The case for integrating the environment into the definition of bioethics.

• Author: Chaffee, Mary W.

1. INTRODUCTION II. HOW A NARROW CONCEPTION OF BIOETHICS EMERGED A. Bioethics Has Two Fathers B. Birth-Father #1: Van Rensselaer Potter C. Birth-Father #2: Andre Hellegers, Father of the Georgetown Perspective D. Georgetown's Dominance E. The Georgetown Definition of Bioethics Takes Hold F. Potter Attempts to Resuscitate His Bioethics Model III. INDICATORS OF THE GEORGETOWN VIEW'S PROLIFERATION A. Bioethics Organizations B. Bioethics Textbooks IV. THE TRUE SCOPE OF BIOETHICAL DILEMMAS A. The Health Sector as a Porous System B. The Human Connection to the Environment C. Social Determinants of Health D. Public Health E. The Environment and Health V. POTTER'S VIEW IS BETTER ALIGNED WITH THE TRUE SCOPE OF BIOETHICAL DILEMMAS A. The Value of Theory B. Complexity Theory Offers Support for Potter's View of Bioethics 1. Complexity Theory--An Overview of its Characteristics 2. Porous Boundaries 3. Emergence 4. Co-evolution C. Biocentrism and Bioethics VI. A BROADER VIEW OF BIOETHICS IN PRACTICE A. Expanding Bioethics Practice B. Expanding Bioethical Tools 1. Principlism in Bioethics C. Applying Potter's Bioethics Definition . 1. Air Pollution 2. The Impact of the Health Sector VII. CONCLUSION I.

INTRODUCTION

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. (2)

--Jessica Pierce

In 1971, Van Rensselaer Potter first coined the term "bioethics" to advocate for the exploration of medical science and values with the goal of protecting life on earth. (3) Historically, bioethicists have focused primarily on medical dilemmas and issues in health care more generally, and have paid scant attention to how environmental issues influence human health. (4)

Examining the history of the word "bioethics" illuminates why it was medicalized; however, the ethical decisions that permeate our lives today require broader contemplation of factors that influence human health. Failing to consider influences outside the health system is analogous to standing on a porch mulling over whether to use a rake or a broom to disperse a pile of leaves, while a tornado is bearing down on the house. Looking at the "bigger picture" provides important context for our ethical decisions.

Ethical issues relating to the maintenance and management of human health do not exist solely within hospitals and medical clinics. The environment in which people work, play, and carry out their lives significantly influences their health. Thus, ethical discussions within the health sector that are insulated from the broader world may not address important influences on human health. Potter's broader view of bioethics should be reexamined and adopted in light of growing knowledge regarding health and the environment.

This Note argues that ethical work that is limited to issues within the health system should be termed "medical ethics." Broader ethical issues that have links to the health care system as well as to public health, social determinants of health, and environmental health should be defined under the broader conceptualization of "bioethics."

The remainder of this Note proceeds as follows: Part II-How a Narrow Conception of Bioethics Emerged describes how bioethics came to focus on ethical issues that are largely confined to medicine. Part III--Indicators of the Georgetown View's Proliferation offers contemporary examples of the narrow scope of bioethics. Part IV--The True Scope of Bioethical Dilemmas discusses the value of broadening the definition of bioethics to include public health activities, social determinants of health, and the human connection to the environment. Part V-Why Potter's View is Better Aligned with the True Scope of Bioethical Dilemmas demonstrates how complexity theory and biocentrism are aligned with Potter's view of bioethics. Part VI-A Broader View of Bioethics in Practice discusses how bioethics practice could be adapted to embrace Potter's view. Part VII-Conclusion summarizes key elements in the Note.

II.

HOW A NARROW CONCEPTION OF BIOETHICS EMERGED

Scientific evidence helps tell us what we can do and ethics helps tell us what we should do. (5)

--Lisa M. Lee, PhD, MS

1. Bioethics Has Two Fathers.

   In the 1880s, Nikola Tesla and Thomas Edison engaged in a "war of the currents," which would ultimately determine whose vision of an electrical system powered the world. (6) Edison triumphed, and Tesla's contributions were obscured by history. (7)

   The conception of "bioethics" had similar beginnings. Prior to the 1960s, "medical ethics" focused on physicians, patient welfare, and medical professionalism. (8) But then, the 1960s boomed with advancements that stretched the boundaries of medical ethics, including organ transplantation, a new definition of death, technology to sustain human life, and new forms of contraception. (9) To address these changes, two men--Van Rensselaer Potter and Andre Hellegers--independently introduced the term "bioethics." The two men proposed distinct definitions for the term: Hellegers's was narrow and medically-focused while Potter's was much broader. The former definition took hold and has eclipsed the latter for several decades, which has had significant implications for an entire field of scholarship, professional practice, and research.

2. Birth-Father #1: Van Rensselaer Potter

   Van Rensselaer Potter was one of two individuals to propose a new discipline known as "bioethics" that would merge science and philosophy. (10) He broadly conceived of bioethics as a global integration of biology and values, and envisioned that it would guide human survival. (11)

   Potter was trained as a biochemist and engaged in a career as a cancer researcher at the University of Wisconsin. (12) In the 1960s, in addition to his cancer research, he wrote articles on human progress, the interrelation of science and society, and individuals' roles in modern society. (13) Potter crafted the term "bioethics" to express the need to balance medical science with human values. (14) Though some disagreement continues about whether Potter was the first to employ the term, he was first to publish a book about it, Bioethics: Bridge to the Future, which appeared in 1971. (15)

   Potter perceived survival of the human species as the vital priority. (16) The new discipline of bioethics, as he saw it, would address basic problems related to "human flourishing." (17) Importantly, Potter viewed bioethics as a bridge between present and future, nature and culture, science and values, and humans and nature (thus the title of his first book). (18) He was concerned about problems like population growth, poverty, pollution, and progress. (19) He saw these as threats to human viability, and bioethics as a solution--a "new science of survival." (20) Potter placed bioethics in the bios--the life in the world--drawing connections between medicine and conservation. (21)

3. Birth-Father #2: Andre Hellegers, Father of the Georgetown Perspective.

   Dr. Andre Hellegers at Georgetown University's Kennedy Institute of Ethics in Washington, DC, proposed a new field called "bioethics" contemporaneously with Potter's efforts to do the same. (22) Hellegers, the Georgetown Institute's first director, was a professor of obstetrics and gynecology. His institute focused on perinatal medicine (health care from conception to shortly after birth), and care in operating and delivery rooms, as well as other clinical areas where life and death decisions involving both science and ethics are made daily. (23) Hellegers had served for two years as Deputy Secretary General of the Papal Commission on Population and Birth Control and had become a confidant to leaders in the Catholic Church. (24)

   Hellegers' Georgetown center, formally the Joseph and Rose Kennedy Institute for the Study of Human Reproduction and Bioethics, was funded by a grant from the Kennedy family. (25) It would have the unique purpose of combining science and ethics, as well as considering contemporary questions such as whether parents of a mongoloid (26) child have a duty to keep the child alive, what obligation a physician has to keep an aged patient alive when the patient's condition is hopeless, and who should benefit from artificial kidney machines when few are available. (27)

   While Potter's view of the term bioethics included long-range environmental concerns, the Georgetown perspective was much narrower in its scope. (28) It defined bioethics as the ethical analysis of moral questions arising in medical practice due to advances in biomedical science and technology. (29) According to an early Kennedy Institute publication, the Georgetown conceptualization of bioethics limited bioethics to the study of the ethical dimensions of medicine and the biological sciences. (30) Bioethics, as framed by Georgetown, would deal primarily with concrete medical dilemmas in three areas:

   1) Rights and duties of patients and health professionals

   2) Rights and duties of research subjects and researchers, and

   3) Formulation of public policy guidelines for clinical care and biomedical research. (31)

4. Georgetowns Dominance

   Over the last four decades, the Georgetown view of bioethics has become dominant and has marginalized Potter's broader conception of the field. (32) The narrow, medicine-focused Georgetown definition of bioethics may have thrived while Potter's did not because Hellegers obtained federal and private funding for the new Georgetown Institute; endowed chairs in bioethics; encouraged government and other agencies to seek bioethical consultation; built a network of accomplished scholars in ethics, biology, and social sciences; and also launched a graduate program in philosophy and bioethics. (33) Potter had none of these systems in place to promote his view of bioethics. (34) He was a career biochemist and a part-time bioethics scholar. (35) He lacked funding...