Paying the Ultimate Price:
Emergency Health Professionals Grapple
with Obligations During Crises

By Lisa A. Eckenwilder and Elizabeth O. Cooper

Their valiant images remain etched in our national consciousness. They are the firefighters, police officers and emergency medical workers who willingly jeopardized their lives to assist those trapped in the World Trade Center and the Pentagon following the September 11, 2001, terrorist attacks. Many of these emergency personnel made it to safety in the wake of their courageous endeavors; however, many others perished along with those they were trying to save.

These individuals have been rightly lauded as heroes. However, their experiences have also raised a wide range of ethical questions for health professionals in the context of crises, as well as in these times of preparation for the possibility of similar catastrophes in the future, according to Lisa A. Eckenwiler, an associate professor of philosophy at Old Dominion University. Eckenwiler began focusing on these issues in the wake of the September 11 attacks when she was invited to contribute an article for In the Wake of Terror: Medicine and Morality in a Time of Crisis (MIT Press, 2003). Her article looked at the ethical issues facing emergency health professionals in the event of a crisis. More generally, she argues that “biodefense and emergency preparedness initiatives raise an array of crucial questions about ethics for health professionals, ethicists and most importantly, citizens, to consider.”

An Old Dominion faculty member since 1997, Eckenwiler specializes in biomedical ethics or ethical issues that emerge in the life sciences, medicine, public health and health policy, with much of her work exploring ethical issues in clinical research. She recently spent two years on leave from the university to direct the Consortium to Examine Clinical Research Ethics at the Center for the Study of Medical Ethics and Humanities at Duke University. Eckenwiler will return to Old Dominion this fall where she plans to continue working in research ethics, as well as widen her scope. She is developing a book on the ethics of bioethics and is involved in several projects focusing on justice and care-giving for the elderly, as well as the ethical implications for public health arising from the current emphasis on bioterrorism preparedness.

Eckenwiler decided to pursue bioethics in the wake of the AIDS pandemic. “In college, I took a fabulous course that brought together a wide array of disciplines in the humanities and social sciences to help understand the rise of AIDS in the United States as well as the early response of the scientific, medical and public health communities,” she recalls. “Moral philosophy was the most compelling area for me to study as it is especially well suited to help us understand the value dimensions of practices and policies in the sciences, medicine and public health. More generally, philosophy helps us think through important questions in searching for a good life as individuals and communities, and in finding the best ways to organize our social and political institutions.”

Will National Issues Put Added Burdens on Public Health?
In addition to exploring ethical issues for emergency health professionals in a crisis, Eckenwiler is studying ethical issues concerning biodefense, emergency preparedness and public health.
“Public health is basically a utilitarian endeavor,” she says. “It aims at promoting as much good as possible and minimizing harm. The arguments behind current policy say that these initiatives will help to ensure health protection and strengthen public health infrastructure. Some hold, however, that the current policy focus on biodefense and emergency preparedness will accomplish little toward protection, will place health professionals in danger without protection, and over time, divert resources from urgently needed and proven public health endeavors and limit public health accomplishments.”

Eckenwiler adds that these issues are particularly relevant among those who believe that social justice is central to public health. Those who embrace a social justice perspective are most concerned about self-determination and equality. They insist that focusing on emergency preparedness will further burden the nation’s already weakened health system and exacerbate existing inequalities. “Under-resourced hospitals, nursing shortages and growing numbers of the uninsured are conditions with which the country’s health system is already contending,” she notes. “The worry for many people is that by vigorously pursuing these initiatives we may undermine the public’s health and perpetuate health disparities in the United States and worldwide.”

In addition, many health professionals and ethicists maintain that the ideals public health workers have pledged to support could easily become compromised as links are forged between public health and national security. “They question whether the climate of security — where research programs may be subject to scrutiny and data censored on the basis of national security concerns — will somehow tarnish the democratic commitment to open and independent inquiry and harm public health,” Eckenwiler says.

Who’s in Charge in a Crisis?
Under proposed revisions to federal and state public health laws, health professionals could be granted emergency powers to place people under quarantine. “Debates over whether law enforcement or public health officials should have authority in a health crisis with national security implications have raised concerns regarding the degree to which the roles of health professionals will become organized around the goals of law enforcement,” Eckenwiler notes. “They worry about violating people’s liberties, but they are also concerned about losing the public’s trust.”

Others question whether medical professionals harm health by participating in biodefense and emergency preparedness. They contend that such actions bolster military alertness, thereby perpetuating an arms race. “These concerns focus on social justice and the best strategies to exercise the collective moral agency of health professionals in the face of challenges posed by protectionist policies,” Eckenwiler adds.

Her current work explores the belief that policy surrounding biodefense and emergency preparedness can be best understood and evaluated by examining the relationship between ethics and assumptions made by policy-makers and others about social organization and how best to formulate knowledge for protecting the public from the health effects of terrorism. According to Eckenwiler, “Different understandings of how and why people engage in social cooperation combined with contrasting models for seeking knowledge generate different conclusions about what constitutes ethical policy.”

As for the United States’ emphasis on biodefense and emergency preparedness, proponents maintain that protection is the primary function. Eckenwiler notes that these advocates believe protection is essential because the country faces serious health threats from chemical, biological and a host of other weapons.

Expanded Role for Public Health?
“Health promotion is a secondary aim,” she adds. “Supporters argue that emergency preparedness initiatives will strengthen the public health infrastructure and enhance our understanding of the human immune system and advance capabilities to address toxicological disasters and new or re-emerging natural infectious diseases.”

According to Eckenwiler, under current policy, health professionals are asked to participate in activities, such as funding research on biological pathogens and potential medicines to combat those threats. They are also called upon to reshape the government’s health and security infrastructure and relationships between the government and pharmaceutical and biotechnology industries around security. In addition, health professionals have been asked to strengthen capacities for laboratories, perform surveillance, track pathogens and improve protection for food, water and agriculture, restructure communications systems, organize task forces and detail plans for emergency response.

Eckenwiler points out this protectionist approach assumes that the nation is rightly on the defensive and should prepare for future acts of aggression. It also assumes that pre-emptive aggressive action to deter threats is justifiable. She notes that social relationships are presumed to be hostile and shaped by suspicion, with protection needed from both outside aggressors as well as from insiders who might try to undermine security by expressing misgivings or concerns about policy-makers’ judgments. Another operative assumption is that citizens who benefit from living in a protective society tacitly consent to any measures deemed necessary by those in authority.

She adds that another interesting philosophical dimension of biodefense and emergency preparedness initiatives is a particular approach to developing knowledge (and the basis for policy). “With emergency preparedness, knowledge-seeking aims to control or contain terrorist-induced or other health emergencies. The stance that informs biodefense identifies biological pathogens or other toxins, unleashed by malevolent intruders as the cause of the ‘extreme events’ it hopes to control through integrating military, scientific and medical means.”

Other approaches in philosophy and public health might question these underlying philosophical commitments about social life and social cooperation and this model for knowledge-seeking, Eckenwiler notes. “They might suggest that we should more carefully assess the relationships between affluent nations such as the United States and those who would harm them. They might encourage us to try to understand the relationships between global economic structures that contribute to insecurity about financial systems in many countries, weakened democratic structures and processes, the erosion of cultural identity and political freedoms and the emergence of violence. They might call for cultivating and nurturing relationships with others and argue that social cooperation should be aimed at enhancing the capacities of people everywhere to realize equality and self-determination and to engage in vigorous debates about important issues such as the course of health and social policy.

“The architects of bioterrorism preparedness policy have been criticized for being reductionist for their understanding of the relationship between the health system and terrorism threats and for centering on ‘extreme events’,” Eckenwiler contends. “Some say they have generated narrow assessments of problems, and in particular, retreated from advances made in understanding the relationship between social structures and relationships and health.”

She says that critics of current policy believe that bioterrorism may well defy narrowly targeted scientific, medical or technological fixes. They see a role for health professionals in responding to terrorism by addressing social determinants of health around the world, which is not their role under present policy. “Many say, that because of its flawed assumptions about social organization and relationships, and what we need to know to protect public health from terrorists, present policy and practice surrounding emergency preparedness is not as ethical as it might be. If it isn’t likely to be effective in bringing protection or a stronger health system, and it threatens important ethical ideals, critics say it is not sound policy.”

Eckenwiler quickly adds that criticisms should be leveled with caution. “We need to be sure not to assume that the central problem is the presence of scientists or public health officials with bad intentions or bad characters. Sometimes this is true, but it is also important to consider specific assumptions about how society is and should be organized and how political and scientific institutions can undermine people’s abilities to act ethically and design health policy in a way most likely to protect and promote health in the United States and around the world.”