1 00:00:00,540 --> 00:00:13,000 Failing to understand that the first come first serve principle does not work in a pandemic like this can lead to really catastrophic consequences. 2 00:00:13,000 --> 00:00:21,000 Hello. I'm Katrien Devolder. This is thinking out loud conversations with leading philosophers from around the world on topics that concern us all. 3 00:00:21,000 --> 00:00:25,000 This is a special edition on ethical questions raised by the Corona pandemic. 4 00:00:25,000 --> 00:00:31,000 In this video, I talk to Dr. Marco Vergano. Intensive care specialist in Turin northern Italy. 5 00:00:31,000 --> 00:00:35,000 Dr. Vergano is also first author of the recently published clinical ethics 6 00:00:35,000 --> 00:00:40,230 recommendations for allocating intensive care treatments when resources are limited. 7 00:00:40,230 --> 00:00:47,000 In other words, recommendations about who to give access to potentially lifesaving treatments and who to let die. 8 00:00:47,000 --> 00:00:52,000 You worked during the night. Say yes, and I'm working tonight as well as well. 9 00:00:52,000 --> 00:00:59,000 I'm between two night shifts. And I slept one hour after lunch. 10 00:00:59,000 --> 00:01:09,000 Oh, wow. It's OK. Thank you very much for giving up some of your very precious time for their Thinking Out Loud video series. 11 00:01:09,000 --> 00:01:15,420 And I realise very well how little time off work you have. Maybe to start with, 12 00:01:15,420 --> 00:01:20,710 Could you describe a little bit the current circumstances in your hospital? 13 00:01:20,710 --> 00:01:24,000 The situation is changing almost every day for sure, every week. 14 00:01:24,000 --> 00:01:36,000 We started a little less than one month ago to admit the first severe cases of COVID-19 patients, a sorry in my ICU. 15 00:01:36,000 --> 00:01:44,000 And now after a month, it looks like we need, some commentators, 16 00:01:44,000 --> 00:01:51,000 they say that the one month of COVID life equals to, probably a couple of years of normal life, 17 00:01:51,000 --> 00:02:01,000 because you learn a lot of things and things it changes so quickly that it's really when you think about your previous two weeks, 18 00:02:01,000 --> 00:02:07,000 it looks like really very remote time in the past. When we issued this recommendation 19 00:02:07,000 --> 00:02:12,000 with the Italian Society on Anaesthesia and Intensive Care at the beginning of March. 20 00:02:12,000 --> 00:02:18,000 Now, the situation was already an emergency in some so-called red zones in Lombardia 21 00:02:18,000 --> 00:02:22,000 In the areas around Milan. But still it was manageable. 22 00:02:22,000 --> 00:02:30,000 In Chiaramonti and Turin where I live. Now, we are very under pressure and we worked a lot 23 00:02:30,000 --> 00:02:39,000 with a really huge force in order to increase our ICU bed capacity and also hospital ordinary work capacity. 24 00:02:39,000 --> 00:02:45,060 But still, we are admitting more and more patients every day. 25 00:02:45,060 --> 00:02:51,030 But the situation is still it is not so difficult. 26 00:02:51,030 --> 00:02:57,000 And compared to Lombardia and compared especially with the some hospitals and 27 00:02:57,000 --> 00:03:02,000 some provinces in Lombardia. So you mentioned the recommendations, 28 00:03:02,000 --> 00:03:05,000 can you give us a little bit more insight into these recommendations? 29 00:03:05,000 --> 00:03:14,340 Well it is a pretty short document and with an introduction and then fifteen short recommendations. 30 00:03:14,340 --> 00:03:19,000 So just a few pages. Because also our aim was to, 31 00:03:19,000 --> 00:03:30,740 to develop a tool that could be easily accessed by colleagues in a time where your personal time is extremely, very limited. 32 00:03:30,740 --> 00:03:34,720 And we produced this document in just a few days. 33 00:03:34,720 --> 00:03:43,000 And it was not an easy process and very short time by the very I mean, a lot of discussion and some disagreement. 34 00:03:43,000 --> 00:03:53,000 Because, for example, professors and people and colleagues in Central and South of Italy really 35 00:03:53,000 --> 00:03:59,710 didn't grasp at the time the severity of the situation that is in Lombardia. 36 00:03:59,710 --> 00:04:07,800 And so now I realise that it's happening everywhere. And then what were sort of the major disagreements? 37 00:04:07,800 --> 00:04:11,160 Do you remember these debates or disagreement? 38 00:04:11,160 --> 00:04:19,530 Well, some colleagues say, yeah, they're probably well written and that we agreed general principles about. 39 00:04:19,530 --> 00:04:23,430 It's a matter of opportunity because we we issue a document like this. 40 00:04:23,430 --> 00:04:34,020 Now, this can depict a more catastrophic situation than the real situation. 41 00:04:34,020 --> 00:04:40,000 But then after just a couple of weeks, all of this sort of a, I would say, 42 00:04:40,000 --> 00:04:48,500 negationism of the crisis and the severity really dissipated more and more silent. 43 00:04:48,500 --> 00:04:59,000 And I have a colleague that he wrote an article comparing this sort of negation ism that still is present in Italy in some environments. 44 00:04:59,000 --> 00:05:11,000 And so I think that, compared to the plague in Milan, in it might be 620 that Alesandro Manzoni described from a supposedly famous novel. 45 00:05:11,000 --> 00:05:17,640 And where where the authorities in Milan, where indicating the existence of the plague. 46 00:05:17,640 --> 00:05:25,000 Even after establishing this site, I think the neighbourhoods where thousands of people were dying because of the plague. 47 00:05:25,000 --> 00:05:38,950 But do they use different names? Because they were scared of admitting that the that the city was really hard hit by the plague. 48 00:05:38,950 --> 00:05:43,620 Well, what did your recommendation say? How to decide between patients? 49 00:05:43,620 --> 00:05:47,730 And presumably it's not on a first come, first serve basis? 50 00:05:47,730 --> 00:05:51,000 No, that's exactly what we wanted to avoid, 51 00:05:51,000 --> 00:06:03,570 because the usual attitude in admitting patients to the ICU's in a pandemic like this would result in such rating immediately. 52 00:06:03,570 --> 00:06:08,000 Your ICU, with the very old and frail people who are the most vulnerable, 53 00:06:08,000 --> 00:06:15,670 who are the first who get sick with a severe form of COVID-19 interstitial pneumonia. 54 00:06:15,670 --> 00:06:21,190 And that you are probably able to keep them alive for many days or for weeks because 55 00:06:21,190 --> 00:06:27,000 we have a lot of Know-How and the technology and the skills in order to do this. 56 00:06:27,000 --> 00:06:37,940 But it's very unlikely that those people will survive the ICU because are too severe and because we learnt that this a severe form or COVID-19, 57 00:06:37,940 --> 00:06:42,540 that is really deadly for elderly, frail people. 58 00:06:42,540 --> 00:06:49,680 And while you keep them alive without reasonable hope of recovery and survival, 59 00:06:49,680 --> 00:06:57,660 the risk is that many more people with much greater chances of survival will die outside of your ICU door. 60 00:06:57,660 --> 00:07:05,250 You have to understand that you are responsible in a pandemic, not only for your single patient you admitted, 61 00:07:05,250 --> 00:07:10,560 but also for everyone else that it is outside of your door and that that probably 62 00:07:10,560 --> 00:07:15,960 is they will not receive intensive care treatment then that lifesaving treatment, 63 00:07:15,960 --> 00:07:25,000 these fifteen recommendations that they set some triage criteria for admission to the ICU and also for the withdrawal of life sustaining treatment. 64 00:07:25,000 --> 00:07:33,600 The principles used that are basically the same over some past documents about by our society at a different threshold. 65 00:07:33,600 --> 00:07:43,590 So we stated that the combination of a functional status age chronically in this and Frazey in general, 66 00:07:43,590 --> 00:07:51,810 combined with other steps like, for example, the surprising question of asking yourself or your colleagues, 67 00:07:51,810 --> 00:07:59,430 would you be surprised that if your patients, your patient would be dead in just a few weeks or a few months, 68 00:07:59,430 --> 00:08:05,580 just as a trigger of your approach and your decision making process? 69 00:08:05,580 --> 00:08:09,800 And so we use this basically these principles that are shared. 70 00:08:09,800 --> 00:08:13,000 Then in the medical literature, it's all over the world. 71 00:08:13,000 --> 00:08:25,000 And just with more focus on the need to be very stringent in your criteria and to 72 00:08:25,000 --> 00:08:37,000 focus on the shortage and under these exceptional shortage of ICU resources in this current pandemic, 73 00:08:37,000 --> 00:08:47,000 some of the principles are the same. So many critics of our recommendations criticise us and accuse us of being discriminatory, 74 00:08:47,000 --> 00:08:57,000 unconstitutional ageist without realising that the modern medicine and intensive care medicine in general is already 75 00:08:57,000 --> 00:09:09,750 full of priorities and and their prioritisation of patients, transplant medicine and access to emergency departments. 76 00:09:09,750 --> 00:09:16,000 What changes here is just the general framework and the and the scale of this, 77 00:09:16,000 --> 00:09:29,690 because this does not involve just a few recipients of lifesaving organ transplants, but maybe a large part of the population. 78 00:09:29,690 --> 00:09:35,000 So the criteria are the same and about. But the threshold, it could be a little different. 79 00:09:35,000 --> 00:09:41,000 And it's flexible and must be flexible. And the people involved are 80 00:09:41,000 --> 00:09:50,000 Many more. what I would like to underline is that it is a clinical decision before being an ethical decision, 81 00:09:50,000 --> 00:10:04,800 because if you think that that admission to the ICU is inappropriate because that patient has really unreasonable chances of survival, 82 00:10:04,800 --> 00:10:16,000 it is not a value judgement or it's not deciding to save a just a young patient because they think his life is worth more than the 83 00:10:16,000 --> 00:10:26,000 life of an elderly patient. It is just because he gets much more chances of survival from this severe form of COVID 19 pneumonia. 84 00:10:26,000 --> 00:10:34,000 And also, not only he has much more chances of survival, but all things equal 85 00:10:34,000 --> 00:10:45,930 You save a much more life years. So I know this is a hard statement but failing to understand that the first come first serve 86 00:10:45,930 --> 00:10:54,240 principle does not work in a pandemic like this can lead to really catastrophic consequences. 87 00:10:54,240 --> 00:11:00,000 And so does age play a more important role in this pandemic? 88 00:11:00,000 --> 00:11:11,000 Yes, it plays a more important role, especially for the characteristics of this pandemic, because it could be different. 89 00:11:11,000 --> 00:11:20,000 For example, now we know that many children just get sick and remain asymptomatic and get infected and remain as symptomatic or experience 90 00:11:20,000 --> 00:11:25,950 Just the sort of mild flu. And also teenagers, for example. 91 00:11:25,950 --> 00:11:30,000 But we know that is almost deadly for the elderly. 92 00:11:30,000 --> 00:11:40,000 If the severity of the disease reaches this A.R.D.S acute respiratory distress syndrome, a clinical stage. 93 00:11:40,000 --> 00:11:46,000 So you can have elderly people with COVID-19 that stay at home and do not require oxygen. 94 00:11:46,000 --> 00:11:52,000 And in that case, they deserve all of the treatment they receive. 95 00:11:52,000 --> 00:12:01,740 But if their respiratory failure worsens and they need oxygen and in danger, if it worsens again, they need non-invasive ventilation. 96 00:12:01,740 --> 00:12:06,000 And if even if non-invasive ventilation is not enough for probably under threat of intubation, 97 00:12:06,000 --> 00:12:14,000 that would be inappropriate because it could be just the prolonging their agonal phase and then that dying process. 98 00:12:14,000 --> 00:12:24,000 So to be clear, it's not age in itself, but it's because age in this pandemic is associated with very low chance of survival. 99 00:12:24,000 --> 00:12:34,500 Yes. Yes. This was one of the main misunderstandings of our recommendations in the media. It's a bit of a controversial question. 100 00:12:34,500 --> 00:12:39,630 I think within amongst ethicists about whether health care workers, 101 00:12:39,630 --> 00:12:47,610 doctors and nurses and so on should get priority access to essentially life-saving resources, 102 00:12:47,610 --> 00:12:54,440 because after all that, they are needed to keep other patients alive. 103 00:12:54,440 --> 00:13:01,820 And yeah, from what I read, a lot of health care workers are already ill themselves. 104 00:13:01,820 --> 00:13:06,680 Right. Yeah, you are right. Of course. Yeah, we are at risk. 105 00:13:06,680 --> 00:13:16,100 Of course, we have a lot of exposure to the virus. And we cannot do anything else because that's our job. 106 00:13:16,100 --> 00:13:20,090 And I think we should get the priority for testing. 107 00:13:20,090 --> 00:13:26,540 And that's the safety of the healthcare staffing. Hospitals should be a priority for hospitals. 108 00:13:26,540 --> 00:13:30,800 I have to admit that, of course, this situation. 109 00:13:30,800 --> 00:13:37,820 This is really heavy. Sometimes everyday because we have exhausting shifts and we've doubled our shifts. 110 00:13:37,820 --> 00:13:40,700 And we have a lot of course, 111 00:13:40,700 --> 00:13:49,940 we have an emotional burden and colleagues that sometimes are really collapse and then they need support by psychologists. 112 00:13:49,940 --> 00:13:57,680 And there are psychologists that probably will need support by their colleagues because we will need psychologists for psychologists. 113 00:13:57,680 --> 00:14:05,720 And when you treat your colleagues in the ICU are in high dependency units, a colleague said, be your age. 114 00:14:05,720 --> 00:14:09,770 And that we're working with you the previous week. 115 00:14:09,770 --> 00:14:17,120 Sometimes you are scared and you think that maybe your roles could be easily exchanged in just a couple of days. 116 00:14:17,120 --> 00:14:20,090 But we did strengthen a lot of our connexions, 117 00:14:20,090 --> 00:14:28,530 our sense of belonging to a community of healthcare workers in the ICU, especially since doctors and nurses. 118 00:14:28,530 --> 00:14:35,660 And even if we don't have an official priority, 119 00:14:35,660 --> 00:14:45,000 everyone knows that if one of us gets sick and needs a [INAUDIBLE] intubation, that, for example, we remain in our hospital. 120 00:14:45,000 --> 00:14:49,000 So we will try to do that extra bed. 121 00:14:49,000 --> 00:14:58,790 And just for us, because this gives you a sort of safety net, and not only because you access you have access to a bed an ICU bed, 122 00:14:58,790 --> 00:15:05,490 but also because you know that you or your colleagues that are your friends in a certain sense, your brothers. 123 00:15:05,490 --> 00:15:12,000 We take care of you. So we will not be transferred to another hospital either other 200 kilometres away from the 124 00:15:12,000 --> 00:15:19,190 hospitals because our hospitals are becoming a second sort of a house and their home. 125 00:15:19,190 --> 00:15:24,230 Their home. Because. Yes, I mean, because you spend so much time, so much time. 126 00:15:24,230 --> 00:15:29,300 Equity said I tried to protect their families. And so they might even go home. 127 00:15:29,300 --> 00:15:34,000 OK. So it becomes your home. Yeah. 128 00:15:34,000 --> 00:15:38,420 in some senses. That's tough. It's one of the less criticised recommendations. 129 00:15:38,420 --> 00:15:50,000 But I think one is becoming one of the most important thing is that is the focus on the on the moral injury of healthcare workers. 130 00:15:50,000 --> 00:15:59,000 Moral distress and the burnout, not only physical exhaustion, but also emotional and moral exhaustion. 131 00:15:59,000 --> 00:16:08,870 Because when you have to face the heart of the allocate allocating choices for many weeks or for months. 132 00:16:08,870 --> 00:16:19,850 Of course, you will need support because you will remember a lot of faces of patients that you are not able to treat. 133 00:16:19,850 --> 00:16:23,920 And so this becomes a real burden. And that makes a difference. 134 00:16:23,920 --> 00:16:29,000 So I got a little bit angry with some commentators because they think there's a real, 135 00:16:29,000 --> 00:16:39,000 real, real difference between the armchair philosophers and the people on the front line. 136 00:16:39,000 --> 00:16:46,000 I mean, not in your case, not because you are interested in the reasons of the recommendations, 137 00:16:46,000 --> 00:16:57,050 the people that started criticising and with very harsh criticism and with really venomous words and terms, 138 00:16:57,050 --> 00:17:04,680 without even that interested in that, in asking our reasons. 139 00:17:04,680 --> 00:17:08,300 And that is really difficult to bear. 140 00:17:08,300 --> 00:17:17,630 And because of that, the main difference thing that we try to reflect on these principles and treating these patients at the same time. 141 00:17:17,630 --> 00:17:22,450 And it's not the same as just reflecting on the principles and then having someone else and 142 00:17:22,450 --> 00:17:28,120 nobody of us would be would like to be in that trolley problem scenario with the trolley. 143 00:17:28,120 --> 00:17:37,000 With the lever in your hand. Exactly. And that the people that negate that were still negation of the severity of this epidemic. 144 00:17:37,000 --> 00:17:43,460 They didn't want to make a choice not pull the lever or let the trolley just go. 145 00:17:43,460 --> 00:17:47,000 They just refused the that that you could be there. 146 00:17:47,000 --> 00:17:53,000 So just refused the idea that you could be in a position of having to 147 00:17:53,000 --> 00:17:57,000 Make these choices. It's like they're denying that there is the scarcity of healthcare resources. 148 00:17:57,000 --> 00:18:00,740 Yeah. 149 00:18:00,740 --> 00:18:05,000 It's just a simple fact. I mean, yeah, that that is what it is. 150 00:18:05,000 --> 00:18:11,000 Yes. Unrealistic solutions. Like, for example, not let's build or buy. 151 00:18:11,000 --> 00:18:15,060 Five thousand ventilator's. They people do not understand it. 152 00:18:15,060 --> 00:18:21,530 A life saving treatment is not just the bed and the ventilator and a couple of syringe pumps. 153 00:18:21,530 --> 00:18:25,000 You need the skilled professionals. They do not get sick. 154 00:18:25,000 --> 00:18:30,750 And they they they that they are able to treat you for weeks. 155 00:18:30,750 --> 00:18:38,050 And and you cannot just build these resources, human resources from scratch just in a few days. 156 00:18:38,050 --> 00:18:44,000 So that's what also was misunderstood by many commentators. 157 00:18:44,000 --> 00:18:52,470 Currently, any support because you as doctors and the nurses, you're all working basically round the clock almost? 158 00:18:52,470 --> 00:18:59,000 Yeah, it seems like now there's not even time probably to go and see a psychologist. 159 00:18:59,000 --> 00:19:03,000 It seems like it's all building up. Yeah. we are living in a bubble now? 160 00:19:03,000 --> 00:19:18,000 Yeah. We are all hoping that all this will really end pretty soon and then we will have to we will need a sort of huge debriefing. 161 00:19:18,000 --> 00:19:26,750 And and to heal also the emotional and moral injury after this from. 162 00:19:26,750 --> 00:19:34,000 I also wanted to just ask how you feel when you see people not complying with their rules of social distancing because 163 00:19:34,000 --> 00:19:39,000 you're in the middle of the crisis and I can imagine you walk on the street or you're in your car or something. 164 00:19:39,000 --> 00:19:44,640 And then a group. I have to recognise that in Turin 165 00:19:44,640 --> 00:19:50,400 I think that there is a good compliance to this containment and social distancing measures. 166 00:19:50,400 --> 00:19:59,010 So we cannot complain. Maybe a couple of weeks ago, still, there were a lot of people that used to underestimate the severity now. 167 00:19:59,010 --> 00:20:05,700 People understood. I think it's very difficult to enforce these measures at the beginning of the 168 00:20:05,700 --> 00:20:09,960 epidemic surge because they are very unpopular and people do not realise it. 169 00:20:09,960 --> 00:20:20,910 So it's difficult to to just force them to stay at home if they do not understand exactly what is happening and and how bad is the situation. 170 00:20:20,910 --> 00:20:29,640 Of course, many of my colleagues, they get angry of people just go go running in the parks or go for a walk. 171 00:20:29,640 --> 00:20:37,350 And so these stay at home mothers become a sort of mantra. But I think that the things are working. 172 00:20:37,350 --> 00:20:47,210 I'm not sure they will be able. The government and the authorities will be able to implement these measures for a very long period of time. 173 00:20:47,210 --> 00:20:52,470 So people are expecting just this quarantine to end in a couple of weeks. 174 00:20:52,470 --> 00:20:57,510 But probably we will need to to keep it for at least a couple of months, probably. 175 00:20:57,510 --> 00:21:01,800 So I'm not sure there is a lot of uncertainty about the future. 176 00:21:01,800 --> 00:21:09,790 Do you think Italy and other countries will be more prepared for the next time? 177 00:21:09,790 --> 00:21:15,360 There will be for the next one? Yeah, for sure. We are learning things week after week. 178 00:21:15,360 --> 00:21:22,080 Clinical treatments, experimental drugs and ventilations strategies. 179 00:21:22,080 --> 00:21:27,210 We are sharing a lot of information on these days. We have weekly webinars. 180 00:21:27,210 --> 00:21:38,650 We have networks with colleagues from China, United States, UK, everywhere, because we are learning very quickly at this change completely the speed. 181 00:21:38,650 --> 00:21:43,000 Also the sharing of medical information, scientific information. 182 00:21:43,000 --> 00:21:51,150 You are learning a lot for the next one. I don't know. I think that this COVID 19 pandemic really changed a lot of things so deeply. 183 00:21:51,150 --> 00:21:58,000 Also, people, people around me and myself, I really felt so, 184 00:21:58,000 --> 00:22:08,690 really so bad after this criticism that with a couple of colleagues who strengthen you, it's a joke about the president of our society. 185 00:22:08,690 --> 00:22:13,000 She's a professor, almost retired, just about to retire. 186 00:22:13,000 --> 00:22:23,260 So and and I had a lot of distance from her a couple of months ago, of course, because she's and now we exchange e-mails. 187 00:22:23,260 --> 00:22:35,000 So where we are sort of like in the Caulkins how to say Lord of the Rings, we are the Fellowship of the Ring. 188 00:22:35,000 --> 00:22:40,860 And she put her signature in the emails. is Galadriel, the president of the society. 189 00:22:40,860 --> 00:22:44,000 And I am Frodo because I carry that the ring for three weeks. 190 00:22:44,000 --> 00:22:54,000 And I have colleagues who are Aragon. And I mean that this strengthens our relationship. 191 00:22:54,000 --> 00:23:00,900 And. And also I think our characters. Because now we we are really. 192 00:23:00,900 --> 00:23:07,020 I will be heard by in a couple of weeks by the National Committee of Bioethics in Italy. 193 00:23:07,020 --> 00:23:14,190 That remains the sort of of a castle like in reading a sort of filter bubble, 194 00:23:14,190 --> 00:23:21,000 because they really do not even acknowledge the fact that there are recommendations that were cited all over the world, 195 00:23:21,000 --> 00:23:30,600 probably sometimes criticise. But they just that a lot of those conservative members of the committee, 196 00:23:30,600 --> 00:23:36,000 they just do not even want to recognise the fact that we issued those recommendations. 197 00:23:36,000 --> 00:23:46,000 So I read a couple of e-mails and they they there are people there in there in the committee that refused to participate in 198 00:23:46,000 --> 00:23:57,000 the discussion because they say that our our principles and our criteria are a new form of defining Untermensch. 199 00:23:57,000 --> 00:24:06,000 OK, so that this is the level of the discussion in those places. it's like they're living in a different world like a bubble. 200 00:24:06,000 --> 00:24:10,000 Yeah. Like a bubble. Like. Like. Like a fairy tale. 201 00:24:10,000 --> 00:24:13,860 like the plague in Milan for four centuries ago. 202 00:24:13,860 --> 00:24:22,500 I was scared at the beginning. And now I'm really I just I like to be there tomorrow because I feel that much stronger than one month ago. 203 00:24:22,500 --> 00:24:27,720 So because I think I have good reasons to. We just want to save lives. 204 00:24:27,720 --> 00:24:34,000 Exactly, I mean, you're there. People that. Yeah. Then there are people there that say it's better. 205 00:24:34,000 --> 00:24:40,410 Two people dead. Than the one homicide. And then this pandemic that it would also mean like it may. 206 00:24:40,410 --> 00:24:44,880 Or 2000 people. Yeah. Yeah. We're like. Yeah. Yeah, that's. 207 00:24:44,880 --> 00:24:49,120 Yes. Yeah. Also because the numbers are totally positive when you read it. 208 00:24:49,120 --> 00:24:52,000 We have 1000 deaths in Italy today. 209 00:24:52,000 --> 00:25:00,820 It is probably between four and eight thousand because we don't have enough testing capacity to test leaving patients, not the dead patient. 210 00:25:00,820 --> 00:25:09,230 Not all of the patients in the red zone started dying outside the hospitals because they don't have even gets an ambulance or something. 211 00:25:09,230 --> 00:25:14,580 So this is what's happening. Yeah. Thanks so much for sharing your thoughts on this. 212 00:25:14,580 --> 00:25:19,000 Thank you. And I hope the situation in Italy will improve. 213 00:25:19,000 --> 00:25:27,000 Very soon. Yes. And I also wanted to say how many grateful we all are, of course, for all the work that you do. 214 00:25:27,000 --> 00:25:33,140 And I'm sure that's not what this video will be extremely grateful just so much right now. 215 00:25:33,140 --> 00:25:39,860 I hope that the situation in the U.K. will not reach the intensity and the severity of our. 216 00:25:39,860 --> 00:25:46,080 So I really hope. Yes. Thank you. OK. Thank you very much. 217 00:25:46,080 --> 00:26:03,240 If you like this video, don't forget to subscribe to the practical ethics channel and the Thinking Out Loud Facebook page.