Book Review

The Ethics of Environmentally Responsible Health Care

By Jessica Pierce and Andrew Jameton

New York:Oxford University Press, 2004. 149 pp. ISBN: 0-19-513903-8, $36.95 cloth

The answer to the ethical question "How should we live?" depends in part on what we know. Years ago, Aldo Leopold called for a "land ethic" as a consequence of understanding the interdependence of individuals in a larger ecological system. Here Jessica Pierce and Andrew Jameton examine new ways of thinking about bioethics, with a sense of urgency because of current ecologic realities. They ask for reexamination of the health care system in light of what we know--about not just human biology but also the biosphere.

image credit: Arnold Greenwell/EHP

Brief, well-referenced summaries of the links among health, environmental change, population, and consumption lay the groundwork. People profoundly stress the integrity of soil, water, air, climate, and biodiversity, causing widespread misery. Up to one-third of the global burden of disease is related to environmental factors. Unsustainable natural resource consumption and health care patterns dramatically favor wealthier individuals and countries.

Pierce and Jameton take direction from Herschel Elliott's idea that "an acceptable system of ethics is contingent on its ability to preserve the ecosystems that sustain it." Bioethics, therefore, has a responsibility to life-supporting systems, not just to patient rights or human rights. Good public health is essential to bioethics, in that poor public health and expensive reactions to environmentally related disease add stress to the environment. The authors remind us that poverty is a predictor of poor public health; but once some minimum standard of wealth is achieved, public health does not improve commensurate with spending. The authors then turn to the health care system.

Resource extraction, materials manufacture, and disposal are responsible for most human impacts on the natural world. The scale of health care activities and related material flows contribute substantially to environmental degradation. High-tech equipment, pharmaceuticals, transportation, and water and electricity consumption in health care have major environmental impacts. Despite the commitment of cultural institutions of wealthier countries to growth, material throughput must be drastically scaled back to achieve sustainability. The health care system must do its share, particularly in the United States, where we generate 40% of all global health care expenditures.

Marginal improvements in materials policies may help, but a fundamental reexamination of the scope of clinical services is also required--inevitably leading to concerns about "rationing." But rationing, the authors say, should be thought of not as "less than optimal" care but rather as "sustainable optimal care" if the health care system is going to meet its ecologic responsibilities.

What might that look like? The authors describe the thought experiment of a working group that designed a "green" health clinic, from its guiding ethical principles to its physical structure and menu of clinical services. The dilemmas they faced show just how difficult it will be to get off the treadmill of growth and reliance on curative medicine without a fundamental cultural shift. Economic feasibility must be conditioned by moral feasibility--a daunting prospect, but perhaps achievable.

Bioethics has become largely limited to the narrower field of medical ethics, usually focusing on the rights and responsibilities of individuals. Autonomy, not community and relationship, has taken over discourse in bioethics. Pierce and Jameton argue that philosophies are available to save bioethics, but only by rethinking the roles and meaning of beneficence, biocentrism, ecocentrism, autonomy, coercion, justice, and modesty. Choice can be an expression of respect for one's duties rather than desire, though it may include setting limits on oneself.

This book explores areas of discomfort. To some it may seem unrealistic. However, it calls moral concerns into health care decision making in fundamentally new ways. Who or what is "the patient"? What considerations should enter this relationship? In a world of limits, what is the morally best world? It is a call to link the biologic sciences, public health, and ecologic sciences with ethics. Aldo Leopold thought, "We can be ethical only in relation to something that we can see, feel, understand, love, or otherwise have faith in." This suggests a way forward and, at the same time, the enormity of the cultural challenge.

Ted Schettler

Dr. Ted Schettler is on the medical staff of Boston Medical Center and is science director of the Science and Environmental Health Network. He has published papers and co-authored two books addressing environmental impacts on human health. He has served on advisory committees of the U.S. Environmental Protection Agency and the National Academy of Sciences.

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[Table of Contents]

Last Updated: May 18, 2004