Medical Ethics

Lecture 2, Sept. 12, 2023 Fall Semester

Professor Silberman
 “Show and Tell”,

 “Newly Found Viruses, Hints to Covid Origins;

 Coronaviruses discovered in Laotian bats adept at

infecting human cells;
 Scientists went to Laos catching bats thought to be
cousins of the pathogen;
 Mist nets, canvas traps, snagged bats coming out of caves;

 Gathering of saliva samples, urine, feces.

 Coronavirus Found

 Fecal samples positive for coronavirus;

 Three of coronaviruses unusual, they carried molecular

“hook” similar to virus causing Covid-19;
 This hook can latch on to human cells;

 Under right circumstances, these unusual viruses could

also turn into a pandemic.
 Origins As to Current Pandemic

 New finding suggest that a natural spillover from an

animal could have caused coronavirus in humans;
 Discounts the failed lab or maverick lab concept;

 Bat viruses also discovered in Cambodia, China, Thailand,

scientists concentrate on these strains and where to look;
 U.S. announced $125M project identifying thousands
viruses Asia, Latin America, Africa determine spillover risk.
 First SARS-CoV2

 Closest relative, 2016 bat coronavirus Chinese researchers

found in a mine in China’s Yunnan Province;
 Called, RaTG13, shared 96% genome with SARS0CoV-2;

 Scientists estimate RaTG13 and SARS-CoV2 share common

ancestor infecting bats 40 years ago;
 “Receptor-binding domain, the hook latches on to bat cells
clings weakly to human cells”;
 SARS-CoV-2’s hook clasps to cells in human airway potential
lethal dose of Covid-19.
 Coronavirus, Also From Pangolins

 Researchers went to Laos, 150 miles from mine where

Chinese researchers found RaTG13;
 645 bats caught, 45 species, bats had 24 types of
coronaviruses;
 Three of 24 similar to SARS-CoV-2 with receptor-binding;

 Close matches, 16 of 17 building blocks of the virus

identical to SARS0CoV-2.
 Next Steps

 Blood samples taken from Laotian workers who gather bat

guano for a living;
 These workers carried immune markers, antibodies similar
to the virus;
 Linfa Wang, molecular virologist, Duke Medical school ,
Singapore, says infection possible;
 Says new viruses can attach to protein on human cells,
ACE2, “these guys are dangerous.”
 Virus Hybrids Possible

 Infected bat can be infected with a second virus;

 Then, two different viruses can end up in a single cell at

once;
 Genes become shuffled together, producing new virus
hybrids;
 Laotian coronaviruses gene shuffling gave receptor-
binding domain similar to SARS-CoV-2.
 Gene Shuffling

 Now being studied on past viruses;

 Called “recombination”-may be reshaping viruses year to year;

 Concentrating on Southeast Asia including site in Laos and

mine in Yunnan;
 U.S. project called, DEEP VZN, Vietnam area where research
will look;
 Other scientists feel virus hunt could cover vast more territory
in Asia.
Nature Calls, Beware of Bats
Bats In Outdoor Toilets
 New Discovery

 Recombination caused coronavirus in dogs in Malaysia;

 Result was a hybrid infecting eight children;

 Colin Carlson, biologist Georgetown;

 “When a coronavirus, that was monitored for decades,

that we think of as only our pets can get, can make the
jump—we should have seen that coming, right?
 Thoughts? Scary and/or the way to conduct research.
 Show And Tell

 North Korea accused of using VX (nerve gas) for killing

stepbrother of country’s leader;
 Why use of nerve gas extremely risky;

 Kim Jong-Nam died about 20 minutes after VX poisoning;

 VX considered most toxic nerve agent ever produced;

 UN weapon of mass destruction, paralyzes nervous

system, kills by suffocation half hour after exposure.
 VX (cont’d)

 Surveillance cameras captured moment Kim’s face was

wiped allegedly with the VX;
 Kim fell ill died at airport after two women wiped his face
with VX nerve agent;
 VX—extremely toxic, odorless, tasteless liquid with
brownish color formerly used in chemical warfare fatal
through direct skin contact or inhalation.
 Agenda

 Examine cyber issues related to healthcare;

 Ethical challenges, personal enhancement through drugs,

how perspectives change depending on the circumstances;
 Analyze critical issues related to personal enhancement
within a defense or battle space perspective.
 The Electronic Cyber Threat To
Healthcare

 Vulnerability of governments, non-government

organizations and individuals from cyber attacks;
 Electronic attacks originate from either individual cyber-
criminals or nation-backed operators;
 Recent cyber attacks originate from leveraging connectivity
of objects, the “Internet of Things (IoT);
 Attacks take form of advanced persistent threats (APTs),
dedicated denial of service (DDOS), malware infections,
cyber espionage, data and intellectual property theft.
 The Harm Potential

 Potential of significant harm, affects multiple

organizations, government, private sector including direct
attacks to healthcare institutions, pharmaceutical
corporations, and university research;
 Serious consequences to healthcare subject to electronic
attack for example, hacked MRI machines, robot assisted
surgical devices, or compromise of medical records.
 More Vulnerabilities

Healthcare organizations lack resources, processes and

technologies to protect themselves—they spend 3% vs. 10%
norm;
 Healthcare records, a treasure trove of accessible information;

 Why, because individual personal information, credit card

information, and protected health information (PHI) are
accessible in one place;
 FBI claims credit card information may be worth $5, but PHI
goes from $20 and up on the Dark Web.
 Reality Of Healthcare Cybercrime

 Due to IoT “connection”--software and hardware to the

Internet, possibility for cyber criminals to actively exploit
institutions’ systems is a waiting target;
 Ironically, progress expanded potential for compromise;

 Last decades, became aware of drive to digitize all records

—including health records;
 Physically carrying a healthcare record considered “old
school” hence the target of the digital.
 Cyber Warfare--The New Warfare
Frontline

 “Less destructive of life than conventional warfare, yet still capable

of disabling critical infrastructure;
 Stuxnet virus disabled computers in Iran referred as first cyber bomb;

 Targets out there—anything dependent on information technology

has security risks;
 2013—40 million credit card numbers were stolen from the Target
computer system;
 2014—83 million customer data accounts were hacked from JP
Morgan.
Exploitation Of Vulnerabilities

 Sometimes exploitation by individual criminals,

sometimes by government;
 Reasons—By government usually for strategic advantage
—by individuals or companies, stealing industrial secrets;
 2014—U.S. DOJ accused China of stealing sensitive
materials from computer systems of five companies and a
trade union.
IT And Electromagnetic Pulse (EMP)

 Diminished security from an EMP;

 One high altitude nuclear bomb exploding in atmosphere

could generate EMP capable of destroying use of
electronic systems over a wide area;
 Only the threat of counterattack is a deterrent to this;

 Countries “backed against a wall” may not hesitate to use

such an attack.
 Health Care Sector “Tantalizing
Opportunity”

 It’s been said that protection of Health Care Systems from

electronic attacks seems to be lacking when compared to
other critical industries like energy;
 Reason for lag may be due to Health Care Industry being
diverse, fragmented with less amount of regulations
mandating protection.
Broad-Based Policy As Means To Protect

 2008—Institute of Medicine “Seven-Stakeholders”

framework Public Health Emergency Preparedness System;
 1) Health Care Delivery System, 2) Homeland Security and
Public Safety, 3) Employers and Businesses; 4) The Media; 5)
Academia; 6) Communities; 7) Governmental Public Health
Infrastructure;
 Framework serves as analytic lens for understanding
interconnected elements for public health emergency
readiness.
 Vulnerabilities of Health Care Delivery
System

 Considered the frontline—such as hospitals and emergency

medical services;
 Two huge threats--Power outages on hospitals caused by the
collapse of power grids, destruction of generators due to
modifying code in Programmable Logic Controllers;
 Subtle threats-loss of patient information (confidentiality)
software outages (availability), loss of confidence,
inadequate security (integrity);
 New threat comes from hacking of personal medical devices.
 Employers And Businesses

 Threats include reputational damage, financial gain and

fraud, commercial advantage and/or economic or political
damage;
 Above activities may disrupt public health resources,
abilities to produce needed medical equipment or drugs;
 Since Stuxnet, potential for users to remotely access and
damage physical systems is very real.
 The Media And Communities

 If the media becomes attacked and “distorted” this detracts

from the overall integrity of the system;
 Corrupted information may disable media transmission or
reception;
 Communities often lack backup generators and systems that
government or industry may have;
 Food and medication may lose refrigeration, medical
apparatuses are vulnerable to power loss;
 Social discontent and unrest may follow community disruption.
 Academia

 Academia serves to provide expert advice during cyber

threats;
 Prior to cyber threats academia has critical role in
preparation for the events;
 Sensitive academic research could lead to weaponization or
for use to induce a public health crisis—arming malicious
actors;
 Academic campuses contain in-house infectious agents,
cadavers, and research animals.
 Governmental Public Health
Infrastructure

 CDC, related public health institutions may be disrupted during

cyber threats;
 CDC’s Select Agent Program could be hacked releasing information
causing public health crises since Select Agent Program focuses on
dangerous agents and potential countermeasures;
 Components of public health supply chain could be unusable by
cyber threats—like the Strategic National Stockpile requiring
refrigeration or electricity;
 Command and Control communication and coordination could also
be impaired by cyber attack.
 Cyber Security Crosswalk

 Analysis of potential for cyber threats highlights extensive

cyber security needed for essential public health services;
 One idea promotes need for improved private and public
relationship;
 Second idea promotes recognition of public health within
total policy making of cyber security;
 Finally, more research needed on relationship between
risk relationships between cyber security, public health.
 Strategic National Stockpile

Office of Public Health Preparedness and Response administers

Division of Strategic National Stockpile;

12-Hour Push Packages, Managed Inventory” 12 hour push

package” can be delivered within 12 hours of decision to deploy;

CHEMPACKS—containers of nerve agent antidotes—more than

90% of the U.S. population is within one hour of a CHEMPACK
location.
 A New “Super Soldier”

 Gains in technology produced surge in what is available to

the modern and future soldier;
 Will require advanced planning to determine how best to
incorporate the new technology into the fighting force;
 Will take more than physical methods for incorporating
technology, will take advanced complicated ethics
planning to embrace and comprehend the changes.
 Historical Enhancements

 480 BC—Battle of Thermopylae Spartans used shields,

swords, spears;
 1415--Battle of Agincourt Henry V used knights on
horseback with armor and English bowman using long
bows;
 Horseman using stirrups bolster in the saddle conveys
tremendous leverage against foot soldiers who have
nothing close to dig in just by standing.
 Future Enhancement Tools

 Future enhancements will likely be advanced through:

 1) Neuroscience;

 2) Biotechnology;

 3) Nanotechnology;

 4) Genetics;

 5) Pharmacology (Drugs)
 Reducing Warfighter Risk

 According to Patrick Lin (Cal Poly):

 “Soldier enhancements through biological, technological

augmentation of human capabilities, reduce warfighter
risk by providing tactical advantages over the enemy”;
 “Super soldier” concept in many ways is able to perform
like a machine.
Ethics of Cognition Enhancement Drugs

 2010 report—U.S. Army Aeromedical Research Laboratory;

 Report stated the Army tested modaniful and caffeine (to

promote wakefulness);
 Off-use of some drugs for cognition enhancement brings in
additional ethical issues.
 Definition Of Enhancement

 “An increase or improvement in quality, value, or extent”

 As applied to warfighters:

 “An enhancement is a medical or biological intervention to

the body designed to improve performance, appearance,
or capability besides what is necessary to achieve, sustain,
or restore health.”
Drawbacks Or Dangers To Enhancements

 A history of negative outcomes;

 Risky enhancements—using addictive drugs to improve

performance;
 Use of high-dose caffeine, modanifil, amphetamines—all
shown to be effective in temporarily reversing mental
performance degradation in sleep-deprived soldiers.
 Soldier Enhancement WW II

 Not unusual for soldiers in WW II to be given amphetamines to

prevent battle fatigue and enhance endurance performance;
 German military provided stimulant Pervitin,
methamphetamine for soldiers likely to encounter extreme
stress--memo for German navy medical officers:
 “Every medical officer must be aware that Pervitin is a highly
differentiated and powerful stimulant, a tool that enables him,
at any time, to actively,…help certain individuals within his
range of influence achieve above-average performance.”
 Pervitin Use

 Between April-July 1940 35 million tablets of Pervitin and

Isophan (modified version) were distributed;
 Serious health damage resulted, including fatal heart
attacks;
 Use diminished but was still available for prescriptive use.
 U.S. Army Use Of Amphetamines

 U.S. Army issued Benzedrine during war usually 5-mg

tablets;
 Studies published after WW II identified concerns
surrounding impaired judgment, and “willingness to
continue nonproductive or dangerous performance”;
 Also noted, amphetamine increased risk-taking that
prolonged wakefulness impaired judgment.
 Amphetamine Withdrawal Symptoms

 Studies of amphetamine use upon withdrawal indicated

anxiety, agitation, excessive sleep, vivid or lucid dreams,
and thoughts of suicide;
 Ethical conundrum surfaced: “Under what conditions did
short-term benefits of being alert and awake overrule
ethical issue of causing amphetamine addiction”?
 More Ethics

 Boundaries of ethics:

 Questions emerge as to “what we ought to do, what is

permitted in good and right thought and conduct, and what
kind of people we ought to be”;
 Issue of ethics not new to warfighter, Geneva Conventions,
treaties, and international agreements attempt to define and
impose restrictions on the use of certain actions and items;
 What occurred is new technology presenting new ethical
questions concerning uses of the technology.
 Ethical Challenges

 Newer technologies present new challenges;

 Use of stem cells, genetics, neurosciences, robotics, etc.

present new ethical challenges;
 Cases of “ethical vacuums developed, prior use did not
afford opportunities to “sort out the technology issues”.
 Enhanced Soldiers Somalia

 1993—Somali men cruising around Mogadishu on

“technicals” converted vehicles with 50-caliber machine
guns became addicted to khat, a mild amphetamine;
 Noted that mid-afternoon usually peak of the daily cycle;

 Most men started chewing around noon, by late afternoon

became wired, jumpy, and “rarin to go.”
 U.S. Enhanced Warriors

 Operation Iraqi freedom, B-2 stealth bombers flew non-

stop combat missions from Whiteman Air Force Base,
Missouri, averaging 35.3 hours per sortie;
 Missions to Afghanistan reached maximum sortie length
of 44 hours;
 Each two-pilot crew used fatigue countermeasures
consisting of preflight zolpidem, and inflight use of
napping, caffeine, or dextroamphetamine.
 Setting of Ethical Boundaries

 2011 “Force Health Protection Concept of Operations

(CONOPS);
 Human performance optimization “will improve the ability
of the future joint force to complete essential tasks.”
 “Human performance will extend physical and mental
endurance and enhance physiological and psychological
resilience to reduce injury and illness.”
 CONOPS Functions For Human
Performance Optimization

 1) Manage warfighter fatigue;

 2) Enhance sensory, cognitive, and motor capabilities;

 3) Enhance learning, communications, and decision

making;
 4) Enhance physiological capability and resilience;

 Is there any mention of ethics within these advancements?

 New Ethical Challenges

 Should enhanced soldiers have to give consent for types of

enhancement?;
 What is the level of consent required?;

 Is a soldier entitled to refuse enhancement based on

ethical or religious grounds?;
 Are there limits as to who should be enhanced?;
 Enhancement Ethics (cont’d)

 Are non-enhanced soldiers entitled to know who is

enhanced?;
 Are soldiers allowed to keep enhancements after they
leave service?;
 What are the side effects and unintended consequences of
enhancement?;
 Are there long-term health consequences of permanent
enhancements—e.g. bionic parts or neural implants?
 Reversibility?

 Are soldiers entitled to live a pre-enhanced “normal life”

after their service?;
 Are soldiers entitled to not receive or accept a risky or
unproven vaccine?;
 Will any enhancements prevent or delay a soldiers return
to civilian life?;
 What additional challenges are presented by enhanced
soldiers contrasted with non-enhanced soldiers?;
 Tactical Considerations

 Second and third order effects;

 Will units be composed of both enhanced and unenhanced

personnel?;
 Will unit cohesion and morale have unintended effects?;

 Could a normal (non-enhanced) soldier lead enhanced

soldiers effectively?;
 Will enhanced soldiers be ordered to take riskier
situations?
Chain Of Command Responsibilities

 If enhanced soldiers go out of control who is responsible?;

 Do laws of war, LOAC need modification to deal with

enhanced warfighters?;
 Will enhanced soldiers be “reverse engineered” to reveal
new components if captured?;
 Altering Emotions

 Is it ethically acceptable to alter through enhancements

the ability of a soldier to be tempered by emotions?;
 Do enhanced soldiers receive priority if treatment is
needed through casualties?;
 Is it lawful for an enhanced soldier to be implanted with a
biological threat in the blood stream?
 Deactivation And Pain Thresholds

 If a service member that feels no pain and then dies on the

battlefield, does that alter battlefield ethics to require
more killing to be necessary?;
 Is there a duty to deactivate a neural implant?
 Thought Question One

 How do you feel about the following statement?

 “Our ability to “upgrade” the bodies of soldiers through

drugs, implants, and exoskeletons may be upending
ethical norms of war as we’ve understood them… . We
want our warfighters to be made stronger, more aware,
more durable, and more maneuverable in different
environments… .
 Thought Question Two

 “Once ethical and safety issues are resolved, militaries will

need to attend to the impact of human enhancements on
their operations;
 In changing human biology, we also may be changing the
assumptions behind existing laws of war and even human
ethics.”