ABC | Volume 115, Nº2, August 2020

Editorial COVID-19 and Uncertainty: Lessons from the Frontline for Promoting Shared Decision Making José Augusto Soares Barreto-Filho, 1,2, 3 André Veiga, 2 Luis Claudio Correia 4 Universidade Federal de Sergipe - Programa de Pós-Graduação em Ciências da Saúde, 1 Aracaju, SE - Brazil Universidade Federal de Sergipe - Departamento de Medicina, 2 São Cristovão, SE - Brazil Emergência Cardiológica do Hospital São Lucas Rede São Luiz D’Or, 3 Aracaju, SE - Brazil Escola Bahiana de Medicina e Saúde Pública, 4 Salvador, BA – Brazil Mailing Address: José Augusto Soares Barreto-Filho • Universidade Federal de Sergipe - Programa de Pós-Graduação em Ciências da Saúde - Rua Claudio Batista, s/n. Bairro Cidade Nova Postal Code 49.060-108 Aracaju/SE Brazil E-mail: joseaugusto.se@gmail.com Keywords COVID-19; Coronavirus; Pandemics; Evidence Based Medicine; Bioethics; Clinical Decision Making; Decision Making,Shared; Off Label Use. COVID-19 has already become the largest and deadliest epidemic of the past hundred years. On a daily basis, healthcare professionals in the frontline are called upon to give answers and make decisions that directly affect the lives of infected patients, and scientists are summoned to the Herculean task of providing “effective medications” in record time for a recently discovered virus with devastating potential mortality. With a hitherto unseen avalanche of information, the debate on how to treat patients with COVID-19 has gone beyond the limits of the technical arena, taking on ideological and political aspects as well. Science is based on facts. The fact is that we do not currently have an etiological treatment with proven efficacy and safety to combat SARS-CoV-2. At the moment, there are only promises in the pipeline. To exemplify, the most emblematic case of lack of rationality and scientific thinking is the polemic regarding chloroquine/hydroxychloroquine (CQ/HCQ) for treatment of COVID-19. CQ/HCQ is a drug that has been widely and successfully used in patients with malaria and systemic lupus erythematosus. Against COVID-19, the drug inhibits replication of SARS-CoV-2 in vitro , and it modulates the inflammatory cascade triggered by the virus. 1 In vitro data demonstrate biological plausibility, but plausibility does not mean likelihood that a hypothesis is true. CQ/HCQwas, nevertheless, promoted to the category of “magic bullet” by a publication from France, 2 whose methodology was characterized by high risk of bias and random error, meaning that it could not be defined as “scientific evidence.” This notwithstanding, the publication was overestimated, in an ideological manner, by the individuals who were least faithful to the precepts of the liturgy of science. Contaminated by this fallacy, feeling obligated to solve the pandemic magically, even presidents took on the role of drug advertisers, thus helping to viralize pseudoscience and amplify the false information problem. Even within the medical scientific community, the debate has also become ideological and scarcely rational. One of the claims of CQ/HCQ enthusiasts was that, in a scenario of war, it is necessary to use whatever weapons are available, even without definitive proof of their efficacy and/or clinical safety. Going against the maxim “Primum Non Nocere, ” they deemed that it was forgivable to do harm, but not to remain inert. On the other side, some embarked on a Manichean debate by emphasizing, also irrationally, observational studies in order to argue that there was proof that it was ineffective. The unwavering defense of CQ/HCQ is seductive, given that there are plausible physiopathological effects, which have been verified in the laboratory, suggesting that the drug is effective. Nevertheless, its clinical efficacy has not been proven in any pathological model of acute viral infection in humans, much less with respect to COVID-19. 3 The final effect of a drug depends on the result of its positive and negative effects. The results may trigger a final effect that is neutral (futile treatment), positive (effective treatment), or negative (harmful treatment). Before rigorous scientific scrutiny has been applied, it is not possible to predict them. The function of a randomized clinical trial is to prove, with probabilistic accuracy, using statistics, that drug A causes improvement in patients with disease B and that it does not have side effects which would contraindicate prescription. In an organized scientific ecosystem, prior knowledge provides a basis for future studies through conditional probability. Unlikely hypotheses, which have not been confirmed, when adopted as health policies, lead to unnecessary expenditure of human and economic resources, and they generate false hope in the collective unconscious in addition to, eventually, significant harm. For physicians who are trained to respond proactively, this uncertainty, in scenarios of collective turmoil, may be extremely disconcerting and, driven by the unconscious desire to resolve their internal conflicts related to medical impotence, they may be betrayed by cognitive biases. Given that the contemporary premise of our vocation is to believe in Medicine based on good science, we need to offer a moment’s rest to our minds, which have been troubled by pandemic tsunami so that we may reflect more lucidly, logically, and in a manner enlightened by our creed. The history of biomedical science should have already taught us, as a scientific community, that straying from the paths of formal science can lead us down a “long shortcut.” The search for a shortcut, in the heat of despair, can even contribute to deaths that could have been avoided, in the event that the toxic potential of CQ/HCQ, in this scenario, is proven by randomized clinical trials. DOI: https://doi.org/10.36660/abc.20200582 149