Bioterrorism brings wave of dilemmas for hospitals

Informed decisions face an unknown threat

The recent massive preparations for a potential bioterrorist smallpox attack may radically change the way the nation’s health system is expected to respond to public health threats, at the same time ushering in a new wave of dilemmas for hospital ethics committees and administrators, say some policy experts.

Though the actual risk of a smallpox release is unknown, last month, hospitals from Boston to Butte were soliciting volunteer health care to serve as the nation’s massive first line of defense.

"It is definitely uncharted territory," notes Robert I. Field, JD, PhD, director of the graduate program in health policy at the University of the Sciences in Philadelphia. "There are questions about how likely a smallpox attack could be. It’s not the easiest weapon for a bioterrorist to use. Even if the people preparing it were themselves immunized, it could spread to those around them. It is less likely than some other threats. On the other hand, it seems more likely given the experience with the anthrax letters."

In the past, health care decision makers were often better able to balance the known risks of a health threat with the impact on the functioning of the health system. When it comes to bioterrorism in general, and smallpox in particular, no one knows the true likelihood of such an event. No one city or region seems more vulnerable than another.

Such factors significantly affect people’s ability to make truly informed choices, says Stephen Pauker, MD, MACP, associate physician-in-chief and vice chair of clinical affairs at Tufts-New England Medical Center in Boston.

"Ordinarily, people would make decisions [about being vaccinated] based on how they, as individuals, view themselves as likely to be exposed, or the likelihood of a smallpox epidemic, whether they will walk around being anxious about the possibility and would feel better if they were vaccinated," he explains. "Then, they would look at the risks of being vaccinated and whether the risk of developing a side effect is worth not having the anxiety of knowing you are walking around vulnerable to smallpox."

The problem, he notes, is that no one really has reliable information about either of those scenarios, he says. Given the history of the smallpox vaccine, the risk of complications would seem small.

But the vaccine has not been widely administered in many years and the incidence of skin conditions and other disorders that would make receiving the inoculation more risky has gone up. And no one can really predict how likely a smallpox attack is, he notes.

The lack of hard information about level of risks means most people will make their decisions about receiving the vaccine based on emotional factors, not scientific ones, he predicts.

The same holds true at the institutional level, he adds. Health care facilities have little reliable information about their potential for seeing smallpox cases compared to those in other areas. So they must balance their perception of the risk with how they feel the vaccine program will affect their ability to care for the patients they know they will have.

"We have to balance the ethics of the individual vs. the ethics of society," he says. "The epidemic will only spread if there are enough unvaccinated people. So, by my taking the risk of being vaccinated, I am making a contribution to society."

But what about the impact of inoculating a percentage of a hospital’s staff with a live-virus vaccine that poses risks to existing patients? Many hospitals are planning to reassign vaccinated health care workers for a certain period of time, and have contingency plans in case adverse reactions necessitate lost time from work. Given the strained staffing ratios and financial situations at many institutions, this is no small matter.

Some hospitals have chosen to not offer the vaccine to health care workers at this time.

"I think that is certainly a supported position," says Field. "Each hospital has to figure that out. It is a difficult question. You are weighing two different kinds of risks: one is a medical risk and one is more of a political risk. How do you compare one against the other?"

On top of the hospital situation, he notes, the massive vaccination campaigns are drawing public health resources away from combating naturally occurring diseases.

Local health departments already are predicting they will have to curtail existing programs unless they receive additional dollars to conduct the smallpox vaccine campaign.

According to a report in The New York Times, Jan. 4, health officials across the country indicate they have already spent most of the $940 million that Congress allocated last year for the Department and Health and Human Services bioterrorism preparedness programs, spending the money on programs to combat anthrax threats.

Programs such as cancer and tuberculosis screening and dental examinations for children will have to be cut back to pay for the smallpox vaccination programs.

"That is a bigger issue with biopreparedness. Are we compromising existing health needs?" he asks. "The fact is, we still face much, much larger threats from TB, AIDS, and the flu. It raises some questions about how we will place our bets."


  • Stephen Pauker, Associate Physician in Chief, Vice Chair for Clinic Affairs, Department of Medicine, Tufts-New England Medical Center, 750 Washington St., Boston, MA 02111.
  • Robert Field, Director, Graduate Program in Health Policy and Associate Professor of Health Policy, Univer-sity of the Sciences in Philadelphia, 600 S. 43rd St., Philadelphia, PA 19104.