Guest Editorial: Sustainability and bioethics: where we have been, where we are, where we are going

Where we have been

Bioethics, as we are too infrequently reminded, was originally an ethical system concerned with the ‘problems of interference with other living beings … and generally everything related to the balance of the ecosystem’ according to the 1978 Encyclopedia of Bioethics (Reich 1978). This definition was predicated on the work of two men – Frtiz Jahr in Germany – and Van Rensselaer Potter in the United States.

In 1927, German minister Fritz Jahr described bio-ethics (German: bio-ethik) as ‘the assumption of moral obligations not only towards humans, but towards all forms of life’ (Jahr and Sass 2010). Jahr drew on Rudolf Eisler’s Bio-Psychik, which was ‘the science of the soul of all, what lives’ to underpin his philosophy of bio-ethics and ultimately promoted a Western, deontological articulation of bioethics, rather than an Eastern, consequentialist bioethic. Jahr summarizes his philosophy by declaring, ‘Respect every living being on principle as an end in itself and treat it, if possible, as such!’ Almost half a century later, the term ‘bioethics’ appeared in English.

In 1971, Van Rensselaer Potter advanced the term bioethic as a way to describe ‘a global perspective with an ecological focus on how we as humans will guide our adaptations to our environment’ (Potter 1971). This life (bios) ethic emerged from a tangible need to evaluate the actions of humans in an industrialized society struggling within a precarious ecosystem. Trained as an oncologist, Potter was particularly sensitive to the connections between health and habitat. Thus, he conceptualized a humanistic ethical system rooted in an intrinsically practical approach to sustainable life, inclusive of the earth and other organisms (Potter 1988). The bios in bioethics is inextricably connected to conservation and medicine.

The ethical commitments of bioethics were initially much more robust than the four principles of biomedical ethics. Conceptually, bioethics was also much broader than the patient-physician relationship. The scope was global, not local; inclusive, not exclusive. And while the development of bioethics as an academic discipline – which was formerly attentive to nature and ecosystems – into a more technological-individual field gave the appearance that ecology is separate from medicine, there have always been scholars and literature where the twain meet. This juncture is most commonly referred to as environmental bioethics.

As an interdisciplinary field, the breadth of biomedical topics which have been folded into environmental bioethics – or addressed with an environmental ethos – are striking. Environmental bioethics, as an applied discipline, takes shape through initiatives in many parts of the world. The United Kingdom’s National Health Services (NHS) and the United States’ Catholic Health Association have emerged as organizational leaders in environmental bioethics in recent decades.

Significantly, the UK is the only region of the world that integrates sustainable health care policy into their national health system. The UK’s model of environmental bioethics relies on legal standards to enforce carbon reduction measures in the NHS. Following from the United Kingdom Climate Change Act of 2008 (UK Public General Acts 2008), the document Saving Carbon, Improving Health: NHS Carbon Reduction Strategy for England encouraged carbon-neutral transportation – like walking and biking – eliminating animal-based foods from menus, and reducing water waste in health care facilities (National Health Services Sustainable Development Unit 2009). A complementary document from the National Institutes for Health Research, ‘highlights areas where sensible research design can reduce waste without adversely impacting the validity and reliability of research’ 2010). Similarly, the NHS Climate Change Strategy for Wales released in 2010 (National Health Services 2010), outlined policies for sustainable health care based on the groundbreaking data from the Carbon Footprint of NHS Wales 2005–2009 study (Lungley 2010). As a comprehensive system of sustainable health care in the UK, efforts in Scotland to reduce carbon emissions include NHS Scotland’s Climate Change Plan (National Health Services Health Scotland 2017) and support from the Scottish Public Health Network and Scottish Managed Sustainable Health Network (SMASH), which also addresses climate change health hazards (Conacher 2019).

The UK model of environmental bioethics depends on the carbon calculations of health care. In addition to the rather straightforward carbon calculations of health care buildings, increasingly studies are published on the carbon emissions of individual medical procedures. Data is available on cataract operations (Morris et al. 2013), heart bypass operations (Berners-Lee 2010), conventional hemodialysis (Lim et al. 2013), caesarian sections and vaginal childbirth (Campion et al. 2012), hysterectomies (Woods et al. 2013), Critical Care Unit stays (Pollard et al. 2014), randomized controlled trials (Lyle et al. 2009), and a variety of dental services (Duane et al. 2017). Carbon calculations are a valuable tool in determining the environmental impact of health care, while also meeting the desires that many patients, practitioners, and health care facilities have to understand the impact of their health choices on the environment.

The NHS continues to systematically address methods for minimizing the carbon impact of health care. Current initiatives include a commitment to reduce single use plastics (Courtney-Guy 2019) and decrease the use of certain anesthetic gasses (Bawden 2019). A thorough evaluation of ‘social prescribing’ of pharmaceuticals is significant, since prescription drugs are the second largest contributor to health care carbon emissions in the NHS, after medical instruments and equipment (Sustainable Development Unit 2018). Recently, the Newcastle upon Tyne Hospitals NHS Foundation Trust declared a climate emergency, which several other NHS Foundations Trusts have endorsed (Wise 2020). These actions, in addition to education about sustainable health care in medical school curriculum (Walpole et al. 2015, Maxwell and Blashki 2016, Walpole and Mortimer 2017), provide a clear and consistent response to the environmental impact of health care.

In contrast to the UK, the US has a decentralized approach to sustainable health care, which codifies environmental ethics into hospitals and health care policy, supported by the oversight of organizations. Health Care Without Harm, Practice Greenhealth, and the Healthier Hospitals Initiative offer umbrella programmes for individual health care facilities to join voluntarily. However, the Catholic Health Association (CHA) with ‘more than 600 hospitals and 1,600 long-term care and other health facilities in all 50 states is the largest group of nonprofit health care providers in the nation’. The CHA creates and implements their own environmental initiatives, which, given their size, is significant in environmental bioethics.

Employees at many CHA hospitals are educated about environmental health and encouraged to recycle paper, carpool, reduce waste in the workplace, and support renewable forms of energy (Florida Medical Association 2015). Health care facilities endorse sustainable design, energy conservation, waste reduction, minimizing bottled water, and eliminating mercury-containing devices. The Catholic Health Association has gone beyond organizational models of sustainable health care by engaging communities in gardening and lobbying for better government support for the environment.

Catholic Health Association initiatives are undeniably tied to Catholic identity and are ‘woven into the very fabric of Catholic mission’ (Catholic Health Association and Practice Greenhealth 2010). As an organization that advocates a ‘seamless garment’ of respect for all life, the CHA simultaneously works for eco-justice and social justice, noting that the two are connected. In 2020, Pope Francis recognized that ‘a true ecological approach always becomes a social approach; it must integrate questions of justice in debates on the environment, so as to hear both the cry of the earth and the cry of the poor’ (Pope Francis 2020). By drawing on common values that cross denominational lines – such as health and stewardship – the CHA is able to provide optimal patient care while also maintaining rigorous environmental standards.

Environmental bioethics, which at once addresses the environmental impact of the medical industry (Pichler et al. 2019), and climate change health hazards, is a dynamic discipline. Simultaneously, thematic elements such as interconnectedness of planetary health and human health, dedication to living in harmony with nature – of which humans are part – and emphasis on systems and symbiosis remains unchanged. This issue of The New Bioethics is not only a celebration of nearly a century of environmental bioethics, but also a reiteration of its necessity today.

Where we are

The original concept of bioethics – both in English speaking and non-English speaking milieus – was attentive to biotic life around us, indicating that environmental aspects of health and obligations to care for each other and our environment were core commitments. Even so, the intellectual starting point of environmental bioethics is significantly different than biomedical ethics. Instead of thinking of technology, medical intervention, and the individual first, environmental bioethics takes an almost primordial approach to health and upends the modern ideology that humans and nature are dissimilar. Zoe-Athena Papalois and Kyriaki-Barbara Papalois’ lead article does double duty in this respect (Papalois and Papalois 2020). It first, acts as a wake up call to those slumbering in the artificially crafted world of technology. It second, draws rich and complicated parallels between the human body and the planet. The examples offered in ‘Bioethics and Environmental Ethics: The Story of the Human Body as a Natural Ecosystem’ are more than analogical; they are parallel descriptors of an intricate system of life that exists in a coherent matrix. To quote the authors, homeostasis ‘describes the human body’s intrinsic tendency towards equilibrium. A change in one direction elicits a response in the opposite direction, restoring harmony. An excessive shift results in a change that cannot be compensated. This imbalance results in illness’. Much like the body, the environment also strives for equilibrium. Significantly, the Papalois’ offer an ecological paradigm to a medical community who primarily conceptualize illness in terms of physical function. By demonstrating that the earth is also a system, which can be well or sick, health care professionals can begin to understand the methodological approach – and contribution of – environmental bioethics. Indeed, some health care professionals are already leading the way.

Four doctors based at the Harvard Medical School-affiliated Massachusetts General Hospital (MGH) for Children detail their initiatives to reduce waste in a pediatric intensive care unit (PICU). Zelda J. Ghersin, Brian M. Cummings, Michael Flaherty, and Phoebe Yager evaluate the medical resources used and disposed of when our bodies become sick (Ghersin et al. 2020). In the PICU, as well as NICUs and ICUs, an enormous amount of hospital waste is generated. While hospital policies on ‘medical waste’ are appropriately based on safety standards, there is little reflection about alternatives which maintain sterility and reduce the carbon footprint of health care. The authors note that medical personnel ‘must find ways to balance the professional duty to prepare with the professional duty to limit the negative impact practices have on the environment, and to save resources when able.’ Hence, the ‘Green Team’ at MGH emerged as a task force which calculated, and thereby tangibly reduced, the amount of medical waste produced in the course of patient care. Their successful endeavour is detailed in ‘Going Greener: Decreasing Medical Waste in a Pediatric Intensive Care Unit’ and is one of only a handful of published quantifiable studies on medical waste in hospitals.

Much like the US-based doctors, UK physician Terry Kemple underscores the tension between professional obligations to protect patients from harm and the impending health threats from climate change (Kemple 2020). Kemple draws upon ethical theories and medical codes to demonstrate that physicians are accountable for patient and public health. Recipients of medical care must be given the best care, not only at the moment of need, but also in the long-run. Medical organizations, such as the General Medical Council, endorse this duty by ‘providing a comprehensive overview of the obligations and professional behaviour of a doctor to their patients and wider society’. Yet, when physicians participate in non-violent actions like those organized by Extinction Rebellion (XR), they may be censured. Arrests of doctor-activists can lead to a GMC tribunal, despite the apparent imperative to actively protect human health. ‘The Climate Emergency: Are the Doctors Who Take Non-Violent Direct Action to Raise Public Awareness Radical Activists, Rightminded Professionals, or Reluctant Whistle-Blowers?’ exposes the internal contradiction of some health care organizations and reinterprets traditional medical codes of conduct to not only include – but also mandate – climate action as a matter of personal integrity.

The Ghersin et al. and Kemple articles describe actions and initiatives that health care providers can take to minimize harm within and outside of the hospital, respectively. A complementary narrative for sustainable health care comes from environmental ethics. In ‘Restorative Commons as an Expanded Ethical Framework for Public Health and Environmental Sustainability’, Robert Gurevich offers a bridge between health care and ecology by providing a model of proactive sustainability (Gurevich 2020). He observes, ‘current sustainability initiatives are limited in their scope; for example, targeted campaigns to reduce carbon footprints may achieve some measure of success, but they do not change humanity’s relationship with the environment, which is the root of the issue’. Therefore, in recognition that humans are part of the Commons, harmonious recommendations for health are offered within and beyond the clinic. Gurevich explores the benefits of ‘ecotherapy’, which immerse individuals with mental and physical health conditions in nature, and green health centres, which integrate conservationist practices into the daily life of a hospital. This ‘both-and’ philosophy restores humans to an ecological nexus which at once protects from disease and contributes to cure. Indeed, if nature is the cure, then health care providers must be persuaded as such through scientific analysis of evidenced based medicine.

Echoing the theme of planetary and corporeal health that was highlighted in Papalois and Papalois’s article, medical doctor Maximilian Andreas Storz draws parallels between the increase in global chronic disease burden and excessive carbon emissions (Storz 2020). The contemporary, Western attitude to both illness and environmental exploitation utilize a reactive model that manages the symptoms but not the disease. Questioning the conventional practice, which permits destructive habits and then offers high tech solutions, ‘Will the Plant-Based Movement Redefine Physicians’ Understanding of Chronic Disease?’ provides indubitable evidence that vegetarian and vegan diets are not only effective in reducing and preventing disease, but also are more environmentally sustainable, as they require fewer natural resources and expend less carbon. Significantly, Storz goes beyond merely describing the benefits of eating lower on the food chain and declares, ‘plant-based diets are a powerful tool – not using and advocating for them is not only unethical, but harms patients and the planet alike’. The ethical demands on health care professionals include accountability to patients and obligations to professionalism. Environmentally aware clinicians braid these two commitments into a variety of ecologically sound health care practices.

To be sure, health care providers are not the only stakeholders in sustainable medicine. The final article offers a rousing call to action for medical researchers, scientists, bioethicists, policymakers, and other individuals who must actively participate in delivering medical care that does not result in a Sisyphean cycle of pollute-treat-pollute. Cheryl Macpherson, Elise Smith, and Travis Rieder maintain, ‘given the goals of healthcare, claims of and calls for health promotion are hypocritical unless they involve strategies and policies that explicitly protect environments and natural resources’ (Macpherson et al. 2020). Health care cannot continue its current trajectory of environmental exploitation – given the widely established facts about climate change health hazards, medical resource consumption, and medical waste. Three concrete solutions are thus offered in ‘Does Health Promotion Harm the Environment?’: slowing the global birthrate, transforming the food system, and genetically modifying mosquitoes. Utilizing the ingenuity of science to safeguard human health and protect the planet is emphasized, demonstrating that environmental bioethics encompasses many outlooks. And still, the double-dividend approach, which works towards the common goals of satisfying the ethical standards of human rights to health and the moral imperative for environmental conservation, is the common theme in this issue of The New Bioethics.

Where we are going

Sustainable medicine will continue to address the most pertinent aspects of environmental health while compounding the irrefutable evidence that the health care industry must embark on a radically different path than the one it is on now. The Coronavirus pandemic highlighted the importance of environmental bioethics for health in a variety of ways. First, simply examining the biological spread of COVID-19 and the precautionary measures of social isolation and self-quarantine remind the human collective that we are all interconnected. One person’s actions effect another and may set off a chain reaction that has local, national, and international implications. Although much ecological destruction is invisible to the general public, each purchase that is made, each health care procedure used, and every medical choice has an environmental impact. Humans have had to adapt to thinking in terms of long-range cause and effect by imagining the spread of Coronavirus on surfaces. An infected person may touch a product, which will be shipped to a store, which will be stocked by a worker, which will be purchased, brought home, and shared with family, thus transmitting this highly contagious virus. Humans also need to understand the carbon impact of consumerism in the same way. The creation of a product had a carbon footprint, as did the fuel used for transportation, the cooling system used in the grocery store, the emissions from the car ride home, and the disposal of the bottle. Although the immediate consequence of the resource use is unrecognized, the environmental outcome will surely be accounted for later.

Second, many people are now living in a world where movements and actions are considerably limited. There are mandated home quarantines for those of advanced age and people who are symptomatic. Road closures, domestic bans, and closed borders prevent travel. Daily updates about increased restrictions offer little warning before implementation and in some parts of the country, are not readily disseminated. Yet, these measures will become more commonplace unless carbon emissions are reduced and climate change health hazards are minimized. All adults and children will need to shelter in place when air quality compromises respiratory health. Severe weather, including hurricanes, tornados, floods, and blizzards will close access points, leaving hundreds or thousands of people stranded. As with the Coronavirus, the elderly, disabled, poor, homeless, and those with young children will be most affected.

Third, the devastating economic effects of the Coronavirus have illuminated the need to re-think commerce. Certain businesses that provide ‘fast fashion’, lifestyle trends, other ‘non-essential’ services have been curtailed, while sanitation, health care, and education are preserved. Disposable life cannot be sustained. As policymakers work towards economic recovery, more should be done to support the triple bottom line of people, planet, and profit. This includes green collar jobs with a variety of entry level positions, a green gig economy, and investment into technologies that both clean and preserve the environment.

Despite the devastating parallels between COVID-19 and climate change, the global emergency has offered windows of hope. Communities are able to discern the essential – health, family, food – from the trivial. Worldwide, people are placing emphasis on generous relationships, outdoor activity, and a marked reduction in eating and drinking out. Health care is being prioritized as a national interest, as is the necessity of keeping open spaces, such as hiking trails, parks, and sidewalks, available and well maintained. This reorientation towards low carbon activities will perhaps remind many about the emotional and spiritual goods that cannot be bought.

A prescient Van Rensselaer Potter wrote in 1971 that ‘technological decisions should not be made on the basis of profit alone, but should be examined in terms of survival’. Whether in the medical industry or designing a better world, survival, here, does not mean a reckless exploitation of resources and energy. Rather, survival is dependent on the cohesion of the natural and built environment. The way back is also the way forward.