Ethical Considerations for the Delivery of Obstetric and Gynecologic Care During a Pandemic

Ethical Duty to Patients in a Pandemic

During pandemics, it is ethically appropriate for the balance of clinical care to shift from routine clinical ethics that prioritize clinical outcomes for individual patients to a community-oriented ethical framework that prioritizes the general population's health.

Obstetrician–gynecologists (ob-gyns) are essential to providing high-quality health care. In general, the duty to provide high-quality care remains unchanged during pandemics. During the human immunodeficiency virus (HIV) epidemic, physicians refused to treat patients with HIV or acquired immunodeficiency syndrome (AIDS) due to social stigma surrounding presumed mode of transmission, incorrect medical information surrounding HIV, and fear given incomplete scientific understanding of the virus or its sequelae 2 3. Physicians have a duty to provide care in a manner that is nondiscriminatory, during both routine care and pandemics.

There is often a paucity of clinical data regarding novel infectious pathogens and their management, especially among women and gender-expansive people, and particularly during pregnancy and lactation. Data may be lacking regarding an infectious agent's transmissibility, its potential for teratogenicity, the severity of morbidity associated with infection, or even the risk of mortality among those affected. Among pregnant and lactating people, data surrounding therapies or vaccines may be unavailable or delayed for these populations because they are often excluded from trials 4 5 6. Further considerations regarding the inclusion of pregnant and lactating individuals in research efforts are detailed in Committee Opinion 546, “Ethical Considerations for Including Women as Research Participants.”

Obstetrician–gynecologists should counsel their patients, including pregnant and lactating patients, about the safety and efficacy of preventive and therapeutic measures against the pandemic disease as they become available. Consistent with the ethics guiding routine patient–physician communication, these measures should be discussed in an evidence-based and patient-centered manner through shared decision making so that patients are able to make an informed decision about their use 7.

As novel vaccines or other therapies are developed, ob-gyns should recommend these in accordance with Centers for Disease Control and Prevention and ACOG guidelines. Additional guidance regarding ethical issues surrounding vaccination is available in the Committee Opinion, 829 Opinion “Ethical Issues With Vaccination in Obstetrics and Gynecology.”

Resource Allocation

  Obstetrician–gynecologists should be involved in developing and implementing institutional guidelines for clinical care during a pandemic.

In deciding whether to proceed with an in-person clinical encounter (including surgery, medical procedure, or clinic visit) during a highly transmissible infectious disease pandemic, several factors should be considered, including: 1) the direct effect on patient health of proceeding with in-person care; 2) potential sequelae as a result of postponement of in-person care or proceeding with telehealth care; 3) risk of infectious disease exposure for the patient, other patients, and the health care staff; 4) implications for the use of scarce resources; and 5) the availability of alternative management strategies. Health care prioritization protocols should be developed at the institutional level to maximize consistency in implementation, avoid exacerbating disparities, and alleviate the potential moral distress experienced by individual clinicians when attempting to triage scarce resources at the bedside. Collaborations among institutions and interstate or national agencies may lead to more equitable application and consistency of protocols. Despite having protocols in place, the proper management of some patients may not be clear. In such cases, it may be helpful to seek consultation among colleagues in obstetrics and gynecology and other relevant medical specialties, as well as to seek the assistance of local ethics committees.

Physicians should advocate that time-sensitive reproductive health care procedures (such as abortion, sterilization, contraceptive care, and fertility treatments) remain available, valued, and prioritized in a just manner while clinical institutions make choices to allocate resources 8 9 10.

As health care guidelines related to pandemics are created, ob-gyns have a responsibility to advocate for obstetric and gynecologic health priorities. For example, during the COVID-19 pandemic, early bans on nonemergent procedures did not consider the adverse outcomes from postponing obstetric and gynecologic procedures 11. These adverse outcomes include but are not limited to inability to prevent pregnancy by lack of contraception access, continuation of an undesired pregnancy or increasing surgical risk by advancing gestational age through lack of abortion access, and inability to become pregnant and decreasing efficacy of treatment given age-related changes to fertility by lack of infertility treatment access 8.

Many clinical practice decisions made to reduce the spread of the infectious agent will have ramifications on patient satisfaction, the patient–physician relationship, and equity in health outcomes. Examples include limitations on visitors in the health care setting and delay of nonacute surgical care. Unique to obstetrics care, proposed measures to mitigate the spread of infection may suggest separating newborns from parents who test positive for the infectious agent or limiting the presence of support persons (including doulas) during delivery 12. Separation of parents and neonates for infection-control purposes causes substantial distress; ob-gyns should ensure that adequate evidence or theoretical scientific basis exists to support such a practice before it is implemented 13. Societal pandemic measures such as quarantine or social distancing may also have ramifications for patients, such as adverse effects on mental health, exacerbation of gendered differences in childcare burdens, and increased rates of intimate partner violence 14.

Pandemic-related changes to institutional policies should be explained to patients as serving several important purposes: to maximize physicians' ability to care for those who need help and to minimize patients' and physicians' exposure risks. Additionally, physicians should advise patients that usual care will resume as soon as it is safe and feasible to do so. It also may be helpful to involve community members in the development of policy, to clearly explain the rationale used in the decision-making process, and to discuss the availability of clinical ethics committees or other mechanisms for reviewing appeals or adjudicating exceptions to policies or both.

For pandemic-related health care allocation protocols to achieve their goals, exceptions to their implementation must be rare. Acceptance of the ethical and clinical impetus behind community-focused decision making can help alleviate some of the moral distress experienced by physicians during a pandemic and promote physicians' adherence to clinical care triage and resource-allocation policies. Health care institutions should support physicians as they implement appropriate triage and resource-allocation guidelines in a pandemic setting. Physicians who struggle with the implications of individual treatment decisions should be encouraged to consult colleagues and institutional resources for support.

Deferral of nonurgent clinical care may result in moral distress for ob-gyns concerned about the ramifications of triage policies on individual patients. Further, patients may feel abandoned by the shift in clinical focus toward prioritizing public health outcomes. It is important to convey to patients that protecting community health is imperative to protecting the individual and the public at large during a pandemic and offers the greatest chance of a faster return to routine clinical care. Communicating with patients is important to maintaining a therapeutic relationship, even if temporarily limited by constraints on clinical care. Telehealth encounters, which have become more common during the COVID-19 pandemic, may be useful for this purpose, though concerns remain regarding equitable access to the technology required for their use 15.

Screening for the Pandemic Agent

  Choices of patients with decision-making capacity should be honored, including the choice to decline infectious disease screening or diagnostic testing. Clinicians should address patients' concerns and advise patients of how their decision to decline testing may affect their clinical care. Clinical institutions should develop protocols to manage patients who decline testing, including potentially treating them as presumptively positive for infection.

When available, routine screening for the pandemic agent may be implemented in various health care settings, including before surgery or on admission to labor and delivery. Screening can assist in risk stratification of patients, planning patient care, guiding the use of isolation practices, and appropriately allocating personal protective equipment (PPE). When routine screening is planned, patients should be notified of institutional testing practices as soon as feasible, preferably in the outpatient setting. Pretest counseling and the informed consent process should explain the rationale for universal testing and how test results will guide management decisions. If reporting of pandemic cases to third parties is required (eg, to state health departments), this should be disclosed. Patients' hesitation about routine screening should be explored in a respectful and empathetic manner. Patients may consider declining screening tests for various reasons, including stigma, mistrust, and fear of real or perceived effects of a positive test result (such as possible separation of mothers and their neonates while in the hospital).

Policies for treating patients who decline testing vary among institutions, and the following considerations may help guide management decisions. In general, clinicians have an ethical obligation to proceed with emergent care regardless of a patient's infectious status 16. Patients with unknown infection status may be treated as presumptively positive, depending on physicians' clinical judgment and institutional policy. In accordance with institutional policies, it is ethically permissible to defer care that is not time-sensitive until a test result is obtained or until the population prevalence or anticipated morbidity of the pandemic pathogen decreases sufficiently. Consultation among colleagues in obstetrics and gynecology and other specialties and with institutional ethics committees may be helpful when making decisions regarding time-sensitive care.

Equity in Pandemic Care

Although resource-allocation strategies are often justified as maximizing a health care systems' ability to care for patients during a pandemic, implementing these policies may exacerbate inequities in care already experienced by otherwise underserved patient groups. Obstetrician–gynecologists should be mindful of the potential effect of resource-allocation strategies on disadvantaged patient populations and should work to minimize inequity in care delivery whenever possible 17 18. For example, during the COVID-19 pandemic, reductions in doulas, breastfeeding support, and visitors to labor and delivery were broadly implemented to reduce transmission 13 19. However, such policies may have compounded racial and ethnic disparities in perinatal health outcomes 20. Thus, ob-gyns should be aware of, and advocate for improvement in, inequities in health care highlighted during pandemics.

Institutions and practices should consider health equity in the development and application of protocols to allocate scarce clinical resources.

Protocols should be informed by relevant state and federal guidance and ideally should be developed with input from relevant and multi-disciplinary stakeholders (eg, clinicians, supply chain representatives, patient advocates, community relations teams, and bioethicists). Health care institutions and practices should be transparent with employees and the public about the principles used for resource allocation and the rationale underlying those principles 21.

In general, allocation decisions should maximize the benefit associated with using scarce resources without unfairly harming or benefiting any single group 22. For example, medical risk and prognosis may be used to allocate resources, but the ability of patients to reimburse the clinical institution may not. Specific allocation principles may vary by local setting, but health care institutions should still strongly consider sharing their experience, expertise, and triage policies with others. Rural centers with limited resources may use protocols developed at proximal tertiary care or urban centers and build networks for collaboration and transfer that may not have been needed before a pandemic.

Considerations Regarding Physicians in a Pandemic

  To avoid their contribution to the spread of disease, obstetrician–gynecologists without a recognized medical contraindication have an ethical obligation to be vaccinated against the causative agent of a pandemic, per current state and federal law and Centers for Disease Control and Prevention and ACOG guidelines.

Obstetrician–gynecologists are obligated to protect themselves and others by using appropriate protective measures, including PPE; undergoing testing or screening as recommended; and observing institutional, state, and federal guidelines for appropriate isolation of patients with suspected or confirmed disease. Physicians who meet criteria for isolation based on symptoms or exposure often may be required to remove themselves from in-person patient care expeditiously. Likewise, health care institutions and policymakers have an ethical obligation to protect the health and safety of ob-gyns and other health care professionals. Such protections include following their institutional protocols and state, federal, and public health guidance to the extent possible; ensuring adequate supplies of PPE; and discussing the reassignment of physicians who are at the highest risk of complications associated with illness (eg, those with immunosuppression or other comorbidities).

Physicians are not ethically obligated to provide care that places them at high risk of infection without adequate protections in place. Individual physicians, after careful consideration, may opt to provide care without these protections.

During pandemics, physicians should recognize that they are scarce, critical resources and must balance their responsibilities to individual patients against their responsibilities to act as good stewards of their capabilities to care for the greater population. Further, alongside a physician's duty to provide patient care, individual obligations to personal health, family, and community also should be considered when deciding whether to provide care. Thus, when shortages of PPE occur, or when PPE cannot mitigate an infectious agent, the risk posed to unprotected physicians by the pandemic agent may exceed a level that health care institutions and policymakers should require or expect of them.

Physicians may be in a challenging position, balancing their commitment to care for patients with suspected or confirmed disease alongside the probability that they may contract and further transmit the pandemic agent and be unable to treat other patients due to their infection while also experiencing the adverse effects of the disease itself. The individual assessment that a physician may undertake may be influenced by the severity of potential morbidity or mortality caused by the pathogen. As the personal risk that physicians are asked to assume escalates, the balance of competing duties and obligations becomes inherently personal. This is complicated by the uncertainty that arises when a novel pathogen is discovered, where risk may not be entirely ascertained.

Although it is permissible to offer economic incentives to clinicians caring for patients under high-risk circumstances (ie, “hazard pay”), it is unethical to penalize clinicians for declining to practice outside their scope of training. If decreased clinical volume occurs due to a pandemic, physicians also may be concerned about their practices' financial viability and, thus, their short-term and long-term ability to care for patients. Institutions should not exert social or economic pressure on physicians to assume unreasonable levels of risk. Furthermore, institutions should provide ongoing resources to support physician mental health and wellness to aid in coping with the ramifications of providing care during and after a pandemic 16 23 24.

Trainees in obstetrics and gynecology are especially vulnerable to pressure to provide patient care absent adequate protections 25. Additionally, the need to ensure ongoing and appropriate education continues during a pandemic; this can be challenging when minimizing the number of people in contact with a patient with infection is important to reduce transmission. Institutions should address trainee protections and responsibilities as part of their pandemic response. Consideration of medical trainees as integral members of the health care team should be balanced against the relatively vulnerable position of trainees within the medical hierarchy. It is also important to be mindful of any unfair risk allocation toward trainees and away from supervising physicians.