Table 1.

Ethical principles and their application in the cardiac setting during COVID-19

Principle	Definition	Application	Example
Minimize harm (non-maleficence/ beneficence)	Society should take steps to protect the public from harm and minimize physical, psychological, social, and economic impacts of a pandemic	Ensure there exists reserve capacity in critical care settings to accommodate any surge related to future waves of disease transmission	Cardiac surgery volumes should be balanced by weighing patient acuity and waiting lists against the need for critical care beds and ventilators
Fairness (distributive justice)	Persons matter equally and should have equal access to resources. However, those with greater needs and who stand to gain the most (utility), as well as services that provide the greatest benefit to the greatest numbers (efficiency), should be prioritized. Care must be taken to avoid placing undue burden on particular segments of the population or further perpetuating systemic or structural inequities	Surgeries, invasive and noninvasive interventions, as well as diagnostic testing, that are likely to benefit more people to a greater degree are prioritized over procedures that will benefit fewer people to a lesser degree	The resource investment required to operate high-volume ambulatory heart failure clinics should be balanced against those required for aggressive therapies, such as mechanical circulatory support or cardiac transplant, which greatly benefit a few
Respect for persons (autonomy)	Autonomous, informed choice, as well as cultural safety, privacy, and confidentiality, must be respected and promoted	Explore individual patients’ perspective, including goals and assessment of quality of life	Those patients who do not want to attend a recommended procedure or test due to concerns over COVID-19 transmission and infection should not be prejudiced against either for acute care during the pandemic, or for regular care once the pandemic abates
Proportionality	Decisions should be proportional to balance potential benefits of an activity against risks of harm. These calculations must be evidence-based and data-driven, wherever possible	Risks of exacerbating nosocomial COVID-19 spread and precipitating an unmanageable increase in pressure on healthcare resources should be considered	Exposing an elderly patient or a patient with significant comorbid disease burden to a COVID-rich environment, where adequate risk mitigation cannot be achieved, must be balanced by the potential benefit of the proposed procedure or test
Reciprocity	Those who are asked to take increased risks, or face undue burdens, should be supported in doing so, and harms mitigated as much as possible	Patient and provider safety should be considered when deliberating on available treatment options	Decision to perform an aerosol-generating medical procedure is balanced by sustainable access to PPE
Flexibility	Plans should be iterative and adapt to new evidence and public health directives	Proposals increasing access to services and associated communications must acknowledge the possibility of, and be responsive to, the ebb and flow of future COVID-19 surges	Patients and providers must be prepared for services to be abruptly altered, and the resultant reduction may not be consistent across all therapeutic areas
Procedural justice	Decisions should be accountable to a fair and transparent process throughout the planning and implementation stages. Stakeholders should be engaged, and decisions should be applied in a consistent manner with open communication	The decision on how to reintroduce service capacity and where resources will be allocated should be deliberate and informed by all stakeholders	The allocation of operation and procedural room access should be governed by an established set of principles