Typically, the ethical issues faced by orthopaedic surgeons can feel abstract, and the applicability of the concepts can be difficult to appreciate. Rarely are large numbers of patients affected in a tangible manner by our individual decisions, yet the current coronavirus disease 2019 (COVID-19) crisis has introduced a sense of urgency and weight to our moral decision-making1. The question of how we should behave during this time is not merely a thought experiment or intellectual exercise. It is more critical now than ever to fully articulate, explore, and debate the ethical role of the orthopaedic surgeon within this new context. We are currently at a pivotal juncture as some states are beginning to lift social-distancing mandates, and the choices we make now about when and how to resume our practices are of the utmost importance. We aim to stimulate the development of an ethical calculus suitable to meet the current challenge or any serious public health crisis in the future. Ethical Theory Unpacking and examining every angle of a philosophical question can feel like a game of mental tennis at times, volleying an idea back and forth from different viewpoints, trying to decide which position wins out over the other and makes the most sense. Does the soul exist as a separate entity from the mind, or is it nothing more than connections of entangled neurons and electrochemical impulses in the brain? Do numbers exist in the same way that dumbbells and koalas and wool socks exist, or are they located instead in some other realm? Does a person who walks into a cloning machine walk out as 1 of the 2 clones, or both, or neither? These questions are fun to ponder and can even help us understand our own existence by examining this existence in different ways. There is no urgency to answering those questions, which happen to fall under the branch of philosophy known as metaphysics2. The same is true of problems in epistemology, the study of how we gain access to knowledge3. However, there is an urgent need to understand and answer questions about the third main branch of philosophy: ethics. Ethics is the study of how to differentiate right from wrong4. This governs our behaviors, if we are interested in exercising our moral agency. As moral agents, we assume we have free will to make independent decisions about how to act5. The notion of what is “good” or “right” is difficult to pin down and define with exactness. Moral philosophers have been attempting to elucidate moral decision-making from the ancient times of Plato and Aristotle, later with Immanuel Kant and Jeremy Bentham, and up to contemporary philosophers like Peter Singer and Robert Nozick6. The overwhelming number of moral theories and conflicting opinions does scare away some students of ethics—or turn them into nihilists, who believe that the pursuit of what is “right” is a futile exercise7. Such a skeptical view is unproductive, however, because at the end of the day, we do need to make decisions about how to act. Arriving at those decisions by using some sort of moral framework, with principles or values of weighted importance, seems to be more attractive than relying on gut reactions and base instincts. This is especially true if we value consistency and logic and desire to use the executive functions of our brains, rather than to rely on the whims of our autonomic nervous system to make important decisions. The 2 major opposing doctrines of ethics are consequentialism and non-consequentialism. Consequentialism is the notion that what is “right” is the state of affairs that maximizes “goodness,” in whatever conception one chooses as most important8. Only the outcomes matter. The ends justify the means. The most famous consequentialist philosophy is utilitarianism, in which pleasure or lack of pain is seen as “goodness” to be maximized by the decision-making calculus in every situation8. This means that if a runaway trolley were headed toward 5 people tied to the tracks and there was a lever that could be pulled to switch the track to one in which only 1 person was tied down, the utilitarian would argue that you must pull the switch to kill 1 rather than letting 5 die. The problem with this line of thinking down the “slippery slope” is that we must also be willing to accept conditions like mandatory organ donation lotteries, in which 1 person is killed against their will in order to save the lives of others, or the “repugnant conclusion” described by Parfit, in which the good of the world would be maximized by creating the largest population that Earth could sustain, even if the people were all on the verge of being miserably unhappy9. In other words, there are reasons to think twice about being a consequentialist. Non-consequentialists, on the other hand, are allowed to care about the outcomes, but the end result is not the only factor that matters in decision-making10. Instead of valuing only the results, non-consequentialists can attribute value to notions like rights and liberties and can adhere to principles like not lying or not unnecessarily causing harm. Non-consequentialists can still care about maximizing happiness or minimizing pain and suffering but acknowledge that those are not the only aspects of decision-making for moral behavior. The most famous non-consequentialist was Kant, who fervently believed that principles like not lying or not killing were absolute10. Critics of this approach might have you imagine a situation in which a known murderer knocks on your door and asks if your family is home because he wants to kill them. Kant would say that you must tell the truth because lying is always wrong, even if it means you are facilitating the murder of your family. Obviously, that scenario is a bit hard to swallow. For that reason, most would agree that principles like not lying or killing are important, but if assigned absolute stringency they do not apply well to all conceivable situations. Ethical Analysis The COVID-19 pandemic has required us to put our moral theories into action and to alter our individual behaviors. What do we value most: the stringency of individual rights and liberties or the minimization of the number of avoidable deaths? Any public-health intervention requires giving up some individual liberties for the sake of improving the health of the population. Vaccination, fluoridating city drinking water, and smoking bans in restaurants are all examples of public-health initiatives that we tend to accept, and all require some degree of limiting individual rights or liberties for the sake of the common good11. In times of crisis, are we morally required to give up individual liberties? In the current COVID-19 pandemic, epidemiologists have shown that social distancing is an effective measure to reduce viral spread12. Were we morally obligated to give up going to hair salons, restaurants, and sporting events if these sacrifices save lives, even at substantial economic cost? The majority of Americans have demonstrated a willingness to make these sacrifices, but a vocal minority has emerged recently who tout the importance of individual liberties at any societal cost13. How much sacrifice is required of orthopaedic surgeons? The answer certainly depends on local factors, such as whether there is community spread in an individual area or how vulnerable the patient population is in that area. As Spock gave his life to save the ship in the movie Star Trek II: The Wrath of Khan, his last words were “the needs of the many outweigh the needs of the few.”14 Personal sacrifices are morally required if one finds unnecessary deaths unpalatable during the COVID-19 pandemic, and this principle is widely applicable in any type of public-health crisis. Many levels of leadership have prescribed recommendations for substantially limiting surgical indications during the COVID-19 crisis, including the Surgeon General, the American Academy of Orthopaedic Surgeons, and individual specialty societies and hospital committees15,16. Most hospitals throughout the country have asked surgeons to cancel elective cases but have ultimately left this decision to the discretion of the individual surgeons17. Orthopaedic surgeons have made economic sacrifices, with fewer RVUs (relative value units) and less income for their hospitals or practices, and are suffering the consequences of reduced productivity. Cutting down on the number of elective cases reduces the risk of viral transmission to our patients, ourselves, and our families and has helped to “flatten the curve.”17 The decision-making algorithm for each individual may be slightly different, but the overall response of orthopaedic surgeons during the COVID-19 crisis has been in line with the notion of professional sacrifice of productivity in order to ensure the safety of others18. The question of when and how to resume elective surgical procedures is the next moral challenge, and moving forward, the way that our behavior affects others is a crucial element to consider when making these important decisions. Some of the measures being considered across the country to minimize the harms of COVID-19 include testing patients and operating-room staff for COVID-19 prior to procedures, resuming only outpatient procedures to reduce the length of time patients spend in the hospital, and selecting procedures that can be performed under spinal anesthesia or blocks to preserve paralytic medications for intubations. Kant would have argued that codes of morality must have universal application and that we need to behave in such a way that, with universal application, the state of affairs would be acceptable6. Would it be acceptable for all surgeons to be performing elective cases like trigger-finger releases or total knee arthroplasties this week, or for us to behave exactly as we did before the outbreak—shaking hands, attending birthday parties, and holding conferences? Most agree that “business as usual” has not been an acceptable way to behave during this time because of the potential exponential viral transmission. For that reason, Kant would argue that none of us should behave that way when conditions are so tenuous. We can apply this principle to guide our individual behaviors in any future situation that threatens public health. We have been deviating from our typical behaviors in order to protect others from unnecessary exposure to COVID-19, but are we—or were we—morally obligated to put ourselves in the way of harm by continuing to take call, washing out infections, surgically stabilizing fractures, or even changing roles to be on the front line and take care of patients in dedicated COVID-19 wards? The larger question of the extent to which we are morally required to volunteer beyond our typical role as orthopaedic surgeons is not easy to answer and depends on the moral framework of the individual. If our conception of morality is driven by duties and principles, perhaps we believe that sacrificing personal health (e.g., during residency, with sleep deprivation, poor diet, etc.) is a stringent and serious job requirement, regardless of adequate personal protective equipment or other limiting factors. However, if we believe that outcomes matter in the moral framework, then the question that becomes key is how much good is derived from our presence on the front lines. If we were to find ourselves in roles that require us to intubate patients in respiratory distress, adjust ventilator settings, and insert central lines, things that are out of most of our comfort zones and for which we lack intensive training, it is easy to imagine that we could harm patients and make the situation worse. For this reason, it is essential that each of us carefully weighs the opportunities to contribute to providing care during disasters, considering our personal skill sets and limitations as well as the situational context. Another important and notoriously challenging ethics issue that has been illustrated by the COVID-19 crisis is scarce resource allocation. We have limited resources in each practice, hospital, state, and country. What is the best way to distribute the resources that are urgently needed yet are in short supply? This issue has come to the attention of many as a result of the experiences of health-care workers in Italy, who were forced to choose who will live and who will die because there was not enough equipment to save everyone who was in respiratory distress19,20. When resources are limited, how should we decide who should have access to them? This question has applicability not only to ventilators and personal protective equipment, but also to other treatments and equipment that are too rare or expensive to offer to every patient who would benefit. So many allocation schemes have been created for these limited resources that it would be impossible to mention them all. Some have proposed allocating resources on the basis of need, chronology, likelihood of survival, age, or ability to pay, or even randomly21. This decision-making gets messy quickly, and ultimately no scheme provides a perfect outcome because there will always be individuals who are worse off than they would have been if a different scheme had been chosen. But does this mean that efforts to create a distribution algorithm are futile or pointless? No, because decisions must be made. This is an ethics thought experiment that became reality with COVID-19. Whether one decides to assign coefficients of relative importance to the values of need, age, disability, comorbidities, etc., or use some other algorithm to determine the worthiness of a patient for use of scarce supplies, at the end of the day, decisions must be made about how to distribute limited resources. During the COVID-19 crisis, the decisions about which procedures need to be performed and which can be postponed have largely been made by multidisciplinary hospital committees22. Even before the COVID-19 pandemic, we have been making important decisions about when to order magnetic resonance imaging, when to use expensive custom implants, and even who needs a blood transfusion after a surgical procedure. In short, we deal with resource allocation ethics on an everyday basis, more than we may realize. Conclusions The theoretical trolley problems and Kantian dilemmas are not simply for entertainment, although they can be fun to use to explore the important concepts in a thorough and rigorous way. At the end of the day, it may not seem important whether you would decide, in the trolley problem, to pull the switch and kill 1 person to save 5 others, but the answers to these questions are crucial in determining how you will act in the real world. Depending on how much emphasis one places on the overall outcome, including how many lives are lost unnecessarily, duties and principles, and other values like the individual liberty to live as we choose, we will all make changes to our everyday lives and to our orthopaedic practices. Our individual responses and practice patterns vary tremendously from 1 surgeon to another. One thing is certain, however: individuals affect the outcome when there is a public-health crisis. During the COVID-19 crisis, surgeon discretion to cancel cases and clinics has directly affected patient volumes and potential for exposure. Our behavior is crucially important as we determine when and how to resume our elective practices. Additionally, no matter which distribution scheme we choose to allocate any scarce resource, it is not possible to accommodate everyone, so the best way to affect the outcome in a positive way is to seriously evaluate our individual behaviors. In times of crisis, our moral decision-making calculus is put to the test, and how we choose to behave reflects the moral framework on which we rely to make all important decisions.