Ethical Implications of Resuming Elective Orthopedic Surgery During the COVID-19 Pandemic.

The COVID-19 pandemic has had unprecedented impact on the United States health care system. One of the consider-ations was the decision to halt elective orthopedic surgery to preserve consumption of scarce resources. However, as the number of COVID-19 cases decrease, there will be discus-sions regarding the modality of resuming elective orthopedic surgery. Ethical considerations will come to the forefront in terms of determining the best course of action, patient selection, resource rationing, and financial implications. These factors will be examined through the lens of the four tenets of bioethics, beneficence, maleficence, autonomy, and justice, to elucidate the best approach in ethically manag-ing elective orthopedic surgery during a global pandemic.

Maternal request caesareans and COVID-19: the virus does not diminish the importance of choice in childbirth.

It has recently been reported that some hospitals in the UK have placed a blanket restriction on the provision of maternal request caesarean sections (MRCS) as a result of the COVID-19 pandemic. Pregnancy and birthing services are obviously facing challenges during the current emergency, but we argue that a blanket ban on MRCS is both inappropriate and disproportionate. In this paper, we highlight the importance of MRCS for pregnant people's health and autonomy in childbirth and argue that this remains crucial during the current emergency. We consider some potential arguments-based on pregnant people's health and resource allocation-that might be considered justification for the limitation of such services. We demonstrate, however, that these arguments are not as persuasive as they might appear because there is limited evidence to indicate either that provision of MRCS is always dangerous for pregnant people in the circumstances or would be a substantial burden on a hospital's ability to respond to the pandemic. Furthermore, we argue that even if MRCS was not a service that hospitals are equipped to offer to all pregnant persons who seek it, the current circumstances cannot justify a blanket ban on an important service and due attention must be paid to individual circumstances.

The COVID-19 Pandemic and Plastic Surgery: Literature Review, Ethical Analysis, and Proposed Guidelines.

BACKGROUND: Coronavirus disease 2019 (COVID-19), known as the "coronavirus," has spread to over 170 countries. In response, many organizations have spoken out and called for cancellation of all elective surgical procedures. This study aimed to provide clear recommendations for plastic surgeons to follow by addressing the following issues: (1) What defines elective surgery, and where does one draw the line between essential versus nonessential services? (2) How does this differ in the hospital versus private practice setting? (3) If called on to operate on a patient with COVID-19, how do plastic surgeons protect themselves and still provide excellent medical care? METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review of the literature on plastic surgery in the setting of a pandemic was performed on March 19, 2020. An ethical analysis was conducted using the four principles of medical ethics. RESULTS: The initial search yielded 118 articles. Eighteen articles were relevant and included for analysis. Only one editorial article was published in a plastic surgery journal. Accordingly, no peer-reviewed published COVID-19 guidelines exist for plastic surgery. Given that this pandemic may place health care systems under undue stress with an unpredictable trajectory, it is the responsibility of the plastic surgeon to assess and postpone cases whenever possible to properly contribute to adequate resource allocation and patient safety measures. CONCLUSIONS: This article fills an important gap in the literature by addressing COVID-19 and providing guidelines for upholding ethics and responsible resource allocation. By upholding these standards, plastic surgeons can do their part to help minimize the spread of this virus.

Rethinking "Elective" Procedures for Women's Reproduction during Covid-19.

Common hospital and surgical center responses to the Covid-19 pandemic included curtailing "elective" procedures, which are typically determined based on implications for physical health and survival. However, in the focus solely on physical health and survival, procedures whose main benefits advance components of well-being beyond health, including self-determination, personal security, economic stability, equal respect, and creation of meaningful social relationships, have been disproportionately deprioritized. We describe how female reproduction-related procedures, including abortion, surgical sterilization, reversible contraception devices and in vitro fertilization, have been broadly categorized as "elective," a designation that fails to capture the value of these procedures or their impact on women's overall well-being. We argue that corresponding restrictions and delays of these procedures are problematically reflective of underlying structural views that marginalize women's rights and interests and therefore threaten to propagate gender injustice during the pandemic and beyond. Finally, we propose a framework for triaging reproduction-related procedures during Covid-19 that is more individualized, accounts for their significance for comprehensive well-being, and can be used to inform resumption of operations as well as subsequent restriction phases.

Ethical surgical triage of patients with head and neck cancer during the COVID-19 pandemic.

BACKGROUND: Coronavirus has serially overtaken our metropolitan hospitals. At peak, patients with acute respiratory distress syndrome may outnumber mechanical ventilators. In our Miami Hospital System, COVID-19 cases have multiplied for 4 weeks and elective surgery has been suspended. METHODS: An Otolaryngologic Triage Committee was created to appropriately allocate resources to patients. Hospital ethicists provided support. Our tumor conference screened patients for nonsurgical options. Patients were tested twice for coronavirus before performing urgent contaminated operations. N95 masks and protective equipment were conserved when possible. Patients with low-grade cancers were advised to delay surgery, and other difficult decisions were made. RESULTS: Hundreds of surgeries were canceled. Sixty-five cases screened over 3 weeks are tabulated. Physicians and patients expressed discomfort regarding perceived deviations from standards, but risk of COVID-19 exposure tempered these discussions. CONCLUSIONS: We describe the use of actively managed surgical triage to fairly balance our patient's health with public health concerns.

Elective Impairment Minus Elective Disability: The Social Model of Disability and Body Integrity Identity Disorder.

Individuals with body integrity identity disorder (BIID) seek to address a non-delusional incongruity between their body image and their physical embodiment, sometimes via the surgical amputation of healthy body parts. Opponents to the provision of therapeutic healthy-limb amputation in cases of BIID make appeals to the envisioned harms that such an intervention would cause, harms such as the creation of a lifelong physical disability where none existed before. However, this concept of harm is often based on a normative biomedical model of health and disability, a model which conflates amputation with impairment, and impairment with a disability. This article challenges the prima facie harms assumed to be inherent in limb amputation and argues in favour of a potential treatment option for those with BIID. To do this, it employs the social model of disability as a means to separate the concept of impairment and disability and thereby separate the acute and chronic harms of the practice of therapeutic healthy-limb amputation. It will then argue that provided sufficient measures are put in place to ensure that those with atypical bodily constructions are not disadvantaged, the chronic harms of elective amputation would cease to be.

'Operating is the easy part': Surgeons' decision-making processes and responses to parental requests for elective paediatric appearance-altering facial surgery.

Some parents request elective appearance-altering facial surgery for their children for cosmetic, psychological and/or social reasons. These operations have attracted controversy in the bioethics literature. They are also the subject of professional guidance documents internationally, which leave much to individual practitioners' discretion. Despite their controversial nature, very little is known about surgeons' practices and decision-making processes regarding these operations. Individual semi-structured interviews were conducted by 22 plastic surgeons and oral and maxillofacial surgeons in Australia to explore their descriptions of the types of parental requests they receive for these operations, their decision-making processes and their responses to these requests. Interviews were audio-recorded, transcribed and analysed using inductive content analysis. Surgeons reported parents often request these operations to alleviate or prevent teasing and associated psychosocial distress. However, surgeons expressed concern some parents may be requesting surgery to further their own interests, rather than their child's. Surgeons reported considering multiple factors when making decisions about the ethical justifiability of facilitating these parental requests, including children's wishes about surgery, the severity of the facial difference, the child's growth stage and parents' reasons for requesting. Although most surgeons appeared comfortable denying parental requests when they believe surgery is not in the child's best interests, some indicated they will acquiesce if parents persist. This study provides insights into surgeons' practices and decision-making processes regarding elective paediatric appearance-altering facial surgery requested by parents. It also highlights implications for clinical practice and education, and identifies areas warranting further research.

[Obtaining Informed Consent for Anesthesia in Elective Surgery at a Tertiary-Care Hospital: Practices and Ethical-Legal Context]. / Obtenção de Consentimento Informado para Anestesia em Cirurgia Eletiva num Hospital Terciário: Práticas e Contexto Ético-Legal.

INTRODUCTION: Informed consent is an active process of the doctor-patient relationship, based on ethical and legal principles. The anesthetic act has inherent risks, which should be subject of specific consent. The aim of this study was to evaluate the degree of implementation of written specific informed consent for anesthesia in the context of elective surgery. MATERIAL AND METHODS: An observational prospective study, at a tertiary university hospital, in 230 patients aged 60 years or older, undergoing elective surgery between May and July 2017. Eligible patients who consented to participate were interviewed clinically on the day before surgery. In the postoperative period, the anesthetic technique and the existence of the written informed consent for the anesthetic and surgical procedures were assessed. Patients who were unable to give informed consent or those admitted in the Intensive Care Unit after surgery were excluded. RESULTS: Written informed consent for the surgical procedure was obtained for 225 (97.8%), while it was obtained in just 96 (41.7%) patients for the anesthetic act. There was a higher prevalence of stroke, anemia, and higher Charlson and physical American Society of Anesthesiologists scores in patients without written informed consent for the anesthetic act. DISCUSSION: We identified a low implementation of written informed consent for anesthesia. This situation may have important implications in the context of disciplinary, civil or criminal liability. CONCLUSION: Despite its importance, the practice of written informed consent for anesthesia in this institution is not yet implemented on a regular basis.

Introdução: O consentimento informado é um processo ativo na relação médico-doente, assente em valores éticos e legais. O ato anestésico tem riscos inerentes, que devem ser alvo de consentimento específico. O objetivo deste estudo foi avaliar o grau de implementação do consentimento informado escrito para o ato anestésico no contexto de cirurgia eletiva. Material e Métodos: Estudo observacional prospetivo, num hospital terciário e universitário, em 230 doentes com idade igual ou superior a 60 anos submetidos a cirurgia eletiva entre maio e julho de 2017. Aos doentes elegíveis que consentiram participar, foi realizada entrevista clínica no dia prévio à cirurgia. No pós-operatório, foi averiguada a técnica anestésica realizada, e a existência do consentimento informado por escrito para o ato anestésico e cirúrgico. Doentes incapazes de dar consentimento informado ou admitidos na unidade de cuidados intensivos após cirurgia foram excluídos. Resultados: Em 225 (97,8%) dos doentes, verificou-se a obtenção, por escrito, do consentimento informado para o ato cirúrgico, mas apenas em 96 (41,7%) verificou-se a obtenção por escrito do consentimento informado para o ato anestésico. De entre os doentes sem registo de consentimento informado para o ato anestésico, foram mais prevalentes antecedentes de acidente vascular cerebral, anemia e scores de Charlson e de estado físico conforme à Sociedade Americana de Anestesiologia mais elevados. Discussão: Identificámos uma baixa implementação do consentimento informado escrito para o ato anestésico. Esta situação pode ter importantes implicações em contexto de responsabilidade disciplinar, civil ou penal. Conclusão: Apesar da sua importância, a prática do consentimento informado escrito para o ato anestésico nesta instituição não está implementada regularmente.

Conjoined Twins Separation Leading to the Death of One Twin: An Expanded Ethical Analysis of Issues Facing the ICU Team.

A recent case of conjoined twins required multiple hospitalizations in the pediatric intensive care unit and led to a difficult situation confronting staff regarding the potential separation where surgery would result in the death of one twin. The hospital ethics committee was consulted. A systematic approach was utilized to examine medical standards, historical precedents, and various ethical and legal frameworks. The ethics committee believed that either proceeding with or forgoing attempted separation surgery would be ethically acceptable. We share our reasoning and lessons learned for others facing this situation in the future.

Too Close to the Knives: Children's Rights, Parental Authority, and Best Interests in the Context of Elective Pediatric Surgeries.

This paper advances a novel conception of the child's best interest in regard to pediatric surgeries that do not promote the preventive or therapeutic health needs of children, namely elective pediatric surgeries (EPS). First, children's capacity for decision making is examined, and the best decision-making model for EPS is identified as the Best Interest Standard. What follows is a discussion of the interests of children in the context of EPS, the correlation of fundamental interests to rights, and guidelines for weighing children's competing interests. Next, the rights and duties of parents as proxy decision makers are considered. Finally, a reinterpretation of the Best Interest Standard is proposed, identifying as paramount a child's ability to make elective medical decisions for herself when she reaches maturity.

An ethically-justifiable, practical approach to decision-making surrounding conjoined-twin separation.

Conjoined twins present unique ethical and palliative care challenges. We present an ethically-justifiable, practical approach to decision-making with regards to surgical separation. These decisions must account for the short- and long-term prognoses for each infant prior to, and after, separation. Other considerations include the benefits and burdens of separation and the family's values and goals. Caregivers should recognize that decisions surrounding separation may be unduly influenced by social biases. The palliative care team aids in developing goals of care to guide decision-making by promoting communication between the medical team and family. They play an important role in supporting families regardless of the planned course of treatment. This support may be social or spiritual in nature, and is promoted by the interdisciplinary structure of the team. Early involvement of palliative care services facilitates complex decision making and can aid in the transition from cure-oriented therapies to support if needed during and after the dying process.

Formats of responsibility: elective surgery in the era of evidence-based medicine.

This article illustrates what pragmatic sociology refers to as investments in form, by examining the formats created and used by a group of surgeons to determine when elective surgery for pelvic floor disorders could be responsibly undertaken. Drawing upon ethnographic observations of surgical consultations at an academic medical centre in Canada, we show how two specific formats - that the patient is sufficiently bothered and the patient accepts the risks of surgery - allow for justifiable action in conditions of uncertainty and contingency and in light of the demands of dominant imperatives in medicine and health care, especially evidence-based medicine (EBM). We argue that an analytic of justification is necessary for understanding when and how surgery is offered and elected for, and for considering how surgical consultations might be improved.

Voluntary sterilisation and access to IVF in Québec.

Bill 20, An Act to Enact the Act to promote access to family medicine and specialized medicine services and to amend various legislative provisions relating to assisted procreation, was introduced to reduce costs associated with Québec's healthcare in general and in vitro fertilisation (IVF) in particular. Passed in November 2015, the new law introduces a number of exclusion criteria for access to and funding for IVF treatment. Remarkably, one exclusion criterion-prior voluntary sterilisation-has prompted little critical commentary. The two justifications offered for restricting funding for IVF on the basis of voluntary sterilisation are that (1) there are cheaper options than IVF for sterilised individuals who want children, and (2) society should not have to pay for IVF for persons who are infertile by choice. I argue that both of these justifications are unsatisfactory, insofar as they contravene the chief value underlying, and current practices of, Canadian healthcare, and rely on problematic ascriptions of personal responsibility for health.

Medical and bioethical considerations in elective cochlear implant array removal.

OBJECTIVE: Cochlear explantation for purely elective (e.g. psychological and emotional) reasons is not well studied. Herein, we aim to provide data and expert commentary about elective cochlear implant (CI) removal that may help to guide clinical decision-making and formulate guidelines related to CI explantation. DATA SOURCES: We address these objectives via three approaches: case report of a patient who desired elective CI removal; review of literature and expert discussion by surgeon, audiologist, bioethicist, CI user and member of Deaf community. REVIEW METHODS: A systematic review using three scientific online databases was performed. Included articles addressed the benefits and/or complications of cochlear implantation in young children, CI explantation with or without revision surgery and the ethical debate between the medical and Deaf communities on cochlear implantation and explantation. CONCLUSIONS: The medical and audiological perspectives identify a host of risks related to implant removal without reimplantation, including risk from surgery, general anaesthesia, cochlear ossification and poor audiometric outcomes. The member of the deaf community and bioethicist argue that physicians need to guide the principles of beneficence, non-maleficence and patient autonomy. Taken together, patient desires should be seen as paramount, if the patient is otherwise fit for surgery and well informed. IMPLICATIONS FOR PRACTICE: Similar to the case of device implantation, device explantation should be a multidisciplinary and collaborative decision with the patient and the family's desires at the centre. While every case is different, we offer a CI explantation discussion to assist in clinical decision-making, patient counselling and education.