It is well over a decade now since environmental concerns became pressing enough to command attention in almost all realms of intellectual and practical affairs, and well over four decades since environmental ethics developed as a recognizable field of study in response to a growing set of global problems. Yet in contrast to this broad trend, environmental concerns have remained at the farthest margins of bioethics. As improbable as it seems, bioethics has remained tuned out and disconnected from the ecological realities of our current world.
But, you might argue, environmental issues—as important as they are—are just not the same as the issues of medicine and health care. It is best that environmental issues remain separate from bioethics, so that bioethics can retain its sense of purpose and inner coherence. This response might have held up a decade ago (albeit in a flimsy kind of way). But not any more. Climate change and the related conundrum of peak oil, to offer an example, are no longer issues that only environmentalists worry about. Doctors, health policy experts, the World Health Organization, hospital administrators, and patients worry, too. And worry they should. Climate change and peak oil both have the potential to become health catastrophes of unparalleled proportion; it is therefore morally imperative that health systems change the way they use energy, which means changing the way we care for the sick and injured. How could these issues not be within proper domain of bioethics?
The normative vision guiding bioethics might be stated thus: biology, and especially medical science, should be used to promote and sustain health and well-being for all people, coupled with broad respect for human rights and ecological viability. The word “bioethics” suggests an ethics concerned with bios, or life. And this, indeed, is what American biochemist Van Rensselaer Potter had in mind when he coined the term. He conceived of ethics as a dialogue between medical science and values, the ultimate purpose of which is to protect and nurture life on earth. Bioethics, in Potter’s formulation, is a “bridge.” It is a bridge not only between a scientific orientation and a values orientation, but it is also a bridge to the future. Our survival depends on being able to bring values and science together, allowing values to shape the scientific enterprise in ways both sustainable and humane.
The story of how bioethics began is familiar to many. Yet as we also well know, for most of its life as an academic field, bioethics has veered away from this broad Potterian vision. It has instead remained focused on the narrower enterprise of medicine, without explicitly placing this enterprise within its larger context of planetary health. It is a truism, of course, that there can be no enduring health without a healthy home planet. But this necessary natural substrate of human health has been largely invisible and taken for granted, both by health professionals and by bioethicists. It is time to bring the background into the foreground. It is time for bioethics to take stock of what it has been missing, and pay attention to where it needs to go in order to remain relevant and useful. As a first step, I propose Environmental Bioethics as an official sub-field of bioethics.
Environmental bioethics
Environmental bioethics addresses ethical issues arising in the complex interactions between humans, health, healthcare systems, and the natural environment. It is not simply concerned with genetically engineered crops and Frankenfoods (as is often assumed). Environmental bioethics is about the doctor-patient relationship, and the proper scope and limits of personal responsibility for health; it is about reproductive ethics in an age of scarcity and a contracting resource base; it is about distributing benefits and harms fairly, where harms include the invisible “externalities” of medicine such as carbon emissions and toxic pollution; and it is about how to properly view death and dying and end of life care within a bloated and unsustainable healthcare system. These are relevant questions for the field of bioethics, and, I would add, more pressing than many of the trivia on which professional ethicists build their careers.
What would it mean to recognize environmental bioethics as an official sub-field? First of all, no textbook that claims to offer a comprehensive overview of the field of bioethics should be without a chapter on environmental bioethics, and likewise no bioethics survey course should be without a segment on environmental bioethics. Graduate programs in bioethics should have faculty available with training in environmental issues, and should seek to build interdisciplinary connections with environmental science, energy policy, biology, and other relevant fields. No bioethicist should be without at least a rudimentary understanding of the core issues in environmental science, particularly climate change and its relationship to health and health care. Environmental bioethics should be much more strongly represented at professional conferences, and bioethics journals should publish widely and willingly in this area. (A special journal called Environmental Bioethics would be nice, too.) Given its centrality as an official sub-field, the insights from environmental bioethics must be extended to other sub-fields such as reproductive ethics, end of life ethics, research ethics, and so on.
But perhaps this is not enough. Perhaps bioethics needs to do much more than pay lip-service to environmental issues by including them in textbooks and on syllabi. The problem with a subfield is that it suggests compartmentalization—and this is exactly what an environmental bioethics works against. Environmental bioethics is not so much a specific cluster of bioethical problems as a new way of understanding the entire theoretical and practical agenda of bioethics—it suggests, in an important sense, a new bioethics. (It is also, of course, a very old bioethics, since the vision of the field’s pioneer, Van Potter, was deeply environmental.)
To consider healthcare and medicine detached from their larger context—which certainly includes the interconnections between health care and the natural environment—is to seriously “decontextualize” moral problems. It leaves problems only partially moored to reality. For example, let’s consider the appropriateness of physician X deciding to ease a suffering patient Y into death by increasing the concentration of morphine in her IV. Most ethicists would agree that this clinical dilemma must be placed within its proper context, which might include the desires and beliefs of the patient, family and health care team, hospital policy, state and federal laws, public attitudes toward euthanasia, and perhaps much more. And, in fact, the role of an ethicist on staff at a hospital is really to do exactly this: to provide the most complete, inclusive, and nuanced context within which decisions are made about particular moral problems, often by challenging people to see beyond where they normally look, and by raising sometimes uncomfortable and unspoken issues. Likewise, bioethicists working in academic settings challenge people to consider moral problems broadly and without falling prey to stereotypes, presumptions, or personal preoccupations. The most important kind of work we can do as ethicists is to help make the moral discourse broader, more nuanced, and more inclusive. This broader discourse must reach beyond the bedside, beyond the hospital doors, and out into the world within which medicine is situated and which largely determines who stays healthy and who winds up sick.
An agenda for environmental bioethics
There is a great deal of work to be done in environmental bioethics.
First of all, there is work to be done exploring whether and how alternative theoretical paradigms challenge basic commitments of bioethics. Some scholars have begun to consider how theoretical paradigms borrowed from environmental ethics (e.g., biocentrism and ecocentrism) might alter bioethical theory. This is useful work, but we also need to examine theoretical commitments that are far more subterranean, such as the paradigm of growth. It is clear that unfettered growth is unsustainable, yet a commitment to growth remains essentially unquestioned within medicine and more broadly. For a small and unsettling instance of the larger problem, look at the potentially catastrophic collision between our paradigm of economic growth and the realities of petroleum scarcity and peak oil, and think for a moment what this might mean for health care. (NB: the American Journal of Public Health is preparing an entire issue devoted to preparedness for the coming shocks. Not recommended for bedtime reading.).
One of the ways in which bioethics can be most useful is in helping health professionals, patients, and policy wonks make connections. Wendell Berry urges us to “solve for pattern,” by which he means exploring the roots of problems and finding solutions that don’t simply create new problems. For example, we can treat the sequelae of obesity. We can try to make room in the hospitals for legions of diabetics and those dying from heart disease. Or we can try to address the roots of the epidemic, which will force us into areas far beyond the traditional scope of bioethics—into the global food production system, the cultural addiction to meat, patterns of transportation, and so forth. “Everything is interconnected.” This is one of the mantras of environmentalism, and it is a lesson that would be well heeded by health professionals and bioethicists.
Bioethicists also need to work at the level of principles and norms. We can enrich the moral dialogue by introducing new vocabulary, since the four traditional core principles—beneficence, nonmaleficence, respect for autonomy, and justice—are really inadequate to the task at hand. We might explore, for example, whether and how to incorporate the following values within medicine: balance, sustainability, adequacy, modesty, diversity, limits, generosity, and mindfulness. Each of these values (might we call them “principles”?) will need careful specification and balancing, parallel to the early and ongoing work in bioethics on beneficence, nonmaleficence, justice, and respect for autonomy. Bioethics can draw on available resources in environmental ethics, where work has been done on the specification of basic values such as respect for the environment. But a good deal of innovative work also lies ahead.
As an example, consider “sustainability”, which needs to become one of the guiding principles of bioethics. Sustainability is overly open-ended. Brutal dictatorships can be sustainable. Even the modified principle of “sustainable health” needs careful specification. We could seek to make health sustainable for the world’s elite, but in so doing fall short on justice and compassion. When we commit to sustainable health, we will want to commit to creating a health system that can endure over time, and in which we can sustain not only human well-being but also the many health values that are most important to us—the values of compassion, empathy, beneficence, fairness, and respect for personal autonomy. Furthermore, we can include within the list of things that matter to us the well-being of our children and grand-children, the flourishing of non-human life, and the continued viability of our planetary ecosystem. Within one overarching principle, sustainability, we can subsume diverse and competing values. But not without careful work.
In addition to enriching bioethics with new moral vocabulary, we also need to consider how the core principles of bioethics can continue to evolve and maintain their relevance. For example, we need to put a new spin on the old principle of nonmaleficence by reexamining what constitutes “harm.” The activist group Health Care Without Harm has documented that the healthcare system causes substantial environmental harm, both to people and to nature, and has helped us see that the duty of nonmaleficence extends far beyond the bedside.
It has always been important for bioethicists to grasp not only the philosophy, but also the actual facts of what’s happening in the world of medicine. For example, a bioethicist would certainly not speak with authority about gene therapy without a good understanding of the science of genetics. Likewise, bioethicists consulting with physicians and patients about end of life care cannot speak with moral clarity on terminal sedation without a sound knowledge of what medicines are used to palliate pain and how exactly they work. All bioethicists need to have a reasonable grasp of the field of medicine, and no self-respecting bioethicist should be ignorant of the environmental aspects of their work. In particular, all bioethicists need to understand how climate change, resource consumption, and patterns of energy use will profoundly challenge health systems over the next decade.
Finally, there is a huge amount of work to do at the level of real problems. Here are just a few specific issues bioethicists might address:
- What are the responsibilities of individual physicians to reduce the harmful side-effects of medical care, such as dioxin and mercury pollution?
- Should physicians (and bioethicists) be vegetarian on principle?
- What specific responsibilities do clinics and individual physicians have in relation to climate change?
- What responsibilities do patients have to limit their use of health resources, either by working to maintain good health or by choosing to forego certain medical interventions?
- What discounting of future interests is fair? (How much carbon pollution can we justify today?)
- How might specific faith traditions respond to environmental issues?
- How does the shift to ozone-friendly asthma inhalers impact low-income patients, and how do we judge the trade offs?
- What medical services are most important to maintain, once we enter the inevitable crash from peaking oil production?
One of the strengths and defining characteristics of the field of bioethics is that it rides the crest of the wave of current events. Given its usual responsiveness, I’m not sure why the field has been so slow to acknowledge the importance of climate change, the need for sustainability in our health systems, and the environmental and health hazards of our medical system, since we’ve been riding this collective tsunami for well over three decades now. But my hope is that bioethics will be able to tune in and connect—sooner, rather than later.
