WEIGAND AND WEIGAND, LOSSES IN TIMES OF A PANDEMIC , VOICES IN BIOETHICS, VOL. 6 (2020) *Bárbara Bowoniuk Wiegand MS Bioethics (PUC-PR - Brazil), lawyer and teacher *Solange do Carmo Bowoniuk Wiegand MS Bioethics (PUC-PR - Brazil), psychologist and teacher © 2020 Bárbara Bowoniuk Wiegand and Solange do Carmo Bowoniuk Wiegand. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduc tion, provided the original author and source are credited. Losses in Times of a Pandemic: Bioethical Perceptions about Mourning Caused by COVID-19 in Brazil Bárbara Bowoniuk Wiegand* Solange do Carmo Bowoniuk Wiegand* Keywords: Brazil, End-of-life care, palliative care, mournig, COVID-19, discussing death INTRODUCTION As of June 22, 2020, Brazil had 1,106,470 confirmed cases of COVID-19, in addition to 571,649 recovered cases. Furthermore, 51,271 deaths were caused by the coronavirus in the country.1 Brazilians are dealing with a mourning routine due to fear of the disease and the readjustment of life or death itself. According to a survey commissioned by the Union of Cemeteries and Private Crematories of Brazil,2 “talking about death is taboo for more than 73% of Brazilians.” In this regard we argue that dialogues on bereavement are needed, especially in a country where citizens do not like to talk about death and are not prepared to face it. The aim of this paper is to discuss types of mourning caused by COVID-19 in the lives of Brazilians from three perspectives: health professionals; infected patients and their families; and other non-infected individuals in society. I. Health professionals Caring was not always a priority in medical schools in Brazil which train doctors to treat or cure reflecting their Hippocratic Oath. This understanding has been gradually changing, especially with clinical bioethics. The paternalistic physician, which decides on the treatments for the patient, is left aside, giving the patient autonomy over their medical decisions. According to the National Academy of Palliative Care (ANCP, Brazil), there were nearly 190 palliative care services across the country in 2019. "T[t]here are financing sources, greater availability of morphine, training centers and more palliative services available to the population."4 In WEIGAND AND WEIGAND, LOSSES IN TIMES OF A PANDEMIC, VOICES IN BIOETHICS, VOL. 6 (2020) 2 addition, doctors are valuing care at the end of life. The increased life expectancy in Brazilians and aging of the population will be better addressed by doctors. In this context, the concepts from the principlist bioethics of Beauchamp and Childress3 are verified daily in health centers and hospitals across the country. Issues related to autonomy, non-maleficence, beneficence, and justice, accepted principles of bioethics, seem to come out of books and acquire new shapes in face of health professionals’ exhaustion, resource scarcity, and hospital bed shortages caused by COVID -19. Public health in Brazil suffers due to lack of resources, diversion of funds, overcrowding, outdated infrastructure, and low quality technology, among other aspects.5 According to a survey carried out by the Paulista Medical Association, nearly 50 percent of physicians stated that there is a lack of N95 or PFF2 masks suitable for blocking the coronavirus; they also suggested a lack of other facial protections (38.5 percent), glasses (26 percent), aprons (31 percent), and surgical masks (36.5 percent).6 Accordingly, we argue that the pandemic accentuates already known problems and ends up creating new concerns. Since the coronavirus pandemic is worsening, Brazilian hotels are housing doctors and nurses who prefer not to have contact with family members to spare them from contagion. Hotels charge a small daily rate to maintain costs. Thus, owners can “keep the hotel running without [the need to] waive or reduce salaries of its employees.”.7 Health professionals are experiencing latent mourning in Brazil. Those providing palliative care are essential in this pandemic moment. Taking care of those who care and recognizing the efforts of health professionals is also a way to alleviate suffering, by supporting professionals and those who suffer a loss. The City Hall of Curitiba (Brazil), for example, “decreed Official Mourning for the death of nursing technician Valdirene Aparecida Ferreira dos Santos, 40, victim of COVID-19, who died while performing her duty.”8 More than healing and being healed, the act of protecting is increasingly necessary. Palliative care since ancient times brings with it a mantle of protection providing “a form of care, aiming to alleviate pain and suffering, whether they are of physical, psychological, social or spiritual origin.”9 II. Infected patients and their families The vulnerability of elderly patients and / or those who have underlying diseases, such as diabetes, heart disease, and obesity may be accentuated , putting them in a risk group for COVID-19. According to Protection Bioethics, a Latin American school of thought in Bioethics led by Fermin Roland Schramm and Miguel Motow, these patients should be considered vulnerable, since “they are not able to protect themselves or do not have any protection.”10 Besides the condition of heightened vulnerability, Brazilian patients face the lack of communication with family members, as visits to hospitals are not allowed. In addition, "relatives of people with suspicion or confirmation of the disease need to deal with the lack of information about patients admitted to health facilities in the State."11 The communication is currently made with a single family member responsible for the patient, with daily bulletins, to allow the reception of family members by the health teams. In cases of death, families are called to the hospital and receive the news in person.12 There is also another challenge in the Brazilian reality: the distress of family members of infected patients who do not know if they also have the coronavirus due to the lack of mass testing in the country. In Brazil, the recommendation of the States, together with the Health Commission, is that, given the scarcity of tests, “they should be directed to patients under COVID-19 suspicion with more severe health conditions.”13 This new reality also causes mourning feelings due to treatment uncertainties and the disease itself. WEIGAND AND WEIGAND, LOSSES IN TIMES OF A PANDEMIC, VOICES IN BIOETHICS, VOL. 6 (2020) 3 Brazilian families are also facing changes in the way of dealing with the deaths of relatives. Funeral homes had to adapt to the changes imposed by the new disease. An example is what is being done in Natal (Brazil), where funeral homes now offer virtual funerals to families, to avoid displacement and agglomerations.14 In addition, families need to face the difficulties in freeing bodies in the health system, coffins must be sealed, and goodbyes are short or nonexistent. There is difficulty in locating deceased ones since the number of bodies allocated in cold chambers is greater than the capacity. There are reports of family members who cannot find the bodies of their deceased relatives, while in other places the families receive incorrect death certificates with the names of strangers on them.15 Thus, in the Brazil, there are extreme situations for both patients and family members, and it is not possible to predict how long this context of uncertainty will last. III. Other non-infected individuals in society Considering the general population, we can highlight the abrupt change in routine caused by the pandemic. Suddenly, bereavement permeates Brazilian society, whether due to the limited mobility suggested by the health authorities, the deprivation of freedom and farewell, the collective loss of thousands of citizens, or the suffering related to news of bed shortages in hostpitals.16 There is also the possibility of additional mourning, pointed out by the Brazilian doctor Ana Claudia Quintana Arantes, related to the losses that still occur during pandemic “due to the lack of awareness” about the severity of the disease.17. The Brazilian scenario indicates a concern with the mental health of citizens in times of pandemic, which points to a “hidden epidemic.” 18 Other Brazilian tragedies marked our era and have repercussions in our thoughts. However, the concern with the mental health of Brazilians stands out due to the economic crisis that reached the country with COVID-19. Therefore, "it will be necessary to reinvent and adjust expectations to ensure both economy and mental health balance."18 Unfortunately, uninfected Brazilians are spectators of a pandemic that continues to create victims, including patients, their families, and even health professionals. The current bleak scenario allows important reflections on the reality of public health and social relations in Brazil, with the expectation of contributing to and improving of public policies. CONCLUSION Death during pandemic times is lonely and mourning is composed of new aspects. We argue that death in Brazil in the time of COVID-19 is lonely for everyone involved in this process: families are deprived of contact; patients find themselves alone in bed; health professionals, now exhausted by the imposed care, are often isolated from their own family members. Brazilian society, at home, practicing isolation, and readjusting the routine as much as possible also goes through a social mourning. But at the same time, the isolation allowed the mourners to have a new perspective. Isolation has made people think about their finitude and the end of their lives. Discussions about palliative care and Bioethics are more present in the routine of Brazilian residents and doctors are beginning to address the importance of end-of-life care. All individuals are more vulnerable: patients, families, healthcare providers, and the general public.COVID For these reasons, the bioethical perceptions about the mourning WEIGAND AND WEIGAND, LOSSES IN TIMES OF A PANDEMIC, VOICES IN BIOETHICS, VOL. 6 (2020) 4 caused by COVID-19 in Brazil allow a look at the present with a view to the future and the new possibilities in health and in relation to social life. 1. Brasil, Ministério da Saúde. Painel coronavírus. [Internet]. May 31, 2020, https://COVID.saude.gov.br/. 2. Coelho, Tatiana. Brasileiro não gosta de falar sobre morte e não se prepara para o momento, revela pesquisa. [Internet] June 06, 2020, https://g1.globo.com/bemestar/noticia/2018/09/26/brasileiro-nao- gosta-de-falar-sobre-morte-e-nao-se-prepara-para-o-momento-revela-pesquisa.ghtml. 3. Santos, André Filipe Junqueira dos; Santos, Esther Angélica Luiz Ferreira e Guirro, Úrsula Bueno do Prado. Atlas dos cuidados paliativos no Brasil 2019. Organização Messa, Luciana; Coordenação Piovezan, Stefhanie. 1. ed. São Paulo: ANCP, 2020. [Internet] June 06, 2020, https://paliativo.org.br/wp- content/uploads/2020/05/ATLAS_2019_final_compressed.pdf. 4. Beauchamp, Tom L. Making principlism practical: a commentary on Gordon, Rauprich, and Vollmann. Bioethics. [Internet]. 25(6):301-3. May 02, 2020, http://onlinelibrary.wiley.com/doi/10.1111/j.1467- 8519.2011.01908.x/pdf. 5. Brasil, CEEN – Centro de Estudos. Os 6 maiores desafios que a saúde pública do Brasil vem enfrentando. [Internet]. May 31, 2020, https://www.ceen.com.br/os-6-maiores-desafios-que-a-saude- publica-do-brasil-vem-enfrentando/. 6. Bocchini, Bruno. Coronavírus: pesquisa mostra que 50% dos médicos acusam falta de EPI. [Internet] June 06, 2020, https://agenciabrasil.ebc.com.br/geral/noticia/2020-04/coronavirus-pesquisa-mostra-que- 50-dos-medicos-acusam-falta-de-epi. 7. Knoploch, Carol. Coronavírus: profissionais de saúde se 'isolam' da própria família para minimizar riscos de contágio [Internet] June 06, 2020, https://oglobo.globo.com/sociedade/coronavirus-servico/coronavirus- profissionais-de-saude-se-isolam-da-propria-familia-para-minimizar-riscos-de-contagio-24323533 8. Jornal “Bem Paraná”. Prefeitura de Curitiba decreta luto oficial por morte de técnica de enfermagem [Internet] June 04, 2020, https://www.bemparana.com.br/noticia/prefeitura-de-curitiba-decreta-luto-oficial- por-morte-de-tecnica-de-enfermagem#.Xtv6jDpKjIU. 9. Brasil, Academia Nacional de Cuidados Paliativos. O que são cuidados paliativos. [Internet]. May 14, 2020, https://paliativo.org.br/cuidados-paliativos/o-que-sao/. 10. Schramm Fermin Roland. A bioética de proteção: uma ferramenta para a avaliação das práticas sanitárias? Ciênc. saúde coletiva [Internet]. 22 (5): 1531-1538. May 31, 2020, http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232017002501531&lng=en. 11. Rainheri, Amanda. Familiares de pacientes internados por coronavírus reclamam de falta de informação. [Internet] June 06, 2020, https://jc.ne10.uol.com.br/pernambuco/2020/04/5607514-familiares- de-pacientes-internados-por-coronavirus-reclamam-de-falta-de-informacao.html 12. Brasil, Governo do Estado da Bahia. Desafios da comunicação entre equipe assistencial e família durante a pandemia de COVID-19. May 30, 2020, http://www.saude.ba.gov.br/2020/05/27/desafios-da- comunicacao-entre-equipe-assistencial-e-familia-durante-a-pandemia-de-COVID-19/. 13. Mota, Camilla Veras. Coronavírus: a angústia das famílias que não sabem se foram infectadas. [Internet]. May 31, 2020, https://noticias.uol.com.br/ultimas-noticias/bbc/2020/03/26/coronavirus- angustia-das-familias-que-nao-sabem-se-foram-infectadas.htm. WEIGAND AND WEIGAND, LOSSES IN TIMES OF A PANDEMIC, VOICES IN BIOETHICS, VOL. 6 (2020) 5 14. Brasil, Tribuna do Norte. Funerárias se adequam às novas regras impostas pelo COVID-19. [Internet]. May 02, 2020, http://www.tribunadonorte.com.br/noticia/funera-rias-se-adequam-a-s-novas-regras- impostas-pelo-COVID-19/478907. 15. Coutinho, Rogério. Famílias de pacientes mortos com coronavírus têm dificuldade para localizar corpos em hospitais do RJ. May 31, 2020, https://g1.globo.com/rj/rio-de- janeiro/noticia/2020/04/15/familias-de-pacientes-mortos-com-coronavirus-tem-dificuldade-para-localizar- corpos-em-hospitais-do-rj.ghtml. 16. Rossi, Marina. [Internet]. “Vamos ter um luto pela falta de consciência. Muitos vão se arrepender de não ter ficado em casa”. 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