The Ethics of Coercion in Mass Casualty Medicine

Preface

This book inquires about coercion in mass casualty medicine: What are its proposed uses? How are these justified? Which justifications are adequate? The term coercion here denotes the intentional use of a credible and severe threat of harm or force to control others. Mass casualty medicine denotes preparation for and provision of medical treatment or other health-preserving actions in mass casualty events or in situations in which large numbers of casualties will result unless there is quick and decisive intervention. Much of the preparation and implementation in mass casualty medicine (MCM), including proposed uses of coercion, occurs at the level of public policy and public health oversight. Hence, this book deals not only with clinical mass casualty medicine, in which medical services are rendered directly to victims, but also, and perhaps more importantly, with public policy and public health issues. Indeed, public deliberation about uses of coercion in MCM occurs predominantly at the policy-making level. When rescuers and clinicians encounter victims in the field, there is little time for individual deliberation—and the time for public deliberation typically has passed. Mass casualty events occur when large numbers of serious casualties (i.e., seriously injured or ill individuals), usually ranging in the thousands, generate overwhelming demands on local health care systems. Coercion is used in MCM when it is crucial that the public, or one of its subgroups, comply with directives that they cannot be trusted to follow voluntarily. Possible examples are (1) forced isolation and quarantine of ill or exposed individuals, (2) conscription of health care workers for service in MCM, (3) physical detainment of individuals who need to be decontaminated after a chemical or radiological exposure, (4) forced medical treatment or examination, (5) legal sanctions against those who attempt to acquire or distribute restricted medical treatments (such as the smallpox immunization), and (6) legal sanctions against those who publicly reveal restricted scientific information (such as the formula for a lethal chemical warfare agent). Each of these instances of coercion , and several others, are treated in this book. Preface The most common precipitants of mass casualty events are disasters such as hurricanes , earthquakes, tornadoes, chemical spills, explosions, nuclear events, and epidemics (though not all such disasters cause mass casualties). Among the most feared of these disasters are human-made, intentional disasters perpetrated, for instance, by terrorists wielding weapons of mass destruction. In the aftermath of the September 11 attacks and the subsequent anthrax attack in the United States, public concern over these threats is high, and there are large-scale efforts to develop workable prevention and response strategies. Hence, much of the discussion in this book focuses on intentional attacks and the complex political, public health, and medical structures that are emerging as we struggle to address them. On the other hand, the preparation for and response to natural disasters has hardly been perfected. As this book neared completion, Hurricane Katrina struck the Gulf Coast region of the United States, killing hundreds and causing massive social and economic damages —much of which was preventable, given better disaster preparations. A year earlier , warning systems proved inadequate as a tsunami in Asia produced far more staggering devastation. Hoping to preclude further debacles, politicians and other policy makers currently are spending billions of dollars to address the threat of a global avian influenza epidemic. In the effort to prepare for these natural disasters, many of the same coercive strategies and tactics discussed in the context of intentional disasters are now being proposed. Indeed, the increasingly familiar notion of “all-hazards” disaster preparation draws from the overlapping content in strategies designed for intentional disasters and those designed for natural disasters. We will find in the ensuing discussion that many intentional disasters bear more in common with analogous natural disasters than with other intentional disasters. In the end, factors such as the appearance of warning signs, the timing and duration of effects, lethality, transmissibility, and the threat to social structures are what matter most in gauging our preparation and response. The distinction between intentional disasters, accidents, and natural disasters is less important. Because this book focuses on crucial factors that pertain in the response to both intentional disasters and natural disasters, it should be useful for inquirers into both phenomena. It will also be of interest to readers with a general interest in public health ethics and/or public policy ethics, because coercion and its political legitimization are central to any discussion of these topics. The book is written...