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The Medical Implications of Nuclear War, Institute of Medicine. @) 1986 by the National Academy of Sciences. National Academy Press, Washington, D.C. Summary and Perspective: With Some Observations on Informed Consent HERBERT L. ABRAMS, M.D. Stanford University, Stanford, California By accident, rather than by design, the symposium on the Medical Implications of Nuclear War took place almost exactly at the time that arms control negotiations between the Soviet Union and the United States resumed in Geneva. The papers in this volume constitute an argument of unparalleled persuasiveness for the superpowers to reach agreement before it is too late. Physicians and scientists can take great pride in the role that they have played in raising the consciousness of America and the world to the threat of nuclear war and in educating themselves, the public, and policymakers. The papers presented in this volume are further examples of the educational process at work. Let me present, in summary form, a series of propositions some old some new that emerge from this meeting. 1. In the wake of a massive nuclear exchange, deaths from the acute effects will go far beyond those of any other period in human history. 2. While acute deaths will result from burn, blast, and radiation, the impact of fire will be far greater than anticipated, and thermal injury will be a dominating cause of the immediate casualties. 3. The effect of ionizing radiation may exceed that of prior projections; the LDso the dose at which 50 percent of all those exposed will die- may well be considerably less than previously accepted figures. 4. The estimated casualties both of countervalue and of counterforce attacks are formidable; the delicately crafted surgical strike that would 583

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584 CONCLUDING REMARKS destroy the adversary's offensive weapons while doing little damage to the population is probably a fiction. 5. Climatic changes will occur with the injection of soot, smoke, and dust into the atmosphere; this may radically alter the conditions of life on the planet. 6. The degradation of agriculture by temperature change and the de- struction of the world's bread basket the United States and Europe Will cause tens of millions (possibly even billions) of deaths from star- vation. 7. Large amounts of oxides of nitrogen (nitric oxide) will alter the stratospheric ozone layer and expose the surviving population of the planet to excessive, harmful ultraviolet B. 8. Other toxic chemicals and carcinogens, including dioxins, furans, and sulfates, will be emitted consequent to the fires and blast. 9. The synergistic effect of ionizing and ultraviolet radiation, trauma, burns, and malnutrition will create an acquired immunodeficiency con- dition in survivors that will augment the spread of exotic infections in the post-nuclear-war period and may underlie an increased incidence of can- cer. 10. The medical care system is highly vulnerable to disruption. In either a massive exchange between the superpowers or a single one-megaton attack on a large urban center, the system will be severely stressed, and there will be huge disparities between availability of and need for vital medical resources. 11. Developing nations depend on the developed world for much of their drugs and medical supplies and equipment. Destruction of the sources of supply will cripple their capacity to respond to injury and disease. 12. The threat of nuclear war engenders profound reactions of anxiety and concern among some children and adolescents. 13. It is said that Americans believe that nuclear war is unlikely, but when asked, they estimate that there is a one-third or a 50/50 chance that it will occur in their lifetime. If it occurs, they do not expect to survive, and they doubt that there is much they can do about it either way. The issue of nuclear war is not central to their thinking and is far more remote than bread and butter issues, but there is remarkably uniform support for a nuclear freeze. 14. The managerial demands of modern weapons systems may exceed the capacity to respond without error in times of crisis. 15. At any one time nuclear weapons personnel include numerous un- stable individuals drug addicts, alcohol abusers, and psychotics. 16. Crisis-induced stress clearly affects the capacity of decision makers in times of international tension.

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SUMMARY AND PERSPECTIVE 585 17. The two superpowers hold a mirror image of each other. The USSR and the United States each believes that the other is an expanding, ag- gressive, imperialist society intent on dominating large portions of the globe remote from its geographic borders. Methods to reduce mutual fear and mistrust are central to the maintenance of peace and avoidance of nuclear weapons use in the modern era. 18. In the short term, improvements in screening of nuclear weapons personnel, crisis prevention measures, and substantive changes in both structural design and day-to-day management of policymaking systems are essential to ensure our ability to cope with crisis and to avoid inad- vertent nuclear war. Most of the uncertainties have also been delineated: 1. How many deaths? How much soot and smoke? What degree of temperature change? 4. What time of the year? 5. How long will it last? 6. To what degree and in what time period can agriculture respond after a massive nuclear exchange? 7. How profoundly will the synergistic effects augment each other? 8. Will national leaders work together to handle the common threat? 9. How can that process be augmented by the social, political, and behavioral sciences? 10. How can the public be better educated and more involved? The research agenda-the unanswered questions that remain-is a for- midable compilation of work that lies ahead. Part of that work will resolve some of the uncertainties amenable to careful scientific scrutiny. But I am in full agreement that until that time, the truly conservative approach and the conservation of life and health is the central concern of the phy- sician is to consider the uncertainties at the worst case level. This is how physicians best protect their patients: by a full consideration of the hazards of the illness that the patient confronts and of the possibilities of complications. As we have wrestled with the weighty problems arising from the most intense and potentially catastrophic arms race in history, a number of oddities have become apparent. Does it strike you as extraordinary that this great National Academy of Sciences-with the best scientific minds in the country and many of the best in the world could write a report on the ecological effects of nuclear war as recently as 1975 and totally neglect the impact of soot and smoke in producing climatologic changes?

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586 CONCLUDING REMARKS Is there something peculiar about the new projections of fatalities based on the understanding that firestorms-studied in detail in Dresden and Hamburg will be fiercely destructive and cause death in a range two to four times as great as those previously predicted? Is it unusual to hear in 1985 that the effects of fire will dominate those of blast and radiation as the central killer in the Third World War? Can we really be satisfied with the concept that nuclear winter emerged as a credible consequence only because Ambio asked Crutzen and Birks to write an article on nitrogen oxides, ozone, and dust? I think not. The message presented in the papers in this volume is that just as we knew less about the effects of massive nuclear war on this planet in 1975 than we do in 1985, so by 1995 dimensions as yet totally unrealized and undescribed will then be apparent. Those effects will be worked out and scientifically validated within the limits of our methods. My most profound hope is that none of these phenomena will have the kind of experimental verification that has established the credibility of modern science that no one of us, in the near term or in a distant era, will have the opportunity to match the predictive brilliance of modern science with the empiric observations of the magnitude of these effects. When Small, Brode, and Postol start with the fires; when Crutzen, Birks, and Carrier inject hundreds of tons of smoke and soot into the atmosphere; when Harwell and SCOPE define the effects on agriculture and the ensuing starvation in Asia, then it becomes manifest beyond question that the superpowers are engaged in an adventure that has po- tential ramifications extending far beyond their borders. Physicians and scientists must emphasize that in the nuclear age, there are questions more profound and more serious than ever before as to the conduct and obligations of governments, not only toward their own citizens but toward all peoples who may be affected by their policies and actions. Over a long period, the medical profession has worked out a set of criteria for appropriate behavior of physicians toward their patients. Their failure to use due care embodies negligence, or malpractice, for which the patient has legal recourse. Is it possible that governments may be guilty of malpractice? Surely they have the same responsibility to populations as physicians have to individuals. Due care, when referring to the affairs of nations, implies the use of ordinary skill and judgment in enhancing life, liberty, and the pursuit of happiness; conforming to international standards of reasonable conduct; acting in the light of current knowledge as to how conflicts can be resolved without the death of tens of hundreds of millions of people. When gov- ernment departs from accepted practice, it must only be done if the people understand and if the people consent.

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SUMMARY AND PERSPECTIVE 587 In medical malpractice cases, the standard of care most frequently applied has been the community standard. A change has now occurred in the locality rule, and a specialist is expected to perfo'~ at a level of care equivalent to that of other specialists in his field, regardless of geographic location. The community standard has been extended to embrace the national medical community. In international discourse, it may equally be said that the national stan- dard must be extended to embrace the international community. Activities or behavior which threaten third parties must be looked upon as an ab- erration from this rule. In the general nuclear debate, the failure of the U.S. and Soviet poli- cymakers to recognize the potential effect of their actions on the rest of the world goes hand in hand with the absence of any consideration of the doctrine of informed consent. In recent years, the malpractice doctrine has been considerably broad- ened to include the physician's duty to obtain an informed refusal, to warn third parties, and to notify patients whenever past procedures or treatment are discovered to be potentially harmful. The physician has the duty to disclose information any and every time a risk is posed and must divulge information to related third parties when harm to others is reasonably foreseeable. In the conduct of governmental affairs, far-reaching actions must also be explained: the risks, the potential benefits, the alternatives. The ques- tions to be answered are not only those of the citizens of the involved nations but of all potentially affected countries. The uninvolved, the in- nocent bystanders, must understand that they are free to refuse or withdraw consent in the nuclear age. It can hardly be said of the Soviet and American governments that they have systematically attempted to inform their own people fully, let alone those of other nations, of the potential consequences of their actions. Such actions have always been couched in terms of national security, rather than in terms of the extraordinary international insecurity they have pro- duced. Physicians have a responsibility to use appropriate diagnostic tests and to interpret them well. If a doctor makes a misdiagnosis on the basis of negligence, he is liable for malpractice. Unfortunately, if the diagnosis of the leaders of the superpowers is incorrect, and if the 50,000 nuclear weapons ultimately prove catastrophic to the Northern Hemisphere and much of the rest of the planet, there is no court of law in which they will be able to be tried. The serious questions remain. How can governments be called on to account for their behavior? How can policymakers be placed in the courts not only of public opinion but of the developing world on whose lives

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588 CONCLUDING REMARKS their policies may impinge so radically? How can they be made to un- derstand that the old Roman precept-if you desire peace, prepare for war is, in the words of Lord Mountbatten, " absolute nuclear nonsense " ? ~ cannot close without commenting on the notion expressed in some quarters that the grave matters dealt with in the papers in this volume are less than a proper subject to engage the energies of the Institute of Med- icine. When we are asked to forego a scientific inquiry into the most important potential health and life issue of the century to agree that we must leave it to the politicians or to the military-we know that to do so is to renounce our obligations in medicine and science. There is nothing political about knowledge. Educating the public is not a Republican or a Democratic or a Soviet Communist act. It is a traditional obligation that began in biblical times indeed, at the dawn of civilization. So when we are asked: Wasn't this a depressing symposium? Why spend your time in an auditorium confronting the apocalypse during the magnificent early autumn days of Washington? Isn't there something mor- bid about such a preoccupation? Then we can reply, with a sense of buoyancy and optimism, that we have asked the questions; we have ob- ta~ned some, but not all, of the answers; we know more than we did yesterday; and our constituents patients, the public, the policymakers- will all fee} the ripple effect. They too will know in time, and it will affect their decisions and perhaps even the future of the world and of our grandchildren.