Ethical challenges in times of COVID-19

In times of pandemic, ethics and morality principles are expected to prevail and make us proud of the human being

Pandemics are always a challenge for societies, but the dimension of the COVID-19 pandemic suddenly uncovered situations that were camouflaged or were not in sight. The ethical challenges of health, economics, politics and human rights now weigh more than ever. Deciding on the unknown, deciding without enough information, deciding by conviction, deciding on the basis of evidence, deciding on the near future has never been more difficult. In all situations where doctors find themselves powerless to cure the disease, they are tempted to look for alternatives, some with proven evidence that they have not worked in similar situations. The myopia of society makes the vision of ethics and morals distorted and discussions about the concept of ethics have never been more needed.

To learn more about the subject, the Communication Office of the Brazilian Society of Tropical Medicine (SBMT), interviewed Dr. Ylmar Corrêa Neto, neurologist, Associate Professor at the Federal University of Santa Catarina (UFSC), in the disciplines of Neurology and Semiology, in addition to Medical Ethics and Bioethics in the Medicine Course and in the Graduate Program in Medical Sciences, and also interviewed the Dr. Marco Antônio Azevedo, physician from the Federal University of Rio Grande do Sul, with a masters and doctorate in Philosophy from the same University, researcher at the National Council for Scientific and Technological Development (CNPq), professor in the undergraduate courses in Philosophy and Medicine at Unisinos and doctor of the Hospital de Pronto Socorro de Porto Alegre/RS.

Check out the interviews in full.

SBMT: There are countless scientific productions on coronavirus research and discoveries and possible treatments. In your opinion, what are the ethical dilemmas faced by doctors in this context?

Dr. Ylmar Corrêa Neto: Critical judgment in the evaluation of the various published studies on coronavirus, its prevention and treatment, is the only ethically justified path for doctors. Unfortunately, the pandemic revealed a serious failure in the training of most of our doctors. It seems that the ability to evaluate new scientific data falls short of enough.

Dr. Marco Antônio Oliveira de Azevedo: For any layperson, it is easy to identify that there is a great divergence among doctors about how to deal preventively and therapeutically with Covid-19. In a way, everyone admits that, being a new disease, it is natural to have divergences, many of them based both on the lack of consensus and on the lack of experience with this new disease. But I also imagine that it is quite difficult for a layman to understand what is going on and why the divergence has become so intense and public. Patients were already accustomed to accepting that often, especially in the most difficult cases, there may be differences in approach between specialists. So much so that patients for the most complex cases often look for “second opinions”, make comparisons and seek to consult with those they trust most or for whom they receive referrals from people they know or trust. This has in some ways always been taken for granted. But what we see now is something different. The divergence between doctors, or between groups of doctors, is a public divergence. And it is not a question, as it was more common, of saying that “I respect the opinion of my colleague, but I treat it differently, like this or that”. Each group accuses the other of committing an ethical malpractice, of acting in a wrong, reckless or negligent manner (depending on what it is about). This applies both to public health measures to contain the epidemic, as well as the debate about the prudence of social isolation measures, especially lockdowns, but also to pharmacological measures.

In addition to being a philosopher interested in topics of bioethics and philosophy of medicine, I am also a physician and clinician. I am a specialist in family medicine and pediatrics, with experience in emergency medicine. I treat people with Covid-19, both outside and inside the hospital where I work, the Hospital de Pronto Socorro de Porto Alegre. I also have my opinions, which, in general, are in line with the positions defended by the Brazilian Society of Infectious Diseases and also by the WHO. But since I am a philosopher, I try to understand the point of view of my colleagues and, as a bioethicist, I also think about the ethical and deontological implications of each position. I have already thought about expressing my opinions publicly. Some have been published in articles. But I am still intrigued by some aspects of the ongoing controversy.

There are indeed two major controversies. As I said, one concerns collective health measures. The other concerns the prescription of treatments whose effectiveness is questioned or questionable. Regarding public health measures, the majority of epidemiologists, as well as bodies such as the WHO, recommend that measures of physical distance between people be carefully used, recommending, however, that, in the event of worsening contagion, activities that favor agglomerations should be prohibited. This mainly affects the free movement of people, leisure, but mainly important economic activities, such as trade. But there is a group that questions these measures. Public health specialists in some countries, such as Sweden, were even famous for defending the opposite. Although it is a different theme, there is also disagreement about the use of masks. I am not an epidemiologist, but the thesis that distance and activity limitation measures, such as commerce, are indispensable, and essential to prevent the number of sick people from increasing far above our current capacity to care for these people and to intern them in intensive care units. But as a philosopher Im interested in the fact that there is a divergence and I always try to understand which thesis is defended by each side. Thus, I see that critics of the lockdown seem to argue that the only rational way to deal with the pandemic of a new disease (for which we have no natural immunity) is to hope that the formation of a “herd” immunity will reduce the speed of contagion. and control its pandemic spread. But the thesis has a dramatic consequence; because it is skeptical about the possibility that we can somehow prevent or even mitigate the catastrophe. I am of course summarizing the position. But one of the perverse consequences of the thesis is that, by adopting it, we would simply have to admit that the death of almost 3 million people worldwide is an inevitable contingency of the pandemic, something that we must simply settle for. Some philosophers understand that this view expresses a kind of “necropolitics” (a term coined by the African philosopher Achille Mbembe to criticize the neglect of the current world order with endemic death, especially of the poorest and most vulnerable), meaning that its defenders invert the order of what is most important, peoples real and present life, in favor of other interests, power or economy. Supporters of the thesis that we should simply let the pandemic sweep the world and wait for natural herd immunity to emerge (a view that others call “denialist”, although this label is misleading, because what its supporters deny is not that there is a pandemic, but the value of giving priority to preventing death over other social objectives, such as the economy) argue, finally, that the focus of combating the disease should be in the treatment of the sick and not in the prevention of contagion.

It turns out that there is no known efficient treatment. If this position were to be fully taken, we would even have to incite people to let themselves be infected. We would have to promote contagion instead of avoiding it. Thus, if masks avoid contagion, we should avoid using them, as preventive measures would prevent the establishment of a natural herd immunity. Now, lets face it, this obviously leads us into a disgusting situation. A philosopher can draw from this the conclusion (by reducing it to absurdity) that adopting this strategy simply cannot be correct, because its consequences are unacceptable. And even if the defenders were right (that death in the pandemic is inevitable), we would have to fight even such facts, in the hope that we will be better off. The fundamental divergence, therefore, is about what, after all, we must value and prioritize. For those who value people and their present life, whether or not the critics of the lockdowns are correct, their sense of humanity leads them to reject the “letting die” thesis.

On the subject of treatments, I think we are publicly observing a confrontation between two different conceptions about medicine. On the one hand, we have those who believe that clinical experience, combined with good pathophysiological theories, are sufficient to guide preventive or therapeutic prescriptions, given the emergency situation in which we find ourselves, and considering the lack of safe knowledge. On the other hand, we have those who defend that the canons of clinical prescription are guided by precautionary principles, based on the “primum non nocere”, arguing that treatments, new or redirected, but without sufficient evidence, should be avoided and, mainly, they cannot serve of public policy guides.

Personally, I align myself with that second position. However, the dispute became riddled with moralistic criticism from side to side. My conclusion is that we should adopt a position of tolerance, in recognition of the fact of divergence in the professional community. Even so, it is not acceptable that public policies can be guided by medical conducts that are not sufficiently proven and not consensual. Each doctor should be allowed to judge in a decision shared with his patient on the best course of action. However, could the government take as a policy the indiscriminate use of medicines without sufficient evidence? Now, if there was a consensus among experts that, given the critical context, we must break with the precautionary principles of evidence-based medicine, I admit that it would be acceptable for certain conduct without robust scientific evidence to guide public managers and clinicians. But this is not the case. There is no consensus on this and it is quite plausible that we should not abandon these rational canons of Evidence-Based Medicine. So, if there is no consensus, what can and should guide public policies is only what has obtained sufficient scientific evidence (“I say “sufficient” and “robust”, for it is not the case that there is no scientific study in progress, for there are many; what we are still lacking are studies of good quality, that is, of low observational or inference bias, supporting these controversial conducts”).

SBMT: What are the biggest ethical challenges to be faced by doctors in this pandemic?

Dr. Ylmar Corrêa Neto: For those who study medical ethics and bioethics, the pandemic has unfortunately proved to be an inexhaustible source of ethical problems. Greater examples are the difficulties of dealing with scarce resources, such as ICU vacancies, availability of oxygen, or vaccines. Transparent and fair prioritization criteria were developed, but at the expense of great stress from the health professionals involved. Smaller examples, but also of great importance due to the high frequency, was the clash between scientific knowledge and patients requests for ineffective treatments, putting on one side the physicians autonomy, necessarily limited by science, and the patients autonomy, heavily influenced by fake news promoted by many groups with interests that do not aim at the better health of the population.

Dr. Marco Antônio Oliveira de Azevedo: I think that the biggest ethical challenge is precisely to find a path of agreement between the divergent ones. Medicine is publicly exposing a fracture that can be dangerous to the confidence in our profession. Trust in specialists has always been a fundamental link to confidence in the profession. The great challenge for doctors at the moment is how to face the commitment to help people, our patients, the patients of Covid-19, in a united way and with integrity and respect for our profession and the limits imposed by science.

SBMT: A regrettable aspect of this pandemic, at least in Brazil, is politicization. We have followed disobedience to the guidelines of the World Health Organization (WHO) and scientific institutions recognized for their work and credibility, on the best way to deal with the lack of vaccines and specific treatments. What is your opinion about this?

Dr. Ylmar Corrêa Neto: A contemporary characteristic, of the so-called liquid phase of modernity, is the relative susceptibility of the institutions traditionally involved in social regulation. This susceptibility is beneficial when it facilitates the renewal of standards in the face of technical scientific and social advances. However, this fragility is harmful when influenced by narratives of a non-scientific, radical political nature, or religious dogmatic narratives. We still do not know how to deal properly with the force of non-traditional media in the dissemination of alternative truths, a force that has been shown to be effective both in the general population and surprisingly among most Brazilian physicians.

Dr. Marco Antônio Oliveira de Antônio: I have already mentioned this before. But when it comes to the topic of vaccines, the political dispute in society (we have also seen this in the United States) has clearly negatively influenced peoples confidence in health authorities. In Brazil, we had even started well, with the guidance given at the beginning by the Minister of Health, doctor Luiz Henrique Mandetta. The fall of the minister was an unfortunate event for the success of what we needed and still need: a unitary approach to the crisis by health authorities. It was unfortunate and we are paying for it so far. An important aspect for all public policy, especially in the area of healthcare, is that we have authorities leading actions in a way that converges with the opinions of specialists in the area, in this case, epidemiologists and infectologists in particular. The separation between politics and the technical area is essential for us to obtain results, even though we will eventually conclude that there were better paths. However, in a crisis such as the one we are experiencing, with serious repercussions for peoples health and life, it is important to seek this convergence. This has not happened in our country until now, at least not at the ministerial level, which has become an appendix to the Presidents political and electoral interests. The fall of Minister Mandetta was a clear sign of this.

SBMT: Physicians are not trained and qualified to prescribe medications just because they believe in a good result or based on personal or other observations. It is necessary that there is sufficient scientific evidence of the efficacy of the drug on the disease and the absence of serious or lethal adverse effects that prevent its use; that it has gone through the research stages, duly authorized by the responsible bodies in the country. So, in the case of the COVID-19, pandemic, how to deal with medical ethics in this case?

Dr. Ylmar Corrêa Neto: Doctors are trained to use treatments with the best available evidence. Pathophysiological theories, in vitro studies, anecdotal cases and expert opinion are suitable evidence and can be used in clinical decision, however in the face of randomized studies or systematic evaluations of randomized studies, they totally lose their importance. In this pandemic year, for various treatments, we have evolved from the absence of clinical evidence of efficacy to the presence of robust evidence of ineffectiveness. Fortunately, in other situations, medications have been shown to be effective in well-designed studies.

Dr. Marco Antônio Oliveira de Azevedo: In fact, the view you present in the question, that personal observations or subjective expectations of good results are not enough to support conduct, is a recent view in medical practice. This is the view that the movement known as Evidence-Based Medicine supports, but EBM discourse is recent in the history of medicine. It is probably no more than 40 years old. It would have started in 1981, when a group of doctors and researchers from McMaster University published the first of a series of articles in the Canadian Medical Association Journal, proposing principles and criteria for assessing the quality of medical literature, in order to guide clinical practice in a more rational and efficient way. 1981 was the year I entered the medical school at the Federal University of Rio Grande do Sul. The concept was called “clinical epidemiology” and was, some years later, called “evidence-based medicine”. The idea of an “evidence-based” professional practice has been and still is criticized by scholars in the medical humanities and also by some philosophers of science. Some medical humanities scholars have come to criticize it for seeing it as a way of reducing the human and social dimension of medical practice to a purely biological dimension. Some of them say that medicine cannot be “based” on evidence (that is, on scientific information only). The basis of medicine, they argue, is constituted by ethical foundations. As for the philosophers of science, many questioned the use of the term evidence (what kind of evidence, they question, is it, after all, relevant?). Recently, in June 2020, in the midst of the Covid-19 crisis, two critical advocates of a person-centered medicine approach published an article in which they claim that the pandemic has shaken the pillars of EBM, which they hold responsible for much of the confusion and scruples that have disoriented doctors, contributing to a sense of panic being generated in the public. I am not of the same opinion as them, but there are true elements in what they say. Older physicians in general tend to overestimate clinical experience, while younger physicians are already being trained based on the view that they must adjust their conduct to the recommendations guided by Cochranes systematic reviews. But few think about what makes their conduct rational and why they should do it one way and not otherwise. Furthermore, it is also not easy for both of them to convince their patients that they are right. The more “traditional” need to ensure that their patients trust them and their experience; the most precautionary ones certainly find it difficult to explain to their patients why they should avoid treatments that are advertised on social media as beneficial (and sometimes even as miraculous!), especially when patients believe that if treatments have few side effects, they would have little to lose (since they have a tendency to imagine themselves at the imminent risk of dying from the disease). Few think they are able to explain either the basic theory of early treatment (which is based on complex knowledge of viral biology) or the internal precautionary logic of EBM (this, incidentally, leads me to think about how the shared decision” takes place in practice, one of the most important topics of the modern doctor-patient relationship, in the context of Covid-19).

In fact, we must admit that the epistemological bases of EBM are not yet well established. Personally, I think Gordon Guyett and Benjamin Djulbegovic have made progress on this topic, but their suggestion is still initial and superficial. Guyett and Djulbegovic suggest that the epistemological basis of EBM lies in the union between two philosophical approaches known as evidentialism and trustworthiness. The concept of evidence they employ is broad. Evidence is anything that provides support for any claim or belief. In this broad definition, clinical observations are also evidence, whether they are collected systematically or not. The problem is that the evidence we have to believe or not believe in something differs in reliability. Thus, when we decide to affirm or reject a belief, we act rationally when we examine the totality of evidence in its favor or against, considering its epistemic “strength”, that is, its quality (or reliability) – this would be the contribution of the reliabilistic epistemology. I think that this view by Guyett and Djulbegovic clarifies the epistemological basis of EBM and its advantages over the more traditional conceptions, which give more value or weight to the theories or pathophysiological explanations corroborated by observation and clinical experience. EBM therefore did not come to eliminate the role of these explanations or the clinical observations and studies based on them; it came to show its limitations and to emphasize the importance of demanding better scientific studies and to classify the available evidence regarding its epistemic strength. Faced with fragile evidence, we must, according to EBM, be more cautious, parsimonious and prudent. The principle that should guide our conduct is based on the idea of balance or clinical equipoise: when we assume that we still do not know if something is beneficial or harmful, unless one is voluntarily participating in an experiment, we must avoid exposing our patient to known risks associated with a certain question that is still questionable or under study.

Anyway, I think that what we see today at Covid is a reflection of this difference in epistemic attitudes, between the traditional view and the modern view of EBM. And the lack of this honest philosophical debate is, I think, a reflection of the lack of discussions among doctors about the logical and epistemological bases of their practices. With Covid, since it is a disease and a serious pandemic, there is no concern to make these issues explicit; as the disease has serious consequences, what is done is to try to “moralize” the blame on the opponents. I believe that it is only after the pandemic has passed that we may be able to resume this discussion in terms that please philosophers: with conceptual and logical deepening and respect for divergence. The mere fact, however, that there is a divergence (be it on the surface, in the dispute over conduct, or in depth, on the logical bases of each approach) should lead us to some conclusions on medical ethics. I think that we already have some consensus that would allow us to draw conclusions about what we can call “right” and “wrong” with regard to the conduct proposed today for Covid. The basis, certainly, is in the EBM, especially in the version proposed by Gordon Guyett and others, which involves a deontological interpretation of what we can extract from systems like GRADE.

SBMT: In your opinion, what is the duty to deal with in the context of the COVID pandemic? What are the limits of this duty?

Dr. Ylmar Corrêa Neto: The limits of the doctors autonomy are the best and most up-to-date scientific evidence and the respect for patients autonomy in choosing between scientifically valid alternatives. During the pandemic, we live in Brazil in a special situation, the fault of the Government and its governors, the fault of the alternative media and the fault of the lack of criteria of the traditional media, in which the population was exposed to an immense volume of contradictory information, clouding or skewing the judgment of many patients [and doctors as well]. This way, common sense and punctual flexibility of conduct are necessary, emphasizing the need on the part of the physician to transmit the correct information from the scientific point of view regarding the real expectation of effectiveness of the adopted procedure.

Dr. Marco Antônio Oliveira de Azevedo: Following the same thought as said above, the question we could ask ourselves is: based on the quality of the available evidence and the different degrees of recommendation for certain conducts, when we can say that a clinician is wrong in proposing or fail to propose to your patient any treatment? My suggestion is that we consider it imprudent to propose conducts or treatments for which there is strong evidence that such guidelines are harmful to the patient, that is, that the recommendation contrary to the prescription is strong. The physician who neglects to recommend something for which there is high quality evidence and there is a strong recommendation in his favor acts in negligence. It is understood, therefore, that one does not necessarily act in error when recommending prescriptions supported by studies of moderate or low quality whose therapeutic recommendation is weak. In the pandemic context, and with science still going on, it is plausible that some doctor concludes that he or her has sufficient practical reasons to recommend a treatment that is still poorly based, but that is thought to be, in their personal clinical judgment, recommendable. One question, however, is: could the reasons for this doctor (or group of doctors) also guide public policies? It seems clear to me that this step is not reasonable and that public authorities should be guided only by what is proposed by panels of recognized experts, these guided by approaches such as the GRADE system (as it has done in Brazil, in fact, regarding the therapeutic procedures for Covid-19, by the Brazilian Society of Infectology). That said, notice that we have to be careful when condemning certain medical conduct as unethical. That is why I have suggested that we start to adopt a view of tolerance, however, making it clear to the public why it is inappropriate to guide government policies based on non-consensual or still in dispute (scientific) conduct.

SBMT: For you, how is medical responsibility in times of coronavirus when the president of the Federal Council of Medicine (CFM), Mauro Ribeiro, says that the claim that early treatment against COVID-19 is ineffective is not true, in which medical entities repudiate early treatment, while other medical entities disapprove of the official position of the Brazilian Medical Association (AMB) that calls for an early treatment ban?

Dr. Ylmar Corrêa Neto: It is up to the Federal Council of Medicine to regulate Brazilian medicine and the autarchy is very well prepared for this. Traditionally, the CFM deals with ethical and moral issues and consults the Brazilian Medical Association and specialist societies on technical and scientific issues. When we elect counselors, we elect colleagues with high experience and moral sensitivity, but not necessarily the best researchers. Likewise, when we elect colleagues for scientific societies, we prefer teaching and research exponents, not necessarily the most humanistic ones. This rupture between the scientific thinking of the AMB and the CFM is unusual and creates greater insecurity for the physician who has to make day-to-day decisions in front of patients.

Dr. Marco Antônio Oliveira de Azevedo: See, this is how I assess the controversy about the so-called “early treatment”. There is no – and we have to be honest about it – evidence that early treatment is harmful to patients. Of course, there are those who think that prescribing it can lead the patient to trust that he is protected and that this can lead him to take risks for himself and others. There may be an association between enthusiasm for early treatment and a certain form of “denialism”, claiming that we should loosen up the social distance measures, since “we have treatment”. But, you see, although I personally tend to agree that certain claims of early treatment are harmful because they encourage reckless practices (not wearing masks, promoting agglomerations, etc.), it is also speculation. There is, frankly, no evidence (I mean strong evidence, of course) that recommending and prescribing early treatment has such perverse clinical or social consequences. What is lacking is strong and reliable evidence that it works, that is, that it achieves the proposed therapeutic goal. It can even be admitted that enthusiasts of early treatment start from a pathophysiological theory that we could even call “plausible”. In short, it is the view that it is necessary to prescribe, already in the first days of the disease (before three days, say its supporters), that is, even before it is confirmed by more sensitive tests, such as RT-PCR, a kit of drugs that would have antiviral activity, or, according to another theory, that would protect the cells of the airways from being penetrated by the virus allowing its replication, thus preventing our body from triggering immune responses capable of injuring pneumocytes and leading the patient, after about 10 days, to pneumonia with hypoxemia, that is, SARS, the severe acute respiratory syndrome associated with Covid-19 and, as a result of severe immunodysfunction and resulting microthrombotic phenomena, the need for mechanical ventilation. What exists is a (or a set of) pathophysiological theories, coupled with a wide variety of observations, many of them systematized in clinical studies of varying quality, and also coupled with the persuasive effect of the thought that it is unwise to leave the patient without options in the face of a disease that can progress severely. On the other hand, the criticism of the use of these treatments is basically that it is only a theory, whose plausibility is also the object of questioning, combined with a collection of globally low quality evidence, subject, therefore, to methodological biases and weaknesses, coupled with the presence of strong evidence that many of these drugs do not achieve the expected result in situations in which they have been meticulously studied (especially in seriously ill or hospitalized people). The criticism is, lets face it, quite consistent: there is no way to elaborate strong recommendations in favor of the use of these therapeutic schemes (which, incidentally, are not unison, there are several). The conclusion is that they cannot be recommended and that precautionary principles should lead us to avoid them, since there are known and well-studied risks, even if small. However, it does not follow that these modalities should be banned as harmful or that those who prescribe them are imprudent (except in cases that studies have already identified, such as, for example, the prescription of chloroquine or hydroxychloroquine in hospitalized patients or those with cardiovascular diseases). The same, incidentally, applies to other types of treatments, such as convalescent serum (also questioned for effectiveness) or monoclonal antibodies (such as tocilizumab, whose studies are equivocal and those that imply that it works show only a debatable and eventually low efficiency or cost-effective benefit). As I argued above, it follows that health authorities should not include them in protocols that can serve as general guidance for doctors, especially in the public system. But it also does not follow from this that those who prescribe them act in an unscrupulous or reckless manner. This is what I understand as a position of tolerance.

SBMT: Would you like to add something?

Dr. Ylmar Corrêa Neto: I believe that some doctors do not follow the best scientific evidence during the pandemic due to party blindness, others due to lack of technical knowledge in the analysis of the studies. Some have difficulty arguing with their patients. All of them deserve some condescension. However, a group of doctors does not follow the recommendations for economic interests. Doctors with specialties usually unrelated to COVID-19 have extrapolated in advertising ineffective treatment methods, deceiving patients in a charlatan way. These deserve punishment. We will have a lot to do in restoring scientific credibility when this storm is over.Dr. Marco Antônio Oliveira de Azevedo: I think I have said enough and maybe it was even more complex and philosophical than it should have been. I have been studying subjects of philosophy and ethics related to Covid since the beginning of last year, in cooperation with three other philosophical colleagues, professors Alcino Bonella, from UFU, Darlei DallAgnol, from UFSC, and Marcelo de Araujo, from UERJ, with who I share many ideas and a high-level research group. In fact, I have a lot to thank them for. But, as I am a doctor, there is an important point that I would like to highlight. Today we see a certain ease of access to social media by doctors, not only by patients and politicians, which has been causing harm to medicine as a profession. Our profession classically is guided by certain principles or virtues, among which magnanimity and humility. We are professionals with a special responsibility. We come from an elite, economic and intellectual. Patients, lay people, place enormous trust in us. In response, we seek to act not in isolation, but as members of a single profession. That is why we cultivate virtues such as collegiality and thrift. It is not for nothing that the code of medical ethics prohibits the sensational disclosure of practices or discoveries. Doctors cannot be proud of themselves. Today we see people hurriedly using social media, disclosing “discoveries” to patients, warning them and accusing colleagues of being “unethical”. The lack of unity in the profession will sooner or later erode public confidence in medicine. It is time for us to start separating our political differences from technical issues. I also think that “medical ethics” cannot be used as an instrument to forcibly standardize thinking in the category. It is time for more tolerance and common sense. We are able to win the pandemic, but to do so, we also need to have patience and balance. Many people have already died, colleagues have died, many because of their professional activity. In memory of those who are gone and those who are still sick, it is our duty to seek to reunify the profession.