General recommendations from the American Society of Clinical Oncology (ASCO) that provide an ethical framework for the oncology community regarding the potential implementation of health care resource rationing during the COVID-19 crisis were published in the Journal of Clinical Oncology.1,2
The large numbers of patients with severe clinical manifestations of COVID-19 infection, and the finite numbers of intensive care beds and ventilators, have led to the realization that fair and consistent policies founded on ethical principles are needed to facilitate institutional decision making related to the allocation of limited health care resources during the COVID-19 pandemic. Toward that end, several practical models to guide these types of decisions have recently been published.3-5
While patients with cancer are a highly diverse group with respect to disease diagnosis, treatment, and prognosis, they also represent a large population of patients that could potentially be at risk of wide-ranging restrictions regarding access to limited health care resources during the COVID-19 crisis.
Hence, ASCO has provided general guidance to oncologists on working with their institutions to apply the aforementioned ethical frameworks when specifically addressing patients with cancer.1-5
Based on the fundamental principle that limited resources should be prioritized and allocated so as to maximize health benefits, these recommendations from ASCO also emphasized that health care resource allocation policies should be developed proactively.
Some of the key elements of the ASCO recommendations include the following:
- A cancer diagnosis, even for a patient with metastatic disease, should not, on its own, be used to determine whether a patient is terminal; rather, individualized decisions should “reflect evidence-based factors” with “input from the treating oncologist.”
- Fair, objective, and consistent decisions regarding health care resource allocation for the individual patient should made by multidisciplinary teams without consideration of the “social worth” of the patient; these decisions should not be made by the treating oncologist, thereby allowing the oncologist to “maintain their fidelity to the patient” — although it is the responsibility of the latter to honestly communicate those decisions to the patient in a compassionate and transparent manner.
- Discussions “early and often” between the oncologist and patient regarding advance-care planning were mentioned as being critically important, as well as careful documentation of those discussions.
“A diagnosis of cancer alone should not preclude access to scarce medical resources, though certain clinical considerations that are known to significantly affect prognosis (eg, widely metastatic, treatment-resistant disease) may factor into allocation policies,” the authors of the ASCO document wrote.
Finally, ASCO emphasized the need for accountability among individuals, health systems, governments, and public health entities involved in the development and implementation of health care resource allocation plans.
- Marron JM, Joffe S, Jagsi R, et al: Ethics and resource scarcity: ASCO recommendations for the oncology community during the COVID19 pandemic. J Clin Oncol [published online April 9, 2020]. doi: 10.1200/JCO.20.00960
- American Society of Clinical Oncology. New guidance released for oncology community on allocation of limited resources during COVID-19 pandemic. Accessed April 20, 2020.
- Berlinger N, Wynia, M, Powell T, et al. Ethical framework for health care institutions & guidelines for institutional ethics services responding to the coronavirus pandemic: Managing uncertainty, safeguarding communities, guiding practice. Accessed April 20, 2020.
- White DB, Lo B. A framework for rationing ventilators and critical care beds during the COVID-19 pandemic. JAMA [published online March 27, 2020]. doi: 10.1001/jama.2020.5046
- Department of Critical Care Medicine. University of Pittsburgh. Allocation of scarce critical care resources during a public health emergency. Accessed April 20, 2020.