Given that, globally, health professionals' involvement in
crises—especially complex crises where human action plays a
contributing role—has risen to new proportions,1
Bok S. The new ethical boundaries. In: Leaning J, Briggs SM,
Chen LC, eds. Humanitarian Crises: The Medical and Public Health
Response. Cambridge, Mass.: Harvard University Press,
1999:179–93.
emergency preparedness is an increasingly
integral capacity of health systems. As the United States has come to see
itself as vulnerable to violence, its leaders have begun to reorganize the
country's health system around protection from terrorism and other
health emergencies, upholding this as an essential element or
“indispensable pillar” in their strategy for securing the
homeland.
2 Nunn S. The future of public
health preparedness. Journal of Law, Medicine, and Ethics
2002;30:202–9. As well, see Baker EL, Koplan JP. Strengthening the
nation's public health infrastructure: Historic challenge,
unprecedented opportunity. Health Affairs 2002;21:15–27;
Gerberding JL, Hughes JM, Koplan JP. Bioterrorism preparedness and
response: Clinicians and public health agencies as essential partners.
JAMA 2002;287:898–900; U.S. Department of Health and Human
Services. News Release. HHS Fact Sheet. Biodefense Preparedness.
Public Health Emergency Preparedness “Transforming America's
Capacity to Respond.” April 2004; Office of the President.
Biodefense Fact Sheet: President Bush Signs Biodefense for the 21st
Century. April 2004. Available at
www.whitehouse.gov/news/releases/2004/04/print/20040428-6.html.
Biodefense and emergency preparedness have thus come to capture the
energies and expertise of nearly all health professionals and,
increasingly, to define the specific ends that organize their work.
3 In keeping with the World Health
Organization's definition of health systems as “all the
activities whose primary purpose is to promote, restore, or maintain
health,” I embrace a broad definition of health professionals here.
See World Health Organization. Health Systems: Improving
Performance. Geneva: WHO, 2000:5.
Here, I describe current initiatives in biodefense and emergency
preparedness and argue that we should take care to shine the moral light
on the epistemological commitments and assumptions about social life and
the terms of social cooperation that shape these efforts. Specifically, I
show how the policy surrounding biodefense and emergency preparedness
emerges from flawed models for understanding present threats to public
health and, with its particular conception of social relations and
cooperation, raises profound ethical implications for the organization of
society and health systems as well as for health professionals.
The current emphasis on biodefense and emergency preparedness also
provides an excellent focal point for efforts to explore the relationship
between epistemology and ethics and to help advance conversations about
public health ethics. Most discussions have focused on which one of
several candidates offers an ideal theoretical framework for public
health. Yet if the field is to embrace an ethical identity, there is
groundwork to do in epistemology.
The Makings of Biodefense
Health systems are teleological in that all energies and attentions
are organized around a particular end: a healthy public. Erected on a
“national vision of the role of public health as protector of the
entire community (against pathogens that could attack anyone),”4
Frist B. Public health and national security:
the critical role of increased federal support. Health Affairs
2002;21:117–30 at 118.
biodefense and related emergency
preparedness initiatives are based on the presumption that the country
faces certain violence and disorder from acts of terrorism.
5 Securing protection from harm is the
reigning purpose of social organization and cooperation on this
scheme.
This is essential, some say, because the United States does face
serious health threats from chemical, biological, and other weapons. From
this perspective, failure to prepare would “constitute a massive
malpractice error of omission on the part of public health and medical
authorities” (p. 719).6
Henretig F.
Biological and chemical terrorism defense: A view from the “front
lines” of public health. American Journal of Public Health
2001;91:718–719.
Health promotion enters in as a secondary
aim. Proponents argue that emergency preparedness initiatives will lend
strength to the public health infrastructure, enhance our understanding of
the human immune system, and advance capabilities to address toxicologic
disasters and new or reemerging natural infectious diseases.
7 Few dispute that attention to bioterrorism and other health
emergencies is justified. Still, many ethical challenges have been raised
in response to the emphasis on biodefense and emergency response. Critics
have taken issue with the proportionality of current efforts and lamented
cuts on crucial fronts of public health.8
Sidel V, Cohen HW, Gould RM. Good intentions and the road to
bioterrorism preparedness. American Journal of Public Health
2001;91:716–8; Sidel VW. Bioterrorism in the United States: A
balanced assessment of risk and response. Sidel VW, Levy BS. War,
terrorism, and public health. Journal of Law, Medicine &
Ethics 2003;31(4):516–23. Cohen HW, Gould RM, Sidle VW. The
pitfalls of bioterrorism preparedness: the anthrax and smallpox
experiences. American Journal of Public Health
2004;94(10):1667–71.
Questions about the ethics of research
under the threat of bioterrorism, and in the wake of emergency the
allocation of resources in crisis, and acceptable limits of public health
paternalism have generated vitriolic discussions.
9 For discussions of several crucial ethical issues, see Moreno
JD, ed. In the Wake of Terror: Medicine and Morality in a Time of
Crisis. Cambridge, Mass.: MIT Press, 2003.
Yet it is also worth exploring more basic underpinnings, or underlying
assumptions of emergency preparedness policy, for what they reveal about
its architects' model of knowledge seeking and their conception of
social organization. In particular, how might we describe the epistemic
orientation reflected in these protectionist health policies? What
conception of society—of relationships and social
cooperation—prevails under such policy initiatives? And what, most
importantly, are the ethical implications—for the public, the health
system, and health professionals—of these guiding philosophical
commitments?
Epistemological Leanings
It is possible to describe key elements of the quest to quell
terrorism that, combined, reflect a distinctive epistemic orientation. A
first feature is that knowledge seeking aims at control or, at minimum,
containment of terrorist-induced or other health emergencies. As well, the
epistemic stance that gives us biodefense identifies biological pathogens
or other toxins unleashed by “evil” intruders or “small
groups of fanatics”10
as the cause of the “extreme events”
11 See Mitka M. Bioterror exercise tests agencies' mettle.
JAMA 2003;289:2927–8; Inglesby TV, Grossman R, O'Toole
T. A plague on your city: Observations from TOPOFF. Clinical
Infectious Diseases 2001;32:436–45; Shenon P. Terrorism drills
showed lack of preparedness, report says. New York Times 2003 Dec
19.
it hopes to control. Control and/or containment can be
obtained, on this model, through integrating military, scientific, and
medical means.
Health professionals' efforts in recent months serve as the best
evidence of this epistemic disposition. Many find themselves working to
secure funding from the “war chest” set aside by the federal
government for research on biological pathogens and medical
countermeasures.12
Enserink M. One year
after: Hunt for NIH funds fosters collaboration. Science
2002;297:1630–1; Malakoff D. Protecting the homeland sets tone for
2004 budget. Science 2003;299:806–8; Fauci AS. Biodefense
on the research agenda. Nature 2003;421:787.
Public
health agencies, academic health centers, and physician specialists have
organized task forces and defined competencies for readiness and have
established protocols for emergency response.
13 American Hospital Association, Office of Emergency
Preparedness, Department of Health and Human Services. Hospital
Preparedness for Mass Casualties. Chicago: AHA, 2000; Centers for
Disease Control and Prevention (CDC). Biological and chemical terrorism:
Strategic plan for preparedness and response. Recommendations of the CDC
Strategic Planning Workgroup. MMWR Morbidity and Mortality Weekly
Report Apr. 21, 2000;49:1–14; CDC. State Emergency
Preparedness and Response Inventory. Atlanta, Ga: CDC; February 2002.
Available at:
http://becker.wustl.edu/bt/stateinventory.pdf. Accessed
April 13, 2004; Perry RW, Lindell MK. Preparedness for emergency response:
Guidelines for the emergency planning process. Disasters.
2003;27:336–50; Association of State and Territorial Health
Officials (ASTHO). Bioterrorism Preparedness. Available at:
www.astho.org/?template=1bioterrorism.html. Accessed April 2, 2004;
Fraser MR, Fisher VS. Elements of Effective Bioterrorism Preparedness:
A Planning Primer for Local Public Health Agencies. National
Association of County and City Health Officials (NACCHO). Available at:
http://www.naccho.org/files/documents/final_effective_bioterrism.pdf.
Accessed April 2, 2004; National Association of County and City Health
Officials. NACCHO Responds to Bioterrorism. Available at:
http://www.naccho.org/files/documents/responds_to_bioterrorism.html.
Accessed April 2, 2004; American Medical Association. Disaster
Preparedness. Available at
www.ama-assn.org/go/DisasterPreparedness. Accessed April 2, 2004;
Rubin ER, Osterweis M, Lindeman LM, eds. Emergency Preparedness and
Beyond. Washington, DC: Association of Academic Health Centers, 2002;
American College of Emergency Physicians. Positioning America's
Emergency Health System to Respond to Acts of Terrorism. Available
at: www.acep.org/1,4634,0.html. Accessed April 2, 2004; American
Academy of Pediatrics. AAP task force on terrorism to help prepare
pediatricians for disaster response. AAP News 2002;20:4; American
College of Surgeons. Disasters from Biological and Chemical
Terrorism—What Should the Individual Surgeon Do? A Report from the
Committee on Trauma. Available at:
www.facs.org/civiliandisasters/html. Accessed March 23, 2004;
Lillibridge S. New developments in health and medical preparedness related
to the threat of bioterrorism. Pre-hospital and Emergency Care
2003;7:56–8; Snyder JW. Role of the hospital-based microbiology
laboratory in preparation for and response to a bioterrorism event.
Journal of Clinical Microbiology 2003;41:1–4.
Education in emergency preparedness—with emphasis on bioterrorism
and weapons of mass destruction—currently constitutes part of the
preferred curriculum for medical students and other health professionals
in training.
14 Association of American
Medical Colleges. Training Future Physicians about Weapons of Mass
Destruction: Report of the Expert Panel on Bioterrorism Education for
Medical Students. Washington, DC: AAMC, 2003. Available at:
www.aamc.org/newsroom/bioterrorism/. Accessed April 1, 2004;
Waeckerle JF, Seamans S, Whiteside M, Pons PT, White S, Burstein JL,
Murray R. Task Force of Health Care and Emergency Services Professionals
on Preparedness for Nuclear, Biological, and Chemical Incidents. Executive
summary: developing objectives, content, and competencies for the training
of emergency medical technicians, emergency physicians, and emergency
nurses to care for casualties resulting from nuclear, biological, or
chemical incidents. Annals of Emergency Medicine
2001;37:587–601; New academic centers for public health preparedness
funded. Public Health Reports 2002;117:592; Agency for Healthcare
Research and Quality. Training Clinicians for Public Health Events
Relevant to Bioterrorism Preparedness. Available at:
www.ahqr.gov/clinic/tp/biotrt.htm. Accessed March 15, 2004;
Filoromo C, Macrina D, Pryor E, Terndrup T, McNutt SD. An innovative
approach to training hospital-based clinicians for bioterrorist attacks.
American Journal of Infection Control 2003;31:51114; Veenema TG.
Chemical and biological terrorism preparedness for staff development
specialists. Journal of Nurse Staff Development
2003;19:218–25; Torne CD, Curbow B, Oliver M, al-Ibrahim M,
McDiarmid M. Terrorism preparedness training for nonclinical hospital
workers: Empowering them to take action. Journal of Occupational and
Environmental Medicine 2003;45:333–7.
Many health
professionals have found themselves serving as participants in (highly
controversial) studies of the smallpox vaccine.
15 Stephenson J. Smallpox vaccine program launched amid concerns
raised by expert panel, unions. JAMA
2003;289:685–90.
Some are redesigning public health
statutes and forging new links with law enforcement,
16 Center for Law and the Public's Health. Available at:
www.publichealthlaw.net. Accessed March 13, 2004; Noji EK. Creating a
health care agenda for the Department of Homeland Security. Managed
Care 2003;12(11 suppl.):7–12.
whereas others are
reconstituting economic and strategic relationships between the
nation's health system, government, and the pharmaceutical and
biotechnology industries.
17 Malakoff D.
Congress homes in on new department's R & D programs.
Science 2002;297:912–3; Bioshield Initiative
www.whitehouse.gov/news/releases/2003/01/20030128-19.html);
Public Health Threats and Emergencies Act of 2000 (P.L. 106-505); Public
Health Security and Bioterrorism Preparedness and Response Act (P.L.
107-188); Bioterrorism: A new frontier for drug discovery and development.
IDrugs 2003;6:773–80.
Social Organization and Cooperation
Delving still deeper, we find that the architects of biodefense
combine this epistemic disposition that aims at control or containment of
calamities with a specific conception of social life and social
cooperation. To the extent that its primary organizing principle is
security, the nation stands in a defensive posture, with leaders
organizing its political, economic, and other capacities around preparing
for future acts of aggression. The need for protection under this
defensive posture has even been offered as a justification for taking
preemptive aggressive action.
Protection from outside aggressors is central to this scheme. Yet also
important is protection from members of the state who might threaten to
undermine security. A second assumption, then, is that social
relationships are construed as presumptively hostile and shaped by
suspicion. Repeated emphasis on the threat of “deliberately
introduced pathogens”18
Anthony Fauci,
Director, National Institute of Allergy and Infectious Disease, quoted in
Hampton T. Biodefense research. JAMA 2003;290:2117. As well, see
O'Toole T. Emerging illness and bioterrorism: Implications for public
health. Journal of Urban Health 2001;78:396–402.
and requests for citizens to report on suspicious activities, for
instance, reveal the hold that this view of social relations has in the
current context.
A third feature of protectionist schemes is that those who benefit
from living in a protected society do not need to give explicit consent to
the terms of social cooperation or to any measures deemed necessary by
those who provide protection in exchange.
How rich is the epistemic orientation that yields biodefense and
related emergency preparedness initiatives and upholds them as priorities
for public health? How well does the conception of social life and
cooperation reflected here fare under closer ethical scrutiny?
Rethinking Ties between Terrorism and
Health: Social Epidemiology and Ecological Knowing
Contemporary work in moral epistemology and social epidemiology can
give guidance in these policy inquiries. Social epidemiology and, in
particular, ecosocial theories in public health integrate biological and
ecological analysis and understand health and disease as being, to a
significant extent, socially produced. That is, they understand population
health and well-being as biological expressions of social relations. They
also take it as given that social relations influence our understandings
of biology and health and our constructions of health and disease.19
Krieger N. Theories for social epidemiology in
the 21st century: An ecosocial perspective. International Journal of
Epidemiology 2001;30:668–77.
Key elements include a
focus on how we biologically incorporate the material and social world and
how this—which is also tied to exposure, susceptibility, and
resistance—is shaped by social relations of power and patterns of
production, consumption, and reproduction. Analysis of these
interrelationships occurs at all levels—individual, group, and
international.
These approaches are critical of and aspire to replace epistemological
models that aim to isolate parts of nature and that serve to obscure
“the constitutive part played by multiple and complex
interconnections” (p. 9)20
Code L.
Knowing ecologically: Remapping the epistemic terrain. Address to the
American Philosophical Association, December 2002.
Unpublished.
models that are deemed reductive and mechanistic.
Modern medicine, and more recently public health—with its molecular
turn—provide ripe environments for a reductionist approach to
understanding and responding to terrorism and other health threats. Yet
according to ecosocial theorists in moral philosophy and public health,
richest in explanatory power are epistemic models that move back and forth
between diverse subject areas, histories, and relationships (biological,
social, economic, political), studying complex interactions among them and
resisting simplistic, singular accounts of causation and control. This
epistemological orientation has been described separately by one
contemporary moral philosopher as “ecological knowing.”
21 The approach underlying
emergency preparedness policy, in this view, represents a methodological
myopia if not an outright retreat from advances in public health and moral
epistemology.
Another notable feature of this disposition is that it reckons
explicitly with the influence of knowers' surrounding social context
and relationships, especially with the subject of inquiry. Stated
differently: a knower's “situation is not just a place from
which to know…. Situation is itself a place to know whose
intricacies have to be examined for how they shape both knowing subjects
and the objects of knowledge” (pp. 10–11).22
From these models, a quite different
picture emerges from the one that focuses principally on eradicating or
mitigating damage wrought by catastrophic events brought on by angry
intruders.
Rendering the richer assessment available from an ecological model,
Vandana Shiva argues that “[t]he war against terrorism
will not contain terrorism because it does not address the roots of
terrorism” (p. 160).23
Shiva V.
Globalisation and Talibanisation. In: Hawthorne S, Winter B, eds.
Aftershock: September 11, 2001: Global Feminist Perspectives.
Vancouver: Raincoast Books, 2003:159–60.
She suggests that
understanding and responding to terrorism calls for attending closely to
the relationships between global economic structures that contribute to
insecurity about systems of production and jobs in many countries,
weakened democratic structures and processes, the erosion of cultural
identity and political freedoms, and the “reactions” of
“angry young men.” In her view, “
‘the ecology
of terror’ [emphasis mine] shows us the path to
peace. Peace lies in nourishing democracy and nurturing diversity”
(p. 160).
24 This epistemic orientation, then, would call for policy initiatives
that aim to understand and address the social and political determinants
of the health threat represented by terrorism. Such initiatives would
reflect a deep understanding of the relational nature of terrorism, that
is, the relationships between affluent nations such as the United States
and those who would do them harm.
Notable too is the link between this epistemic disposition and a model
of social cooperation that sees people as situated or embedded in
relationships of various kinds (biological, cultural, social, economic,
and political) and centers around cultivating and nurturing these. The end
of social organization and cooperative efforts in this scheme is enhancing
the capacities of people everywhere—above all the least
advantaged—to determine their actions and the conditions of their
actions and to flourish in conditions of relative equality. The promotion
of social justice is the proper role of public and other health
professionals in resisting terrorism and protecting and promoting health
more generally.
From the perspective of methods in social epidemiology and work in
moral epistemology, then, the epistemic orientation underlying emergency
preparedness policy is reductionist in generating assessments of what
threatens public health and, in turn, narrowly targeted scientific,
medical, and technological fixes. The accompanying understanding of the
terms of social cooperation presents a narrow and distorted view of social
relations and the ends of social organization. All told, in this analysis
it appears that current approaches fail to generate an adequate account of
the terrorist threat and an effective health policy response. It also
seems there are troubling implications for justice in a global
context.
Concerns of social justice arise on the domestic front as well. Under
the influence of this epistemic disposition and conception of the ends of
social cooperation, resources stand to be diverted from urgently needed
prevention and health promotion endeavors, from already underresourced
hospitals, nursing, and other health professional shortages, and from the
growing population of underinsured or uninsured. Early evidence suggests
that this is not mere conjecture.25
Smith S.
Anthrax vs the flu: As state governments slash their public health
budgets, federal money is pouring in for bioterrorism preparedness.
Boston Globe 2003 Jul 29; Public health spending decreasing while
anti-terrorism funds swell. AP State and Local Wire 2004 Jan 6;
Staiti AB, Katz A, Hoadley JF. Has Bioterrorism Preparedness Improved
Public Health? Center for Studying Health System Change. Issue brief
65, July 2003. Available at:
http://www.hschange.com/CONTENT/588/. Accessed April
14, 2004.
Biodefense and spending for emergency preparedness,
therefore, could serve to undermine the nation's health and
perpetuate or worsen health disparities.
The evolving relationship with military and law enforcement officials
and the mingling of objectives from these divergent fields under the
current policy are other areas of mounting ethical concern. Allegations
about how the FBI and military officials' secrecy may have hindered
the CDC's investigation and, in turn, the swift and effective
response to the anthrax-laced letters are especially poignant
examples.26
Siegel M. The anthrax fumble.
The Nation 2002 Mar 18:14,16,18.
Most recently, health
professionals have found frustration with Department of Defense officials
over a study on the anthrax incidents that was censored for 2
years—and that is still not available in its entirety—on the
basis of national security.
27 Heyman D.
Lessons from the Anthrax Attacks: Implications for US Bioterrorism
Preparedness. Unpublished report. April 2002. Available at:
www.fas.org. Accessed March 29, 2004; Miller J. Censored study on
bioterror doubts US preparedness. New York Times 2004 Mar
29.
Feeling thwarted in their capacities to uphold their
commitment to protecting the public (and themselves) in environs
increasingly organized around national security is thus a major form of
ethical distress facing health professionals.
The integration of health protection and promotion with law
enforcement and national security creates particular tension for health
researchers. Involvement in biodefense-related research—which has
seen an increase in resources from $53 million in 2001 to $1.6 billion in
2004—is seen by some as compromising their commitment to health
promotion. They worry that work aimed at “security” and
carried out under the guise of biothreat agent analysis and assessment
ultimately constitutes participation in an arms race and may ultimately
violate hard-won international agreements like the Biological Weapons
Convention.28
Cohen HW, Gould RM, Sidel V.
Bioterrorism initiatives: Public health in reverse? American Journal
of Public Health 1999;89:1629–31.
Allied with the
criticism that the prevailing epistemic model fails to generate an
adequate account of the origins of terrorism and effective response
strategies, there is concern that research aimed at national security may
ultimately heighten the risks of harm to public health.
Liberties figure prominently among the ethical ideals at stake in the
unfolding of emergency preparedness policy. Recall that a third assumption
concerning the terms of social cooperation in protectionist states is that
those who benefit from living in them do not need to give explicit consent
to the emphasis on security or to any measures deemed necessary by those
who provide protection in exchange. These can include sacrifices of
liberty. Reflection and debate here, for example, can become construed as
expressions of ingratitude and, at worst, harmful impediments given the
apparently imminent nature of the threat.
There are surely several examples we might draw from. Yet this view
manifested itself most clearly in debates regarding the smallpox
vaccination program. Some supporters expressed contempt for those who
raised questions about or rejected it altogether. There are, they argued,
“moral and medical reasons to deplore the decisions of physicians
and hospital officials who opt[ed] not to participate….
Their job is not to assess intelligence risks or second guess public
health officials.”29
Connolly C. Two
hospitals refuse call to vaccinate workers. Washington Post 2002
Dec 18.
Such contempt serves to undermine the ideals integral to a liberal,
pluralist society, chiefly the right to protect one's bodily
integrity and free expression. The willingness to stifle debate and defer
to “experts” in authority also shows disdain for entertaining
alternative positions that could help generate knowledge that contributes
to policy.
Finally, at times the call to support biodefense and emergency
preparedness initiatives has even taken on religious dimensions. Take the
following remarks by President Bush to first responders in South
Carolina:
You know, the evil ones hit us…. We knew they were
evil…. [W]e will stand squarely in the face of the evil
ones who did not understand … who they were attacking. Out of the
evil will come a more lasting peace if we're tough and firm. And out
of the evil will come … renewal.30
See note 10, Remarks by Pres. Bush to First
Responders.
It thus might seem that the terms of social cooperation include
particular religious commitments.
Invoking religious concepts to some suggests that an emergency
preparedness emphasis in public health has divine sanction and is thus
necessary and inevitable. Beyond suggesting that there is no need for
discussion and debate—a subtle but salient suggestion that could
threaten free expression and democratic debate—it can communicate a
message that to engage in this would constitute not just ingratitude, but
a blasphemous affront. Such appeals are also troubling from an ethical
perspective for their associations of religious ideals with public health,
a field rightly free in a secular state from religious affiliation.
After exploring its epistemic commitments and assumptions about social
life and social cooperation, biodefense and emergency preparedness policy
initiatives seem ill suited to understand and address terrorism and other
threats to health and quite likely to compromise critically important
ethical ideals. The epistemic models and conceptions of social cooperation
found in social epidemiology and contemporary work in moral
philosophy—described by some in terms of “ecological
knowing”—are better equipped to generate justified true belief
concerning the nature of terrorism's threats and health policy that
is more ethically defensible.
These conclusions suggest a need for vigorous debate on the course of
current policy.
Reckoning with the Need for Emergency
Response
Although we should strive to design policy that gets at “the
roots” of terrorism and that has greater potential for promoting
ethical ideals (or at least less likely to tarnish them), it will still be
necessary to enlist health professionals in emergency preparedness.
Although decisions on the proper definition of “readiness”
must continue, current evidence suggests that protective equipment,
personnel, facilities, and information on past experiences with
bioterrorism are lacking.31
See note 28,
along with the following: Clarke RA, Metzl JF, Rudman WB. Emergency
Responders: Drastically Underfunded, Dangerously Underprepared.
Washington, DC: Council on Foreign Relations, 2003; Jackson BA, Peterson
DJ, Bartis JT, LaTourrette T, Brahmakulam IT, Houser A, Sollinger JM.
Protecting Emergency Responders: Lessons Learned from Terrorist
Attacks. Santa Monica, CA: RAND, 2002; LaTourrette T, Peterson DJ,
Bartis JT, Jackson BA, Houser A. Protecting Emergency Responders. Vol.
2, Community Views of Safety and Health Risks and Personal Protection
Needs. Santa Monica, CA: RAND, 2003. Terrorism preparedness in state
health departments—United States, 2001–2003. MMWR
Morbidity and Mortality Weekly Report Oct 31, 2003;52:1051–3;
CDC. Assessment of the epidemiologic capacity in state and territorial
health departments—United States, 2001. MMWR Morbidity and
Mortality Weekly Report Oct 31, 2003;52:1049–51;
Chemical-terrorism preparedness—Public health laboratories found
unprepared and overwhelmed. Journal of Environmental Health
2003;66:35–6; U.S. General Accounting Office (USGAO). Severe
Acute Respiratory Syndrome: Established Infectious Disease Control
Measures Helped Contain Spread but A Large Scale Resurgence May Pose
Challenges. Pub. no. GAO-03-1058T. Washington, DC: USGAO, July 2003;
USGAO. Hospital Preparedness: Most Urban Hospitals Have Emergency
Plans but Lack Certain Capacities for Bioterrorism Response. Pub. no.
GAO 03-924. Washington, DC: USGAO, August 2003; USGAO. Public Health
Preparedness: Response Capacity Improving but Much Remains to Be
Accomplished. Pub. no. GAO 04-458T. Washington, DC: USGAO, February
2004.
This presents great concerns for health professionals,
especially those who would serve as first responders, given pervasive
expectations that they come forward to serve in a crisis. Indeed, along
with (at times religiously inspired) calls from the nation's leaders,
legal obligations and ethics codes compel health professionals to confront
danger.
32 It appears that requirements and entreaties for health professionals
to face the grave dangers presented by bioterrorism or weapons of mass
destruction fail to meet the ethical principle of proportionality. The
expertise of health professionals would bring great benefit to public
health in a disaster. But absent adequate resources, health
professionals' capacities to protect their own bodily integrity in a
crisis is severely impaired. This in turn poses serious risks for the
public's health.
Taking a broad view, sustained financial support for strengthening the
health system and its personnel has not been a priority for policymakers.
This has contributed to an overburdened health system and an inadequate
pool of available health professionals as well as difficulties in
recruiting.33
Institute of Medicine. The
Future of the Public's Health in the 21st Century. Washington,
DC: National Academies Press, 2003. For a valuable historical perspective,
see Fee E, Brown TM. The unfulfilled promise of public health:
Déjà vu all over again. Health Affairs
2002;21:31–43.
Along with these largely economic concerns,
social norms greatly undervalue caregiving work. This is now widely
acknowledged by advocates for emergency preparedness policy. Yet expecting
that health professionals will face danger for the sake of others without
sustained financial support for the public health system and long-term,
definitive strategies for shifting social norms toward heightened respect
for caregiving risks exploitation. Even if they agree to heed the call to
come forward in crises, with a weakened health system there can be little
assurance that their efforts would prove effective.
Conclusion: Epistemology and Applied
Ethics
The ethical implications of various choices for policy and practice
can only be fully appreciated when we scrutinize the origins of social
policy—its underlying epistemological orientations and
understandings of social life. I have considered only one example, yet one
might imagine how keen attention to epistemic concerns would strengthen
our capacity to understand and respond more effectively and ethically to
other contemporary challenges. The opportunity for moral engagement comes
in exploring relations between social and institutional norms,
assumptions, and processes—above all those involved in the pursuit
of knowledge—and ethical (or unethical) practices and policies in
public health. The critical point for conversations in public health
ethics, then, is to recommend that the field explicitly embrace an
epistemological orientation that serves to enhance rather than undermine
understanding.
Among the usual suspects for a guiding ethical framework in public
health—principlism, communitarianism, virtue ethics, social justice,
and human rights34
Beauchamp DE, Community:
The neglected tradition in public health. In: Beauchamp DE and Steinbock,
eds. New Ethics for the Public's Health. New York: Oxford
University Press, 1999:57–67; Kass NE. An ethics framework for
public health. American Journal of Public Health
2001;91:1776–82; Mann JM. Medicine and public health, ethics and
human rights. In: Beauchamp and Steinbock, eds., 83–93;
Rodriguez-Garcia R, Akhter MN. Human rights: The foundation of public
health practice. American Journal of Public Health
2000;90:693–4.
—social justice is most compatible with
social epidemiology's methods and moral epistemology's
“ecological knowing.” A full defense of this claim is beyond
my scope here. Yet a conception of social justice that shines the moral
light on social and institutional norms and processes and economic
structures to determine how these shape people's capacities for
development and self-determination and equality holds promise in this
respect. It rests on similar conceptions of persons, social relations, the
ends of social organization, and moral reasoning. Indeed, moral reasoning
in this conception of social justice devotes attention to particularity or
contextual features (and relationships among them) that function to
enhance or undermine people's prospects for achieving this and other
ethical ideals in the course of a good life. Such approaches seem best
disposed to generate a richer understanding of the social realities that
public health interventions should address and produce policy that is
ethically defensible. Future work at the intersections of epistemology and
ethics in public health is surely warranted.
