Ethical Issues in the COVID Era: Doing the Right Thing Depends on Location, Resources, and Disease Burden.

The transplant community is well-versed in ethical issues surrounding the allocation of scarce resources, but the COVID-19 pandemic has escalated moral dilemmas of transplantation far beyond simply allocation of limited donor organs. Emanuel et al1 were unfortunately prophetic in their recent NEJM article addressing the ethical principles guiding medical decisions during the COVID-19 pandemic and the associated depletion of resources. Hospital and intensive care resources are becoming severely limited in high-transmission areas, influencing decisions about who should be transplanted and affecting the availability of donated organs.2 The risk of COVID-19 transmission to donors and recipients further alters such risk considerations. Pre–COVID-19 organ allocation schemes, which are complex, transparent, and organ-specific, are by themselves insufficient to determine who should be transplanted under such conditions, particularly in resource-constrained areas. Complex ethical considerations for transplantation during such a pandemic will inherently vary greatly by country, region, and culture—and be dynamic over time, and affected by both COVID-19 disease burden and trajectory. But the broad principles of nonmaleficence, beneficence, distributive justice, and respect for autonomy must continue to guide these difficult decisions. Nonmaleficence, for example, may dictate that living donor operations be held in heavily affected areas because of the potential risk of COVID-19 infection in donors. Indeed the same concern applies to transplant recipients, whose immunosuppression may put them at increased risk of infection posttransplant. Conversely, beneficence might suggest that successful kidney transplantation could, in addition to its other benefits, prevent the need for further dialysis center visits, potentially reducing the risk of nosocomial COVID-19 transmission. From a distributive justice perspective, by contrast, programs may need to curtail certain transplant activity simply as a result of resource constraints imposed by an overwhelming pandemic disease burden. Finally, autonomy dictates that programs communicate both the known and unknown risks of COVID-19 infection—and the policies we are each enacting as a result—to their transplant patients allowing them to make informed decisions about their care. The urgent need to adapt rapidly during the COVID-19 pandemic has challenged traditional dependence on evidence-based data and peer-reviewed literature. Healthcare workers in transplantation are being asked to navigate our patients through a minefield in the absence of conventional pillars that usually guide clinical management and decisions. For treatment protocols, we traditionally rely on approaches that have undergone a thorough evaluation, testing, and review process. In the absence of such an opportunity for gradual and deliberate review, professional societies around the world have been quick to collaborate and share their global experiences,3 and the distribution of information has largely shifted to rapid, online platforms. In making decisions during this uncertain time, it is essential that our own uncertainty, lack of knowledge, and lack of prognostic ability about the pandemic disease course are recognized and factored into our risk-benefit analyses as well as our respect for the patient’s autonomy. The availability of resources for transplantation is a moving target in the COVID-19 pandemic, dependent on the position of each region and country on the COVID incidence curve, and its baseline access to healthcare resources (Figure ​(Figure1).1). While decisions must be based on available and expected resources, they must also be informed by underlying ethical values that have been and will continue to be the rationale for all our patient-care decisions. Open in a separate window FIGURE 1. Responses on allocation, donor/recipient criteria, and transplant activities will largely depend on the position of centers on the slope of the incidence curve. Geographic and social characteristics will also determine the height of the curve, impacting risk-benefit assessments.