P071 COVID-19 Ethics and Gastroenterology

BACKGROUND: Ethical principles in the field of medicine have become increasingly relevant during the COVID-19 pandemic, during which practitioners are required to provide care in resource-limited settings. Numerous and unique ethical challenges arise in the practice of gastroenterology, due to the field's identity as both a clinical and procedural specialty. It is imperative for gastroenterologists to consider these dilemmas and a case-based primer is useful in initiating discourse. METHODS: Comprehensive literature review was performed through databases including MEDLINE, EMBASE, and Web of Science Core Collection. RESULTS: Case-Based Reasoning: Futility versus Intervention: A 34-year-old with alpha-1 antitrypsin disease, on the transplant list presents with pneumonia and hepatic necrosis secondary to COVID-19 and is now in fulminant hepatic failure. Should this patient still be on the transplant list? The dilemma between futility versus intervention arises in cases in which treatment will provide questionable benefit. Studies have shown that decisions on futility versus intervention are influenced heavily by degree of the patient-provider relationship. In addition to prospects of recovery, key considerations include weighing the post-procedural recovery process and the potential use of the resource for other patients. RESPONSIBILITY TO PRACTICE: A 54-year-old gastroenterologist is immunocompromised. There is a shortage of internists, and he has been recruited to the front lines. In the face of the COVID-19 pandemic, gastroenterologists have been recruited to the front lines, assuming roles as general hospitalists. This dilemma requires weighing the moral duty of practicing versus opting out of putting oneself at harm’s way. The AMA’s 2018 Statement on Medical Ethics stated that providers should have liberty in their decision to practice with exception of emergency situations. The provider should balance their personal risk and professional duty. Resource Distribution: In the liver unit, there are three patients suspected to have profound variceal bleeds and only one gastroenterologist is covering due to provider shortage. Which patient should be prioritized? Resource distribution is not a situation unique to COVID-19, however practitioner shortage has become a more common dilemma. Not being able to treat in the face of an emergency can be cause for provider burnout, and it is important to address as to prevent moral distress. Initiation of Therapy: A 22-year-old nurse, has been suggested to initiate immunosuppressive treatment for Crohn’s disease. It is the onset of the pandemic. The patient is asking if she should still undergo the therapy. Prior to offering recommendations, physicians have the ethical duty to (1) seek unbiased sources of information, (2) consult with experts, and (3) keep updated on clinical guidelines which may arise in the future. The physician should also maximize autonomy, emphasizing the patient’s role in decision-making. CONCLUSION: Major ethical considerations for the field of gastroenterology in the face of the COVID-19 pandemic include (1) futility versus intervention, (2) responsibility to practice, (3) resource distribution and (4) initiation of therapy. A case-based discussion is useful in initiating conversation regarding how best to proceed.