par John R. Fischer
, Senior Reporter | September 16, 2020
From choosing which procedures to delay to rationing PPE and other resources, the COVID-19 pandemic has forced clinicians and administrators to reevaluate, long-term, how they will deliver care to cancer patients.
Researchers at the University of California, San Francisco are looking to low- and middle-income countries like Rwanda and Tanzania for insight on how to balance limited resources against patients in urgent need of care.
“Although the need to triage cancer care may be new to those who underwent training and now practice oncology in high-resource settings, it is familiar for those who practice in low- and middle-income countries,” wrote the authors. “Oncologists in the United States facing unprecedented decisions about prioritization can draw on ethical frameworks and lessons learned from real-world cancer care priority settings in resource-constrained environments.”
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Here are a few of those lessons:
A utilitarian approach
Overall survival is the universally accepted standard measure of clinical benefit in oncology, and in areas with limited resources, a utilitarian approach maximizes survival benefit and should guide decision-making, according to the authors. This means prioritizing curative over palliative treatment, long-term over short-term disease control, and higher magnitudes of benefit. Decisions should be based on objective estimates such as an intervention’s cure rates or disease-free survival, as well as factors such as a patient’s age, performance status and comorbidities. Tools such as work developing prioritization guidelines for limited radiotherapy resources have helped Rwanda make decisions based on estimated incremental curative benefit by cancer type and stage.
Settling conflicting principles
Different stakeholders have different principles that can clash. Motivations include moral and ethical obligations to patients, respect for human dignity, and a legal duty to act in the patients’ best interests. In Rwanda, oncology clinicians recognize that it is difficult to not be able to send a patient for palliative radiotherapy but still prioritize those who have a chance of being cured over those that do not. They also agree that life expectancy and potential life-years gained by curing disease should be accounted for in the allocation of limited radiotherapy resources. One way to make decisions based on morally relevant considerations is through a multi-principle allocation system such as priority scores for ventilator allocation.