgical services in the context of the Coronavirus Disease 2019 (COVID-19) pandemic. In the previous Commentary 1 on the Columbia University-Presbyterian Medical Center article, 2 I had merely posed questions. Dr Fremes' group has attempted to answer them. The ethical principles that they outlined 3 notably incorporate procedural justice, essentially an agreed-upon data-driven "due process" methodology. Referring to their specific example of predicted adverse effects of delaying coronary artery bypass grafting (CABG), a patient of mine whose "elective" CABG was delayed because of COVID-19-related policies sustained an acute myocardial infarction, necessitating an urgent operation. The commonly adopted approaches to resource allocation clearly are not without drawbacks, and thus their proposal merits further analysis. In response, some considerations may be appropriate. Hamlet's statement, in my view, is not an endorsement of moral relativism. Rather, it suggests that determinations of "goodness" or "badness" emerge only after thinking about at least 2 other factors. First, whether a material process or state (eg, a cardiac surgical procedure) is good or bad depends on context. For example, in an absolute sense, performing "elective" CABG is "good" for patients who need it. However, particularly with realistic resource limitations even in the best centers, prioritizing this and thereby delaying a heart transplant with a narrow time window would be "bad"; consequently, and as expected, centers would not do this. This appears in line with Fremes and colleagues' proposal. As someone within the fields of end-stage heart/lung disease as well as general adult cardiac surgery, these are prioritizations with which I am unfortunately familiar and indeed are wicked problems. The second factor is more challenging. This is whether goodness or badness of values exists in an absolute sense, which I believe, or whether social consensus is necessary or sufficient to validate or invalidate them, which I do not believe. This is often viewed as the distinction between morality and ethics. Much that some of us view as immoral may be viewed as ethical by the larger population, or vice versa. Moreover, what is unethical today was ethical in the past or what is ethical today was unethical in the past. This is concerning. Practically, consensus is required to implement policies, but does this mean that consensus should be a fundamental value? Should individual patients suffer as a consequence of consensus or surgeons suffer in response to violating one? Although procedural justice provides appealing hard analytic tools, whether or not they are adopted, and what criteria are used rest on the presence or absence of consensus. Yet, some action needs to be taken. Differences in views must be discussed in good faith. Fremes and colleagues have made an important attempt toward fair cardiac surgery resource allocation. https://doi.org/10.1016/j.jtcvs.2020.06.123 The author reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The Journal of Thoracic and Cardiovascular Surgery c Volume -, Number -e1 LETTER TO THE EDITOR Implications of COVID-19 for cardiac surgery: priorities and decisions The rapid transformation of cardiac surgery practice in the COVID-19 pandemic: insights and clinical strategies from a center at the epicenter Wicked problems and proportionality: is the lesser of two evils the best we can do?