On March 13, a recommendation came from the American College of Surgeons: Minimize, postpone, or cancel all elective surgery amid the spread of coronavirus. This instruction was shared the next day by the U.S. Surgeon General, and in the two weeks that have followed, it’s been echoed in executive orders issued across the country.
In that same time frame, MLB teams announced pitchers who would undergo Tommy John surgery: Tyler Beede of the Giants, Chris Sale of the Red Sox, Noah Syndergaard of the Mets. But what does it mean to have the procedure in a pandemic? Especially when every medical resource is precious—and pro athletes are already under fire for receiving preferential testing and treatment.
Legally, teams and players are on solid ground. The national recommendations are just recommendations, and it’s still feasible to perform a surgery like Tommy John in many parts of the U.S. Among the states that have issued executive orders on the subject, there’s varied language on what exactly is prohibited, from “elective” procedures (New Jersey) to “non-essential” (Ohio) to “non-urgent” (Kentucky). In many states, doctors themselves can determine which of their own procedures fit that terminology, at least for now. So, barring additional local regulations, an individual practice can quite easily make a legal determination that its essential procedures may include Tommy John.
“I think it’s a really fuzzy line,” says Christopher Scott, the chair of medical ethics and health policy at Baylor College of Medicine, when it comes to defining what procedures are, legally speaking, essential or not.
But the question of can a player have Tommy John surgery is different from the question of whether one should. And medical ethicists say that a procedure like Tommy John—which pitchers need to throw hard, but not to lead healthy off-the-field lives—is hard to justify in the middle of a pandemic.
“At the present time, I don’t think there’s even a question that it would be inappropriate and should not be done in any areas that are hit hard by COVID,” says David Magnus, a professor of medicine and biomedical ethics at Stanford and the former chair of the ethics committee for Stanford Hospital. “And I think it’s arguably a bad idea to do anywhere right now…. Even in areas where there have been no reported cases, or very few, and it hasn’t spread yet, that’s changing by the hour. Maybe right at this moment, they don’t need the space, or the personnel that would be involved in the procedure, but that can change so rapidly that I think it would be an irresponsible use of resources. Nobody should be doing this.”
It’s not that the orthopedic specialists who perform the surgery would likely otherwise be responsible for coronavirus patients. But the equipment—such as masks—could certainly be needed. So could the physical space and the other staff, such as nurses, especially when all sorts of nontraditional areas in hotspots—even New York's Central Park—are being converted to treat patients and retired medical personnel are being asked to return to the field.
Beede’s surgery was done on March 20 in Texas, a few days before the state issued an executive order about elective procedures. The Red Sox have not released any details about Sale. But Syndergaard’s was scheduled for late last week in Florida—after an executive order from Gov. Ron DeSantis prohibiting “any medically unnecessary, non-urgent or non-emergency procedure or surgery which, if delayed, does not place a patient’s immediate health, safety, or well-being at risk, or will, if delayed, not contribute to the worsening of a serious or life-threatening medical condition.”
Syndergaard’s procedure was handled by the Hospital for Special Surgery in West Palm Beach. “After reviewing the details of this particular injury, and using rigorous medical criteria as a guide, it was determined this surgery is essential,” a hospital spokesperson said in a statement. HSS said it has cut back significantly on its patient load and has approved only one Tommy John surgery other than Syndergaard’s in the last week. (The other was for “an individual who is not a professional athlete” and took place at an HSS location in New York after it was deemed similarly essential.)
Major League Baseball has long cast itself as an essential piece of America, more deeply woven into the fabric of the country than any other sports league. To see these types of medical procedures continue, while others are halted nationwide, can seem like a betrayal of that trust. “I think there’s a bigger kind of concern around this, and that’s the social responsibility,” Scott says. “That’s where it gets me a little uncomfortable, because if, let’s say, a clinic is performing Tommy John surgery and using medical supplies that might need to be shunted to a city hospital, then that’s a responsibility that private clinics—as well as clinics that are in hospitals, and all the rest—should be thinking about before they’re saying, ‘Well, we’re going to be doing these because the financial health of the player is in jeopardy.’”
This question of financial health is generally the main pushback here. Postponing Tommy John, in which a torn ligament in the arm is replaced by a healthy tendon from elsewhere in the body, will typically not pose a risk to physical health. “There’s no medical need where you need to have that,” says Arthur Caplan, head of the division of medical ethics at New York University School of Medicine. Tommy John certainly affects when a pitcher will be able to finish rehab and return to the mound, however, which can affect earning potential in a sport where careers are often short and volatile. But granting allowances for a procedure based on financial reasons poses its own ethical problems.
In the current environment, Caplan says, “[Surgery patients] don’t get procedures for their livelihood, they get them for their lives.”
That runs counter to the argument Dr. Neal ElAttrache made earlier this week in the San Francisco Chronicle, where the sports surgeon said, “I know that I’m going to get criticized for taking care of these kinds of guys, but it’s essential to their livelihoods. If you have somebody’s career at stake and they lose two seasons instead of one, I would say that is not a non-essential or unimportant elective procedure.”
But the ethicists say that this kind of logic can be faulty in a world where these procedures have already been limited. Should an MLB player whose career is at stake be prioritized over, say, a college kid whose future draft position is at stake? Over a player who could be even younger? “Those are interesting ethical questions that can be deliberated by scholars,” Scott says. But to have surgeons pick and choose on their own is to risk a system that only exacerbates existing inequity.
Some draw a parallel to NBA players getting tested for the coronavirus while people around the country reported problems getting tested no matter their symptoms.
“People worry about the fact that testing may not have been fairly distributed, so people who are famous or are athletes get access when others don’t,” says Magnus. “If the same is true for surgeries, you can’t have elective surgeries under any circumstances unless you’re an athlete, that would foster mistrust and problems with the public around their views about the health system.”
In the last few weeks, it’s become increasingly difficult to try to isolate any one type of medical procedure from the bigger picture of what’s happening in the country, ethicists say. Everything from reproductive care to dental procedures has been put on hold. And sports medicine takes place in this context, too.
“You can’t be in the system and out of the system,” Scott says. “Medicine is all of our responsibilities.”