Should neurosurgeons continue to work in the absence of personal protective equipment during the COVID-19 era?

The coronavirus disease 2019 (COVID-19) crisis has resulted in a widespread shortage of adequate personal protective equipment (PPE). Many healthcare workers, including neurosurgeons, are not sure how to safely and adequately perform their medical responsibilities in these challenging circumstances. Some healthcare workers have even expressed concerns about going to work that stem from conflicts between their willingness to care for COVID-19 patients and the safety of themselves, their families, and non-COVID-19 patients [3, 5, 14, 13, 23, 25]. Indeed, COVID-19 incidence and mortality are considerably higher among healthcare professionals (HCPs) when compared with workers in other sectors, justifying these concerns [1, 6, 7, 29].

Although the first peak of the COVID-19 crisis may have passed in most developed countries and the issues around sufficient supply of PPE might have decreased, concerns about insufficient and inadequate PPE remain. Inconsistent supply, limited efficacy, and continued high demand for PPE exacerbate these concerns in light of the threat of a second COVID-19 wave due to loosening of social distancing restrictions. These hard questions will likely play a role in the short- to intermediate-term future and warrant an ethical evaluation of whether neurosurgeons should perform their professional duties with limited availability of PPE.

The decision about whether or not to go to work when facing shortages of PPE is a personal and moral assessment rather than a matter of legal and professional obligations. Contractual and non-contractual legal obligations have limited relevance in this context, and typically only apply when there is a safe neurosurgical work environment. Professional standards do not offer much guidance, even when they acknowledge that professionals might have to work in risky and even unsafe settings. The World Health Organization (WHO), for example, has explicitly acknowledged that “the duty to work notwithstanding risks to one’s health is not unlimited” [30]. The American Medical Association, the Canadian Medical Association, and some European societies have adopted similar positions [18]. Provisions from the early days of the previous century used to state that physicians should work “even at the jeopardy of their own lives”[8], but such firm obligations are no longer in place [27]. Medical professional guidelines refer to the autonomy of the physician and accede to other responsibilities and interests on the side of the professional even in times of a pandemic [4]. At risk of losing members or support, professional or other health organizations are also unlikely to install and enforce such duties upon their individual members at this point in time.

Consequently, the decision to work is a matter of personal appreciation that includes perceptions on risk and assessment of what risks are unreasonable, instead of a forceful imperative of a social contract between health care providers and the general public. Any duty to society, which is part of the social contract and which we will further describe below, seems to have become less definitive amidst the acknowledgment of other responsibilities of the professional. Clear-cut guidelines about the boundaries of the professional responsibilities are not available to the neurosurgical community, or physicians in general, when it comes to the unprecedented circumstances in the COVID-19 era and the potentially limited availability of adequate PPE.

Some have argued that the risks that come with care for COVID-19 patients are unacceptable when PPE is limited [26]. These unacceptable risks would allow physicians to decline work responsibilities as a result. Neurosurgical care for COVID-19 patients with limited PPE comes with a considerable personal risk of exposure when compared with non-medical professions. Neurosurgeons must get close to patients and perform invasive and potentially aerosol-generating procedures [19]. Yet, one could argue that neurosurgeons accept these risks when they take up a profession in health care and that they sign up for a moral duty to work even in times of elevated health risks. This interpretation supports providing care of COVID-19-positive patients when PPE is available. The severity of the COVID-19 pandemic does not discharge providers of this duty [28]. However, the absence of PPE increases the risk of contracting COVID-19 to a level that, arguably, falls outside the usual range of risk-exposure for neurosurgeons. Neurosurgeons might have never signed up to accept such a level of risk.

Hence, additional assessment is necessary to determine what risks are (un)reasonable. Risks could include medical, social, familial, or mental health risks for the neurosurgeon and their family members. Risks are the product of anticipated harms and their respective probabilities. The likelihood of contracting COVID as an HCP is estimated to range from 8 to 30% [10‐12, 24]. The estimated probability of mortality for HCPs is 0.001% [20]. These numbers are just averages, and the risk of death for an elderly overweight doctor could be much higher. The acceptability of the calculated risks will mostly depend on personal judgment. If the risks of adverse outcomes in particular situations are exceedingly high, it may be necessary to protect HCPs regardless of their choice to provide care. A provider who accepts a certainty of death in their line of professional duty, either for themselves or for their family members, would have to be stopped for lack of professional judgment. Yet, beyond such extreme scenarios, no single or simple tool can determine what risks are acceptable if the basic safety equipment is missing. We recognize at least three determinants of the acceptability of risk: factors related to the likelihood of contracting COVID-19, factors associated with the severity of adverse outcomes, and factors related to a duty to work.

The rapidly changing nature of the pandemic, the increased demands on healthcare systems, the varying availability of PPE, and the local variations in the density of infected patients complicate the estimation of the probability of contracting COVID-19. Uncertainty about acceptable viral loads further complicates this calculation. The effectiveness of PPE itself depends on its nature and its quality. For instance, there may be a shortage of N95 masks when suboptimal PPE (e.g., regular surgical masks) remains available. Suboptimal equipment may offer some protection and may be acceptable in some scenarios, but this level of protection will not provide enough safeguards in many cases. At the same time, PPE might not be entirely fitting for the individual providers, i.e., most equipment is based around male models and becomes uncomfortable when worn for extended periods [15].

A neurosurgeon’s probability of getting infected or suffering adverse outcomes is also determined by individual factors such as age, body mass index, or comorbidities. Moreover, neurosurgeons must consider the nature, duration, and frequency of neurosurgical procedures. Endoscopic endonasal surgery, for instance, will come with higher chances of exposure than procedures that do not generate aerosols or require ventilation [21]. The duration of potential exposure for neurosurgeons may further increase the risk of COVID-19 contraction, as many neurosurgical interventions entail lengthy assessments and operations.

Besides the actual factors determining the probability of getting infected, neurosurgeons must weigh the implications of either contracting COVID-19 or the discontinuation of care to decide what risks are reasonable and acceptable. The importance of these implications and the complexity of this calculation are determined by a series of potentially conflicting duties that are summarized in Table 1 and outlined below. These duties illustrate that providers have different roles and responsibilities. Neurosurgeons, consequently, might be confronted with conflicting ethical duties, such as a duty to oneself versus a duty to the community. Modern society, however, ultimately places the decisions about how to weigh these duties on individual providers. Traditional perceptions about the health care providers’ elevated duties to the community have been reduced, due to diminished professional privileges and status, so that the individual provider is freer to exercise their individual rights and choices. This overview of duties can help structure such individual decision-making.

The individual autonomy of a neurosurgeon is a central component in the decision-making progress about providing care to COVID-19 patients when PPE is limited. Still, it may not be ideal to leave considerations entirely up to individuals without any external support. Some neurosurgeons may be willing to accept higher risks of contracting COVID-19 compared with more risk-averse colleagues. This unequal spread of chances to contract COVID-19 may be further complicated if those exposed are also those with higher probabilities of adverse outcomes. Risks of contracting COVID-19 would seem to increase with repeated exposure [2]. Unequal sharing of risks may negatively impact long-term availability and continuation of neurosurgical care.

Therefore, parties involved in neurosurgical care need to elaborate on what constitutes the duty to work, which risks are acceptable, and how to solve the questions discussed in this article. This elaboration could happen on a local, national, and international level. Striking a balance and coming to ethically acceptable decisions depends strongly on the local access to PPE, local neurosurgical healthcare structure, and the current local severity of the COVID-19 pandemic. Neurosurgical societies could provide reports and guidelines to help institutions continue care in their local healthcare system ethically. All parties involved should also look outside of neurosurgery for innovative solutions but keep the uniqueness of neurosurgery in mind. Continuous elaboration may result in a broad consensus on what risks are acceptable. This consensus needs constant updating by all parties involved as the COVID-19 pandemic progresses. Consensus may empower the neurosurgical community to make ethical decisions and ensure continuity of quality health care. In the end, both neurosurgeons and patients will benefit from an optimal continuation of high-quality care in the long run.

The decision to work in the absence of PPE in the COVID-19 era is a personal one that involves weighting factors like the probability of contracting COVID, the urgency and nature of the neurosurgical procedure, as well as conflicting duties to family members, society, and the neurosurgeon as a person. No legal or professional guidelines adequately prescribe what the provider ought to do in the absence of PPE. Neurosurgeons, therefore, need to decide for themselves whether they deem the risks unreasonable and when to discontinue care for neurosurgical patients. Well-written guidelines can facilitate these decisions. Transparent data of individual risk and understanding of ethical principles are fundamental to make these well-informed and personal decisions. There is no duty to treat patients at the risk of one’s own life. Physicians may expect reciprocity when practicing their profession. Reflection and elaboration within the neurosurgical community will be essential to establish a spectrum of acceptable risks. A continued discussion may also result in a higher level of agreement about the reciprocity that neurosurgeons may expect. Such collaboration will hopefully ensure the continuation of high-quality neurosurgical care in the long run. At the same time, neurosurgeons must continue to balance duty to work and other duties in the absence of PPE.