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The coronavirus disease 2019 (COVID-19) pandemic has forced oncology clinicians and administrators in the United States to set priorities for cancer care owing to resource constraints. As oncology practices adapt to a contracted health care system, expertise gained from partnerships in low-resource settings can be used for guidance. This article provides a primer on priority setting in oncology and ethical guidance based on lessons learned from experience with cancer care priority setting in low-resource settings.
Lessons learned from real-world experiences are myriad. First, in the setting of limited resources, a utilitarian approach to maximizing survival benefit should guide decision-making. Second, conflicting principles will often arise among stakeholders and decision makers. Third, fair decision-making procedures should be established to ensure moral legitimacy and accountability. Fourth, proactive safeguards must be implemented to protect vulnerable individuals, or disparities in cancer treatment and outcomes will only widen further. Fifth, communication with patients and families about priority setting decisions should be intentional and standardized. Sixth, moral distress among clinicians must be addressed to avoid burnout during a time when resilience is critical.
Conclusions and Relevance
Although the need to triage cancer care may be new to those who underwent training and now practice oncology in high-resource settings, it is familiar for those who practice in low- and middle-income countries. Oncologists in the United States facing unprecedented decisions about prioritization can draw on ethical frameworks and lessons learned from real-world cancer care priority setting in resource-constrained environments.
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Accepted for Publication: May 7, 2020.
Published Online: August 6, 2020. doi:10.1001/jamaoncol.2020.2976
Correction: This article was corrected on September 10, 2010, for a misspelled word in the title.
Corresponding Author: Rebecca J. DeBoer, MD, MA, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, 505 Parnassus Ave, M1286, San Francisco, CA 94143-1270 (firstname.lastname@example.org).
Author Contributions: Dr DeBoer had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: DeBoer, Shulman, Van Loon.
Acquisition, analysis, or interpretation of data: DeBoer, Fadelu.
Drafting of the manuscript: DeBoer, Van Loon.
Critical revision of the manuscript for important intellectual content: All authors.
Supervision: Shulman, Van Loon.
Conflict of Interest Disclosures: None reported.
Funding/Support: The research referenced in this article is supported by a “Making a Difference in Real-World Bioethics Dilemmas” grant from the Greenwall Foundation. Dr DeBoer was supported by the National Cancer Institute, the Fogarty International Center under Award D43TW009343, the Global Cancer Program at UCSF Helen Diller Family Comprehensive Cancer Center, and the University of California Global Health Institute (UCGHI).
Role of the Funder/Sponsor: The funding sources were not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding sources.
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