BIOTERRORISM

The issues associated with bioterrorism are as broad in their scope and as challenging in their complexity as any in bioethics. These issues engage the resources of basic sciences, history, political philosophy, sociology, healthcare administration, and public health, as well as clinical medicine. In some instances they present unique concerns, in others they are variations on more familiar bioethical problems. In providing a sound bioethical account of these problems this entry will presuppose that the terrorist threat in question is morally unjustifiable either because the cause it represents or the means used to advance this cause cannot be rationally defended.

Public Health and Civil Liberties

There is broad agreement that individual liberties of speech, movement, and personal privacy may be abrogated when they present an imminent risk of serious harm to other persons and when no other means of ameliorating this risk is available. This doctrine is familiar within the traditional domain of public health. An additional element presents itself when there is an intentional threat to public safety from persons or states that seek to advance a political agenda.

Whether the political element is in itself sufficient justification for permitting the state to have greater latitude in the abrogation of civil liberties than it would in a naturally occurring public health emergency is an issue that may be raised. One might argue that the intentionality of a terrorist act, expressed through a biological attack, is liable to sow panic in a fashion that differs from the psychological effects of a naturally occurring epidemic. Whether that is the case or not is an empirical matter, and whether it is sufficient justification for a more aggressive response is a matter of political philosophy.

It is clear that the tactics required to minimize the harms of a disease outbreak are not substantially altered by the cause of the contagion. In the case of highly contagious and dangerous diseases like smallpox, public health theory calls for the identification and isolation of primary cases and the creation of a ring around plausible secondary cases. This surveillance and containment strategy requires that all those exposed, and their immediate contacts, be vaccinated, isolated, and quarantined if they become ill. Treatment of all cases within that ring should be sufficient to control the epidemic.

Conceivably a disease might be more likely to appear simultaneously in several distant places as part of a terrorist conspiracy than it would as part of a natural event. There is disagreement among public health experts concerning the point at which a certain number of far-flung individual cases would constitute a dire emergency that would render the ring strategy inadequate.

Although bioethics has emphasized self-determination, the public health context presents demands that are incompatible with strict adherence to individual rights. Some have argued that, especially in an emergency, effective public health interventions may entail justifiable limitations on civil liberties that would at other times be unacceptable. Limitations on such rights as speech, privacy, and travel should not be excessive or arbitrary, and they must be rationally linked to protection of the public. They may be imposed no longer than required by the circumstances.

Not all agree that more stringent restrictions on civil liberties may be required by a bioterrorism event. Some oppose abrogating the right to refuse treatment and any requirement that doctors treat patients against their will. These critics also question the practicality and effectiveness of large-scale quarantine. All these actions tend to under-mine the most important defense against panic, which is trust in government authority. Adequate and equitable healthcare for all would, under this view, go farther than draconian measures to build public trust and elicit cooperation in an emergency.

Resource Allocation in a Response to Bioterrorism

Standard accounts of a formal principle of justice require that similar cases be treated similarly. In an extreme event healthcare institutions may not have the capacity to absorb large numbers of patients that suddenly present themselves. An important problem is whether differential treatment is always morally wrong, or whether it can be justified in some instances.

The classic approach to sorting battlefield injuries is triage, a nineteenth-century French policy based on the strictly utilitarian principle of the greatest good for the greatest number. Depending on the particular model, triage utilizes three or five categories that range from urgent to non-urgent to care not needed. Although triage has become a familiar term in the civilian medical world, especially in busy emergency rooms, in its original military context the idea included a criterion of social merit, that the argument for care in any particular case turned on the potential for the individual to return to duty.

Under ordinary circumstances clinical triage differs from battlefield triage. In the former case the most seriously ill are not simply set aside. Rather, resources are made available through such ad hoc means as the temporary diversion of ambulances to other emergency rooms (Kipnis). Under extreme conditions these routine bypass procedures may not be feasible. A social worth criterion could be transferred to civilians if the circumstances were sufficiently dire that, for example, the very survival of the community was threatened. According to theologian Paul Ramsey, the comparative social worth of individuals can justifiably be measured in these highly defined circumstances.

First priority must be given to victims who can quickly be restored to functioning. They are needed to bury the dead to prevent epidemic. They can serve as amateur medics or nurses with a little instruction—as the triage officer directs the community's remaining medical resources to a middle group of the seriously but not-so-seriously injured majority. Among these, one could argue, a physician should first be treated (Ramsey).

A social worth criterion applied to extreme conditions appears to be incompatible with respect for each individual person, for the inevitably unsuccessful act of treating some is sacrificed in exchange for the potential survival of a valuable individual whose survival would in turn benefit the larger number. However, an argument can be made that the unequal treatment is justifiable precisely because one respects all of the others whose survival is made more likely because of the treatment of this one. Respect for all the others that might survive is respect for each of them as individuals, hence egalitarianism is preserved (Childress, 2003).

But not all who are possessed of critical skills may be required for the benefit of the community. Rather, only a few may be needed, therefore it would be unfair to guarantee all of these individuals a place at the head of the queue. Instead, to ensure that at least some of them survive without providing inappropriate advantages to all of them, essential workers may be entered into a weighted lottery in such a way that their selection is more likely, on average, than that of others (Childress, 2003).

As has been observed, the successful management of a bioterrorism event requires a high degree of public trust. Therefore, criteria for triage and resource allocation should be formulated as part of a public consensus process. Transparency in the development and application of resource allocation principles under extreme conditions should include their defense and readjustment in light of public reaction. Precedent can be found in the case of the allocation of organs (Childress, 1997). The articulation and adjustment of allocation principles must take place well in advance of the event itself.

The Obligations of Emergency Health Workers

Healthcare workers are often expected to undergo a degree of discomfort and inconvenience in executing their duties. This expectation is justified by the vulnerability of those under their care, a vulnerability grounded in illness and in the knowledge differential between doctor and patient. Similar role-related obligations apply to other professionals, such as attorneys or securities analysts, whose clientele is inherently vulnerable by virtue of social status or lack of relevant information. Perhaps because of the concreteness and intimacy of their work, no other professional group is held to as high a standard in this regard as are those in healthcare.

The degree to which healthcare workers must compromise their own well being for the sake of others is often unclear. The role-related duties of healthcare professionals imply at least a modest degree of self-sacrifice for the sake of others who are in need of their services. Ordinarily these sacrifices are limited to brief periods of discomfort or inconvenience, particularly embodied in the rigors of the medical residency. At the extreme, martyrdom and other supererogatory acts spell out the limits of these duties, but detailed guidance is lacking. Although emergency health workers have been designated as a special group with more extensive duties under circumstances that demand urgent attention, this designation is not informative about the boundaries of their obligations (World Medical Association, Pan American Health Organization).

One set of considerations has to do with the support emergency healthcare workers are given in executing their tasks. Professionals cannot be expected to perform their responsibilities in the absence of adequate materials, much less expose themselves to conditions that put them at risk. Governments must provide "an effective and centralized authority to coordinate public and private efforts." (World Medical Association). In the context of terrorism the society under threat should also provide the material support required for emergency healthcare workers to do their job, particularly as there is an expectation that their personal welfare is at somewhat greater risk than that of other health professionals (Eckenwiler). The failure to provide suitable support is not an excuse for the healthcare worker to abandon his or her post. Rather it reflects the reciprocity that skilled professionals may fairly expect considering the physical and psychological stresses to which they are exposed.

Another consideration relevant to the question of the limits of emergency healthcare workers' duties is that of moral responsibilities to distant others, as compared to appropriate concerns for one's own welfare or that of significant persons in one's life. As the victims of catastrophe are less familiar to us, as they become more distant in space or culture, it may become more psychologically challenging to relate to their circumstances, especially if their plight competes with that of someone in greater geographic or social proximity.

A feature of the healthcare workers' morality that should, in principle, set them apart from the rest of society is that their circle of concern knows no distance. Yet it is worth asking if this presumption of universal concern, of impartiality, is always sound when it competes with more local concerns about one's own family, friends, and colleagues. Further, partiality is not a vice if it is conceived as one way in which human beings express their individuality through the uniqueness of their relationships (Eckenwiler). Healthcare professionals functioning in emergencies may not be expected and should not be required to subvert justifiable tendencies to place primary value on personal relationships when forced to allocate their caregiving under extreme conditions.

The Role of Private Sector Institutions

Many of the human and material resources that may be required in catastrophic circumstances are in the private sector, especially pharmaceutical manufacturers and managed care organizations. Nonpublic entities are generally agreed to have some responsibilities to the society that provides a stable framework for their business activities, responsibilities that must only increase in the event of social emergency. The contours of these corporate social responsibilities assume a special character in the context of bioterrorism.

Yet private industry cannot be expected or required to resolve all societal problems that are more appropriately considered the province of public entities, such as providing access to medication or healthcare for all. Rather, these private interests have a duty to participate in the public discourse that seeks the resolution of policy problems and to engage in business practices, such as fair pricing policies, that make solutions practicable. The rationale for this duty can be expressed in terms of the primary moral purpose of any business, to produce goods or services that contribute to the pursuit of the good life (DeRenzo).

Within this scheme drug companies can be said to have certain obligations with regard to the bioterror threat. For example, they are obligated to provide security to guard against any potential vulnerabilities in their production activities or storage arrangements. They should make positive efforts to help ensure that medications are available for the treatment of bioweapons injuries with a wide therapeutic range and based on different mechanisms, rather than simply produce medications similar to those already available. For cases wherein there is only one patented drug for a certain indication that is related to a bioterror threat, government may consider a stop the clock mechanism that permits at least temporarily lifting the patent so that production and distribution can be accelerated. (DeRenzo)

Managed care organizations (MCOs) have concentrated a large portion of the highly skilled healthcare work force in the private sector. Not limited to bioterrorism, this arrangement raises questions about the relationship between corporate responsibilities and threats to the public health. Controlling of costs while also providing excellent healthcare has proven to be a significant challenge to the industry, and quality improvement efforts have proven disappointing in resolving the cost-quality tension. Because public health agencies have limited resources, any severe public health problem would further tax the private healthcare system as MCOs would be obligated to provide care for victims even if they are not enrolled in some defined health or insurer plan (Mills and Werhane).

In one sense, as the burden of providing care for a potentially large patient population at risk from bioterrorism falls on MCOs—in the form of vaccination, treatment of victims and planning for attacks—the tension between cost and quality will become still more pronounced. In another sense, however, the requirements of physical survival in extreme circumstances render the cost issue moot, as the best possible care will simply have to be provided. From an economic standpoint the goods and services involved are decommodified or removed from the marketplace because market mechanisms are unable to deal with such conditions. Instead, MCOs should think of themselves as part of a wider system of healthcare, along with government agencies, the pharmaceutical industry and academia. Paradoxically, the threat of bioterrorism introduces a community perspective into privatized healthcare in a way that normal economic and political conditions do not (Mills and Werhane).

Research Ethics and National Security

The development of human research ethics, and of biomedical ethics itself, has been decisively influenced by experience with the involvement of human subjects in national security experiments. The signal event in this often dispiriting history was the exploitation of concentration camp prisoners in experiments under the cover of World War II, many sponsored by the Nazi German military apparatus. The culmination of the Nazi doctors' trial in 1947 was the creation of the Nuremberg Code, which set down rules for human subjects' research and is generally considered a landmark document in biomedical ethics (Moreno).

Subsequent policies regulating human experiments on biological, chemical and atomic warfare in the U.S. military during the cold war specifically referenced the Nuremberg Code. However, these policies were not always followed, in some instances because the activity in question was not considered to be a medical experiment but a training exercise. Secrecy has itself proven to be among the greatest single obstacles to developing consistently applied ethical standards in this area.

The populations that have been involved in national security research represent a wide range, from military personnel, conscientious objectors, and institutionalized persons including prisoners, mental patients and medical patients. Military personnel in particular occupy a complex role because they are expected to subject themselves to risks that would not be required of others, and must accept medical interventions that will preserve or reestablish their fitness for duty (Moreno). Certain basic ethical standards have been recommended, such as appropriate security clearance for all parties, including subjects, prior review by an institutional review board, an appeals process, informed consent, and record keeping (Advisory Committee on Human Radiation Experiments).

Like the other bioethical issues associated with bioterrorism, the development of ethical standards for the involvement of human beings in national security experiments requires the resources of several disciplines. Still more challenging, is the application of these standards, which requires a level of engagement with the political system that clearly identifies bioethics as a practical moral activity.

jonathan d. moreno

SEE ALSO: Coercion; Epidemics; Freedom and Free Will; Harm; Hazardous Wastes and Toxic Substances; Holocaust; Homicide; Immigration, Ethical and Health Issues of; Race and Racism; Warfare: Chemical and Biological Weapons

BIBLIOGRAPHY

Advisory Committee on Human Radiation Experiments. 1996. Final Report of the Advisory Committee on Human Radiation Experiments. New York: Oxford University Press.

Childress, James F. 1997. Practical Reasoning in Bioethics. Bloomington, IA: Indiana University Press.

Childress, James F. 2003. "Triage in Response to a Bioterrorist Attack." In Bioethics after the Terror, ed. Jonathan D. Moreno. Cambridge, MA: MIT Press.

DeRenzo, Evan G. 2003. "The Rightful Goals of a Corporation and the Obligations of the Pharmaceutical Industry in a World with Bioterrorism." In Bioethics after the Terror, ed. Jonathan D. Moreno. Cambridge, MA: MIT Press.

Eckenwiler, Lisa A. 2003. "Emergency Health Professionals and the Ethics of Crisis." In Bioethics after the Terror, ed. Jonathan D. Moreno. Cambridge, MA: MIT Press.

Kipnis, Kenneth. 2003. "Overwhelming Casualties: Medical Ethics in a Time of Terror." In Bioethics after the Terror, ed. Jonathan D. Moreno. Cambridge, MA: MIT Press.

Mills, Anne E., and Werhane, Patricia H. 2003. "After the Terror: Healthcare Organizations, the Healthcare System, and the Future of Organization Ethics." In Bioethics after the Terror, ed. Jonathan D. Moreno. Cambridge, MA: MIT Press.

Moreno, Jonathan D. 2001. Undue Risk: Secret State Experiments on Humans. New York: Routledge.

Ramsey, Paul. 1970. Patient as Person. New Haven, CT: Yale University Press.

U.S. v. Karl Brandt et al., Trials of War Criminals before the Nuremberg Military Tribunals under Control Council Law No. 10 (October 1946–April 1949).