Can we say that there is any fairness in the handling of surgical waiting lists in Spain? Why is there no fairness? What factors should we take into account to minimise this situation? Are there objective and universal criteria for prioritising these lists?
The development of health care systems and technological advances have failed to keep pace with the growing demand for health care. In the surgical field, supply is limited – health care systems with scarce funding and resources and demand is growing; an ageing population with more comorbidities, giving rise to an increase in surgical procedures and the need to establish surgery waiting lists (SWLs).1 The order of this list must be based on clinical priorities and ethical values.2 The problem is that criteria are often neither universal, public nor agreed upon. In this article, we will attempt to define the main criteria adopted in the prioritisation of surgical patients and the ethical values that should guide them.
From a medical perspective, the consensus is that patients should undergo surgery according to criteria of severity (the patient’s condition in relation to the disease and the expected progression whilst waiting); priority (the patient’s situation relative to other patients); and fairness (the patient in relation to society and the health care system).1,3 To determine severity, various objective tools have been tested, which are theoretically capable of classifying patients according to their condition and medical specialties. In these systems, priority is given to operating on patients who are in a serious condition or whose condition is expected to deteriorate rapidly, whilst patients without pain, dysfunction, disability or rapid deterioration in their condition, caused by the wait, are scheduled later.3,4 Other prioritisation criteria are applied on top of this objective identification, taking into account the patient’s personal circumstances, the efficiency of the system and other considerations. Thus, for example, non-emergency elective surgery may be scheduled at the end of a shift to fit the remaining operating theatre time and staff availability, despite being less necessary than other cases. The problem is that mild conditions may be prioritised over others that are genuinely serious. Another concern is the failure to give sufficient priority to surgery for a stable patient who has suffered unexpected clinical deterioration and requires emergency surgery; the complications arising from this delay were avoidable and sometimes difficult to explain to the public.5 Furthermore, some studies indicate that in practice there is no real prioritisation based on clinical symptoms or preventable disability in many types of elective surgery, so that that these criteria are not really useful and should be reviewed.6
With regard to prioritisation of patients with equal severity of illness, some econometric studies have found that there are significant inequalities based on socioeconomic status; one plausible explanation is that patients with greater purchasing power opt for the private sector if they anticipate a long wait in the public system.7 The use of new surgical techniques (such as the Da Vinci robot) may be another factor affecting equitable access to elective surgery. Whilst these advances may make certain procedures safer, their learning curve initially requires a reduction in the number of surgeries performed by the surgical team, as well as the prioritisation of patients according to their suitability for surgery using one device (or technique) rather than another. This technological advancement will undoubtedly impact the overall efficiency of the system. Significant differences between hospitals have also been documented for institutional or geographical reasons8 Unfortunately, Spain is no stranger to this type of inequality.9 Criteria of fairness are more difficult to apply. Four main strategies have been proposed for prioritising scarce health care resources: treating people equally; favouring the most disadvantaged; maximising total Benefit; and promoting and rewarding social usefulness.2 These strategies have their pros and cons, however they should help managers decide on hospital staffing and the provision of resources. The problem is that, with the exception of transplants and cancer—absolute, unquestioned priorities within the system—there are insufficient mechanisms to treat patients equally across specialties or between conditions within a surgical department: surgery waiting lists are viewed at a macro level but are managed locally by surgical units, according to available resources. Furthermore, there are conditions that are excluded from the system, such as bariatric surgery or gender reassignment surgery, procedures that some managers do not consider to be genuine medical obligations. These situations can lead to significant disparities between patients, undermining the constitutional right to health care protection and the ethical duty to care for patients swiftly and with compassion, without any discrimination.10
For all these reasons, prioritisation strategies and the organisation of waiting lists should bear in mind an axiological perspective. We propose that the values to be safeguarded when drawing up waiting lists are equity—understood as fairness and opportunity—transparency, and certainty—understood as consistency in decisions regarding admission to and removal from the list. At the same time, the defence of these values must coexist alongside the expectation that surgeons will strive to do their best for each of their patients individually, along with the inclusion of patients’ and society’s views within the prioritisation processes.3
Some concrete measures to prevent inequities would be to increase the transparency of the process (ensuring the patient can always see ‘where they are’ and ‘how long they have to wait’); to expand outpatient surgery programmes: to use centralised referral mechanisms within the public system; and, above all, to implement standardised management of waiting lists for non-complex surgical procedures, with patient involvement in choosing the date of surgery, depending on their risk of deterioration and corresponding priority.5
By incorporating ethics into the prioritisation of patients awaiting surgery, we can achieve a fairer health care system.
Ethical considerationsThis paper is original and has not been published previously. It does not involve experimental studies involving human beings or animals. Consequently, approval from any ethics committee or application of the Declaration of Helsinki has not been required, as the paper is based solely on a review of the literature and conceptual reflections.
Informed consentAs no individual patient data has been used and no clinical or experimental procedures have been carried out, the requirement to obtain informed consent does not apply, in accordance with the journal’s editorial guidelines.
FundingThe authors declare that they have not received any funding for the completion of this paper. No grants, subsidies or external resources were involved in its preparation.
Declaration of Generative AI and AI-assisted technologies in the writing processNo artificial intelligence tools, such as content generation, predictive models, machine translation or assistance in drafting have been used at any stage of the paper, including the drafting of the text, analysis or content review. The paper was produced exclusively by the authors.
There is no conflict of interest among the authors, whether of a personal, professional or financial nature. All authors have contributed independently and declare the complete absence of any ties that might affect the impartiality of the manuscript.
