Book review: Ethical preparedness

In the wake of terror: medicine and morality in a time of crisis Jonathan D. Moreno, editor. Cambridge (MA) and London: MIT Press; 2003 229 pp US$24.95 (cloth) ISBN 0-262-13428-4 Although bioethics has never been more visible in universities, medical centres and the popular media than it is at present, much of the intellectual creativity of the field seems to have dissipated. Bioethicists circle endlessly around well-worn topics such as informed consent, resource allocation, physician-assisted suicide and advance directives. Although such subjects are important, their discussion seems to have reached a point of diminishing returns. Fortunately, there are some encouraging signs of efforts to explore new terrain. As though suddenly aware that human existence is not exclusively confined to the geographical boundaries of North America, some researchers are examining international inequalities and global health. Others are considering how “enhancement” technologies such as forms of cosmetic surgery, psychopharmacology and germ-line gene therapy extend beyond the “disease model” by offering the promise of being “better than well.” Now that some themes have been fished to near-extinction, the most promising research agendas are attempting to take bioethics into unfamiliar waters. In the Wake of Terror: Medicine and Morality in a Time of Crisis, edited by Jonathan Moreno, tries to take bioethics in new directions. However, it remains stuck on the launch pad as too many contributors treat the subject of bioterrorism in an unimaginative, uninformed or outright misguided manner. There are some noteworthy exceptions: James Hodge and Lawrence Gostin, Ronald Bayer and James Colgrove, and Eric Meslin provide well-researched and insightful contributions. Hodge and Gostin provide a careful exploration of the relation between law and public health. Their essay suggests how state legislation can strike a reasonable balance between protecting individual liberties and private property while striving to promote public health and the common good. They suggest practical measures for respecting civil liberties while recognizing that terrorist acts — particularly those involving biological or chemical weapons — can require governmental bodies to place restrictions on individual freedoms. Hodge and Gostin sensibly recognize that profound social crises can lead us to temporarily weigh competing moral norms in a manner at variance with how these values would be weighed at a time when there is no significant threat to public health. Similarly, Meslin recognizes how acts of terrorism can lead to a revaluation of social priorities. For example, he considers the place of secrecy in genetics and other forms of biomedical research, how acts of bioterrorism might lead scientists and other social actors to consider whether some findings should not be published in widely accessible media, and the extent to which funding for public health measures should be directed toward bioterrorism preparedness in contrast to other, perhaps more valuable, social objectives. One shortcoming of most of the contributions is a sort of cultural myopia or ethnocentrism. There is no serious discussion of terrorism outside the American context; discussions of law, history, jurisprudence, government agencies and government policies are likewise limited to the US. Since acts of terrorism are scarcely confined to the US, it would be helpful to have some insight into how politicians, public health specialists, scientists, emergency response teams, hospitals, legislators and other social actors around the world have attempted to respond to terrorism and the threat of terrorism. Too many of these essays provide abstract, entirely predictable discussions of the tension between civil liberties and the public good, triage and resource allocation, and organizational ethics. In many instances, the relation between a chosen topic and the overall theme of the collection is tenuous. James Childress, for example, doesn't simply recycle his ideas on triage and resource allocation; he lifts entire paragraphs from his previous work. The result is that his chapter provides insight into general utilitarian and egalitarian models of emergency triage, but does not make a distinctive contribution to how emergency medical providers ought to respond to different kinds of terrorist attacks. Certainly, the individual emergency department director, triage nurse or disaster-response planner is unlikely to take any practical lessons away from this chapter. Similarly, George Annas offers a largely irrelevant discussion of Black Hawk Down, Lord of the Rings and a Tom Clancy novel before offering his usual defence of individual liberties against the tyranny of government agencies. He seems unwilling to concede that 3000 deaths in a single day caused directly by a terrorist attack might lead reasonable individuals to conclude that it is time to reassess the balance between individual liberties and the public good. Many other contributors ride their favourite ponies. Several scholars provide arguments for universal access to health care in the US. Griffin Trotter, in a rather stunning example of missing-the-point, worries about the paperwork required by the US Emergency Medical Treatment and Active Labor Act. He seems concerned that emergency care providers will be bound by bureaucratic requirements in situations of mass emergencies. Although this legislation might well need to be revised, it is rather hard to believe that emergency physicians and nurses will proceed in a business-as-usual fashion after a massive catastrophe. Surely there are other issues related to bioterrorism more worthy of our consideration. If many of the contributions provide familiar philosophical platitudes in response to hugely complex social emergencies, what might constitute a useful contribution? First, scholars in bioethics and health law should not assume that they have useful lessons to teach physicians, policy-makers and government agencies. It would be helpful for a collection of this sort to offer contributions from a number of different perspectives and professions. For example, a discussion of bioterrorism ought to provide some insight into the major potential sources of terrorism. Recognizing that terrorist acts are difficult to predict and anticipate — uncertainty and unpredictability are important components of terrorism — are there particular scenarios that deserve our attention as we develop professional, legislative, and organizational responses to terrorist threats? These are questions that bioethicists and humanities professors are not particularly well equipped to address; contributions from researchers working in conflict studies, international relations, or in national security agencies might provide insight into these matters. Second, discussions about preparation for terrorism are, in part, conversations about risk analysis and risk management. What terrorist-related acts ought to be uppermost in our minds as we develop antiterrorist legislation and emergency measures acts? What portion of funds ought to be allocated to preventing and responding to bioterrorism, for example, in relation to other threats to public health? If one goal of advance planning is to reduce rates of mortality and morbidity, how should planning for bioterrorism be weighed against other significant risks? Finally, what topics most deserve public consideration when deliberating threats posed by terrorism? Various contributors to In the Wake of Terror mention the need for seeking “public consensus” and promoting “transparency” in public deliberations. Unfortunately, they are much less explicit about the core social issues that ought to be at the very top of the list of matters requiring public deliberation and consultation. If In the Wake of Terror suffers from one salient weakness it is that too many of the contributors were permitted to ride their favourite hobby horses instead of addressing the new and profound challenges posed by terrorism. One might think that the events of Sept. 11, 2001, would lead American bioethicists to reconsider their intellectual priorities and recognize the importance of issues that have previously attracted the attention of foreign policy specialists, the intelligence community, and emergency care providers far more than bioethicists and health law specialists. Instead, too many contributors have been content to remain within the well-worn ruts of research ethics, organization ethics, and access to health care. After reading In the Wake of Terror, I am quite confident that if a bioterrorist attack ravages Los Angeles and San Francisco, and an earthquake sheers California away from the mainland, there will still be an ethicist willing to argue that the problem could have been prevented had all Americans had access to universal health care and biomedical research been better regulated. Leigh Turner Assistant Professor Biomedical Ethics Unit Department of Social Studies of Medicine McGill University Montreal, Que.

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