As the Covid-19 epidemic began to put an unprecedented strain on the U.S. health care system, the Centers for Medicare and Medicaid Services along with many state agencies issued directives that non-essential care be discontinued. The goal was to redeploy resources that were being used for them to fight the spreading coronavirus.
While these efforts were done hastily, and not necessarily according to any generalizable framework, they largely succeeded in halting care that did not absolutely need to occur in a timely fashion.
The vague nature of the effort to curb non-essential care spurred an outcry from special interest groups desperate to have their needs deemed essential, regardless of the impact on the overall system. Lobbyists were called, public emotional appeals were made, and some restrictions have been relaxed, even as coronavirus infections accelerate.
Infertility treatments have become an example of one such turnabout in New York state.
In early April, the New York Department of Health issued guidance expanding the definition of essential care to explicitly include fertility services and infertility treatments. These expensive, resource-intensive medical therapies, which include egg harvesting and in vitro fertilization, maximize a patient’s chances of conceiving a biological child. They are also major sources of revenue for specialists, clinics, and hospital systems. It is not entirely clear, however, that they should be considered essential in this dangerous moment for the American health care system.
To determine whether care such as infertility treatments should resume in the age of Covid-19, it is necessary to dispense with terms such as necessary and essential and instead focus on the purpose of limiting care, which is fundamentally about diverting as many resources as possible to fight Covid-19. This can be condensed into two questions.
The first question is: What must we do? Our health care system has a responsibility to protect patients from catastrophic consequences of health issues whenever possible by employing lifesaving surgeries, chemotherapy, and the like. These are the types of care that must be administered even if they take resources away from Covid-19 patients.
The second question is: What other types of care can we begin to provide? In other words, what non-emergent or non-life-sustaining medical care can be gradually restored without drawing significant resources away from the Covid-19 effort?
These two basic questions combine into a simple but potentially useful two-part framework that government agencies can use to consider what care should be brought back. The framework does not try to answer the question of which particular medical services should be reinstated, but instead provides a structured and ethical way to think about which sorts of services should be considered essential and which ones might be restored even if they aren’t deemed essential.
Here’s the first question that must be addressed using this framework: Does delaying treatment worsen a life-threatening or debilitating prognosis? If yes, the treatment is likely essential. This covers a substantial segment of health care — emergency care, aggressive cancer treatments, dialysis, and organ transplants are all examples if services that would qualify. In contrast, cosmetic procedures and many elective procedures such as cataract surgery and gastric bypass surgery would not satisfy this criterion.
Infertility treatments do not meet the prognosis threshold. While delaying them can certainly cause significant emotional distress to couples forced to delay their plans to start a family, waiting does not worsen any life-threatening or debilitating prognosis. Many couples seeking infertility treatments are perfectly healthy, and temporarily withholding fertility services will not change that. It is possible that a small number of women or couples will lose the window of fertility if treatments are delayed, but exceptions could be made for these uncommon instances.
Infertility treatments have an additional complicating aspect: Providing them may actually worsen health outcomes. Little information exists about the risks Covid-19 poses to a pregnant woman or her fetus. Some evidence suggests that Covid-19 may lead to an increased risk of preterm delivery, and a few reports suggest that a pregnant woman can pass the coronavirus to her fetus, but no studies have been done yet regarding birth defects or maternal health issues. So not only does postponing fertility treatment not worsen a serious prognosis, but providing successful fertility treatments may expose patients or their unborn children to increased risk.
Meeting the requirement that postponement of care not worsen a life-threatening or debilitating prognosis does not necessarily rule out all elective procedures. Certain cancer surgeries, for example, are deemed elective because they don’t need to happen right away. Yet the longer they are postponed, the larger a tumor can grow, damaging structures around it, and the higher the chance of life-threatening metastasis. Procedures like these, then, should be considered essential as — unlike with infertility treatments — delay is costly from a health perspective.
If delaying treatment does not worsen a life-threatening or debilitating prognosis, then it’s time to consider the second part of the framework: Does providing this care take away substantial resources that are necessary for the efforts against Covid-19? These resources include physician time; personal protective equipment such as masks, gloves, and drapes; hospital beds; operating rooms; and the like. If the answer is “no,” then such providing care can likely be resumed.
Infertility treatments also fail this test. The majority of services provided by fertility specialists require multiple appointments and procedures. For the duration of the Covid-19 pandemic, all in-person appointments require personal protective equipment for patients, providers, and staff. Everyone needs to wear a mask, as is now recommended by the Centers for Disease Control and Prevention, and providers need gloves and other sterile equipment to perform examinations.
Procedures such as IVF require even more resources, including sterile drapes, face shields, and bouffant caps — the same type of protective equipment hospitals are begging for in their fight against the novel coronavirus. Providers in regions experiencing surges of Covid-19 are being asked to reuse masks, shields, and gloves that were designed to be single use because there simply are not enough to go around. A dearth in adequate protective equipment puts patients and providers at risk — and many health care providers have already lost their lives due to insufficient protection.
When the benefits of using those resources for infertility treatments are weighed against their use to protect patient and physician lives in the context of a global pandemic, for the time being fertility treatments simply do not meet the threshold of warranted resource utilization.
The framework we present is not meant to definitively indicate which health care services should be resumed during the Covid-19 pandemic and which should remain temporarily suspended. Instead, it provides a set of guiding principles for prioritizing the types of care that should be brought back that are more logical and less political than allowing special interests with largely affluent constituents to lobby for their specific needs potentially at the expense of patients’ and providers’ lives.
At the moment, the landscape in the United States for health care resources is a zero-sum game. Any protective equipment that is used for elective or unnecessary care could be used more appropriately in Covid-19 wards or intensive care units.
As the pandemic loses steam, the restoration of services ought to be guided by the redeployment of resources that put the least strain on the health care system while making the biggest difference to those at most risk of death or serious disability.
Infertility treatments do not yet meet this threshold. But as the pandemic runs its course, the framework we propose can be used to periodically reassess which services should be reinstated as the resource landscape changes.
No provider or government agency wants to ration care, but if it must be done, it should be in a thoughtful, consistent, objective way, to help ensure that as many patients as possible receive the care they absolutely need.
Shailin A. Thomas is a student in a joint M.D./J.D. program between New York University Grossman School of Medicine and Harvard Law School. Arthur L. Caplan is professor of bioethics and the founding head of New York University School of Medicine’s Division of Medical Ethics.