Since the outbreak of COVID-19 in China, and the subsequent global pandemic, there has been an unprecedented response from the global healthcare community in an attempt to curtail both the spread of the infection and the associated morbidity and mortality.(1)
The information age in which we live has also played a significant role in the pandemic. When our forefathers encountered the 1918–1920 influenza pandemic, responsible for killing nearly 75 million people worldwide, there was no Internet. Expert opinion was confined to textbooks in university libraries and the media as a force to influence behaviour and the sharing of ideas and information was relatively non-existent (relative to today's terms).(2)
The niched world of transplantation has not been immune to the above influences and changes. For numerous reasons such as suspension by authorities at a local and national level of transplant centres’ activities, loss of availability of donor organs and patients not accessing care has led to a serious curtailment of transplant activity.(3,4)
It is important to note is that in many parts of the world, and certainly in South Africa, this curtailment occurred during a period when admissions associated with the COVID-19 pandemic were either non-existent or at a minimal level.
Rather than make an argument for or against a particular approach to the management of transplantation during the pandemic, we would like to highlight a number of areas which require debate and consideration before statements and recommendations by health authorities in South Africa are applied, without requisite attention given to the possible consequences.
AVAILABILITY OF RESOURCES
Many transplant centres closed or significantly curtailed work during a time period when there was no shortage of bed and hospital resources. For transplant patients in need of care, this is clearly an inadvertent act of harm. It was noted in the United Kingdom and other countries that admissions for non-COVID-19-related illnesses decreased dramatically, resulting in an increase in the mortality rate for these conditions.(5) The so-called ‘out-of-site-out-of-mind’ phenomenon is not so easily apparent in transplantation when there exists data such as wait-list mortality numbers which bring home this point all too clearly.
We suggest that there has been an insufficient effort into the task of planning and consultation on how to downscale services when the pandemic escalates and how to partition the resources appropriately, to ensure that patients for whom we as transplant teams are responsible, are adequately cared for.
ALLOCATION OF THE RESOURCE
Resource allocation presents an ethical dilemma daily for clinicians all over the world, especially true for clinicians in resource-limited environments. Access to limited resources is a topic of on-going ethical debate and depends on many factors such as utility, futility, resource availability, cost constraints, cultural and religious considerations. These ethical and resource dilemmas are compounded at a time of crisis such as the COVID-19 pandemic.(6) It is accepted that there is a subtle, albeit critical alteration in the ethical precepts governing allocation of resources during a pandemic, when the greatest good for the greatest number of patients principle trumps the maximal benefit of the individual patient in this scenario.(7)
In a country like South Africa, where facilities for transplantation are rare, where capacity to manage the transplant patient population exists in both the private and state sectors, questions have been raised whether enough has been done to ensure adequate on-going access to these patients.(8) We recommend that these objectives could be achieved through better private/public collaboration and transfer of patients out of regions that are unable to service the transplant burden adequately. Would it also not be rational and ethically appropriate to access other types of transplant care when the resource such as deceased donors becomes scarce? In this case, we refer specifically to institutions with the capacity to perform living donor transplantation.(9) Given the relatively small transplant community of healthcare providers across the country, this is a plausible alternative.
The vast majority of transplant recipients are younger and have better co-morbidity profiles than their COVID-19 counterparts who require intensive care. These young recipients if treated appropriately have excellent long-term outcomes and thus is it rational to allocate a resource, such as an intensive care unit bed or ventilator, to the COVID-19 positive patient? Put another way, is it ethical to deny the transplant patient access to care when the transplant patient care has been shown to have a higher likelihood of long-term success and without which he/she will most certainly die versus allocating that resource to a patient who derives little benefit of the care being provided (positive pressure ventilation in a COVID-19 positive patient) and in whom the likelihood of long-term survival is poor?(10)
Can this allocation of resources be deemed acceptable when the case fatality rate of all patients with COVID-19 in South Africa is currently 2.3% and the wait-list mortality of patients in South Africa for liver transplants in the largest programme is at 10–15% for adults and 15–20% for children?(4)
One cannot justify the allocation of critical care beds to ventilated COVID-19 patients where mortality rates are as high as 65%, when the one-year mortality rate after liver transplantation is between 10% and 15%.(10)
TRANSPLANTATION AND COVID-19
There remains a paucity of data with regards to the transplantation of organs from COVID-19 positive patients, outcomes of patients who subsequently develop COVID-19 after solid organ transplantation and the likelihood of COVID-19 infection in transplant recipients during the pandemic. Whilst one can assume, like with all viral pathogens, that the acquisition of disease in transplant recipients, especially in the perioperative and early post-transplant period would have morbidity and possibly mortality considerations, there is no evidence to suggest we should manage the scenario any differently to other communal viral outbreaks.(11)
This would entail appropriate screening of both the donor and recipient, followed by polymerase chain reaction-based testing of both, the application of an augmented consenting process for recipients during a pandemic and the early post-operative isolation of recipients. There is scant data to suggest that this approach, applied in many parts of the world and in our center in Johannesburg, has resulted in increased mortality of transplant recipients. Interestingly, there is a significant body of literature that shows that the inadvertent transplantation of organs from donors with viral pathogens such as influenza has no impact on recipient or graft survival. There is no data that infection with COVID-19 is different, but more data is clearly needed.
THE ISSUE OF OMISSION
Entrenched in the depths of medical ethics are the concepts of the commission of an act and omission. The tendency towards inaction, related to the ethical standpoint of non-maleficence is the basis for the common omission bias which occurs in healthcare. This bias, which interestingly occurs more commonly than commission bias, allows for events that are perceived as the ‘natural course of disease’ to be more acceptable than acts attributable directly to the healthcare practitioner.(7,12)
An act of omission makes it easier to not to treat transplant patients during a pandemic, especially if there is perceived or actual lack of availability of resources, interference from outside forces such as the government leading to transplant programme directors giving into political expediency or where there is so much hype created around the pandemic that non-COVID-19 patients’ needs are drowned out and that the system omits to care for these patients regardless of the ethical validity of that decision.
We are therefore calling for a more balanced approach to the need for the curtailment of transplantation in South Africa. The capacity for transplantation is so small and the relative need so great that decisions made for any other reason(s) than that which is in the best interests of transplant patients, is in our mind, in service of the virus over the patient.