Wicked problems and proportionality: Is the lesser of two evils the best we can do?

To the Editor:

The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

We read with great interest the commentary by Dr Rajagopal on priority setting and decision-making during the Coronavirus Disease 2019 (COVID-19) pandemic as they pertain to the reduction in cardiovascular surgical procedures in anticipation for a surge in the COVID-19 pandemic.¹ The question from his commentary is an important one: If cardiac surgery is lifesaving, how do we prioritize scarce critical care resources such as ventilators and intensive care unit beds?

What Dr Rajagopal describes is a “wicked” problem, not in the sense that the problem is evil but in that the problem is highly complex, a term derived from social policy studies.² In contrast to “tame” problems, wicked problems can be difficult to define, because the problems are commonly rife with competing goals and values. Furthermore, there are no simple solutions or “easy fixes” to wicked problems; proposed solutions are usually characterized as “good enough.” In fact, any possible solution may unleash a fury of new problems or concerns. These characteristics of wicked problems aptly describe our current conundrum of how to manage patients with cardiac disease during the COVID-19 pandemic in the setting of resource constraints.

Resource allocation decisions can be made on principles of distributive justice or procedural justice. Prominent frameworks in distributive justice include utilitarianism, egalitarianism, and communitarianism.³ Undoubtedly, cardiac surgery improves life expectancy for patients with severe cardiovascular disease, and thus its prioritization can be justified on utilitarian principles. However, the shifting away of resources from cardiac surgical patients to treat critically ill patients with COVID-19 helps limit disease transmissions and may be justified on communitarian principles. Furthermore, although our surgeries are lifesaving, we note that some elective patients may potentially tolerate a modest delay. However, such delays may not pass without a price. For example, patients awaiting coronary artery bypass surgery are at risk of developing complications during the wait-time period. Head and colleagues⁴ reported a rate of death and nonfatal myocardial infarction at 1.1% and 1% per 1000 patient-weeks, respectively, when awaiting surgery.⁴ This highlights the important concept of proportionality, where decided actions should be proportional to the good that can be accomplished and the inevitable resulting harm.⁵

Overall, we have the daunting task of caring for the cardiac surgical patient in front of us in the midst of a deadly and rapidly evolving public health crisis that impacts society. To begin to tackle this difficult problem, our decisions must be made on the best available data and evidence in a transparent manner. When reasonable disagreement exists, the principles of distributive justice such as utilitarianism and communitarianism may not be enough to placate all stakeholders, and we must rely instead on procedural justice.⁶ Procedural justice may take several forms but typically involve the use of decision tools and processes to justify the distribution of constrained resources after accounting for competing stakeholder interests.⁷ The use of decision analytic modeling can be a useful tool to help synthesize available evidence to model the envelope of possible scenarios and help inform critical resource decisions during a pandemic.⁸ Rapid iteration of these models with real-time data may help efficiently allocate resources to COVID-19 or cardiac surgical patients depending on the prevailing COVID-19 incidence rates in that jurisdiction.⁹ In Ontario, Canada, such a model was used to estimate both COVID-19–related deaths versus cardiac procedure waitlist death and help informed decisions around halting and resuming elective cardiac procedures based on the evolving COVID-19 transmission epidemiology. These models help ensure that when we invoke principles such as proportionality, which may be a detriment to cardiac surgical patients, the most urgent cardiac cases can continue to be treated while resources are dedicated to those with COVID-19. Although there may be no perfect answers, we must use all tools available to find solutions that are at the least acceptable to stakeholders.