Some hospitals and surgery centers continue to conduct elective surgeries amid the COVID-19 crisis, defying federal requests and state bans seeking to stop the nonessential procedures even as essential medical supplies dwindle.

Medical staff members said the refusal to comply puts them and their families at risk as they are forced to reuse personal protection gear such as face masks. Some said the outsized influence of revenue-generating surgeons is a driving factor.

Kathleen Bartholomew, an author and nursing safety advocate in Washington state, polled members of an online nursing group about elective surgeries late last week for USA TODAY. Fewer than five of more than 170 respondents reported their hospitals continued to conduct them, which Bartholomew said is still too many.

"Why is there a debate at all when the facts so clearly point to stopping all elective procedures immediately?" Bartholomew said. "Many health care practitioners are still practicing with an antiquated hierarchy mindset where surgeons hold all the power, despite the fact that research has shown that only working as a team will keep our patients safe."

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Elective surgeries are medical procedures scheduled in advance because they aren't emergencies and may not be essential. They include cosmetic changes, such as nose jobs, but can include much-needed breast reconstruction, knee replacements and operations that relieve pain or make it easier to see. When it comes to plastic or orthopedic surgery, elective surgery can be among the biggest ticket procedures at a hospital.

Procedures aren't considered elective if delaying them could be life-threatening, such as for heart conditions. They include tumors that are spreading or "active bleeding" in the gastrointestinal tract, said Connecticut gastroenterologist Latha Alaparthi.

This month, nearly 300 University of Pittsburgh Medical Center medical staff members – the majority of them residents and anesthesiologists – signed a seven-page letter outlining concerns about elective surgery and routine visits. It was sent to the health systems' management March 21, but some elective procedures have continued, according to two doctors who asked to remain anonymous.

Employees reported backlash from management because of the letter, one of the doctors said.

"We ask our colleagues and co-workers to act in a professional and respectful manner

to all those that voice their concerns regarding this crisis," the letter said.

Nivedita Lakhera, an internal medicine physician who treats many COVID-19 patients at a California hospital, is connected to more than 10,000 health care workers on social media. Her hospital is not doing elective procedures, but she has heard from many who work at hospitals that are.

Doctors and hospital staff "have been put in a situation of deliberate sacrifice and are told to put our personal safety aside for monetary reasons," said Lakhera, who has written two books on mental health and healing. "When hospitals do nonemergency procedures, we see them as being OK with our death over their greed about short-term revenue. We resent that, but we are powerless, and we are forced to be there anyway."

Even though many doctors and nurses "feel ethically violated," she said, they are worried about losing their jobs if they speak up.

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It's a phenomenon retired travel nurse John Kauchick saw often in his 37 years working.

"These are probably the same hospitals where manager retaliation ... and firings are the norm," said Kauchick, a nursing safety advocate. "When I worked in surgery, it was not unusual for a surgeon to change a classification to urgent or emergent to get a case on schedule or move a case to the top of the list, especially after hours."

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Finances vs. ethics

USA TODAY reported March 21 that hospitals, including UPMC and Virginia Hospital Center in Arlington, allowed some elective surgery. Surgeon General Jerome Adams wrote an op-ed for USA TODAY that day further urging physicians and hospitals to stop. VHC has apparently halted nonemergency procedures.

"As we are in the midst of a whole-of-government effort to fight COVID-19, we need all our health care workforce and more to meet the demands of this challenge," Adams wrote. "Every non-urgent case takes precious staff time and energy, straining a workforce already going above and beyond in this fight."

The American College of Surgeons cited the financial pressure in "ethical guidelines" it released.

"Health systems, and federal and state governments should begin developing comprehensive solutions to address the financial impact on hospitals, physicians, and other health care providers that result from canceled operations, so that these perceived financial risks do not influence some surgeons to continue to perform elective operations," the guidelines say.

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Facilities allowing nonemergency surgeries include Steward Health Care. The more than 30-hospital chain, which operates in states including Texas and Louisiana, said in a statement that it will "continue to support all scheduled surgeries and procedures, and we will leave the decision on whether it is appropriate to proceed now to our physicians and their patients."

Steward said it is "committed to preserving access to scheduled procedure time for as long as possible." Steward did not respond to a request for comment Tuesday.

The Wisconsin chain ProHealth Care said it limits elective surgery but leaves the decision on whether to do nonemergency procedures "to the medical judgment of individual physicians."

In a statement, ProHealth Care said it won't postpone procedures if doing so would risk harm. The chain said March 20 the "pause in elective procedures" will be in effect for two weeks, and ProHealth Care will reassess the situation after that period. ProHealth did not respond to a request for comment Tuesday.

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Surgeries delayed

Marty Makary, a Johns Hopkins University hospital surgeon and professor, said, "Any entirely elective procedure that uses valuable supplies at this critical time is short-sighted."

"It is borderline unethical for any U.S. hospital to perform elective surgery if the operation can be delayed three or more months without any health consequences to the patient," said Makary, author of "The Price We Pay: What Broke American Health Care – and How to Fix It."

In Baltimore, Johns Hopkins University medical center told the parents of Davidson Alagno last week that it postponed the transplant planned for June of a kidney from Karen Alagno to her 7-year-old son because of COVID-19. Davidson has a rare kidney disease and his health began to decline recently, but the procedure was still considered elective.

Alagno told WRC-TV in Washington she both understood and was frustrated by the delay. She and her son hope people who don't need to be at the hospital won't go, so his surgery can be rescheduled soon.

"There are people like Davidson who need the health care system to work the way it should," she said.

Email Jayne O'Donnell confidentially at jodonnell@usatoday.com