Ethical Guidelines and Moral Distress During the COVID-19 Pandemic: The Trainees’ Perspective

To the Editor:

The article, “Cardiothoracic Surgeons in Pandemics: Ethical Considerations,” by Drake and coworkers¹ is of special importance to trainees. The pandemic has affected every aspect of cardiothoracic surgery, including the decline in elective and emergent case volume, rationing of resources, and redistribution of surgical staff to other domains. One area that can be overlooked, however, is the potential long-term consequence of incurring moral distress, especially for those in early, formative stages of training.

The pandemic raises ethical concerns regarding limited resource allocation. At the frontlines of patient management these concerns are not academic or theoretical but rather carry significant implications for the well-being of patients and providers alike.² The burden of decision-making necessarily falls on providers on a case-by-case basis when the shift from a patient-centered to a public interest approach becomes necessary, including prioritizing number of lives and life-years saved. When life-support devices must be withdrawn from 1 patient to provide to another with greater need, rightfully so as recommended by guidelines,¹ these decisions should not be made by bedside clinicians but by specially designated triage teams; nevertheless patient care teams will observe these difficult decisions being made and must be deeply distressed when they become necessary. Although such deliberations and observations may help each of us grow as physicians and hone our ethos, surely the psychological toll of these times will have long-term consequences for everyone involved, especially trainees.

Ethical guidelines such as the one put forth in The Annals of Thoracic Surgery and tiered triage guidance statements for adult cardiac surgery,³ congenital heart surgery,⁴ and thoracic malignancies⁵ provide peace of mind and moral protection to trainees to allow them to focus on performing their clinical duties without becoming overwhelmed with many of the unknowns and unanswerables. We applaud cardiothoracic surgery leadership for their development of resource utilization predictions tools based on data from The Society of Thoracic Surgeons Database to assist healthcare providers in making informed resource allocation decisions and triaging cardiothoracic surgical cases. As we navigate the uncharted territory together, ethical guidelines, albeit never absolute, provide some degree of transparency, strength in shared decision-making, and cognitive clarity to alleviate the potential moral distress faced by trainees and others in this defining public health crisis of our time.