Public Health Crisis Warrants Liberty Restrictions

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Parker Crutchfield, PhD

Preventing Harm
Suppose your colleague was diagnosed with tuberculosis on Friday but tried to come into work on the following Monday. You would be right to call local public health officials, and they would be warranted in isolating him. Now suppose instead that he was diagnosed with lung cancer on Friday but came into work Monday. You would be wrong to call local public health officials and they would be wrong to isolate him. When a person’s health or behavior are a threat to others’ well-being, there is greater moral justification for restricting the liberties of that person. This is just the converse of Mill’s Harm Principle, which states that the only time it is permissible to restrict a person’s actions is when those actions threaten to harm another person.

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Image description: A dry and cracked river bed in Sri Lanka. Image source: Bioversity International/S.Landersz/Flickr

Recently, the Australian Medical Association declared climate change a threat to the public’s health. This comes after a similar declaration was backed by organizations such as the American Medical Association, the American College of Physicians, the American Academy of Pediatrics, and the American Lung Association. Climate change is a health emergency that threatens the health and well-being of the public. Just as your colleague is a threat to the health and well-being of those around him, climate change is a threat to the public’s health and well-being. Thus, Mill’s Harm Principle applies—in principle it is permissible to restrict liberties to prevent the harm that ensues from climate change.

Public Health Ethics
When your colleague sees his oncologist about his lung cancer, the physician likely prioritizes the patient’s well-being. But public health ethics takes a more utilitarian approach: the individual’s interests are secondary to the greater good. Instead of balancing values such as patient autonomy and the physician’s judgment about what is most medically appropriate, public health ethics primarily balances liberty, equality, and utility (benefit). This to say that, for example, one person’s liberty may be justifiably restricted so that greater utility to the public may be achieved, or that it may be permissible to sacrifice some utility so that everyone can be subjected to the same treatment. Other values such as transparency or solidarity may be incorporated secondarily.

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Image description: A large stack billows dense smoke into the air that appears pink against blue sky. Image source: Billy Wilson/Flickr

Viewing climate change through the lens of public health ethics, which interventions best balance liberty, equality, and utility? There is significant disutility of not doing anything—there will be incalculable harm to very many people. The cost of doing nothing is so high that there is almost no benefit we might achieve presently that could outweigh it. Trading the harms we will suffer by doing nothing for the benefit we might achieve by doing nothing is a bad deal for us and a much worse deal for the next generation.

It is not commonly noted, but the same could be said for liberty—by doing nothing we trade future liberties for present ones. If we want to promote liberty in the future, we need to restrict it now. Currently those who are best positioned to intervene on climate change enjoy an extensive scheme of liberties. We can cool our houses to 68 degrees in the middle of summer; we can travel by jet to anywhere we might want to go; we can preserve our food in disposable plastic containers; we can mostly go outside without fear of catching a mosquito-borne illness; we can even use plastic rather than paper straws!

Inaction and Liberty
If we do nothing in the name of preserving these liberties, we stand to lose much more. It’s pointless to travel by jet to a place that’s underwater or that’s so hot it could kill you, to say nothing of the prospects of actually living there. When the changing climate displaces those living in New Orleans, Phoenix, Miami, the mid-Atlantic, or anywhere else in the world that will be uninhabitable, those people have to go elsewhere, increasing population density in those areas. Cooling our residences and workplaces may be prohibitively expensive, along with refrigerating our food, manufacturing plastic straws, or going outside in shorts and a t-shirt. Such effects will only exacerbate social inequalities.

Or consider the worst-case scenario, one in which climate change exerts too much pressure on governments, undermining their ability to uphold the laws that democracies have agreed to, such as laws prohibiting taking another person’s stuff. In such a scenario one’s scheme of liberties might be as extensive as it could possibly be. But in that case life is solitary, poor, nasty, brutish, and short—all conditions that make it impossible to exercise those liberties and that significantly limit one’s self-determination. The dead have no liberties. For people who want to preserve and promote individual liberty, it makes sense to intervene now.

To What Extent?
If ethical intervention upon threats to the public’s health requires finding the best balance of liberty, equality, and utility, then we have justification to restrict present liberties. Doing so not only promotes greater future utility, but it also promotes greater future liberties. I have not addressed equality, but as things stand now doing nothing will exacerbate social inequalities. But to what extent can present liberties be restricted?

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Image description: two brown and white cows are shown within a crowded group of cattle. Image source: Beatrice Murch/Flickr

Given the severity of the threat climate change presents to future liberties, it may be reasonable to prohibit air travel, driving vehicles that fail to meet certain emissions standards, eating beef, or even using plastic straws and incandescent light bulbs.

I mention above that there are other values that may be considered. If it is permissible for states—in the name of public health—to restrict present liberties to promote future liberties, how can they do so transparently? Does restricting present liberties promote or undermine solidarity among the population? If restricting present liberties undermines solidarity, does it do so to the degree necessary to outweigh the promotion of future liberty, equality, and utility?

parker-crutchfield-cropParker Crutchfield, PhD, is Associate Professor in the Program in Medical Ethics, Humanities, and Law at the Western Michigan University Homer Stryker M.D. School of Medicine, where he teaches medical ethics and provides ethics consultation. His research interests in bioethics include the epistemology of bioethics and the ethics of enhancement, gene editing, and research.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, October 10, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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Climate Change and Medical Risk

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This post is a part of our Bioethics in the News series. For more information, click here.

By Sean A. Valles, Ph.D.

 After winning the 2007 Nobel Peace Prize, the UN’s Intergovernmental Panel on Climate Change has returned to the headlines. Heeding the growing body of climate evidence, they say, “it is extremely likely [95%-100% likely] that human influence has been the dominant cause of the observed warming since the mid-20th century” (IPCC Working Group I 2013, pp. SPM-2, SPM-12). Unfortunately, according to a March Gallup poll:

In contrast to majority acceptance of global warming as real, Gallup finds Americans less than alarmed. One-third worry “a great deal,” and 34% expect it to threaten their way of life. These could be the attitudes that matter most when it comes to Americans’ support for public policies designed to address the issue (Saad 2013).

That skepticism about climate change’s seriousness (and, to a lesser extent, about humans’ responsibility for it) is impeding democratic action in the US. The leadership provided by a skeptical vocal minority has turned the public dialogue into a dispute over uncertainties in how we predict future climate, whether it is accusing researchers of inadequate “objectivity” (LaFramboise 2013) or publicizing pieces of climate data that seem inadequately explained (Darwall 2013). I encourage my bioethics colleagues to help change the conversation, and re-frame the US climate change dialogue to focus on one crucial fact: even with lingering uncertainties, climate change poses health risks that we would be foolish to ignore.

A 2009 special report by The Lancet and University College London Institute for Global Health Commission declares, “climate change is the biggest global health threat of the 21st century” (Costello, et al. 2009, p. 1693). These are bold words, especially coming from The Lancet—one of the most prestigious medical journals. The report lists a number of health risks: more numerous heat waves will worsen respiratory and cardiovascular symptoms (Costello, et al. 2009, p. 1702), mosquitoes and mosquito-borne diseases will spread and flourish in newly warm areas (Costello, et al. 2009, p. 1702), and extreme weather events will become more common and stronger (impacting mental health, access to food, access to sanitation infrastructure, etc.) (Costello, et al. 2009, p. 1706). The list goes on, and policy groups such as the EPA have demonstrated that they take it quite seriously. A recent article in Bioethics by Cheryl Cox MacPherson explains that such risks make it clear “Climate Change Is a Bioethics Problem” (MacPherson 2013, p. 305).

Unfortunately, bioethicists’ involvement in the climate change dialogue—a crucial medical dialogue—has been the exception rather than the norm. Bioethicists are already expert communicators, researchers, interdisciplinary collaborators, and public advocates in the management of multiple intersecting risks and ethical considerations. They apply this expertise to issues such as tissue donation, vaccination, and pharmaceutical testing. I recommend that they add climate change to their list of priorities. Economic constraints, individual liberty, public welfare, being mindful of social justice; these sorts of difficult climate change considerations are very much in bioethicists’ wheelhouse.

Recent research on science communication indicates that pragmatically it would be a wise strategy to move health out of the background in the climate change dialogue. A recent study compared audience responses to three different presentations of climate change, “emphasizing either the risks to the environment, public health, or national security;” the researchers found that, “across audience segments, a public health focus was the most likely to elicit emotional reactions consistent with support for climate change mitigation and adaptation” (Myers, et al. 2012, p. 1105). Maibach et al. explains that the “dominant mental frame used by most members of the public to organize their conceptions about climate change is that of ‘climate change as an environmental problem’” (Maibach, et al. 2010, p. 2). We all hear plenty of talk about ‘saving the environment,’ but switching to a health frame would offer important benefits.

Re-defining climate change in public health terms should help people make connections to already familiar problems such as asthma, allergies, and infectious diseases experienced in their communities. The frame also presents the opportunity to involve additional trusted communication partners on the issue, notably public health experts and local community leaders (Maibach, et al. 2010, pp. 9-10).

Pictures of forlorn polar bears floating on melting blocks of ice have proved compelling for some people, but a health-centered approach looks more promising as a default strategy.

Shifting the climate dialogue to emphasize medical risk creates a fresh conversation, wherein both unshakable believers and unimpressed skeptics can perhaps recognize the ethical imperative to prevent likely harms. In an analogous situation, I am encouraged by the way that ever-embattled evolutionary biology has become incorporated into the daily life of clinical healthcare workers. The evolutionary biologist Joan Roughgarden points out that (limited) survey data shows “acceptance of evolution is far from unanimous among Christian doctors” (Roughgarden 2006, p. 8). This is cause for great concern, since evolutionary biology shows that the misuse of antibiotics since their introduction in the 1940s has created an environment where natural selection favors the evolution of antibiotic-resistant pathogens, creating a global medical crisis (Chambers, et al. 2009). The good news is that despite the aforementioned (human) evolution skepticism among doctors, as a group they recognize that their actions are partly responsible for the problem of antibiotic resistance. In a recent survey of US physicians (“clinical faculty and residents”), 97% agree “inappropriate [antibiotic] use causes antimicrobial resistance” (Abbo, et al. 2011, pp. 714-715).

Recognizing climate change medical risk as worthy of attention and action does not mean that one must fully understand or even fully trust the underlying science. In the case of the antibiotic-resistant pathogens, the perceived risk (uncontrolled infectious diseases) seems capable of overriding theoretical qualms about natural selection’s role in biology. Analogously, the aforementioned communications research suggests that climate skepticism and climate ambivalence can perhaps be overcome by shifting emphasis to medical risks.

The antibiotic resistance case can also shed light on how to synchronize multiple climate change strategies. Philosopher Stephen Gardiner highlights the dangers of proposed climate change strategies that largely abandon the mitigation of climate change (e.g. reducing greenhouse gas emissions) in order to pursue adaptation strategies to cope with the effects of the change (Gardiner 2004). Indeed, the antibiotic resistance dialogue already incorporates both mitigation strategies (preventing antibiotic overuse in order to slow the evolution of antibiotic resistance) and adaptation strategies (creating treatment guidelines to help patients who have resistant infections) (Centers for Disease Control and Prevention 2013).

Climate change is a growing medical problem, and there is increasing recognition that this needs to be highlighted. Perhaps most importantly, evidence from communications research and the analogous dialogue about antibiotic resistance indicates that framing climate change as a health risk would be a productive shift. I hope bioethicists will increasingly join with their colleagues in climatology, public health, etc., so that together we can make the case for action.

References:

Abbo L, Sinkowitz-Cochran R, Smith L, Ariza-Heredia E, Gómez-Marín O, Srinivasan A, et al. (2011). Faculty and Resident Physicians’ Attitudes, Perceptions, and Knowledge about Antimicrobial Use and Resistance. Infection Control and Hospital Epidemiology, 32(7), 714-718. Retrieved from http://www.jstor.org.proxy1.cl.msu.edu/stable/10.1086/660761

Centers for Disease Control and Prevention (2013). Antibiotic Resistance Threats in the United States, 2013: Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/features/antibioticresistancethreats/

Chambers HF, & DeLeo FR (2009). Waves of Resistance: Staphylococcus Aureus in the Antibiotic Era. Nature Reviews Microbiology, 7(9), 629-641. Retrieved from http://www.nature.com.proxy2.cl.msu.edu/nrmicro/journal/v7/n9/full/nrmicro2200.html

Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, et al. (2009). Managing the Health Effects of Climate Change. Lancet, 373(9676), 1693-1733. Retrieved from http://www.sciencedirect.com.proxy1.cl.msu.edu/science/article/pii/S0140673609609351

Darwall R (2013). The Political Science of Global Warming. The Wall Street Journal. Retrieved from http://online.wsj.com/news/articles/SB10001424052702303464504579106993839343868

Gardiner SM (2004). Ethics and Global Climate Change. Ethics, 114(3), 555-600. Retrieved from http://www.jstor.org.proxy1.cl.msu.edu/stable/10.1086/382247

IPCC Working Group I (2013). Working Group I Contribution to the IPCC Fifth Assessment Report Climate Change 2013: The Physical Science Basis (Summary for Policymakers). Geneva: Intergovernmental Panel on Climate Change. Retrieved from http://www.climatechange2013.org/images/uploads/WGIAR5-SPM_Approved27Sep2013.pdf

LaFramboise D (2013). Warming Up for Another Climate-Change Report. The Wall Street Journal. Retrieved from http://online.wsj.com/article/SB10001424127887323981304579079030750537994.html

MacPherson CC (2013). Climate Change is a Bioethics Problem. Bioethics, 27(6), 305-308. Retrieved from http://onlinelibrary.wiley.com.proxy2.cl.msu.edu/doi/10.1111/bioe.12029/full

Maibach EW, Nisbet M, Baldwin P, Akerlof K, & Diao G (2010). Reframing Climate Change as a Public Health Issue: an Exploratory Study of Public Reactions. BMC Public Health, 10, 299. Retrieved from http://dx.doi.org.proxy1.cl.msu.edu/10.1186/1471-2458-10-299

McGrath M (2013). IPCC climate report: humans ‘dominant cause’ of warming. BBC News. Retrieved from http://www.bbc.co.uk/news/science-environment-24292615

Myers TA, Nisbet MC, Maibach EW, & Leiserowitz AA (2012). A Public Health Frame Arouses Hopeful Emotions about Climate Change. Climatic Change, 113(3-4), 1105-1112. Retrieved from http://link.springer.com/article/10.1007%2Fs10584-012-0513-6

Roughgarden J (2006). Evolution and Christian Faith: Reflections of an Evolutionary Biologist. Washington, DC: Island Press.

Saad L (2013). Americans’ Concerns About Global Warming on the Rise Retrieved October 4, 2013, from http://www.gallup.com/poll/161645/americans-concerns-global-warming-rise.aspx

Subramanian C (2013). Rebranding Climate Change as a Public Health Issue. Time. Retrieved from http://healthland.time.com/2013/08/08/rebranding-climate-change-as-a-public-health-issue/

United States Environmental Protection Agency (2013). Climate Impacts on Human Health: United States Environmental Protection Agency. Retrieved from http://www.epa.gov/climatechange/impacts-adaptation/health.html

Note: The resources for this post include both public access links and Michigan State University Libraries access links. The MSU library links are available to current MSU faculty, staff and students.

SeanVallesblogphotoSean A. Valles, Ph.D.,  is an Assistant Professor in the Lyman Briggs College and the Department of Philosophy at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Friday, November 8, 2013. With your participation, we hope to create discussions rich with insights from diverse perspectives. You must provide your name and email address to leave a comment. Your email address will not be made public.