CLIMATE CHANGE IS A BIOETHICS PROBLEM

CHERYL COX MACPHERSON

Keywordsclimate change,autonomy,public health,social values,public policy,bioethics,risk assessment

ABSTRACTClimate change harms health and damages and diminishes environmentalresources. Gradually it will cause health systems to reduce services, stand-ards of care, and opportunities to express patient autonomy. Prominentpublic health organizations are responding with preparedness, mitigation,and educational programs. The design and effectiveness of these pro-grams, and of similar programs in other sectors, would be enhanced bygreater understanding of the values and tradeoffs associated with activitiesand public policies that drive climate change. Bioethics could generate suchunderstanding by exposing the harms and benefits in different cultural,socioeconomic, and geographic contexts, and through interdisciplinary riskassessments. Climate change is a bioethics problem because it harmseveryone and involves health, values, and responsibilities. This articleinitiates dialog about the responsibility of bioethics to promote transparencyand understanding of the social values and conflicts associated with climatechange, and the actions and public policies that allow climate change toworsen.

For millennia humans have enjoyed, relied on, andvalued nature and the natural environments that providespaces for agriculture, shelter, play, sport, relaxation,creativity, and reflection. Extreme weather, rising sealevels, and other environmental disruptions caused byclimate change harm these environments. Growingemphasis on globalization, consumption, and immediategratification obscures their inherent value and their con-tributions to food, water, and wellbeing. Harming theseenvironments threatens economic growth and nationalsecurity,1 human rights,2 agriculture and food security,3

and health.4 The March 24, 2012 issue of the British

Medical Journal includes several articles about thesechallenges. The World Health Organization (WHO),U.S. Centers for Disease Control (CDC), BritishNational Health System (NHS), and other leading healthorganizations have initiated mitigation and preparednessprojects relevant to diverse cultural, socioeconomic, andgeographic conditions.5

The severity of and certainty about climate change arereal. These constitute the biggest health threat of this

1 L. Jarvis, H. Montgomery, N. Morisetti, et al. Climate Change, IllHealth, and Conflict. BMJ 2011; 342: 777–778.2 S. Caney. 2010. Climate Change, Human Rights, and Moral Thresh-olds. In Climate ethics: Essential readings. S. Gardiner, S. Caney, D.Jamieson, et al., eds. Oxford: Oxford University Press: 163–180.3 A. Haines, K.R. Smith, D. Anderson, et al. Policies for AcceleratingAccess to Clean Energy, Improving Health, Advancing Development,and Mitigating Climate Change. Lancet 2007; 370: 1264–1281.4 A.J. McMichael, S. Friel, A. Nyong, et al. Global EnvironmentalChange and Health: Impacts Inequalities, and the Health Sector. BMJ2008; 336: 191–194.

5 World Health Organization (WHO). 2012. Health Topics: Climatechange. Geneva. Available at: http://www.who.int/topics/climate/en/[accessed 20 Sep 2012]; National Health Service Sustainable Develop-ment Unit (NHS SDU). 2012. SD and the NHS: NHS Carbon Footprint.London. Available at: http://www.sdu.nhs.uk/ [accessed 20 Sep 2012];Health Canada. 2012. Climate Change and Health. Ontario. Avail-able at: http://www.hc-sc.gc.ca/ewh-semt/pubs/climat/index-eng.php[accessed 20 Sep 2012]; Centers for Disease Control (CDC). 2012. PublicHealth Response to a Changing Climate. Atlanta. Available at: http://www.cdc.gov/Features/ChangingClimate/ [accessed 20 Sep 2012]; Euro-pean Commission. 2010. Adaptation to Climate Change: What is the EUDoing? Available at: http://ec.europa.eu/clima/sites/change/what_is_eu_doing/health_en.htm [accessed 20 Sep 2012].

Address for correspondence: Cheryl Cox Macpherson, PhD, St George’s University School of Medicine, PO Box 7, St George’s, Grenada, West Indies,Phone: 1 473 444 1470, Fax: 1 473 439 4388. Email: ccox@sgu.eduConflict of interest statement: No conflicts declared

Bioethics ISSN 0269-9702 (print); 1467-8519 (online) doi:10.1111/bioe.12029Volume 27 Number 6 2013 pp 305–308

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century.6 Climate change is caused by greenhouse gasemissions that accumulate in the atmosphere faster thanthey can dissipate. Their accumulation increases withsocioeconomic development, and with global populationgrowth which doubled from three to six billion between1960 and 2000, and will reach eight billion around 2025.7

The environmental resources of the 1960s will not stretchfar in 2025 when population, emissions, and global tem-peratures will have risen to unsafe levels. Without pre-ventive measures, the movements of more people andgoods will generate still more emissions. The healthcaresector, among others, generates vast amounts of emis-sions but could mitigate these without reducing health-care quality.8 Failing to mitigate emissions posesphysical, economic, and moral problems that shouldconcern bioethics and other disciplines.

Climate change results from individual and collectiveactivities that, like healthcare, paradoxically benefit indi-viduals, populations, and nations. These activitiesinvolve choices about whether, when, and how torespond to evidence about the causes and harms ofclimate change. Deeper understanding of values and soci-etal conditions that permit emissions to accumulate atpresent rates would strengthen efforts to minimize furtherdamage. This article initiates dialog about how bioethicsmay contribute to such understanding, and its responsi-bility to do so. It invites bioethics to initiate interdiscipli-nary explorations of technologies, activities, and policiesthat generate emissions in order to deepen understandingabout the ethics, values, and societal conditions thatallow climate change to worsen. Bioethical analyses areintegral to effective responses because ethics, values, soci-etal conditions, and potential conflicts of interest deter-mine what risk assessments are conducted, how they areinterpreted, and how their findings are communicatedand responded to.

CLIMATE CHANGE HARMS HEALTH

Data from many scientific sources is conclusive thatclimate change raises air and water temperatures and sealevels, and that these changes occur globally and last for

decades or centuries. These changes have already causedcardiovascular and respiratory deaths; facilitated thetransmission of water borne and vector borne diseasethrough impacts on pathogen reproduction, vectordensity, and other means; and worsened acute andchronic conditions including mental illness.9 By raisingthe salinity of fresh water they have reduced food sources,nutrition, and physical activities conducive to health, par-ticularly among indigenous peoples.10 By causing morefrequent and severe weather events, climate change dis-places populations and diminishes both quality andquantity of water, food, and shelter. This facilitates out-breaks of water borne, nutritional, infectious, and otherforms of disease. Even in wealthy nations these spreadrapidly in overcrowded and emergency settings, but thosewith fewer resources and less capacity to prepare orrecover are the most vulnerable.11 Bioethical analyses ofthe associated injustices are needed.

To mitigate the harms of climate change it is neces-sary to reduce activities that produce emissions. Thereare many ways of doing so without compromisinghealth or socioeconomic development. Making masstransit systems and bicycle lanes more user friendlyincreases their use and reduces net energy consumption,urban heat, and risk factors for asthma, heart attack,and obesity.12 Livestock production generates 18% of allglobal emissions but reducing meat consumption wouldreduce emissions and the cancer and heart diseasecaused by its overconsumption.13 The ‘contraction andconvergence’ strategy recommends raising meat con-sumption in poor nations to improve nutritional statustherein while reducing it in wealthy nations with highlevels of cancer and heart disease in order to reduce netemissions, improve nutrition, and create healthier envi-ronments.14 Cost effective ways of reducing emissionsexist and new ones are being developed but there is rela-tively little public, policy, or bioethics dialog about theneed to fund the associated research or support itstranslation into practice. The nature and history ofbioethics is such that it has a responsibility to offeranalyses of the burdens and benefits of emissions

6 A. Costello, M. Abbas, A. Allen, et al. Managing the Health Effectsof Climate Change. Lancet 2009; 373: 1693–1733.7 United States Census Bureau. 2012. International Programs: Interna-tional Data Base: World population: 1950–2050. Washington D.C.Available at: http://www.census.gov/population/international/data/idb/worldpopinfo.php [accessed 20 Sep 2012].8 G. Kwakye, P.J. Pronovost, & M.A. Makary. Commentary: a Call toGo Green in Health Care by Reprocessing Medical Equipment. AcadMed 2010; 85: 398–400; S. Gilbert. 2012. Why Hospitals ShouldGo Greener. Bioethics Forum. Garrison, NY: The Hastings Center.Available at: http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=6116&blogid=140 [accessed 19 Feb 2013]; NHS SDU, op. cit.note 5.

9 Costello et al., op. cit. note 6.10 J.D. Ford. Indigenous Health and Climate Change. Am J PublicHealth 2012; 102: 1260–1266.11 C.C. Macpherson. Public health, Bioethics and Policy: Protectingour Health and Environment. International Public Health Journal 2010;4(2): 535–540.12 H. Frumkin, A.J. McMichael. Climate Change and Public Health:Thinking, Communicating, Acting. Am J Prev Med 2008; 35: 403–410;Haines et al., op. cit. note 3.13 B.M. Popkin. Reducing Meat Consumption has Multiple Benefitsfor the Worldzyxonethreetwoxyz Health. Arch Intern Med 2009; 169:543–545.14 A.J. McMichael, J.W. Powles, C.D. Butler, et al. Food, LivestockProduction, Energy, Climate Change, and Health. Lancet 2007; 370:1253–1263.

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producing activities; utility and distributive justice of agiven intervention; and procedural justice regarding theassignment of related responsibilities.

RESPONSIBILITY

In democracies individuals, industries, and governmentsmay choose their activities and policies but these choicesare often made with limited information about the costs,consequences, and alternatives. If there is only one way toobtain water, food, or income, for example, then there isno choice about how to obtain it. If fuel efficient cars costmore than others and a car is a necessary means of trans-portation, as is sometimes the case, then economic statuslimits opportunities for fuel efficiency. Is there a respon-sibility to make more such choices available to all, and ifso, whose is it? Ethics and values determine the extent towhich nations, industries, and institutions accept andfulfill such responsibilities, and how they respond to theassociated economic, political, health, and human rightschallenges.

Human rights declarations highlight the responsibili-ties of nations to promote autonomy and health amongindividuals and populations. By failing to educate popu-lations about the causes and impacts of climate change,and failing to create opportunities for rich and poor toreduce emissions, nations jeopardize human rights to lifeand health and violate these declarations.15 Healthsystems in Scandinavian nations uphold these declara-tions by promoting universal access to healthy lifestylesand environments, and facilitating individual choiceabout how and when to access these. Through these poli-cies Scandinavian systems generate healthier and moreautonomous populations and lower healthcare expendi-tures than other health systems.16

Increasing the ease of transportation by foot andbicycle with more accessible and pleasant paths; facilitat-ing greater consumption of whole foods and less ofanimal products by increasing access to whole foods andnutritional and climate information; and providing otheropportunities to choose healthy lifestyles simultaneouslyreduces emissions and improves health. Values determinewhether individuals, nations, or other entities accept anyresponsibility for protecting against climate change; andwhat climate and health related strategies and policiesthey adopt.

Policies and health systems that expand access tohealthy choices reduce emissions, improve health, andpromote autonomy. The successful design and implemen-tation of policies that accomplish this requires multisec-

toral and multidisciplinary collaborations. Whetherpolitical and financial commitment is made to such workdepends largely on ethics, societal and individual values,and the contexts in which the work is needed. Explora-tions of values and ethics in different geographic, socio-cultural, and economic contexts should inform publicand policy dialog about the complex harms and benefitsof emissions producing activities in those contexts. Suchexplorations would deepen understanding of some of themoral and practical conflicts inherent in emissions pro-ducing activities.

AUTONOMY

Nobel prize winning scientist Sir John Sulston reported atthe opening ceremony of IAB’s 2012 Congress thatclimate change is worsening because global population,and per capita energy consumption, have each increasedseven fold in 150 years.17 He explained that this is at leastpartly due to cultural and other conditions that depriveover 200 million women of family planning infor-mation and resources; that giving those women greaterautonomy in their reproductive choices would probablyreduce global population growth and emissions; and thatbioethical analyses of sociocultural influences would behelpful in balancing choices about emissions. As notedabove, bioethical analyses would also help to frame andinform dialog about how the responsibility to mitigateemissions varies in different settings.

Health systems in low and middle income nations tendto maximize the utility of their limited resources by pri-oritizing basic primary services. Few have the resourcesto provide these services to all, or at standards typical ofWestern nations. The scarcity of resources and infra-structure contributes to the historically paternalistic poli-cies of such health systems and their limited concern withpatient autonomy. The impacts of climate change onresources for health, healthcare, and infrastructure willeventually impinge on autonomy even in wealthy nations.

The principle of autonomy is vital to Western health-care but many inappropriately prioritize autonomy overbeneficence, nonmaleficence, utility, and justice.18 Thisdeflects attention from societal problems and injustices

15 Caney op. cit. note 2.16 C. Munthe. The Goals of Public Health: An Integrated, Multidimen-sional Model. Public Health Ethics 2008; 1: 39–58.

17 J. Sulston. People and the Planet. Keynote address at the openingceremony of the 11th IAB International Congress. Rotterdam. 26 June2012. Sulstonzyxonethreetwoxyz address was based on the 2012 reportof a working group that he chaired for the Royal Society. Available athttp://royalsociety.org/policy/projects/people-planet/ [accessed 21 Sep2012].18 A. Dawson. The Future of Bioethics: Three Dogmas and a Cup ofHemlock. Bioethics 2010; 24: 218–225; D. Callahan. Autonomy: AMoral Good, not a Moral Obsession. Hastings Cent Rep 1984; 14:40–43; R.M. Veatch. Autonomyzyxonethreetwoxyz TemporaryTriumph. Hastings Cent Rep 1984; 14: 38–40.

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in non-Western and non-wealthy populations19 andobscures the significance of cultural, socioeconomic, andgeographic conditions for health.20 Bioethics uses its vastacademic, financial, and intellectual resources to teachWestern conceptions of autonomy around the world butneglects many of the bioethical problems and priorities ofnon-Western and non-wealthy nations. Practical and costeffective solutions to climate change require engagementwith its variable manifestations of harm in different geo-graphic, economic, and societal circumstances. These cir-cumstances affect access to the benefits of emissionsproducing activities; burdens of and vulnerability to theharms; and whether the associated responsibilities areshared ethically.

Many emissions producing activities generate collec-tive benefits even as they damage the quality and quantityof environmental resources. Bioethical attention to thebenefits, burdens, and responsibilities associated withclimate change are needed to frame risk assessments;inform choices between individual and collective gain;elucidate distinctions between subsistence and luxurygoods; and better clarify when and how to implement theharm and precautionary principles. The harm principlesupports minimizing emissions in order to avoid harmingothers, and the precautionary principle supports takingprecautions that are proportional to the severity and cer-tainty of the harms. Bioethical perspectives might helpclarify how and when to apply these principles, whoseresponsibility it is to enforce them, and what is gained bydoing so. The gains include the protection of resourcesthat enable health systems to respect patient autonomy,and the outcomes of objective risk assessments that canbe used to determine the utility of a given emissions pro-ducing activity or mitigation strategy.

CLIMATE CHANGE IS ABIOETHICS PROBLEM

Climate change harms health everywhere and allowing itto worsen is a choice involving values and responsibili-ties. Bioethics has a responsibility to promote transpar-ency and understanding about the actions and policiesthat allow climate change to worsen, and to explore the

associated values and conflicts. Bioethical and multidis-ciplinary analyses would enhance understanding aboutthe utility and justice of emissions producing activitiesand mitigation strategies; elucidate the values at stake;and inform protective responses pertinent to cultural,geographic, and other circumstances. Morality pervadeschoices about how to minimize and rectify the damages,and the quality and quantity of environmental resourceswe leave to our children and grandchildren. New concep-tions of moral responsibility and virtue might helpresolve some of the dilemmas about these choices.21

Bioethics could help formulate these conceptions, and afew bioethicists are beginning to do so.22

Values and virtues traditionally center on places,things, and activities that societies have cherished forcenturies. These are largely being displaced by goods thatoffer immediate gratification like inexpensive clothes, air-fares, foods, and electronics. Today the extent to whichindividuals purchase and own such things reflects theiridentity and how others perceive them, and affects theirhealth and the health of others. Bioethics is concernedwith objectivity, fairness, morality, responsibility, health,and wellbeing. Allowing climate change to continue una-bated is a bioethics problem.

Meaningful analyses of the values, virtues, and utilityassociated with emissions production are needed. Bioeth-ics could boost understanding of the benefits and harms;promote transparency about actions and policies thatallow climate change to worsen; expose potential conflictsof interest that affect the conduct and interpretation ofrisk assessments; generate insights about socioculturalconditions that impinge on autonomy and worsen emis-sions; and ground new conceptions of social responsibil-ity. At the very least, bioethics should inform andfacilitate public and policy dialog about how climatechange threatens health and things societies have valuedfor centuries.

Cheryl Macpherson is professor and chair of the Bioethics Departmentat St George’s University (SGU) School of Medicine in the Caribbeannation of Grenada, and adjunct professor in SGU’s Department ofPublic Health and Preventive Medicine and School of Veterinary Medi-cine. She is currently the Vice Chair of SGU’s IRB, and President of theBioethics Society of the English-speaking Caribbean (BSEC).

19 S. Sherwin. Looking Backwards, Looking Forward: Hopes forBioethics’ next Twenty-five Years. Bioethics 2011; 25: 75–82; H. Bras-well. In Search of a Wide-angle Lens. Hastings Cent Rep 2011; 41:19–21.20 R.C. Fox, J.P. Swazey. Guest Editorial: Ignoring the Social andCultural Context of Bioethics is Unacceptable. Cam Q Healthc Ethics2010; 19: 278–281; R. De Vries, L. Rott. 2011. Bioethics as MissionaryWork: The Export of Western Ethics to Developing Countries. InBioethics around the Globe. C. Myser, ed. Oxford: Oxford UniversityPress: 3–18.

21 D. Jamieson. 2010. Ethics, Public Policy, and Global Warming. InClimate ethics: Essential readings. S. Gardiner, S. Caney, D. Jamieson,et al., eds. Oxford: Oxford University Press: 77–86.22 D.B. Resnik. 2007. Bioethics and Global Climate Change. BioethicsForum. Garrison, NY: The Hastings Center. Available at: http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=426&blogid=140&terms=Bioethics+and+Global+Climate+Change+and+%23filename+zyxonezerothreexyz.html [accessed 19 February 2013]; D.B. Resnik.2012. Environmental Health Ethics. NY: Cambridge University Press:171–201; V.A. Sharpe. ‘Clean’ Nuclear Energy? Global Warming,Public Health, and Justice. HCR 2008; 38: 16–18.

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