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From The New England Journal of Medicine

The terrorist attack on the World Trade left, which was followed shortly by the still-unsolved mailing of anthrax spores, brought about much soul-searching among workers in the field of public health. This self-examination has led to the creation of a literature on preparedness that seeks to identify the sources of threat and to respond appropriately. In the Wake of Terror is a collection of essays that look at the problem of preparedness from another angle: the implications for ethics and public health of the prospect of terrorism against the United States, whether in the form of massive, instantaneous casualties or bioterrorism. The subjects covered range from the controversial proposed law that would considerably expand the power of the government to investigate, detain, and curb those who supposedly pose a threat to public health, to the problem of triage after a terrorist attack, to the ethical obligations of clinicians -- including whether they have a duty to expose themselves to danger -- and to the nature of corporate responsibility in a world of terrorist threats. (See Figure.) A number of the assessments are surprisingly upbeat. Some authors see in the challenge posed by terrorism the means of realizing long-held goals for a transparent and accountable public health system, one that would be linked to an equitable distribution of health care resources. These hopes are perhaps best captured in the essay by Mills and Werhane, who discuss how the need for a population-based response to the threat of bioterrorism will overcome the obsession with cost containment in health care services. Other authors see an opportunity for a greater openness of and communication by the pharmaceutical industry and for a more rational approach to emergency health care for the poor. These optimistic possibilities, though, remain a footnote to the two most pressing ethical concerns terrorism poses for the public health: first, whether civil liberties are a means or an obstacle to addressing terrorism; and second, whether the war on terrorism is skewing public health resources away from the essential focus on disease prevention and toward civil defense. The second concern does not receive the sustained attention it deserves, especially given the shifting of resources in the domain of public health and the ethical questions raised by the stockpiling of smallpox virus and the proposed vaccination of health care workers against the disease. The questions related to civil liberties, on the other hand, are quite sensibly considered at length. The leading antagonists, Hodge and Gostin, who proposed a model law that would vastly expand the government's power in the face of broadly defined threats to the public health, and Annas, who makes the civil-liberties-based case against the model law, have their say. Bayer and Colgrove provide the historical context to show how a debate about public health and civil liberties that had once been considered to be resolved was in fact only suppressed during the early efforts to fight AIDS in the United States. And Childress, who does not even discuss the model law, provides the most illuminating perspective on this debate by showing, in an essay on triage, how dependent an effective governmental response to a biologic attack will be on the transparency of the government's actions and the public trust it has developed. The recent experiences with the severe acute respiratory syndrome (SARS), a disease that is not the result of terrorism (although it probably would have qualified as a public health emergency sufficient to trigger draconian measures under the model law), provides a reminder that threats to the public health are best resolved through aggressive and well-coordinated investigation, surveillance, and information sharing, and that our supposedly outdated laws have been sufficient to address this threat. The country that did the worst in dealing with the outbreak of SARS, China, used its limitless authority to suppress information, eliminate transparency, and undermine trust. Leonard S. Rubenstein, J.D.

Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS. --This text refers to the Hardcover edition.

Review

"This anthology on the bioethical implications of terrorism contains some superb contributions." - Ian Roberts, British Medical Journal"

"In the Wake of Terror establishes a scholarly beachhead in our thinking about ethics and the war on bioterrorism. In looking both forward and at important historical events, it offers lessons for how to avoid mistakes from the past, and how to apply thoughtful approaches in our efforts to confront the terrors of the future. The lessons in its chapters have a particular resonance at a time of heightened attention to homeland security, and are important for students, scholars, and policymakers alike."

—Jeffrey Kahn, Director, left for Bioethics, and Professor of Medicine, University of Minnesota

"In the Wake of Terror should be required reading for policymakers and scholars alike as we prepare and evaluate our responses to bioterrorism and other emergent crises of the twenty-first century destined to overwhelm our public health system. The scope and depth of the topics covered in this volume will serve as a crucial resource for anyone interested in understanding and critically assessing health policy and decision making in a time of urgency."

—Anna Mastroianni, University of Washington School of Law and Institute for Public Health Genetics

"From preparation to response to aftermath, a comprehensive and sobering look at the challenges for ethically sound research and health care in a time of terror."

—R. Alta Charo, Professor of Law and Bioethics, University of Wisconsin Law and Medical Schools

"It is impossible to do full justice (herein) to the rich and varied nature of...this collection."

— Jonathan Kahn, JAMA

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