A Better Way to Prioritize 'Essential' vs 'Elective' Care During COVID-19

Arthur L. Caplan, PhD; Shailin A. Thomas


April 15, 2020

Cosmetic procedures and many elective procedures would not satisfy this criterion. Tommy John surgery (ulnar collateral ligament reconstruction), which received some media attention because two Major League pitchers received the surgery at the end of March as other elective procedures were being canceled, would not qualify. While not receiving the surgery would delay the recipients' return to athletic activities, such ligament tears are often chronic, and the long-term prognosis doesn't worsen over the span of a few months.

Quality of Life vs Critical for Survival

Meeting this threshold requires that postponing care will not worsen a life-threatening or debilitating prognosis. This doesn't necessarily rule out all elective procedures. Certain oncologic surgeries, for example, are deemed elective because they don't need to happen on an emergency basis. However, the longer they're postponed, the larger the tumor will get, damaging structures around it, and the higher the chance of life-threatening metastasis.

There is a gray area: care that patients need to significantly improve their quality of life but that won't worsen their prognosis if they must wait for it. Orthopedic procedures are a good example. Joint replacements for patients who can't walk due to severe arthritis would greatly improve their quality of life. But even if those patients need to wait an extra 3-4 months to have an operation, their postprocedure prognosis remains good.

It's difficult to comprehend the pain felt by patients in the throes of…fertility treatments that have been put on hold, or patients awaiting gender-affirming surgeries.

This category is where restrictions on nonessential care will hurt the most. These patients are often suffering while they wait for the care they need. Some can't work until they receive treatment, leaving their financial future in jeopardy. For others, waiting for care takes an emotional toll. It's difficult to comprehend the pain felt by patients in the throes of difficult and expensive fertility treatments that have been put on hold, or patients awaiting gender-affirming surgeries that have been canceled.

But scarcity forces difficult decisions. If the overall prognosis remains unchanged with a temporary delay, then the personal protective equipment (PPE) and personnel would be better spent in COVID-19 wards.

If delaying treatment doesn't worsen a life-threatening or debilitating prognosis, then we consider part 2 of the framework: Does providing this care take away substantial resources that are necessary for the efforts against COVID-19? This includes physician time, PPE (masks, gloves, drapes), hospital beds, operating rooms, etc.

If no, then it can probably continue. Many of the interventions considered above would also fail this benchmark. Tommy John surgery requires substantial highly skilled physician and nurse time, lots of PPE, and valuable OR time. IVF would require significant PPE, as every patient and staff member requires such equipment for the frequent appointments. Each of these procedures also requires extensive lab support.

Preserving Resources, Preserving Patient Care

A good example of a healthcare service that would pass the resource-utilization part of the analysis—and so could be allowed to continue—is outpatient psychiatric care. Much of psychiatric care can be provided remotely. The main resource it requires is the psychiatrist's time. At the moment, most psychiatrists have not been drafted into intensive care settings, so continuing with telepsychiatry doesn't take resources away from COVID-19 patients.

Very early elective abortion, despite being deemed nonessential in some locales, passes as well, in that pharmaceutical abortion is not resource-intense.

The devil is in the details regarding restrictions based on resource utilization. Any in-person healthcare interaction for the foreseeable future will require masks at the very least—masks that could be sent to emergency departments and intensive care units to protect doctors and nurses.

But there are some instances of in-person, nonessential care that use so few resources that they might be permitted to continue. An example of this type of care is Botox injection for migraines. While this procedure requires the use of masks, gloves, and physician time, it takes only about 10 minutes and is performed just once every 3 months. Moreover, one of the most common presenting complaints in emergency departments is severe migraine headache. So, if providing this treatment keeps patients out of emergency departments, the overall resource utilization may be lowered by administering Botox in the outpatient setting.

The framework presented here doesn't definitively determine which healthcare services should continue during the COVID-19 pandemic and which should be temporarily suspended, nor does it permit politics to shape what is restricted or restored.

What it does do is discard unhelpful labels such as "essential" or "necessary" and provide a structure for how to think through care decisions in a way that promotes what healthcare institutions are trying to achieve through care rationing.

Restoring medical services ought to be guided by the redeployment of resources that put the least strain on the system while making the biggest difference to those at most risk for death or disability. As the pandemic runs its course, this framework can be used to assess which services should be reinstated as the resource landscape changes. No physician wants to ration care, but if it's done in a thoughtful, consistent, objective way, it can help ensure that as many patients as possible receive the care they absolutely need while still getting the care they might want.

Arthur L. Caplan, PhD, is director of the Division of Medical Ethics at New York University Langone Medical Center and School of Medicine. He is the author or editor of 35 books and 750 peer-reviewed articles as well as a frequent commentator in the media on bioethical issues.

Shailin A. Thomas is enrolled in a joint MD/JD program between New York University Grossman School of Medicine and Harvard Law School.

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