Loyalty in the trenches: practical teleology for office clinicians responding to terrorism

Were terrorists ever to effectively deploy weapons of mass destruction, medical practice would be quickly transformed. Many ordinary clinicians would be asked or required to treat unfamiliar yet serious medical conditions in a setting of overwhelming urgency and impossible odds. Clinical focus would shift from doing good things for a succession of individual patients to considering many patients at once, a change that could beget loss of trust and rapport with patients. Clinicians might also experience restrictions in personal liberties and appropriation of their property. The purpose of this essay is to develop a teleological framework for undertaking this transformation. In ordinary clinical medicine, the elusiveness of the individual telos (i.e.,the good for the individual) is acknowledged in procedures (such as social history taking,informed consent and outpatient scheduling) designed to protect patients' (and clinicians')prerogatives to interpret the telos for themselves. In mass casualty scenarios, on the other hand, the telos is standardized and regarded as an Immediate Object (usually as a state of affairs in which survival is maximized and permanent disability is minimized). Clinicians who provide mass casualty care will face a number of ethical challenges that can be negotiated by appealing to the political and ethical rationale, and limits, pertaining to the pursuit of aggregate survival as an Immediate Object.