Environmental Bioethics Research Paper

Introduction

Environmental bioethics stands at the intersection of human health sciences, ecology, and human values; it is an undertaking that seeks just social arrangements that can promote human well-being and, at the same time, preserve the natural environment, both now and in the future. In addition to the challenges of diverse stakeholders, time scales, and cultures, environmental bioethics must also consider how aspects of privilege and injustice are to be recognized, articulated, and resolved.

On its face, the term “environmental bioethics” appears redundant; surely an ethics of the bios or of organic life should address not only relations between humans, but also between humans and non-humans and should include among its duties the maintenance of our common “life support system” – the natural environment. Indeed, the theme of environmental collapse was intellectually and culturally prominent in the post-World War II period, influencing not only the original formulation of bioethics as environmentally inclusive, but also giving rise to new fields of study – such as environmental ethics – centered specifically on values and the natural environment.

Yet bioethics as it developed as an academic specialty is today largely indifferent and unprepared to take up urgent global issues of human survival. Much has been written about the overshadowing of Van Rensselaer Potter’s vision of an environmentally inclusive bioethics by the development of contemporary clinically oriented biomedical ethics. That result, which will not be rehearsed here, should not be understood as vindication of a superior approach, but rather that chance funding favored the particular orientation.

History And Development

As with any history of a concept or theoretical model, there are a number of ways it could be presented. The historical development of what we are now calling environmental bioethics is presented here in terms of three core influences: technology, toxics, and consumption. These representative topics are echoed in the present day as well, although now inflected by recent concerns relating to social justice and global climate change. This section outlines the genesis or beginnings of environmental bioethics; more recent issues are discussed in the section on ethical dimensions. A combined reading of past and present shows environmental bioethics to be the potentially bridging moral framework its authors envisioned.

Genesis

Bioethics in its earliest formulations is that of an environmentally inclusive ethics. Fritz Jahr, a Protestant minister, is credited with first introducing the word bioethics in Kosmos, a German magazine published in 1927: Bio-Ethik: Eine umschau uber die ethischen Beziehungen des Menschen zu Tier und Pflanze or “Bioethics: A Panorama of the Human Being’s Ethical Relations with Animals and Plants” (Goldim 2009). Drawing on ideas ranging from St. Francis of Assisi to Buddhism, Jahr’s bio-ethik was far more expansive than contemporary biomedicine and healthcare; Jahr insisted that all living things be viewed as “partners” for whom we have certain duties of care and respect.

The first sustained development of bioethics is universally credited to Van Rensselaer Potter, a University of Wisconsin research oncologist who introduced the idea of a new synthesis of scientific and humanistic knowledge – “Bioethics, the Science of Survival,” in 1970 (Potter 1970), elaborated further in his book-length treatment in 1971 (Van Rensselaer Potter 1971). Bioethics, as Potter understood it, was “the bridge to the future,” a bridge not only between the sciences and the humanities but a bridge from the current situation in which we are ignorant of, and indifferent to, the consequences of anthropogenic impacts – broadly understood to include climate, deforestation, pollution, and scientific life forms – to one in which we achieve mutual sustainability for human and nonhuman life. Potter’s central organizing principle for the new field, credited to the environmental thinker and conservationist Aldo Leopold, is our mutual interdependence on other life forms and on the ecology of the planet.

Other significant influences on Potter and the development of an environmentally inclusive bioethics were the post-World War II intellectual interrogation of technology and the work of scientists Rachel Carson and Paul R. Ehrlich on particular global environmental health threats: pesticides and population, respectively. These three themes – technology, toxics, and consumption – make up the basic building blocks of environmental bioethics today as then and are therefore a useful starting point.

Technology, Toxics, And Consumption

In the post-World War II period, debates flourished around the capacity of humans to destroy themselves and the planet. The rise of new, poorly understood but potentially catastrophic technologies was seen by some as “dangerous knowledge.” Then, as now, moratoria on certain scientific developments, even entire fields of research, were endorsed. Physician-led organizations such as Physicians for Social Responsibility (PSR) advocated against technologies that altered the environment and human health. In 1961, PSR physicians and citizen scientists raised awareness of the health hazards of atmospheric nuclear testing by documenting the presence of Strontium 90 in cow’s milk and children’s teeth as a result of nuclear fallout. Science and medicine researchers acknowledged their ethical obligation to work collectively to manage serious risks, both in order to prevent disaster and to prevent the banning of scientific endeavors that would result from catastrophic events. Similarly, worries about environmental and occupational health hazards led scientists themselves to call for a moratorium on recombinant DNA experiments in 1974 until the biosafety issues could be studied and resolved to the public’s satisfaction. Advances in biotechnology – from the Environmental Genome

Project to genetically modified agricultural organisms and from engineered viruses to nanomedicine – will continue to demand a bioethics that is prepared to address not only direct risks to human health but also respond to environmental and social impacts.

The second major theme in environmental bioethics originated with the publication in 1962 of two books widely credited with launching the modern environmental movement: Murray Bookchin’s Our Synthetic Environment and Rachel Carson’s Silent Spring. While Bookchin’s work is a foundational text in environmental studies, Silent Spring was serialized in New Yorker magazine and Audubon and published as a Book-of-the-Month selection, educating the general public about the potential hazards of both bio accumulative chemicals and industry-science relationships. Insights from agriculture about the impact of chemicals on the natural environment and on the health of agricultural workers and their families led to clinical specializations in occupational medicine and environmental public health.

Research from occupational and environmental health on the impact of industrial waste and chemical pollution on reproduction and neurological development aroused deep ethical dissonance for professionals managing hospitals and responsible for hospital waste disposal. The healthcare industry itself, a site of pollution and environmentally irresponsible practices, became the object of environmental bioethical inquiry. “Environmentally responsible healthcare” and “sustainable healthcare” refer to diverse hospital-based and physician-led initiatives to reduce the environmental health impacts of healthcare technologies and practices, including water use reduction, “green” hospital building and green purchasing co-ops, waste-to-energy cogeneration efforts, and siting of land uses that disproportionately burden the health of communities of concern (Jameton and Pierce 2001; Fiore and Fleming 2003).

The third major influence on the early development of environmental bioethics was Paul R. Ehrlich’s The Population Bomb (1968). In what became the best-selling environmental book of the 1960s, Ehrlich argued that the human population had outpaced the earth’s capacity to feed all of its inhabitants and offered a grim set of future scenarios predicting mass starvation, disease, and worldwide collapse unless severe restrictions were placed on human reproduction and thus future consumption. Although Ehrlich’s exaggerated predictions have been moderated in the decades since its publication, concerns about excessive resource consumption and allocation under conditions of scarcity remain important issues in both environmental ethics and biomedical ethics.

In the 1970s and 1980s, environmental sustainability discourse explicitly urged population controls, although zero population growth as a feature of environmental advocacy diminished as movement groups attempted to gain legitimacy and extend their political influence with diverse constituencies such as pro-growth business interests, antiabortion evangelicals, and global women’s groups working for reproductive liberty (Beck and Kolankiewicz 2000). In the 1980s, as internal population growth reduced to below replacement in the USA, the UK, and Europe, immigration began to account for both population increase and birth rates above replacement levels; calls for domestic population control became associated with politically illiberal attitudes and worse. By the late 1990s, environmental advocacy and policy had ceased to address population issues directly and instead focused on environmental mitigation and so-called “smart growth” issues such as sprawl and transportation (Beck and Kolankiewicz 2000). The politics of abortion and immigration had succeeded in mystifying the links between population growth and overconsumption.

Conceptual Clarification

The idea of an environmentally inclusive bioethics challenges disciplinary and conceptual boundaries. Before discussing selected ethical dimensions below, we should first say something about the concept of environmental bioethics and its relation to biomedical ethics and to environmental ethics.

The term environmental bioethics seems qualified, derivative: a subgenre of biomedical ethics or environmental ethics rather than the ground for both. Environmental bioethics is perhaps better understood, if not rendered, as environmentally inclusive bioethics. As such, an environmentally inclusive bioethics naturally includes within it normative questions that are traditionally bioethical, but also includes, as it does not now, those that arise in environmental contexts such as in environmental public health and occupational health fields. Moreover, explicitly referencing inclusivity is useful as a way of raising consciousness about the normatively narrow, single-patient oriented emphasis of traditional biomedical ethics. While diverse methodological approaches to bioethical theorizing have been developed, these do not significantly challenge the paradigm because the provision of healthcare and the institutional arrangements remain virtually unchanged. An inclusive bioethics is not merely a better way of theorizing; the concept contains within it an expansive vision of what healthcare and justice could become.

The neglect by traditional biomedicine of environmental sources of health and illness has been dubbed the “eco-medical disconnection syndrome” (Whitehouse 1999). More recently, new physicians are being trained to include social determinants of health (race, ethnicity, gender, SES) in their considerations; however, environmental influences receive little attention despite the attribution by the Institute of Medicine of at least 25 % of health problems to environmental origins. In 1997, the National Institute of Environmental Health Sciences (NIEHS) developed the Environmental Genome Project, modeled on the Human Genome Project, in an effort to better understand the relationship that environmental exposures play in diseases associated with genetic variants.

A radically inclusive bioethics approach might go even further, extending of the idea of patient care to the environment itself, in order to safeguard the provision of natural ecosystem services such as climate stabilization, water purification, pest control, pollution dispersal, etc., on which human health depends. By adapting the professional norm of “protecting the patient” to promote care of the environment, clinicians could better achieve goals of preventing disease and illness in their human patients and the community, both now and for future generations. An environmentally inclusive ethics of care would require that professionals also lead and participate on environmental social policy decisions and actively inform the community and policymakers regarding environmental impacts on human health.

Nor does an ethics that must comprehend both human health and the formal activities of healthcare fit well in the environmental ethics space. First, environmental ethics is primarily taken up with theorizing about the moral qualities of nonhuman animals and natural communities such that human obligations toward them do not depend entirely or even mostly on human purposes or metrics. Thus, the anthropocentrism of environmental bioethics would be incompatible with the dominant views in environmental ethics that nonhuman entities have, variously: intrinsic value, moral standing, and may even have certain claims to legal standing. Second, and most importantly, bioethics spaces are not natural environments but institutions that provide healthcare to humans and do related research: medical schools, hospitals and long-term care facilities, doctors’ offices and public health clinics, and so forth. Thus, despite the similar-sounding names, environmental ethics does not share the same infrastructure or the same normative standpoint as an environmental bioethics.

Conceptually, environmental bioethics is part of a larger project of beneficence and of improving human health and the quality of the environment. The danger of course is that personal goods, including basic rights, are traded off without consent in order to achieve such goods. The work of environmental bioethics is not to optimize the first-order environmental or health goods, but to work on identifying, articulating, and contributing to the maintenance of second-order or ethical goods: that shares are fair, that rights violations are avoided, that values conflicts are mediated, that dignity is protected, that the vulnerable are safeguarded, that the “common environment” is preserved, and so forth.

Ethical Dimension

In the present day, the three core issues – technology, toxics, and consumption – continue to animate environmental bioethics.

Population is, of course, still primarily conceptualized in terms of resource consumption and limits on carrying capacity. However, seen from the perspective of present-day environmental bioethics, population is implicated in a chain of causality that includes pollution and environmental degradation, deforestation and loss of natural ecosystem services, intensification of natural disasters with concomitant disease outbreaks, and social dislocations that further diminish human and environmental health and resilience. Additionally, modern-day environmental bioethics analyses incorporate health disparities and social justice considerations and findings from the new tools of genomics and molecular genetics. This section concludes with a brief consideration of education for an environmentally inclusive bioethics.

Population And Generational Equity

Humans have increased their presence on earth from 1 billion in 1800 to more than 7.3 billion today; the latest United Nations population projections are that world population will reach 10 billion persons in the year 2056, earlier than previously projected (“World Population Prospects” 2015). There is no specific numerical consensus on earth’s “carrying capacity,” the measure of earth’s ability to regulate ecosystem processes such as waste decomposition, water and air purification, pest control, and so forth. However, there is little disagreement that there is some biocapacity upper limit. Population growth is a force multiplier; the increase in consumption from population growth hastens natural resource depletion, pollution, and habitat destruction, leading to deforestation, flooding, and species extinction.

Energy consumption is expressed in terms of a carbon or ecological “footprint” – what is needed for food, water, housing, transportation, consumer goods and waste services, etc., as well as the land needed to sequester carbon dioxide emissions from fossil fuel combustion used for energy.

Using the latest available data from 2011, the USA has the second largest ecological footprint of 6.8 gha (gha = global hectare average); the available capacity is 3.6 gha (“Global Footprint Network”). In other words, the area of biologically productive land needed to supply US per capita demands exceeds what is actually available by almost 3.2 gha. Moreover, humanity as a whole is not living within the resources of the planet. In 2007, humanity’s total ecological footprint was 18 billion gha (global hectares average); with world population then at 6.7 billion people, the average ecological footprint was 2.7 gha. However, there was only 11.9 billion gha of biocapacity available that year or 1.8 gha per person. In other words, in 2007 humanity used the equivalent of 1.5 Earths to support its consumption (Dwyer 2009).

As a consequence of our habits of consumption and energy use, humanity is living in deficit, as if there is no future, no people who will depend on the resources we are using over and above each year’s biocapacity. The idea of equity between generations is that each succeeding generation should have at least a similar range of basic life opportunities, though not the same exact opportunities. If some action we might take today would foreclose a basic opportunity for a future generation, the ethical justification would have to be extraordinary. Thus, stabilizing or reducing human population as well as reducing overall human consumption is essential to the environmental sustainability and the survival of humans. While there might, in the future, be inventions that change the trajectory, stewardship requires that we prudently prepare for the scenarios in which there is not some change in the trajectory.

Paul Ehrlich, an early advocate of expanding the environmental concerns of bioethics, particularly with respect to population and consumption, has more recently argued that small-scale ethical decisions made by individuals – decisions such as whether to have children and how many, to eat or not eat meat, and to use antibiotics – are perhaps as important as regulations in reducing consumption and pollution. Decisions that have been largely understood to be personal preferences in a liberal society, viewed in aggregate, says

Ehrlich, are the equivalent of medium to large-scale common resource issues (Ehrlich 2009). Ehrlich argues for “prudent population control” until births and deaths balance at a population size that can be maintained without harming the natural support system of the earth while still providing a satisfactory though not ample lifestyle.

Procreation, depending on circumstances, can be an intimate personal decision, a deep cultural expectation, an economic necessity, a form of social control, or the inadvertent result of unanticipated or coerced sex. At the same time, procreation – as distinguished from parenting by fostering or adopting children who need families – has environmental consequences. Past efforts by governments to regulate population growth has had poor outcomes from the perspective of ethics. China’s brutal one-child policy (now liberalized) succeeded only with unacceptable human rights abuses. Both China and India’s polices resulted in an imbalance of male births – the “preferred” gender – and disturbing increases in sexual violence toward women.

In societies with high consumption rates, implementing education or a set of policy “nudges” – to encourage individuals who do procreate to reduce their carbon footprint and to encourage adoption and/or non-procreation – could constitute potentially less objectionable approaches to population stabilization. While there is some opposition to nudging – variously, to the tools of behavioral economics, to systematic governmental use of these tools, and to government regulation per se – nudging is perhaps the least intrusive means to achieve the population reduction outcome that is both morally necessary and vitally urgent.

Environmental Justice And Health Disparities

Substantive justice, equity, and equal respect for all humans are central concerns in contemporary moral philosophy, legal theory, and of course in biomedical ethics. Three contemporary justice approaches developed from within an environmentally inclusive bioethics are discussed below: environmental health inequities (Resnik and Roman 2007), fair share of environmental capacity (Dwyer 2009), and justice between generations, especially between those existing now and those yet to be born (Ehrlich 2009).

Social justice analysis begins with the acknowledgment that, notwithstanding theories of equality, policies and practices have disparate impacts on groups of people differently situated. Moreover, certain groups are regularly disadvantaged by policies that appear facially neutral – e.g., policies that invoke “workers” and “occupational health” when women working from home are not considered workers, and so forth. More recent ethical focus on health disparities and social justice and the new tools of genomics have provided good evidence that toxic chemicals are not an equal opportunity risk; those living communities of color and working in hazardous industries receive higher doses of carcinogens and other environmental pollutants capable of interacting with susceptibility genes to cause disease.

Studies in the 1980s revealed that Blacks and Hispanics in the southeastern region of the USA were much more likely than Whites to be living in communities with one or more uncontrolled (closed or abandoned) toxic waste sites; African Americans were found to be the majority of the population in three fourths of communities in which landfills were sited but were less than 20 % of population in the region (Bullard 1990). Moreover, these disparities in siting were perpetuated by the institutional processes which excluded the individuals most affected in land use decisions. Similarly, at the global level, environmental decisions on issues that transcend national boundaries – fishing, toxic waste export, transnational corporate governance, and especially climate change – have potentially serious environmental, justice, and health implications for developing economies and political minorities, precisely those with the least power to affect decision-making.

A critical flaw in distributive justice theories is that they start with an assumed fair starting point or status quo when considering the distribution of some particular good. In other words, when considering the question of access to healthcare services, it has been assumed for the sake of theorizing (erroneously) that the material conditions as they are currently must be fair – even if unequal or unfortunate – because there has been no evident distribution and thus only brute luck accounts for the status quo. This has allowed policymakers to ignore structural biases and force-multiplying social disadvantages such as race, SES, and environment in thinking about fairness. Once we start thinking about the baseline itself, it becomes obvious that what is also needed is a broader view about what makes humans healthy than the mere provision of particular healthcare services: housing, clean air, safe water, sanitation, nutrition, health literacy, and pest control (Resnik and Roman 2007). Many of the factors that cause health inequities are a function of poverty as well as environmental exposures; poverty programs alone will not bring about the desired health improvements unless the environmental impacts are addressed as well. Resnik and Roman propose a division of labor in which bioethicists focus their expertise on the environmental hazards which are underrepresented in healthcare access debates, meanwhile letting those who are already working on the antipoverty aspects continue to do so.

If there were unlimited resources, we could expect to make everyone better and better, no matter the cost. Resources have an upper limit and a capacity, requiring that decisions be made with respect to effective uses. It is a question of fairness as well as capacity; utilization decisions must make good on foundational values of equal respect for all persons. An environmentally inclusive bioethics must also consider the claims of sustainability as part of the justice equation (Dwyer 2009). James Dwyer utilizes consumption (ecological footprint) along with available metrics on mortality and life expectancy to develop a new index of sustainability and justice he calls “fair share of biocapacity” (Dwyer 2009, p. 500). For example, the USA has an average life expectancy of 78 years of age, the same as Cuba and Costa Rica. However, the ecological footprints are the following, respectively: Cuba at .8, Costa Rica at 1.1, and the USA at 5.7 (2nd highest). Both Cuba and Costa Rica are able to achieve the life expectancy of age 78 without consuming more than their fair share, while the USA is much less efficient, consuming several times its fair share with no improvement in life expectancy. In a more dramatic way of presenting the point, Dwyer notes that individuals in the USA, were they restricted to their fair share of biocapacity, could live only to age 15 before running out of resources.

Dwyer acknowledges that the index only measures sustainable living and health as measured by life expectancy and consumption, not overall justice in society or the provision of basic rights, etc. Nevertheless, it demonstrates that some societies have been able to achieve life expectancies greater than age 80 (Canada, Sweden) and greater than 82 (Japan) with a much lower environmental cost than the USA. The point is that there are ways to both reduce environmental costs and achieve health benefits; Dwyer’s particular recommendations are the usual public health recommendations: reduce meat consumption, tobacco, increase walkability, etc. Resnik and Roman’s environmental hazards are another source of improvement in both ends of the index.

Environmental justice analyses have contributed to the understanding of the persistence of racial and ethnic disparities in healthcare: inequitable distribution of burdens and benefits combined with inequitable representation in decision-making. Resnik and Roman identify environmental factors in health disparities that are under-theorized because they are normalized as conditions in which the poor and people of color live and work rather than environmental hazards. New scientific tools in genomics and molecular epigenetics linking toxic environments with gene expression and heritable disease provide additional evidence for the usefulness of environmental justice frameworks for making progress in health disparities.

Molecular epigenetics offers a science-based imperative for bioethicists to expand the scope of their inquiries to include environmental concerns (Dupras et al. 2014). Epigenetic changes are DNA modifications that unfold at the biochemical level and do not change the DNA sequence itself, but can affect gene activity, that is, whether a gene is expressed or silenced. Epigenetic change is a natural occurrence in normal cell differentiation, but both the environment and individual life factors can directly interact with the genome to play a role in disease development. Moreover, we now know that such changes may occur at various stages throughout an individual’s life and, in some cases, may be heritable.

Epigenetic changes are influenced by a number of environments: intrauterine, postnatal (microflora), physical (nutrition, temperature), social (stress), exposures (toxics, drugs), and physical activity. Human epidemiological studies have shown that prenatal and early postnatal environmental factors, such as famine or exposure to allergens, influence the adult risk of developing various chronic diseases and behavioral disorders, and the risks to future generations may be increased as well. Other studies have identified chronic stress as an epigenetic driver. Most importantly, some epigenetic changes may be reversible.

Thus, environment is a critical social determinant of health; one’s social location often determines one’s environments – natal, residential, and occupational – and these have significant health consequences throughout the life-span. Moreover, one’s social location and environmental health legacy are also health and opportunity limiting factors for one’s offspring and perhaps their offspring as well. These findings have deep normative implications for allopathic medicine, public policy, and bioethics and validate the urgent need to attend to environmental factors, broadly understood, both as a matter of disease prevention and as a matter of social justice.

Environmentally Responsible Healthcare

All industrial practices use energy, require water, and produce waste. Hospitals in the USA produce more than 5.9 million tons of waste annually and more than 3 % of total US carbon dioxide emissions according to the latest available data from 2007 (Chung and Meltzer 2009). Similarly, using 2004 data, Great Britain’s National Health Service (NHS) produces 3 % of all UK carbon dioxide emissions and produces 408,000 tons of solid waste annually NHS (4 % of UK total), 3 % of total UK emissions (Chung and Meltzer 2009). These figures do not include upstream supply chain and production of healthcare goods, only hospital-generated waste and energy impacts.

According to the US Environmental Protection Agency (EPA), hospitals are the second largest commercial energy users and are often the single largest water users in their communities, using water to heat/cool healthcare facilities, for laundry, landscape maintenance, and so forth. The healthcare sector relies heavily on fossil fuels to heat, pump, and treat water, contributing approximately 8 % of the USA’s greenhouse gas emissions, a driver of climate change, as well as emitting toxins such as mercury, arsenic, and particulate matter such as nitrogen oxide, sulfur dioxide, and lead (Chung and Meltzer 2009). These by-products negatively affect human health through air pollution and water pollution and have been associated with respiratory diseases, asthma, and premature death.

From an environmental perspective, healthcare is an industrial process with particularly difficult waste challenges and high water and energy usage. According to the EPA, medical waste incineration is the third leading source of dioxin emissions in the USA and the fourth leading source of mercury emissions. Heavy metals and dioxin from medical waste can be widely dispersed during the process of incineration and ingested through local food and water sources. Moreover, due to the way in which undesirable land uses – such as waste incinerators – are sited, hospital wastes are often transported to another community for incineration; the receiving community obtains no services from the hospital whose waste is being disposed of in their community. In other words, the externalities or environmental health burdens of hospital waste are not borne by those who enjoy the amenities or profits of the hospital itself. Non-incinerated waste often ends up in a landfill where it produces methane – a greenhouse gas.

Reducing the environmental impact of delivering services should be considered part of the healthcare mission of hospitals and healthcare professionals, as a matter of logic as well as ethics. Hospital-based nurses were early adopters of sustainable or environmentally responsible healthcare approaches due to their occupational exposures to toxins and radioactivity. The aim is to use evidence-based methods to eliminate pollution in healthcare practices without compromising safety or patient care, to reduce nonessential incineration of medical waste, to promote energy efficiency and water conservation by the healthcare industry, to support the development and use of environmentally safe materials, technology, and products, and to phase out the use of polyvinyl chloride (PVC), mercury, and persistent toxic chemicals.

In 1998, a partnership of the American Hospital Association, the US Environmental Protection Agency, Health Care Without Harm (HCWH), and the American Nurses Association (ANA), with funding from the EPA (until 2006), came together to share ideas and provide information, tools, resources, and expert technical support on sustainability for healthcare organizations committed to the integration of sustainability principles and practices. As Practice Greenhealth since 2008, it has more than 837 members, including hospitals and healthcare systems, healthcare providers, manufacturers and service providers, architectural, engineering, and design firms, group purchasing organizations, and affiliated nonprofit organizations, who report benchmarking data and share best practices (Greenhealth 2015) . The benchmarking project reveals that by 2012 (reporting in 2014), although a high percentage of hospitals have appointed champions and established meetings, too few have undertaken baseline measurements by which future sustainability measures might be evaluated. Two programs, recycling of nonregulated waste and energy savings, both show fairly minimal reductions per institution. However, the aggregate impact on landfills and carbon emissions if all hospitals achieved those small numbers would be a genuine contribution to health.

Cooperative purchasing programs and the trend toward hospital conglomeration have eroded local managerial discretion to implement “green” programs. Without regulatory or community mandates and committed leadership, it is not clear that hospital investments in sustainable healthcare will be maintained given the small returns to date.

Global Climate Change

Climate change is a health issue as well as an environmental issue. Effects of climate change on health will affect all but the most fortunate in the next decades and put many species at increased risk. The most likely source of climate warming is excess greenhouse gas emissions from burning fossil fuels to produce energy. Paradoxically, many of the technologies that benefit humans and improve daily life can also cause or exacerbate disease and ill health. According to the Intergovernmental Panel on Climate Change (Change 2014), global health threats from greenhouse gas emissions include: increased frequency and severity of extreme weather events, habitat and species extinction, expanded reach of vector borne diseases, water scarcity, agricultural collapse and famine, armed conflicts, population displacement, and humanitarian crises, as well as reduced social and economic resiliency.

Effective responses to the health impacts of climate change, however, are differentially available to the global North and South, depending as they do on socioeconomic and environmental resources and technology. According to a 2009 report by the Global Health Commission, the carbon footprint of the world’s poorest one billion people is approximately 3 % of the world’s total, but they will be the ones most affected by anthropogenic climate changes (Commission 2009).

The most vexing ethical issues connected with climate change are those of justice, fairness, and equity. Climate change is global, but actual impacts can vary based on moral luck – geography, natural resources, and culture. Given those starting differences, it may be difficult to determine whether the benefits of industrialization and the burdens of climate change are shared equitably. There are a number of ways in which distributive justice could be cashed out. First, are the burdens distributed according to some pattern in which the ethical relationship between responsibility (for emissions) and consequences (climate disturbance), if any, obtains? Global trade complicates the analysis; for example, China surpasses the USA as the world’s leading greenhouse gas emitter but expends a large amount of its energy in the production of consumer goods for the West. Instead, we might ask, are the beneficiaries of industrialization bearing the costs of mitigation proportionally? More to the point ethically, we might focus on repairing maldistributions, that is, trying to ensure that the health impacts of climate change are not distributed in such a way that the risks and burdens are increased for vulnerable individuals (e.g., the elderly, the women, the medically marginalized) or vulnerable nations/communities.

Taking justice seriously as a bioethical principle or practice requires attending to the health equity implications of our environmental future. For humans, climate change will increase health inequity between well-resourced societies and less-well-resourced societies, between wealthy and poor individuals, and between men and women because of their different cultural locations and privileges. Moreover, climate change will have an exponentially negative health impact on individuals, populations, and habitats that are already at risk from other causes. An ethically robust bioethics must reorient itself according to its original environmentally inclusive aspirations in order to prepare for the future. This is not to say that all bioethics analyses will explicate environmental considerations; only that they will explicitly acknowledge the existence of those questions/ issues for the field to take on.

In the short term, climate change mitigation requires transition to low-carbon economies, that is, changes in industrial practices and the production of energy aimed at significant reduction in greenhouse gas emissions. Low-carbon living also offers direct and immediate health benefits, such as reduced rates of obesity, diabetes, and heart disease. While hospital-based programs to reduce greenhouse gas emissions are essential, more can be accomplished with telehealth initiatives that reduce reliance on transportation.

The American Medical Association Policy H-135.938 on Global Climate Change and Human Health endorsed the findings of the Intergovernmental Panel on Climate Change that climate changes will affect public health, with disproportionate impact on vulnerable populations, especially children, the elderly, and the poor. Significantly, the AMA calls for physicians to educate patients on environmentally sustainable practices and for physicians to serve as role models for promoting sustainability, as well as to participate in policy efforts to reduce contributions by humans to climate change. Those working in bioethics should be expected to do no less.

Bioethics Education

Potter himself commented on the absence of the environment as a bioethical issue in the first bioethics textbooks, which were aimed at philosophy and premed undergraduates, setting the template for the way bioethics education framed the issues. While it is the case that Potterian bioethics, that is, environmental bioethics requires multidisciplinarity – knowledge of ecology and public health, or medicine/nursing and ecology, or biology and botany, and so forth – as well as expertise in humanistic or normative methods (philosophy, law, history, sociology, economics, policy, etc.), this is simply a condition of modernity and of the complexity of twenty-first-century healthcare and cannot be avoided.

Many physicians and nurses, as well as those studying bioethics, are taking additional coursework or degrees in genetics or public health, especially in environmental health and environmental genomics. Clearly, in order for physicians to educate their patients regarding environmental sustainability and for them to participate in climate change related policymaking as the AMA recommends, it will first be necessary for physicians to acquire the necessary knowledge base. Proposals are being put forward to include an environmental health education standard in undergraduate medical curricula (Gomez et al. 2013). Similarly, in 2014, the Sustainable Healthcare Education Network – comprised of students and staff in medical schools across the UK – published three priority learning outcomes related to the environment and human health. By the same token, the numerous graduate bioethics degree-granting programs have an obligation to ensure that environmental bioethics is elevated to a core competency.

Conclusion

As technology becomes more and more advanced, an environmentally inclusive bioethics is better prepared to speak to issues that have both human health and ecosystem implications which either cannot or should not be addressed in isolation: synthetic biology, genetically modified crops, engineered viruses, nanotechnology applications, research chimeras, extractive technologies such as fracking, “dual-use” bioethics, and, most significantly, climate change and public health. The future of bioethics is environmental bioethics.

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