Professionally responsible advocacy for women and children first during the COVID-19 pandemic: guidance from World Association of Perinatal Medicine and International Academy of Perinatal Medicine

Decision making with the pregnant patient

In professional ethics in obstetrics in the perinatal setting, the physician has prima facie ethical obligations to both the pregnant and fetal patient. The physician has beneficence-based and autonomy-based prima facie ethical obligations to the pregnant patient. The physician also has beneficence-based prima facie ethical obligations to the fetal patient. Without exception, the physician should identify all three prima facie ethical obligations. The pregnant patient also has beneficence-based prima facie ethical obligations to the fetal patient. We emphasize that there is no limitless or absolute beneficence-based ethical obligation of the pregnant woman to the fetal patient. This means that she is ethically obligated to take only reasonable risk to herself for fetal benefit from intrapartum management [4].

The informed decision making process should begin with the identification and presentation of the forms of clinical management that in deliberative clinical judgment are considered to be medically reasonable, taking into account beneficence-based prima facie ethical obligations to both the pregnant and fetal patient. The pregnant patient should be supported to understand and assess these forms of clinical management. Finally, the physician should be alert to potential controlling influence of others over the pregnant woman’s decision-making process, e.g., the mother of a teenage pregnant patient who states that her daughter cannot make decisions for herself when there is no clinical evidence to support this assessment. The physician should prevent such controlling influences from occurring, to ensure that the pregnant patient’s decision-making process is voluntary and that she remains the ultimate decision maker.

Decision making with parents

A baby delivered in a hospital becomes a neonatal patient. Clinical management should be guided by professional ethics in pediatrics, which has two components. The first is beneficence-based and is known as the best interests of the child standard. This standard creates the prima facie ethical obligation of the physician to identify and provide medically reasonable clinical management of the neonatal patients’ condition or diagnosis. The second is parental permission, a beneficence-based and autonomy-based concept. Parents are also bound by the best interests of the child standard, when their child is a patient. They therefore have a prima facie ethical obligation to authorize medically reasonable clinical management that has been offered or recommended by their child’s physician. The parents therefore do not provide consent, because they are not ethically free to refuse such authorization. Parental “permission” is used to signal that their autonomy is limited by the best interests of the child standard [6].

It is important that a pediatrician who is involved in the decision making process with the pregnant woman about intrapartum management think like an obstetrician: the perinatal team has autonomy-based and beneficence-based prima facie ethical obligations to the pregnant patient and beneficence-based prima facie ethical obligations to the fetal patient. The pregnant woman is the ultimate decision maker. It is equally important that the obstetrician who is involved in decision making about the birth plan and subsequent neonatal management think like a pediatrician. The best interests of the child standard should guide the perinatal team in this decision-making process and both parents should provide parental permission.

The necessity of frame-shifting

A common feature of pandemics is that the number of patients and their clinical needs can overwhelm the resources of healthcare organizations. When this occurs, it may necessary to triage space, medications, and life-sustaining treatment, in ascending order of clinical impact. Triage is not about meeting the needs of an individual patient, the one-at-a-time clinical application of the concept of medically reasonable. Instead, the concept of medically reasonable is applied to the population of patients served by a healthcare organization. This requires “frame-shifting” [12]. The goal in an overwhelming pandemic is to reduce mortality as much as possible in this population of patients and, to the extent that resources allow, minimize morbidity and disability among survivors. This may mean that some patients will be allowed to die or be undertreated. At the clinical level, this is ruled out by the ethical principle of beneficence; at the population level this is ruled in by the ethical principle of healthcare justice.

This is not easy change to make for any physician. We have used the word “frame-shifting” to signal how jarring and unwelcome this change is. This has important implication for triage of life-sustaining treatment, which we address below.

Allocation of space

In order to continue to provide access to a hospital by COVID-19 and other patients requiring hospitalization, hospitals have repurposed space to ensure access for COVID-19 patients who require admission, to maintain access to the emergency department [12]. A number of measures have been taken. An early step was to eliminate elective surgery. Admission from the emergency department into a hospital bed had to be expedited, so that patients in ambulances could be admitted to the emergency department without clinically unacceptable delay while waiting in the ambulance. It was also crucial to free up ambulances so that they could go to their next urgent calls without clinically unacceptable delay. To meet the higher level of care required by the most seriously ill COVID-19 patients, hospitals have had to add critical care beds in addition to existing critical care units, in effect creating new critical care units in such spaces as operating rooms and pre-operative and post-operative areas. The goal of these and other measures has been to prevent triage of life-sustaining treatment, which is addressed below.

In order to free up even more hospital space, some departments of obstetrics and gynecology have been asked to plan for relocation to a new site, removed from the hospital [10]. The ethical principal of healthcare justice should guide leaders in obstetrics in response to such requests. This ethical principle creates a prima facie ethical obligation to protect the space required to provide each patient with medically reasonable clinical management. Such clinical management includes rapid access to operating rooms for cesarean deliveries. The “time from decision to incision” requires that access be in contiguous space. Medically reasonable obstetric management also includes the involvement of consultants from other specialties, to ensure timely and effective response to sudden intrapartum complications. Finally, medically reasonable clinical management includes rapid and effective access to critical care services when a pregnant or gynecologic patient has a life-threatening condition. In these and other clinical circumstances the location of obstetrics and gynecology in the hospital is required by the healthcare-justice-based ethical obligation to ensure that every patient receives medically reasonable clinical management of her condition or diagnosis [12].

Extreme circumstances may arise in which the hospital needs to maximize space available to provide life-sustaining treatment to all eligible patients, to prevent having to ration such treatment. Ring-fencing obstetric and gynecologic services may prevent the hospital from achieving this goal. From the population-based perspective, the outcome of failing to prevent rationing would be incompatible with the prima facie ethical obligation of the hospital under the ethical principle of healthcare justice. Frame-shifting is required so that an unbiased plan for relocating obstetric and gynecologic services can be evaluated for its compatibility with the ethical principle of healthcare justice. Failure to surge the capacity for life-sustaining treatment can reliably be predicted to result in more mortality and major morbidity from COVID-19 than the increased risk of mortality and morbidity from relocating obstetric and gynecologic services out of the hospital. There is, however, a healthcare-justice-based imperative: the out-of-hospital space should be made as safe as possible by meeting the conditions described above.

Allocation of medications

DeJong, Chen, Lo have recently provided ethics-based guidance on responsibly managing scarce medications during the COVID-19 pandemic [13]. Frame-shifting to a population-based perspective, they prioritize reducing mortality as much as possible and emphasize that patients’ preferences will sometimes justifiably be limited in order to achieve this priority. On this basis they make six recommendations that we support as the basis for creating professionally responsible organizational policy.

1. Allocation should be evidence-based.

2. Prioritization should not exclude patients based on age, disability, religion, race or ethnicity, national origin gender, sexual orientation, or perceived quality of life.

3. Patients already receiving appropriate medications for other serious illness should continue to receive their medication.

4. Clinical judgment about which patients might most benefit should be based on the best available evidence.

5. In the eligible population that results from applying the first four recommendations, to be fair allocation should be based on randomization. It would be ethically permissible to prioritize essential healthcare professionals before randomization is applied.

6. Physicians who are tasked to explain to a patient or patient’s family that the patient will not receive the scarce medication should receive full organizational back-up and support [12].

Allocation of life-sustaining treatment

Every effort should be made to maximize the hospital’s capacity for life-sustaining treatment, utilizing appropriate space and personnel, to prevent the need for triage. Frame-shifting to a population-based perspective will be very challenging, because the triage officer will be deciding which patients will be provided access to life-sustaining treatment and which will. Organizational leaders should designate physicians who are held in the highest professional regard to serve as triage officers. These physicians should have no direct responsibility for patient care, to prevent conflicts of commitment. The sole criterion should be maximal reduction of the risk mortality at discharge with at least some interactive capacity among survivors in the patient population, using evidence-based standards [14]. The triage officers should use scoring systems that include accepted and clinically applicable measures as the basis for predicted mortality and accepted and clinically applicable measures for predicted absence of interactive capacity. No other clinical considerations should be allowed, such predicted post-discharge quality of life or disability, because such clinical considerations introduce the very biases that DeJong, Chen, and Lo correctly exclude [13].

We have deliberately used the plural, triage “officers.” We have done so out of recognition that the role of triage will be extremely demanding and almost take a psychological toll on the physicians assigned this momentous professional responsibility. Rotating the responsibility should be seen as an essential safeguard for the integrity of the triage process. If time allows, an additional safeguard is periodic retrospective review to prevent drift away the focus on maximal reduction of the risk mortality at discharge with at least some interactive capacity among survivors in the patient population.