Collin Delaney, Staff Writer
A brief examination of the fiduciary, ethical, and professional paradigm shifts experienced by the health-care provider following the September 11th terrorist attacks.
As our nation recently observed the fifth anniversary of the September 11th attacks, one cannot help but reflect on the fundamental changes that have occurred since. Foreign and domestic policies have undergone watershed transitions, the effects of which are still being understood. Health-care in the United States, specifically the role of the health-care provider, is no exception.
Significant shifts have occurred and continue to occur in regard to how the government interacts, influences, and regulates health-care. New issues in medical ethics are now being vociferously debated. Even the day-to-day expectations of physicians and hospitals have seen marked change.
While certainly no one with any experience in health-care will classify the pre-September 11th period as simple, the inordinate complexity of health-care administration seems to be metastasizing at ever growing rates. Long gone are the Doogie days of introspectively typing one’s thoughts on the practice of medicine while basked in the green glow of a word processor.
I: Legislation
Considerable legislation has passed following September 11th which may mean significant changes for the health-care provider. The most visible piece of legislation with implications for health-care providers is the Uniting and Strengthening America by
Providing Appropriate Tools Required to Intercept and Obstruct Terrorism Act, better known as the USA PATRIOT Act. [2],[3]. A provision within the PATRIOT ACT, known as the First Responders Assistance Act, allows for significant portions of revenue to be directed, in the event of a terrorist attack, toward “first responders” namely, ambulance companies and hospitals containing emergency rooms. [4],[5].
The Public Health Security and Bioterrorism Preparedness and Response Act of 2002, more succinctly known as the Bioterrorism Act, has far deeper implications for health-care providers. [6],[7]. The Bioterrorism Act was a mammoth $4.6 billion dollar appropriation seeking to increase preparedness in the government and hospitals in the event of a bioterrorist event/public health emergency. [8]. With nearly $520 million specifically earmarked for hospitals, the act can be a vital increase in funding for hospitals struggling to meet government preparedness standards. However, such funding is not without caveat. The Bioterrorism Act brings significant increases in government intervention and oversight in regard to physicians and researchers who work with biological agents and toxins. [9]. It is far too early to tell if such measures are merely precautionary or have the potential to result in significant curtailment in free research and testing.
As anyone who has ever haggled over an insurance premium can testify, fiscal matters are paramount in the world of health-care. The impact of such monetary appropriations seen in the PATRIOT Act and the Bioterrorism Act cannot yet be fully appreciated. However, it is hardly conjecture to state that hospital administrators and physicians will feel the effects considerably.
II: Ethical Concerns
The issue of increased intervention and monitoring of research involving potentially deadly pathogens is not exclusive to governmental entities. The post-September 11th fear of bioterrorism has been an issue that the medical community has been struggling with internally as well.
Increases in technology have allowed advances in the field of virology to grow at unprecedented rates. [10]. There exists significant debate among physicians, researchers, and scientists regarding whether if the results and information of virology based research should be kept restricted and thus out of the hands of bioterrorists. [11]. The stakes on both sides are incredibly high. Those arguing against any limitation point to stunting the development of anti-viral vaccines for diseases such as HIV, SARS, and Ebola. [12]. Would it be worth delaying or compromising research with considerable life saving potential?
Conversely, the cost of human life could be staggering if a bioterrorist were able to convert sensitive viral research into a weapon.
One can certainly appreciate the considerable impasse the respective groups have reached. A sudden, and perhaps entirely unanticipated, ethical and real world quagmire now besets modern physicians and researchers. What might have been the noble pursuit to cure AIDS on September 10th has now been transformed into an increasingly perilous activity with Jack Bauer-esque implications.
III: Practical and Professional Changes
The post-September 11th world also means significant practical changes for the health-care provider. Of the many consequences of the terrorist attacks were the deep emotional and mental traumas experienced by the survivors and those who lost loved ones. [13].
Disproportionately high figures of Post Traumatic Stress Disorder (PTSD) and depression were recorded among residents of New York City following the September 11th attacks. [14]. It has been estimated that nearly 525,000 residents of New York City suffered from PTSD or depression following the attacks. [15]. Despite this, only 129,000 sought treatment. [16]. While there are myriad reasons as to why only a relatively small percentage sought out treatment, there are clear lessons that can be learned from such statistics. [17].
It has been strongly suggested that it is the primary-care physicians, the “go-to” doctors for families and individuals, need greater instruction in being able to identify and screen their patients for stress disorders and depression following terrorist events. [18]. As PTSD is a highly individualized affliction with systems that are not always easily identifiable, often those with the condition do not realize it. [19]. If primary-care physicians have the ability to identify these physiological ailments in their role as administrators of standard heath care, greater numbers of afflicted patients will be able to receive needed care. The potential need for increased training and education for current and future providers will play a role in redefining what day-to-day practice of medicine entails.
IV: What These Changes May Mean for the Post-September 11th Physician
The answer to the terrorist threat under our current administration seems to be one of increased governmental control at the cost of personal liberties. It is this author’s opinion that in the coming years, the health-care providers will experience significant reductions in professional freedom as the need to be able to respond to a terrorist-initiated public health crisis inversely increases.
As evidenced by the Bioterrorism Act, the government is assuming greater influence over the research and laboratory work involving pathogens. Additionally, through conditional money appropriations, the government’s public health subdivisions will be able to exercise increasing amounts of control over the administration of hospitals, both in and outside times of crisis.
Further support for this theory is found in the Center for Disease Control’s Model State Emergency Health Powers Act (Health Powers Act). [20],[21]. The Health Powers Act, enacted in whole or in part in thirty-eight states, reflects a significant curbing of civil and professional liberties in times of public health emergency. [22]. Elements of the act, relevant to physicians and hospitals, allow the government to revoke licensure for non-compliance in “assisting” with operations. [23]. The original wording of the bill, now amended, allowed for the criminal prosecution of health-care providers. [24].
Truly, the world of Joltin’ Doogie has left and gone away. [25]. The role of the hospital administrator and physician is substantially different than it was five years ago. The proposed need for stricter regulations governing the study of pathogens may have immediate consequences regarding how physicians are able to treat their patients. An increased appreciation for the mental health damage caused by terrorist acts may require that hospitals and physicians obtain a deeper understanding of traumatic stress disorders. Increased governmental pressures, both in funding and regulation, may serve to significantly limit professional freedoms previously enjoyed. Increases in governmental power can only come with the reciprocal abdication of power by physicians and hospitals. It is impossible to tell what exactly these changes will mean for the health-care provider in the coming years. What appears certain however, is that fundamental changes in how the administration of health-care is perceived will continue to occur as the United States attempts to grapple with the new world order ushered in by September 11th.
[1] Simon and Garfunkel, MRS. ROBINSON (Columbia Records 1968).
[2] Edward McArdle, 2001-2002 Survey of New York Law, 53 SYRACUSE L. REV. 629, 633 (2003),
[3] USA PATRIOT Act, Pub. L. No. 107-56, 115 Stat. 272 (codified in
sections of 18 U.S.C., 28 U.S.C., 50 U.S.C., 47 U.S.C., 22 U.S.C.,
and 31 U.S.C. (2001)) [hereinafter Patriot Act].
[4] McArdle, supra note 2, at 633.
[5] Patriot Act (codified at 28 U.S.C. 509 § 1005 (2001)).
[6] McArdle, supra note 2, at 633-634;
[7] Public Health Security and Bioterrorism Preparedness and Response Act of 2002, Pub. L. No. 107-88, 116 Stat. 594 (codified in sections in 42 U.S.C., 21 U.S.C., 29 U.S.C., 38 U.S.C. (2002)) [hereinafter BPRA].
[8] McArdle, supra note 2, 633-634.
[9] Id.
[10] See Robert A. Bohrer, Ethical Perspectives on New Ethical Dilemmas for Biotechnology, 760 PRAC. L. INST. 908-909 (2003).
[11] Id., at 912-913.
[12] Id., at 912.
[13] Gerry Fairbrother and Sandro Galea, THE CENTURY FOUNDATION, TERRORISM, MENTAL HEALTH, AND SEPTEMBER 11TH: LESSONS LEARNED ABOUT PROVIDING MENTAL HEALTH SERVICES TO A TRAUMATIZED POPULATION (2005),http://www.tcf.org/Publications/HomelandSecurity/911mentalhealth.pdf
[14] Id., at 15-16 (14% of respondents were found to have PTSD, depression, or both following the attacks. When respondents were limited to those in the vicinity of the attacks, the figure exceeds 20%).
[15] Id. at 28.
[16] Id.
[17] Id. at 35.
[18] Id. at 36.
[19] Fairbrother and Galea, supra note 13, at 36.
[20] Id.
[21] The Model State Emergency Health Powers Act: as of October 23, 2001. Atlanta: Centers for Disease Control and Prevention, 2001, http://www.publichealthlaw.net/MSEHPA/MSEHPA2.pdf. (last visited Sept. 13, 2006).
[22] PublicHealthLaw.Net, Model State Public Health Laws,http://www.publichealthlaw.net/Resources/Modellaws.htm#MSPHPA (last visited Sept. 13, 2006) (“Thirty-eight (38) states [AL, AK, AZ, CA, CT, DE, FL, GA, HI, ID, IL, IN, IA, LA, ME, MD, MN, MO, MT, NV, NH, NJ, NM, NC, OK, OR, PA, RI, SC, SD, TN, TX, UT, VT, VA, WI, and WY] and DC have passed a total of 66 bills or resolutions that include provisions from or closely related to the Act.”
[23] See George Annas, Bioterrorism, Public Health, and Civil Liberties, 346 NEW ENG. J. MED. 1337 (2002).
[24] Id. at 1337-40.
[25] Simon and Garfunkel, MRS. ROBINSON.