Bio-ethical issues in oncology during the first wave of the COVID-19 epidemic: A qualitative study in a French hospital.

BACKGROUND: Using a specific bioethical theory (=global bioethics) and method (=a posteriori), we try here to identify and evaluate the bio-ethical issues raised by the COVID-19 pandemic, and possible solutions, to improve the management of cancer patients at the hospital in future pandemics, before the emergence of vaccines or scientifically validated treatments. MATERIALS & METHODS: Our work is based primarily on the clinical experience of three oncologists from the oncology department of Foch Hospital in France, who were on the frontline during the first wave of the epidemic. We compared their perceptions with published findings, to complete or nuance their views. RESULTS: Three bio-ethical issues were identified, and possible solutions to these problems were evaluated: (1) scientific evidence versus lack of time → the creation of emergency multidisciplinary team meetings (MTM); (2) healthcare equality versus lack of resources → the development of telemedicine; (3) individual liberties versus risk of contamination → role of cancer patients' associations, psychologists and bioethicists. CONCLUSION: We consider the creation of an emergency MTM, in particular, in addition to a true ethics committee with real competence in bioethics, to be a first solution that would be easy to implement in hospitals in many countries.

From a voluntary vaccination policy to mandatory vaccination against COVID-19 in cancer patients: an empirical and interdisciplinary study in bioethics.

BACKGROUND: At the start of 2021, oncologists lacked the necessary scientific knowledge to adapt their clinical practices optimally when faced with cancer patients refusing or reluctant to be vaccinated against COVID-19, despite the marked vulnerability of these patients to severe, and even fatal forms of this new viral infectious disease. Oncologists at Foch Hospital were confronted with this phenomenon, which was observed worldwide, in both the general population and the population of cancer patients. METHODS: Between April and November 2021, the Ethics and Oncology Departments of Foch Hospital decided to investigate this subject, through an empirical and interdisciplinary study in bioethics. Our scientific objective was to try to identify and resolve the principal bio-ethical issues, with a view to improving clinical practices in oncology during future major pandemics of this kind, from a highly specific bio-ethical standpoint (= quality of life/survival). We used a mainly qualitative methodological approach based on questionnaires and interviews. RESULTS: In April 2021, 29 cancer patients refused or were reluctant to be vaccinated (5.6%; 29/522). Seventeen of these patients said that making vaccination mandatory would have helped them to accept vaccination. In October 2021, only 10 cancer patients continued to maintain their refusal (1.9%; 10/522). One of the main reasons for the decrease in refusals was probably the introduction of the "pass sanitaire" (health pass) in July 2021, which rendered vaccination indispensable for many activities. However, even this was not sufficient to convince these 10 cancer patients. CONCLUSION: We identified a key bio-ethical issue, which we then tried to resolve: vaccination policy. We characterized a major tension between "the recommendation of anti-COVID-19 vaccination" (a new clinical practice) and "free will" (a moral value), and the duty to "protect each other" (a moral standard). Mandatory vaccination, at least in France, could resolve this tension, with positive effects on quality of life (i.e. happiness), or survival, in cancer patients initially refusing or reluctant to be vaccinated, but only if collective and individual scales are clearly distinguished.

Cancer and COVID-19: ethical issues concerning the use of telemedicine during the pandemic.

The lockdown imposed in France during the first wave of the COVID-19 pandemic wreaked havoc with access to healthcare. From March 2020 onwards, the oncologists of Foch Hospital, like many others at hospitals throughout the world, were obliged to adapt to the new conditions, including, in particular, the impossibility of seeing patients in classic consultations for the diagnosis and treatment of cancer. Patients with cancer are particularly susceptible to this new virus, due to their immune status, and this made it difficult to carry out standard hospital visits for these patients. Some patients refused to come to the hospital, whereas the doctors decided, for others, that consultation conditions at the hospital were not sufficiently safe, with sanitary measures that had yet to be precisely defined. Telemedicine was one of the adaptations adopted during this period. This mode of consultation was little used before the pandemic, for various reasons, and reimbursement was not automatic. This new approach proved to have limitations as well as advantages, as demonstrated by our empirical ethics research study, a retrospective qualitative survey of the doctors of the oncology and supportive care departments of Foch Hospital, performed during July 2021. The interview grid was based on the studies on telemedicine, oncology, COVID-19 and empirical ethics available at the time. Based on the experience gained in this domain during the first wave of the epidemic, which hit France between March and June 2020, we identified three eligibility criteria for consultations in telemedicine: the consultation concerned should not be the first consultation, the patient should be a known patient that the doctor trusts not to minimize the description of symptoms, and the results of the patient's evaluations and examinations must be good. It may be appropriate to continue the use of teleconsultation in the future, provided that these criteria are respected.

Impact de la pandémie de la COVID-19 sur l’Hôpital : l’apport de la bioéthique Impact of the COVID-19 pandemic on the Hospital: the contribution of bioethics

La COVID-19 a durement touché l’Hôpital en France, et dans beaucoup d’autres pays. Dans ce contexte, la bioéthique peut l’aider à apprendre de cette pandémie, afin d’améliorer la gestion des soins de santé et de la recherche biomédicale lors d’une prochaine, ou au quotidien, dans la perspective de continuer à améliorer la qualité de vie et/ou la survie des patients pris en charge. C’est du moins la mission que s’est donnée le Département d’éthique et intégrité scientifique de l’hôpital Foch. Différentes études sont en cours de réalisation, ou devraient prochainement débuter. Il est désormais impératif de développer une véritable activité de recherche en bioéthique à l’Hôpital en France, ainsi que partout dans le monde.

Impact de la pandémie de la COVID-19 sur l’Hôpital : l’apport de la bioéthique

Résumé La COVID-19 a durement touché l’Hôpital en France, et dans beaucoup d’autres pays. Dans ce contexte, la bioéthique peut l’aider à apprendre de cette pandémie, afin d’améliorer la gestion des soins de santé et de la recherche biomédicale lors d’une prochaine, ou au quotidien, dans la perspective de continuer à améliorer la qualité de vie et/ou la survie des patients pris en charge. C’est du moins la mission que s’est donnée le Département d’éthique et intégrité scientifique de l’hôpital Foch. Différentes études sont en cours de réalisation, ou devraient prochainement débuter. Il est désormais impératif de développer une véritable activité de recherche en bioéthique à l’Hôpital en France, ainsi que partout dans le monde. Summary COVID-19 has hit the hospital hard in France, and in many other countries. In this context, bioethics can help hospitals learn from this pandemic, in order to improve the management of health care and biomedical research in the future, or on a daily basis, in order to continue to improve the quality of life and/or survival of the patients under care. This is at least the mission of the Department of Ethics and Scientific Integrity of the Foch Hospital. Various studies are currently underway, or should begin shortly. It is now imperative to develop a real research activity in bioethics at the Hospital in France, as well as everywhere in the world.