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Ethics
& Medics
JANUARY 2002, VOL 27 NO 1
Ethical Challenges of Bioterrorism
In ways positive and negative we find ourselves launched into a biotech
age. In February of this year it was announced that the entire human genome
had been sequenced. The summer found the nation gripped in intense debate
over the morality of embryonic stem cell research. The first presidential
address of George W. Bush to the nation was on the bioethics of such
research. Regardless how one views the morality of the decision, it was an
indication of how significantly questions of bioethics had risen in public
concern.
During the year there were also reports of remarkable therapies having
been developed using morally obtained adult stem cells. But by October it was
bioterrorism that gripped the attention of the nation as innocent people died
from inhalation anthrax, and public officials and social commentators raised
the specter of smallpox being used as a weapon of terror.
Bioterror and the Common Good
Coming to terms with the dangers of bioterrorism requires a host of public
policy decisions with profound ethical implications. In October of last year
Governor Bill Owens of Colorado created the Governor's Expert Emergency
Epidemic Response Committee to respond to "acts of bioterrorism,
pandemic influenza, and epidemics caused by novel and highly fatal infectious
agents."
In the current situation the United States finds itself virtually at war
with unknown enemies and no battle lines. In such times public authorities
must assume extraordinary powers for the sake of public safety. Laws and
directives often have to be passed that would restrict the liberties of
citizens more than would be the case in periods of peace. Such determinations
are the responsibility of those who bear civil authority, which is ultimately
exercised for the sake of the common good. As St. Thomas teaches, law is a
"certain ordinance of reason, directed to the common good, promulgated
by one who has the care of the community" (ST 1a2ae, 90, 4). There is no
other justification for civil law than the promotion of the common good,
which would be impossible were the law not in conformity with the moral law.
At a time of national emergency brought on by the unleashing of biological
weapons of terror, greater power is placed in the hands of the executive for
the common good. For example, in Colorado, the law gives the governor the
wide discretionary power to do what is outlined in the plan of his Expert
Committee, from confiscating antibiotics to be used to treat the infected to
quarantining the sick or determining the manner of disposal of corpses.
In Washington and across the country public
health agencies have been drawing up guidelines for action in the case of
further biological attacks, guidelines which would admittedly curtail certain
exercises of individual autonomy. Already some bioethicists have expressed
concern that the "hard won" recognition of patient autonomy in
health care might be diminished with appeals to the needs of the community to
protect itself from the spread of a deadly or debilitating diseases. As Dr.
Jonathan Moreno of the University of Virginia writes in the American
Journal of Bioethics:
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... [T]here can be little argument that a principle of
autonomy or self-determination has been virtually the philosophical
flagship of modern bioethics .... According to the standard analysis,
individual rights in health care can only be trumped by a serious public
health concern for which there is an available and effective intervention.
The communitarian analysis that has been proposed would privilege public
well being to a far greater degree than the standard view.
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The Catholic moral tradition would have little difficulty with this
development, however, since it has always regarded the obligation of the
citizen to contribute to the common good to be of paramount importance. An
excessive emphasis on autonomy is alien to the Catholic moral tradition.
As the late Catholic philosopher Jacques Maritain put it: "The end of
society is neither the individual good nor the collection of the individual
goods of each of the persons who constitute it .... The end of society is the
good of the community, the good of the social body." (La personne et
le bien commun, 1947). This good cannot ultimately be realized, however,
if it is ever sought through a direct violation of the integrity and dignity
of any citizen, such as killing those who may be infected to prevent the
spread of the disease. Yet the citizen should be ready to sacrifice, to
surrender, certain liberties for the common good, which ultimately would be
for his own good.
In circumstances of biological warfare decisions may have to be made as to
who should receive treatment and who not, who should receive immuni-zation
and who not. Or if all endangered individuals were able to receive
immunization, decisions would have to be made about who would receive it
first and who subsequently. The general parental right not to have one's
child vaccinated might have to give way to state intervention for the sake of
the child's own life. Situations could easily be envisioned which would
require quarantine for certain elements of the population, and the state
might even have to dictate how to dispose of the corpse of a loved one.
Persons and Greater Social Value
Obviously public officials are charged by their office and indeed by God
to protect and promote the common good of society while respecting the rights
of individual citizens. As long as the natural rights of citizens are not
violated, there is a certain priority which must be given the common good so
that the well being of the largest number of citizens can be advanced as far
as possible.
In the case of biological warfare, for example, it is quite likely that
decisions of triage would have to be made if large segments of the population
were infected and medical resources were overwhelmed. Judgments would have to
be made about when to remove a ventilator from a person who is dying in order
to assist another who may have a chance for survival. Antibiotics might have
to be made available only to those who would have a reasonable likelihood of
responding to the treatment.
In such circumstances, sentimentality cannot direct public policy, but
rather reasonable judgments about the benefits to be derived for the common
good from the decisions of civil authorities.
To try to stop the spread of disease public health officials would have to
know those with whom the sick person had been in contact. In other
circumstances this might be viewed as an invasion of privacy or a violation
of confidentiality, but in the face of the mortal danger of the spread of a
highly contagious viral infection such as smallpox, the sick person would
have a grave moral obligation to reveal the names of those with whom he had
recently been in contact, even if this led to those individuals being quarantined.
Public health authorities would also have to make ethical decisions about
who would first receive vaccines against a dangerous biological agent. These
would not be so much medical decisions as ethical ones, since certain
individuals might first receive medical attention whether or not they were
even sick. That determination would be made on the basis of whether they were
in a position to render a public service in safeguarding the health of the
community and were themselves at risk.
For example, those receiving prophylaxis or treatment first would probably
include health care workers and their staff, emergency medical service
personnel, firefighters and police officers, coroners and medical examiners,
key public officials, such as the president and governors and their public
health officers, members of emergency management teams, perhaps even those
who are responsible for water, power, and communications systems. After these
individuals had been treated or protected, decisions would be made about which
other segments of the population would receive medical attention.
It should be obvious in such a listing that those with greater
responsibility for the common good would be assured first of treatment or
protection so that they might work for the benefit of greater numbers.
Certain lives may actually be of greater social value in the sense
that greater numbers would depend on their good health and their capacity to
make decisions for the sake of the general population.
Such decisions most certainly do not suggest that one group of individuals
is morally better than another. Without entering into the debate over the
moral worth of various types of human character, it is not on the basis of
these differences that one individual might receive treatment sooner than
another but rather on their importance for the well being of the community.
Certainly such decisions ought not to be seen as an indication that one
individual is of greater intrinsic worth than another. All human beings have
the same inherent worth before God. Nonetheless, certain individuals may also
be of greater social value in terms of securing the common good.
Most people who have flown with children are familiar with the airline
directions that they put oxygen masks on themselves before they put them on
the children if an emergency should arise. This is obviously not because the
adult is willing to sacrifice the child for the adult's benefit, and not
because the adult is a "better" person, but rather precisely so
that the adult can be at the service of the child. The same kind of
consideration applies to public servants for the sake of the contribution to
the general public.
John M. Haas, Ph.D., S.T.L.
President
National Catholic Bioethics Center
Boston, Massachusetts
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