Editor’s note: Dr. Hudis hosts the ASCO in Action Podcast, which focuses on policy and practice issues affecting providers and patients. An excerpt of a recent episode is shared below; it has been edited for length and clarity. Listen to the full podcast online or through iTunes or Google Play.
I'm very pleased to be joined by Dr. Jonathan Marron, chair of ASCO's Ethics Committee and a lead author of “Ethics and Resource Scarcity: ASCO Recommendations for the Oncology Community During the COVID-19 Pandemic.” Dr. Marron is also a bioethicist at Boston Children's Hospital, a pediatric oncologist at Dana Farber Cancer Institute, and he is on the Center for Bioethics teaching faculty at Harvard Medical School.
From very early days [of the COVID-19 public health crisis], there was an extraordinarily emotional and widespread concern that medical resources—especially ventilators, but also medications, space, critical and intensive care beds—would be stretched. When those concerns arose, what followed, especially for people who work in this field, was the very real possibility that they would be forced to make some painful and difficult choices.
Dr. Marron and I talk about the paper’s recommendations, and we'll focus specifically on the reasons that ASCO took this step and what oncologists, patients, families, and the entire cancer care community need to know about this issue.
CH: Can you help our readers understand why ASCO thought that this situation needed to be addressed and why we decided to provide guidance and recommendations?
JM: In the outset of the pandemic, it was difficult to tell just how bad everything was going to get. Seeing the experience in China and Italy created a significant concern that the U.S. health care system would not be able to support the critical care needs that we would have.
There is a long history of people thinking about how to best utilize resources like this in the setting of scarcity, and one of the concerns that comes up whenever you must make these impossible choices is how you're going to do so. So, that's where we came in, as oncologists and the ASCO community, to try to figure out how we could best represent the oncology community and to ensure that cancer unto itself was not going to keep a given patient from having a fair chance to access these potentially lifesaving resources, even in the setting of a public health crisis like this, even in the setting of scarce resources.
CH: One of the areas that I think is really a concern, but can be misunderstood, is the high-level statement you just made that people with cancer might find themselves discriminated against in these moments of triage.
Let’s say, for the sake of argument, that there's one ventilator and three patients with need. How do you decide who gets it? Could you talk a little bit about what we mean when we say protecting patients with cancer? We're not saying that cancer as a diagnosis, stage, or prognosis should be ignored, right?
JM: Absolutely. What you said there really is one of the most important aspects here, that there are a couple of different ways that you can go about trying to decide which one of the three patients will get the ventilator. Perhaps the fairest way would be simply to make a choice at random and say each of those three individuals has an equal chance. That's certainly fair.
But some people might say they may not be equal in all ways. If we're trying to maximize our resources and the potential outcome benefits of these scarce resources, then we will want to do something more than just choosing randomly. We've learned in the past from community groups that people don't love the idea of randomly choosing things like this, public health emergency or otherwise.
The question is, how are you going to make that choice? If we're trying to maximize health care outcomes, usually meaning survival, we want to use medical information—but then, what medical information should be used?
One of the concerns is that there could be certain disease processes, cancer or otherwise, that would be exclusion criteria. Like earlier, we have three patients and one ventilator, but Patient 1 has cancer, so therefore we're not even going to give them a chance at the ventilator.
That's where this guidance comes in, because that is not the way to do this. Cancer absolutely should come into the consideration, but that patient's specific cancer—their diagnosis, their prognosis—should be considered so that we can make a maximally informed decision about who is the most likely to survive if they are given access to the ventilator.
CH: It is quite a testimony, when you think about it, to the advances we’ve made in oncology that we're now worried that people will make too much in the negative direction about the prognosis of a cancer diagnosis. I'm thinking of the last few years, where suddenly there are tranches of survivors and long-term survivors with formerly incurable diseases. They need to be protected from this one-size-fits-all judgment.
JM: Absolutely, and as a pediatric oncologist, I run into that every day. People assume that children who are diagnosed with cancer are dying left and right, and people are generally quite surprised to hear that we have an 85% survival rate in children with cancer. A setting of scarce resources would certainly be a concern in that population as well, because even a child with cancer, in many cases, would be expected to have a very good chance of survival.
CH: It's interesting you bring that up, because I will say in a distantly related aside, one of the more interesting and repetitively surprising conversations many of us have is the one that involves pediatric oncology with friends and neighbors who aren't that familiar. They're always surprised at the high success rate in that field. It just makes the point that we can't let a diagnosis stand as the only interpretable fact.
So, these recommendations establish an important principle: A cancer diagnosis alone should not keep a patient from accessing potentially life-saving resources, even during a public health crisis.
Let's go a step further. One of the other recommendations is that decisions regarding allocation of scarce resources should be separated from bedside decision-making. I struggled with this one as a reader—could you explain what the intent or thinking behind this recommendation would be?
JM: Ultimately, that piece comes down to the fact that we as humans and decision-makers are imperfect, and it would be unreasonable and probably impossible to expect that any one of us, as a clinician or just as a person, could weigh all of these different things simultaneously.
There is a huge conflict of interest in saying that I am the clinician taking care of this patient in front of me, and simultaneously my job is to steward the resources for my institution or, even more broadly, the resources for what I might consider to be my patient population. The message we are trying to send with that piece is that not only should it not be the oncologist who's making that resource allocation decision, but it's actually not the emergency room clinician who should be either, because it's completely unreasonable to expect someone at the bedside to be making an unbiased decision.
CH: I hope that readers find this discussion intriguing and take a more in-depth look at the actual publication.
There are other resources from ASCO that you should be aware of, including patient care guidance for oncologists who treat patients with cancer during the COVID-19 pandemic. There is guidance available for practices on how to adjust our policies in response to the virus and on how to begin to return to more normal styles of work. There are also updates on federal activities that have been aimed at responding to this crisis—everybody knows that this has been a very fast-paced time of change. All of these resources are available on ASCO’s Coronavirus Resources page.