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Bioethics ISSN 0269-9702 (print); 1467-8519 (online) Volume 29 Number 5 2015 pp 334–341
doi:10.1111/bioe.12110
BIOETHICS AND THE FRAMING OF CLIMATE CHANGE’S HEALTH RISKS SEAN A. VALLES
Keywords bioethics, climate change, science framing, science communication, antibiotic resistance, environmental ethics, public health
ABSTRACT Cheryl Cox MacPherson recently argued, in an article for this journal, that ‘Climate Change is a Bioethics Problem’. This article elaborates on that position, particularly highlighting bioethicists’ potential ability to help reframe the current climate change discourse to give more attention to its health risks. This reframing process is especially important because of the looming problem of climate change skepticism. Recent empirical evidence from science framing experiments indicates that the public reacts especially positively to climate change messages framed in public health terms, and bioethicists are particularly well positioned to contribute their expertise to the process of carefully developing and communicating such messages. Additionally, as climate framing research and practice continue, it will be important for bioethicists to contribute to the creation of that project’s nascent ethical standards. The discourse surrounding antibiotic resistance is posited as an example that can lend insight into how communicating a public health-framed message, including the participation of bioethicists, can help to override public skepticism about the findings of politically contentious scientific fields.
Recently, Cheryl Cox MacPherson made the case in this journal that ‘Climate Change Is a Bioethics Problem’.1 MacPherson has a persuasive argument for why it would be sensible, and probably even ethically necessary, for bioethicists to become more involved in climate change deliberations. This article continues the bioethics dialog that MacPherson seeks to create. More specifically, this article will show how a variety of evidence indicates that bioethicists’ increased involvement in climate change deliberations promises to strongly and positively influence the course of those deliberations, particularly to aid in overcoming a daunting obstacle that is not highlighted in MacPherson’s article, climate change skepticism. As reviewed below, recent climate change communications research indicates that audiences respond especially favorably to climate change messages when those messages are framed in terms of the health impacts of climate
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C.C. MacPherson. Climate Change is a Bioethics Problem. Bioeth 2013; 27: 305–308.
change. Bioethicists can aid in the broad goal of communicating climate change as a health concern by continuing the various types of activities that they already pursue: public advocacy, communication with lay audiences, interdisciplinary collaborations (as emphasized by MacPherson), advising policymakers, etc. Moreover, as research into the efficacy of various climate change communication strategies continues, there will be increased need for bioethicists to help guide the ethical use of rhetorical strategies, as these strategies must contend with possible tensions between considerations such as truthtelling, beneficence and the power dynamics of experts and non-experts. To show the power of a wellcommunicated medical risk, the example of drugresistant pathogens (and public responses thereto) will be discussed as an illuminating analog to the case of climate change. In that case, as in climate change, a vast social problem caused by incautious human behavior has been uncovered by a branch of science that is distrusted by a large proportion of Americans (evolutionary biology). But unlike the case of climate change, the gravity of the
Address for correspondence: Sean A. Valles, Lyman Briggs College and Dept. of Philosophy, Michigan State University, Holmes Hall, 919 E. Shaw Lane, Room W25-C, East Lansing, MI 48825. Tel. (517) 884-0592. Email: [email protected] Conflict of interest statement: No conflicts declared © 2014 John Wiley & Sons Ltd
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situation’s medical risk was communicated effectively enough to override the public’s underlying skepticism about the science. And, notably, bioethicists are already actively participating in the dialog without hesitating to justify their presence in it.
THE HEALTH RISKS OF CLIMATE CHANGE The scope of climate change and humans’ responsibility for it have led many scholars to take up the term ‘Anthropocene’ to describe the current geological epoch – one defined by anthropogenic (human-originated) effects. The rapidly shifting global climate has innumerable direct and indirect effects on local conditions, and some of those effects did, do or will negatively impact human health. A landmark 2009 special report by the Lancet and University College London Institute for Global Health Commission announces, ‘climate change is the biggest global health threat of the 21st century,’ because of its causal role in a range of health problems: ‘changing patterns of disease, water and food insecurity, vulnerable shelter and human settlements, extreme climatic events, and population growth and migration’.2 To hear such a bold declaration about ‘the biggest global health threat’ from a leading medical journal is striking, but so is the evidence that supports it. Among the many health effects (the 2009 report’s main text runs for 37 pages, and research has progressed in recent years), some stand out as particularly concerning and broad in scope. For example, heat waves will exacerbate cardiovascular and respiratory conditions, particularly among the elderly.3 The dangers of even a single extreme heatwave can be alarming, as illustrated by the mortality spike in France during a 2003 heatwave: ‘14,947 excess deaths were recorded in France for the period of August 4–18’.4 Another notable effect is that ‘the frequency and intensity of extreme weather events such as heatwaves, cyclones, floods, storm surges, heavy precipitation, and droughts are forecast to increase substantially’.5 Aside from the obvious harms of natural disasters such as injuries and fatalities during storms, extreme weather can have more subtle health implications, such as straining local economies (including health-related social services) and inducing stress and trauma that feed into the reciprocal relationship between mental health (e.g. depres2 A. Costello et al. Managing the Health Effects of Climate Change. Lancet 2009; 373: 1693–1733: 1693. 3 Ibid. 4 M. Poumadère et al. The 2003 Heat Wave in France: Dangerous Climate Change Here and Now. Risk Analysis 2005; 25: 1483–1494: 1483. 5 A. McMichael, H. Montgomery & A. Costello. Health Risks, Present and Future, from Global Climate Change. BMJ 2012; 344: e1359: 1.
sion) and somatic health (e.g. self-harm).6 The health effects of climate change are stronger among populations that lack the resources to adapt (e.g. being unable able to pay higher food prices resulting from crop damage), making climate change one of the many public health risks that disproportionately impact those with lower socioeconomic status. Climate change is a global problem, but this article will pay special attention to the US context because it is a locus of organized climate denialism, and the center of much of the research on climate change communication, as discussed below. Notwithstanding those limitations, the article seeks to contribute to the international discussion of bioethicists’ engagement with climate change, as MacPherson’s article does. While public health experts are making climate change into a research priority, bioethicists have been slower to take up the subject. MacPherson’s article is a notable exception, as is a forthcoming volume that she is editing. And there are other scattered exceptions, such as portions of David Resnik’s 2012 book, Environmental Health Ethics.7 Nevertheless, these are indeed exceptions to a broad trend of bioethics’ counterintuitive lack of engagement.
SCIENTIFIC CONSENSUS AND PUBLIC SKEPTICISM The scientific consensus on climate change is firmly established. According to a recent assessment by the Nobel Peace Prize-winning UN Intergovernmental Panel on Climate Change, ‘it is extremely likely [95%–100% likely] that human influence has been the dominant cause of the observed warming since the mid-20th century’.8 The US public is less convinced of the phenomenon and of its seriousness. A recent Gallup poll reports: 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.9 6
Costello et al. op. cit. note 2; H.L. Berry, K. Bowen & T. Kjellstrom. Climate Change and Mental Health: A Causal Pathways Framework. Int J Public Health 2010; 55: 123–132. 7 D.B. Resnik. 2012. Environmental Health Ethics. Cambridge: Cambridge University Press. 8 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: SPM-2, SPM-12. 9 L. Saad. Americans’ Concerns About Global Warming on the Rise. Washington, DC: Gallup, Inc. 2013. Available from: http://www.gallup .com/poll/161645/americans-concerns-global-warming-rise.aspx [Accessed 23 Dec 2013].
© 2014 John Wiley & Sons Ltd
Bioethics and the Framing of Climate Change’s Health Risks That is, concern about climate change’s dangers remains disturbingly low, and it is a distressingly slim majority of Americans (57%) that believes global warming is largely caused by human activities.10 Climate scientists and those who accept their scientific findings desperately wish to convince the public that climate change is: real, largely caused by human activities and threatens to disrupt human life at a massive scale. Success has been mixed. Meanwhile, a small but influential leadership has promoted climate change skepticism. Organized climate skepticism, which flourishes in the US sociopolitical climate, leverages the views of a tiny number of vocal critics in an effort to systematically cast doubt on the scientific consensus. The nuances of denialist tactics are laid out in Oreskes and Conway’s insightful 2010 text, Merchants of Doubt.11 Today, climate skepticism continues to have a healthy life in some corners of the media, such as the opinion section of the Wall Street Journal. There, skeptics have turned the climate change dialog into a debate over climate science uncertainties due to issues such as scientists’ objectivity or purportedly unexplained climate phenomena.12 These leaders have taken on an inflated role in the public discourse, such that only 62% of Americans think, ‘most scientists believe that global warming is occurring’.13 It is unfortunate that a majority of the public is less than convinced that climate change exists and is caused by humans. It is more important, though, that a low percentage of US residents report great concern about climate change’s effects. For an individual to be motivated to action, he or she does not need to be 100% (or even 50%) confident in the likelihood that humans are causing climate change. A low probability risk with very dangerous potential health consequences can motivate us to action; it can provide us with ‘internal reasons’ for action, in Bernard Williams’ phrasing.14 For instance, recalls of potentially contaminated food and drugs are routine, with no public lamentations that a shipment of meat is only possibly contaminated. If the potential consequences are perceived as grave then even someone who finds it very unlikely that climate change is caused by
humans could still have compelling reason to advocate for policies responding to climate change. An unlikely deadly health hazard still requires action. Skepticism about climate change’s causes, about its scientific backing and about its seriousness are disturbingly high and impeding collective action. There is reason for optimism, though, as evidence is increasingly indicating that reframing climate change as a public health risk would be more effective than previous ‘save the environment’ sorts of messages.
BIOETHICISTS CAN HELP TO REFRAME CLIMATE CHANGE RISK AS MEDICAL RISK While there are theoretical reasons why bioethicists can and should get involved in the ongoing discourse about climate change’s health impacts (e.g. MacPherson summarizes that it ‘involves health, values, and responsibilities’),15 there is also a more empirically-motivated reason. Recent climate framing communication research indicates that when audiences hear climate change presented specifically as a health risk then they tend to respond by taking climate change quite seriously. Bioethicists are practiced experts in the analysis and communication of medical risk, so such findings constitute a new invitation to the climate change dialog. A wave of experimental science communication research, largely developed over the last few years at the George Mason University’s Center for Climate Change Communication, has shown that there are pragmatic benefits to framing climate change as a health problem. Extrapolating the lessons from interviews with subjects who have read a public health framed climate change essay, Maibach et al. explain: 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 . . . In the process, giving climate change a public health focus suggests that there is a need to both mitigate (i.e. reduce greenhouse gas emissions) and adapt to the problem (i.e. protect communities and people from current and future health related impacts). The frame also presents the opportunity to involve additional trusted communication partners on the issue, notably public health experts and local community leaders.16
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Ibid. N. Oreskes & E.M. Conway. Merchants of Doubt: How a Handful of Scientists Obscured the Truth on Issues from Tobacco Smoke to Global Warming. New York: Bloomsbury Publishing; 2010. 12 D. LaFramboise. Warming Up for Another Climate-Change Report. Wall St J. New York: Dow Jones & Company, Inc. 2013. Available at: http://online.wsj.com/article/SB100014241278873239813045790790307 50537994.html [Accessed 24 Dec 2013]; R. Darwall. The Political Science of Global Warming. Wall St J. New York: Dow Jones & Company, Inc. 2013. Available at: http://online.wsj.com/news/articles/ SB10001424052702303464504579106993839343868 [Accessed 24 Dec 2013]. 13 Saad, op. cit. note 9. 14 B. Williams. Moral Luck. Cambridge: Cambridge University Press. 1981. 11
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MacPherson, op. cit. note 1, p. 305. E.W. Maibach et al. Reframing Climate Change as a Public Health Issue: an Exploratory Study of Public Reactions. BMC Public Health 2010; 10: 299. 16
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This is an extensive and powerful list of reasons, but an additional and especially encouraging piece of evidence is that public health framing is effective for a wide array of audiences, ranging from audience segments that are dismissive of climate change to those that are alarmed by it. When a related study examined audience reactions to three messages about climate change, ‘emphasizing either the risks to the environment, public health, or national security;’ it found, ‘across audience segments, a public health focus was the most likely to elicit emotional reactions consistent with support for climate change mitigation and adaptation’.17 A positive public reaction to a public health-centered climate change message is a very promising finding, but unfortunately public health messages are not the norm in climate change discourse. Instead, 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”.18 That is, climate change is widely understood as a matter of saving the environment, even though evidence now suggests: 1) climate change is an enormous health problem, and 2) switching to a health-centered frame would be more pragmatically effective. As health behavior psychologists have long known, motivating people to concrete health-promoting actions involves a complex network of beliefs. In the case of climate change, ‘proximal climate threats against which individuals feel highly susceptible, such as heat waves, droughts, or forest fires, are acted upon’.19 In other words, when climate risks (health or otherwise) are seen as menacing and immediately present in one’s life then those risks motivate changes in behavior. The problem is that a recent survey indicated that American respondents, even more than other respondents in other sampled countries, ‘viewed distant people elsewhere (in the United States, in other countries, and in future generations) as more likely to be harmed’.20 It seems that much public action could be catalyzed if only the public were made aware of accessible versions of the information being produced by climate health specialists, such as the complex model projections indicating ‘climate change exacerbates air pollution and increases associated health risks globally’.21 17 T.A. Myers et al. A Public Health Frame Arouses Hopeful Emotions about Climate Change. Climatic Change 2012; 113: 1105–1112: 1105. 18 E.W. Maibach et al. op. cit. note 16. 19 J.C. Semenza et al. Climate Change and Climate Variability: Personal Motivation for Adaptation and Mitigation. Environmental Health 2011; 10: 46. 20 K. Akerlof et al. Public Perceptions of Climate Change as a Human Health Risk: Surveys of the United States, Canada and Malta. Int J Environ Res Public Health 2010; 7: 2559–2606: 2574. 21 Y. Fang et al. Impacts of 21st Century Climate Change on Global Air Pollution-Related Premature Mortality. Climatic Change 2013; 121: 239–253: 250.
Attending to the public health framing research suggests multiple reasons for why bioethicists would have good reason to become more involved in bioethics deliberations. First, as one of many groups with biomedical expertise, there is the rather obvious reason that climate change is a growing health risk and thus is directly or indirectly relevant to all healthcare experts. Second, and more specific to bioethicists, since climate change framing is fundamentally about understanding and communicating medical risk, bioethicists have a particular role to play because understanding and communicating medical risk is one of the discipline’s greatest strengths. For example, bioethicists including Arthur Caplan have fostered an active public dialog about infectious disease risks and the ethics of seasonal influenza vaccinations.22 Bioethicists have multiple roles to play in climate change deliberations. Fortunately, the discipline already includes a large number of experts in a range of public engagement and transdisciplinary collaboration contexts. Bioethicists serve as public advocates in debates over priorities and goals in psychiatry,23 coauthor work with multidisciplinary teams24 and advise government officials in official capacities. Climate change’s health risks will require contending with immensely difficult concepts such as individual liberty, local and global justice, economic constraints and the welfares of various populations. It so happens that these are concepts with which bioethicists have considerable experience as analysts and communicators, especially when combinations of these concepts must be dealt with simultaneously. And, while public health practitioners can assess and predict health impacts, bioethicists have particular expertise and prima facie legitimacy when the time comes to make strong normative claims. While many scientists are reluctant to make strong normative claims or policy recommendations, it would be in the purview of a bioethicist to assert, hypothetically: ‘The US government has been unacceptably slow in providing elderly Americans with access to air conditioning as a means of protecting this vulnerable population from heatwaves brought on by climate change. Immediate legislative action to guarantee such access is ethically necessary.’ There are already various efforts underway to develop climate change arguments that shift focus away from the familiar messages about environmental protection, 22
A. Caplan. Don’t Be Selfish: Get a Flu Shot and Protect the Most Vulnerable, Bioethicist Says. New York: NBCNews.com 2013. Available from http://www.nbcnews.com/health/dont-be-selfish-get-flu-shot -protect-most-vulnerable-bioethicist-1B7944163 [Accessed 4 Jan 2014]. 23 A. Dreger. Gender Identity Disorder in Childhood: Inconclusive Advice to Parents. Hastings Center Report 2009; 39: 26–29. 24 L.G. Aspinwall, T.R. Brown & J. Tabery. The Double-Edged Sword: Does Biomechanism Increase or Decrease Judges’ Sentencing of Psychopaths? Science 2012; 337: 846–849.
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Bioethics and the Framing of Climate Change’s Health Risks such as eco-pragmatism25 and some forms of anthropocentrism.26 Internal debates about the proper focus (Human interests? Non-human interests? Both?) of environmental philosophy and activism can be rather vitriolic, but it seems that bioethicists would be able to promote health-centered concerns without giving offense to those who wish to keep environmental scholarship focused on the intrinsic value of entities such as forests. Meanwhile, Dwyer has explicitly called for a tighter linking of environmental ethics and bioethics, drawing attention to the relationship between sustainability and justice.27 In the bioethics literature, Daniels has called for a ‘broader bioethics agenda’, one that pays greater attention to population-level health and global-level ethical challenges.28 It seems that portions of both the climate change community and the bioethics community have been undergoing similar processes of self-reflection about their priorities, simultaneously making room for healthcentered approaches to climate change.
THE CLIMATE (RE)FRAMING PROCESS NEEDS ETHICAL GUIDANCE As argued above, bioethicists are well positioned to serve as communicators of climate change health risks, including explicit discussions of ethical dimensions of those risks. There is also a second and separate role that bioethicists can play, as expert evaluators of the ethical issues in climate change framing and communication. The framing of climate change dialog has happened and will continue to happen with or without bioethicists’ input. But, as research into the efficacy of various sorts of climate messages and rhetoric advances, there are important questions raised about when the framing of climate change messages might enter into ethically dubious territory. As Matthew Nisbet, a leading climate change communication expert, argued in 2009, there are quite serious ethical challenges and responsibilities in the framing of scientific information.29 If framing effects are powerful tools for shaping and influencing audiences’ perceptions then this power must be wielded in an ethical manner. Nisbet proposes some guiding principles, including man25
M. Shellenberger & T. Nordhaus. Break Through. New York: Houghton Mifflin; 2007. 26 K. McShane. Anthropocentrism vs. Nonanthropocentrism: Why Should We Care? Environ Values 2007; 16: 169–186. 27 J. Dwyer. How to Connect Bioethics and Environmental Ethics: Health, Sustainability, and Justice. Bioeth 2009; 23: 497–502. 28 N. Daniels. Equity and Population Health: Toward a Broader Bioethics Agenda. Hastings Cent Rep 2006; 36: 22–35. 29 M.C. Nisbet. The Ethics of Framing Science. Communicating Biological Sciences: Ethical and Metaphorical Dimensions Nerlich B. et al., editors. Burlington, VT; Ashgate Publishing: 2009. pp. 51–74.
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dates to be accurate and to not use framing to ‘attack a particular social group’ or ‘in the service of partisan or electoral gains’.30 Nisbet’s early steps toward the creation of ethics guidelines for science framing are a clear location where bioethicists can aid in refining and applying standards for the communication of climate change risks. Even Nisbet’s sensible ‘guiding principles,’ such as the prohibition against using framing to promote partisan positions, will inevitably lead to more complex and less obvious ethical choices. For example, while the sociological factors related to climate denialism are complex, acceptance or rejection of climate science’s consensus predictions has become a partisan issue in political discourse.31 Thus, while Nisbet is right to be wary of partisan politics becoming enmeshed with scientific communication, it is also hard to escape the fact that communicating climate change as a serious risk (in any specific framing) serves some partisan goals and clashes with others. Nisbet expresses a great deal of concern over the damage done to science communication when one political or social faction simplistically claims that science is on its side. This is hardly new territory to bioethicists, who have a long record of carefully defending particular positions in politically or religiously contentious topics such as heath care reform policies32 and compulsory vaccination.33 Nisbet is correct that an ethics of framing is needed, and bioethicists have expertise that would be immensely valuable in helping to develop it. Even this article’s basic assertion, that bioethicists should bring climate health risks to the public’s attention, requires ethical scrutiny. Empirically sound data on climate change’s health risks could serve to push some people into fearful compliance with suggested policy changes (e.g. ‘go ahead and tax carbon emissions as much as you want, just stop it all from poisoning my family!’). There is enormous potential for abuse, as Nisbet suggests in the discussion above. But there is also more than enough room for bioethicists to responsibly discuss information about climate health risks with the public. Public health crises often require experts to communicate with the public about deadly and unpredictable hazards. The literature on communicating health hazards, such as pandemics, to the public stresses the importance of ‘building and maintaining trust’, which in turn is founded upon ‘judgments about the competence, fairness, honesty, caring, accountability, and transparency of leaders or 30
Ibid: 53. A.M. McCright & R.E. Dunlap. Cool Dudes: The Denial of Climate Change among Conservative White Males in the United States. Global Environmental Change 2011; 21: 1163–1172. 32 L.M. Fleck. Just Caring: Health Care Rationing and Democratic Deliberation. Oxford: Oxford University Press; 2009. 33 L.O. Gostin. Public Health Law: Power, Duty, Restraint. Berkeley, CA: University of California Press; 2008. 31
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risk managers’.34 So, manifesting qualities such as fairness, caring and transparency facilitates communication while also promoting behaviors that are valued by bioethicists. But, as bioethicists know all too well, the nuances of building caring and trusting relationships in the healthcare world are extraordinarily complex and delicate. In sum, the good news is that there is actually a great deal of overlap between effective health risk communication and ethical health risk communication; the bad news is that there is nothing simple about the business of actually acting in accord with standards for ethical and effective health risk communication. The high stakes and unavoidable complexities of communicating climate health risks with large groups of people require bioethical vigilance.
HEALTH RISKS AND MOVING PAST SKEPTICISM: LEARNING FROM THE SUCCESSES OF THE CASE OF ANTIBIOTIC RESISTANCE IN THE US The potential benefits of shifting the public discourse about climate change are apparent in an analogous case, one in which a socially and politically divisive science’s predictions have found widespread acceptance in the face of a serious public health risk: the evolution of antibiotic resistance. Climate change and antibiotic resistance will be posited as analogous problems. In the latter case the public’s focus on the problem’s health risk has been impressively effective in sidelining skepticism about the scientific basis. And bioethicists have begun engaging with the issue without needing to first pause and carefully justify their engagement in the dialog. The case of antibiotic resistance is an illustration of the power of framing problems in terms of health risks, and adds further support to the proposal that bioethicists should assist in the ongoing process of understanding and communicating the health risks in the analogous climate change case. Despite Americans’ deep-seated skepticism about evolutionary biology, there is broad public acceptance of the seriousness of antibiotic resistant pathogens, so-called ‘superbugs.’ Inside environments where natural selection favors antibiotic resistance (host patients with antibiotics in their systems), microbes have evolved defenses against humans’ continuous reliance on a handful of forms of antibiotics since the 1940s.35 This is a social problem with a global scope and constitutes a clear health risk. 34 E. Vaughan & T. Tinker. Effective Health Risk Communication About Pandemic Influenza for Vulnerable Populations. Am J Public Health 2009; 99: S324–S332. 35 H.F. Chambers & F.R. DeLeo. Waves of Resistance: Staphylococcus Aureus in the Antibiotic Era. Nature Reviews Microbiology 2009; 7: 629–641.
The emerging phenomenon has motivated an accompanying bioethics literature on the subject, attempting to answer related ethical questions: Should public responses to antibiotic resistance stipulate that being free of infectious diseases is a public good?36 Would a global antibiotics treaty be an ethical solution to the problem?37 Must the ethics of antibiotic use be incorporated into broader discussions of justice issues in social determinants of health?38 To what extent are the ethical challenges of antibiotic policies/practices in the developed world and the developing world separable?39 This literature meshes with the literature in environmental/agricultural ethics, which asks related questions, such as: Is existing knowledge about agricultural antibiotic resistance sufficient to make ethical policy decisions?40 Unlike the case of climate change, there seems to be no ambiguity about whether antibiotic resistance qualifies as a bioethics problem. Scientific denialism plays strikingly different roles in the antibiotic resistance discourse and the climate change discourse, which should serve as a reason for optimism among those who advocate for health-framed climate messages about climate change. Evolutionary biologists’ messages about antibiotic resistance are not incessantly rebuked in the opinion pages of newspapers, quite unlike climate scientists’ experiences. Rather, antibiotic resistance is a topic that appears in countless news stories without featuring any input from anti-evolution leaders to see whether antibiotic resistance hypotheses would or would not conflict with their interpretations of the Bible.41 There seems to be little or no public interest in ‘teaching the controversy’ or in presenting ‘both sides of the debate’. Meanwhile, healthcare professionals have had the management of antibiotic resistance incorporated into everyday clinical practice. For example, hospital workers are always on watch for the dreaded MRSA (methicillin-resistant Staphylococcus aureus). According to a survey of clinical faculty and residents in the US, 97% agreed ‘inappropriate [antibiotic] use causes 36
M.J. Selgelid. Ethics and Drug Resistance. Bioethics 2007; 21: 218– 229. 37 J. Anomaly. Combating Resistance: the Case for a Global Antibiotics Treaty. Public Health Ethics 2010; 3: 13–22. 38 M. Millar. Can Antibiotic Use Be Both Just and Sustainable . . . or Only More or Less So? J Med Ethics 2011; 37: 153–157. 39 C. Olivier, et al. Containing Global Antibiotic Resistance: Ethical Drug Promotion in the Developing World. Antimicrobial Resistance in Developing Countries. A.d.J. Sosa et al. editors. New York, NY: Springer; 2010. pp. 505–524. 40 B. Rollin. Ethics, Science, and Antimicrobial Resistance. J Agric Environ Ethics 2001; 14: 29–37. 41 The perplexing position of the influential Answers in Genesis group is that antibiotic resistance exists but that the proliferation of resistant bacteria does not qualify as evolution. G. Purdom. Antibiotic Resistance of Bacteria: An Example of Evolution in Action? Hebron, KY: Answers in Genesis; 2007. Available at: http://www.answersingenesis .org/articles/am/v2/n3/antibiotic-resistance-of-bacteria [Accessed 23 Dec 2013].
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Bioethics and the Framing of Climate Change’s Health Risks antimicrobial resistance’.42 The combination of scientific consensus and serious public health risks, communicated as a public health problem, has bypassed a network of (evolution) denialists far older and more experienced than the climate change denialist network. It may seem obvious that the healthcare community would take antibiotic resistance and the science of its causes quite seriously, but it is important to bear in mind that skepticism about evolution runs deep in the US, including among physicians. A 2005 survey found that 54% of Protestant physicians ‘agree[d] more with intelligent design’ than with evolution.43 The distinction between the two theoretical systems is important, as the leading intelligent design organization, the Discovery Institute, portrays antibiotic-resistant bacteria as lineages that are irreversibly enfeebled by the mutations that provide their resistance.44 This is quite the opposite of the ‘superbug’ rhetoric that has taken hold in the US public discourse, or for example, a mainstream biology paper’s characterization: ‘[Staphylococcus] aureus is an extraordinarily adaptable pathogen.’45 It is difficult to pinpoint the exact mechanisms for how antibiotic resistance discussions have remained largely unaffected by evolution skepticism. It seems that what happened is that no external agents were able to derail the basic public message of antibiotic resistance as a medical risk. This is a powerful message and it took hold in the minds and policies of clinical professionals. Creationists and intelligent design advocates may have wished to reframe the message about what antibiotic resistance is or signifies, but a powerful message framed in terms of grave medical risk is not easily pushed aside. And so, evolution denialists never succeeded in re-framing the issue as a matter of faith in the supernatural or as an extension of long-standing debates over biology textbooks, political opposition to secularism, etc. By contrast, climate change denialists have proven much more successful at framing climate change discourse as a matter of partisan affiliation. The antibiotic resistance case and the aforementioned climate communication research suggest that health risk messages are more robustly able to get past the denialist messages that cloud the issue, and get taken seriously by audiences. 42
L. Abbo et al. Faculty and Resident Physicians’ Attitudes, Perceptions, and Knowledge about Antimicrobial Use and Resistance. Infect Control Hosp Epidemiol 2011; 32: 714–718: 714–715. 43 H.C.D. Research. Majority of Physicians Give the Nod to Evolution over Intelligent Design. Flemington, NJ: HCD Research; 2005. Available at: http://www.hcdi.net/news/PressRelease.cfm?ID=93 [Accessed 23 Dec 2013]. 44 A. Smith. Is Antibiotic Resistance Evidence for Darwinian Evolution? Seattle, Washington: Discovery Institute; 2010. Available at: http://www.idthefuture.com/2010/03/is_antibiotic_resistance_evide_1 .html [Accessed 23 Dec 2013]. 45 Chambers, DeLeo, op. cit. note 35, p. 638.
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The case of antibiotic resistance also shows bioethicists and climate scientists a positive example of the possibility of communicating nuanced proposals for how to respond to medical risks. In climate change and in antibiotic resistance there is need for ‘mitigation’ and ‘adaptation’ strategies to be coordinated. A 2004 paper by Gardiner on the ‘Ethics of Climate Change’ pays special attention to the problem of climate change policies that strongly favor adaptation (e.g. helping farmers to switch to crops appropriate for the new local climate) over mitigation (e.g. reducing greenhouse gas emissions).46 Meanwhile, antibiotic resistance management policy already combines both types of strategies; mitigation through the prevention of over-prescription and adaptation through modified treatment guidelines for infected patients work in concert.47 In all, the professional community and the public at large have received the health-framed message that antibiotic resistance must be contended with forcefully and urgently, and pseudoscientific skepticism has been sidelined. Meanwhile, bioethicists have joined the debate without even needing to explain why doing so is appropriate.
INCORPORATING HEALTH IMPACTS INTO CLIMATE ETHICS DELIBERATIONS Having established that bioethicists have important roles to play in climate change discourse, it is necessary to consider how existing climate ethics deliberations should incorporate considerations of health impacts. MacPherson’s article optimistically cites examples in which changed behaviors or policies can mitigate greenhouse gas emissions, ‘without compromising health or socioeconomic development’, such as expanding public transportation systems.48 But, ethical interests do not always fortuitously align and univocally support one solution; in her article’s abstract, MacPherson makes clear that there are tradeoffs involved in climate deliberations and responses. For instance, health goals and economic goals can conflict. Even MacPherson’s example of expanding public transportation, despite its many benefits, has serious negative health and socioeconomic development impacts for certain populations. Replacing the need for personal automobiles with public transportation options will economically harm employees in the automobile industry, devastate the economic structure of 46 S.M. Gardiner. Ethics and Global Climate Change. Ethics 2004; 114: 555–600. 47 Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2013. Atlanta, GA: Centers for Disease Control and Prevention; 2013. Available at: http://www.cdc.gov/ drugresistance/threat-report-2013/pdf/ar-threats-2013–508.pdf [Accessed 24 Dec 2013]. 48 MacPherson, op. cit. note 1, p. 306.
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related factory towns, and expose those affected to the health risks that accompany sudden loss of income and decreased socioeconomic status. When policy deliberations about transportation take place, then it would be valuable to have bioethicists sitting alongside labor economists, climatologists, urban planners, and the other experts trying to determine what is at stake, what tradeoffs are involved and which options are ethically acceptable. This article’s goal is not to decisively settle individual climate ethics cases, but rather to point to a productive role for bioethicists in deliberations about such cases. In the public transportation case there are many competing interests and considerations, and only some of those considerations are health issues. The economic dimensions of climate change must be deliberated seriously, the full range of non-human environmental impacts of climate change must be deliberated seriously, etc. Climate change’s scope is global and its impacts are complex and variable. As such, it would be unethical for bioethicists to monopolize climate ethics deliberations. No one perspective or type of expertise should dominate the rest. What sets the health impacts apart is that they are serious and growing hazards, but have been poorly communicated to the public and given limited attention by the bioethicists in this journal’s readership. Bioethicists should have seats at the table during climate change deliberations so that they, in turn, can put the ethics of climate change’s health impacts on the table.
CONCLUSION There is still far more research that must be done on the effectiveness and ethics of health-framed climate change communication, which has implications for bioethicists as communicators. The antibiotic resistance analogy gives some reason for optimism, but also points out challenges. First, it is difficult to get individuals to see how their own actions contribute to a larger problem. Physicians seem to take antibiotic resistance quite seriously, but while 62% of respondents accuse others of overprescribing, only 13% are willing to accuse
themselves of doing the same.49 Second, it is unclear how an individual’s beliefs about climate change’s health risks affects his or her longterm behaviors. If someone accepts the seriousness of climate change framed as a health problem then how does that generate new consistent habits? Why? Despite compelling and wide-ranging evidence of negative health impacts from climate change, the climate change discourse is still entrenched in rhetoric dominated by vague imperatives to ‘be green’ or ‘protect the environment’, accompanied by visual strategies characterized by photos of the globe taken from space, or of polar bears perched on ice flows. Given the evidence, it is odd that images of climate change do not more commonly include housebound asthmatic children or families dismayed by the price of (healthy) vegetables at the grocery store. The more-pictures-of-polar-bears rhetorical strategy has thus far been inadequate to motivate the American public to action on climate change, and it has crowded out attention to climate change as a global health crisis. New empirical evidence suggests that a health-focused approach would be more successful. In sum, bioethicists are conspicuously late to the climate change conversation, but there is substantial reason to believe that they can help the world to respond to ‘the biggest global health threat of the 21st century’.50
Acknowledgements This project began as an October 2013 entry for the Michigan State University Bioethics in the News blog series, written for a lay audience (http://msubioethics.com/2013/10/25/climate-change-and-medical-risk). It was subsequently revised, rewritten and expanded. I am thankful for the comments on the earlier project, provided by Tom Tomlinson, Elizabeth Bogdan-Lovis and Kyle Whyte. I am also indebted to Kevin Elliott for comments on this later project, and to two anonymous reviewers for their helpful comments. Sean Valles is Assistant Professor at Michigan State University, joint appointed to the Lyman Briggs College and the Department of Philosophy. He is also an affiliated faculty member in the Ecology, Evolutionary Biology and Behavior program. 49 50
Abbo et al., op. cit. note 42. Costello et al., op. cit. note 2, p. 1693.
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Bioethics ISSN 0269-9702 (print); 1467-8519 (online) Volume 29 Number 5 2015 pp 334–341
doi:10.1111/bioe.12110
BIOETHICS AND THE FRAMING OF CLIMATE CHANGE’S HEALTH RISKS SEAN A. VALLES
Keywords bioethics, climate change, science framing, science communication, antibiotic resistance, environmental ethics, public health
ABSTRACT Cheryl Cox MacPherson recently argued, in an article for this journal, that ‘Climate Change is a Bioethics Problem’. This article elaborates on that position, particularly highlighting bioethicists’ potential ability to help reframe the current climate change discourse to give more attention to its health risks. This reframing process is especially important because of the looming problem of climate change skepticism. Recent empirical evidence from science framing experiments indicates that the public reacts especially positively to climate change messages framed in public health terms, and bioethicists are particularly well positioned to contribute their expertise to the process of carefully developing and communicating such messages. Additionally, as climate framing research and practice continue, it will be important for bioethicists to contribute to the creation of that project’s nascent ethical standards. The discourse surrounding antibiotic resistance is posited as an example that can lend insight into how communicating a public health-framed message, including the participation of bioethicists, can help to override public skepticism about the findings of politically contentious scientific fields.
Recently, Cheryl Cox MacPherson made the case in this journal that ‘Climate Change Is a Bioethics Problem’.1 MacPherson has a persuasive argument for why it would be sensible, and probably even ethically necessary, for bioethicists to become more involved in climate change deliberations. This article continues the bioethics dialog that MacPherson seeks to create. More specifically, this article will show how a variety of evidence indicates that bioethicists’ increased involvement in climate change deliberations promises to strongly and positively influence the course of those deliberations, particularly to aid in overcoming a daunting obstacle that is not highlighted in MacPherson’s article, climate change skepticism. As reviewed below, recent climate change communications research indicates that audiences respond especially favorably to climate change messages when those messages are framed in terms of the health impacts of climate
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C.C. MacPherson. Climate Change is a Bioethics Problem. Bioeth 2013; 27: 305–308.
change. Bioethicists can aid in the broad goal of communicating climate change as a health concern by continuing the various types of activities that they already pursue: public advocacy, communication with lay audiences, interdisciplinary collaborations (as emphasized by MacPherson), advising policymakers, etc. Moreover, as research into the efficacy of various climate change communication strategies continues, there will be increased need for bioethicists to help guide the ethical use of rhetorical strategies, as these strategies must contend with possible tensions between considerations such as truthtelling, beneficence and the power dynamics of experts and non-experts. To show the power of a wellcommunicated medical risk, the example of drugresistant pathogens (and public responses thereto) will be discussed as an illuminating analog to the case of climate change. In that case, as in climate change, a vast social problem caused by incautious human behavior has been uncovered by a branch of science that is distrusted by a large proportion of Americans (evolutionary biology). But unlike the case of climate change, the gravity of the
Address for correspondence: Sean A. Valles, Lyman Briggs College and Dept. of Philosophy, Michigan State University, Holmes Hall, 919 E. Shaw Lane, Room W25-C, East Lansing, MI 48825. Tel. (517) 884-0592. Email: [email protected] Conflict of interest statement: No conflicts declared © 2014 John Wiley & Sons Ltd
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situation’s medical risk was communicated effectively enough to override the public’s underlying skepticism about the science. And, notably, bioethicists are already actively participating in the dialog without hesitating to justify their presence in it.
THE HEALTH RISKS OF CLIMATE CHANGE The scope of climate change and humans’ responsibility for it have led many scholars to take up the term ‘Anthropocene’ to describe the current geological epoch – one defined by anthropogenic (human-originated) effects. The rapidly shifting global climate has innumerable direct and indirect effects on local conditions, and some of those effects did, do or will negatively impact human health. A landmark 2009 special report by the Lancet and University College London Institute for Global Health Commission announces, ‘climate change is the biggest global health threat of the 21st century,’ because of its causal role in a range of health problems: ‘changing patterns of disease, water and food insecurity, vulnerable shelter and human settlements, extreme climatic events, and population growth and migration’.2 To hear such a bold declaration about ‘the biggest global health threat’ from a leading medical journal is striking, but so is the evidence that supports it. Among the many health effects (the 2009 report’s main text runs for 37 pages, and research has progressed in recent years), some stand out as particularly concerning and broad in scope. For example, heat waves will exacerbate cardiovascular and respiratory conditions, particularly among the elderly.3 The dangers of even a single extreme heatwave can be alarming, as illustrated by the mortality spike in France during a 2003 heatwave: ‘14,947 excess deaths were recorded in France for the period of August 4–18’.4 Another notable effect is that ‘the frequency and intensity of extreme weather events such as heatwaves, cyclones, floods, storm surges, heavy precipitation, and droughts are forecast to increase substantially’.5 Aside from the obvious harms of natural disasters such as injuries and fatalities during storms, extreme weather can have more subtle health implications, such as straining local economies (including health-related social services) and inducing stress and trauma that feed into the reciprocal relationship between mental health (e.g. depres2 A. Costello et al. Managing the Health Effects of Climate Change. Lancet 2009; 373: 1693–1733: 1693. 3 Ibid. 4 M. Poumadère et al. The 2003 Heat Wave in France: Dangerous Climate Change Here and Now. Risk Analysis 2005; 25: 1483–1494: 1483. 5 A. McMichael, H. Montgomery & A. Costello. Health Risks, Present and Future, from Global Climate Change. BMJ 2012; 344: e1359: 1.
sion) and somatic health (e.g. self-harm).6 The health effects of climate change are stronger among populations that lack the resources to adapt (e.g. being unable able to pay higher food prices resulting from crop damage), making climate change one of the many public health risks that disproportionately impact those with lower socioeconomic status. Climate change is a global problem, but this article will pay special attention to the US context because it is a locus of organized climate denialism, and the center of much of the research on climate change communication, as discussed below. Notwithstanding those limitations, the article seeks to contribute to the international discussion of bioethicists’ engagement with climate change, as MacPherson’s article does. While public health experts are making climate change into a research priority, bioethicists have been slower to take up the subject. MacPherson’s article is a notable exception, as is a forthcoming volume that she is editing. And there are other scattered exceptions, such as portions of David Resnik’s 2012 book, Environmental Health Ethics.7 Nevertheless, these are indeed exceptions to a broad trend of bioethics’ counterintuitive lack of engagement.
SCIENTIFIC CONSENSUS AND PUBLIC SKEPTICISM The scientific consensus on climate change is firmly established. According to a recent assessment by the Nobel Peace Prize-winning UN Intergovernmental Panel on Climate Change, ‘it is extremely likely [95%–100% likely] that human influence has been the dominant cause of the observed warming since the mid-20th century’.8 The US public is less convinced of the phenomenon and of its seriousness. A recent Gallup poll reports: 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.9 6
Costello et al. op. cit. note 2; H.L. Berry, K. Bowen & T. Kjellstrom. Climate Change and Mental Health: A Causal Pathways Framework. Int J Public Health 2010; 55: 123–132. 7 D.B. Resnik. 2012. Environmental Health Ethics. Cambridge: Cambridge University Press. 8 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: SPM-2, SPM-12. 9 L. Saad. Americans’ Concerns About Global Warming on the Rise. Washington, DC: Gallup, Inc. 2013. Available from: http://www.gallup .com/poll/161645/americans-concerns-global-warming-rise.aspx [Accessed 23 Dec 2013].
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Bioethics and the Framing of Climate Change’s Health Risks That is, concern about climate change’s dangers remains disturbingly low, and it is a distressingly slim majority of Americans (57%) that believes global warming is largely caused by human activities.10 Climate scientists and those who accept their scientific findings desperately wish to convince the public that climate change is: real, largely caused by human activities and threatens to disrupt human life at a massive scale. Success has been mixed. Meanwhile, a small but influential leadership has promoted climate change skepticism. Organized climate skepticism, which flourishes in the US sociopolitical climate, leverages the views of a tiny number of vocal critics in an effort to systematically cast doubt on the scientific consensus. The nuances of denialist tactics are laid out in Oreskes and Conway’s insightful 2010 text, Merchants of Doubt.11 Today, climate skepticism continues to have a healthy life in some corners of the media, such as the opinion section of the Wall Street Journal. There, skeptics have turned the climate change dialog into a debate over climate science uncertainties due to issues such as scientists’ objectivity or purportedly unexplained climate phenomena.12 These leaders have taken on an inflated role in the public discourse, such that only 62% of Americans think, ‘most scientists believe that global warming is occurring’.13 It is unfortunate that a majority of the public is less than convinced that climate change exists and is caused by humans. It is more important, though, that a low percentage of US residents report great concern about climate change’s effects. For an individual to be motivated to action, he or she does not need to be 100% (or even 50%) confident in the likelihood that humans are causing climate change. A low probability risk with very dangerous potential health consequences can motivate us to action; it can provide us with ‘internal reasons’ for action, in Bernard Williams’ phrasing.14 For instance, recalls of potentially contaminated food and drugs are routine, with no public lamentations that a shipment of meat is only possibly contaminated. If the potential consequences are perceived as grave then even someone who finds it very unlikely that climate change is caused by
humans could still have compelling reason to advocate for policies responding to climate change. An unlikely deadly health hazard still requires action. Skepticism about climate change’s causes, about its scientific backing and about its seriousness are disturbingly high and impeding collective action. There is reason for optimism, though, as evidence is increasingly indicating that reframing climate change as a public health risk would be more effective than previous ‘save the environment’ sorts of messages.
BIOETHICISTS CAN HELP TO REFRAME CLIMATE CHANGE RISK AS MEDICAL RISK While there are theoretical reasons why bioethicists can and should get involved in the ongoing discourse about climate change’s health impacts (e.g. MacPherson summarizes that it ‘involves health, values, and responsibilities’),15 there is also a more empirically-motivated reason. Recent climate framing communication research indicates that when audiences hear climate change presented specifically as a health risk then they tend to respond by taking climate change quite seriously. Bioethicists are practiced experts in the analysis and communication of medical risk, so such findings constitute a new invitation to the climate change dialog. A wave of experimental science communication research, largely developed over the last few years at the George Mason University’s Center for Climate Change Communication, has shown that there are pragmatic benefits to framing climate change as a health problem. Extrapolating the lessons from interviews with subjects who have read a public health framed climate change essay, Maibach et al. explain: 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 . . . In the process, giving climate change a public health focus suggests that there is a need to both mitigate (i.e. reduce greenhouse gas emissions) and adapt to the problem (i.e. protect communities and people from current and future health related impacts). The frame also presents the opportunity to involve additional trusted communication partners on the issue, notably public health experts and local community leaders.16
10
Ibid. N. Oreskes & E.M. Conway. Merchants of Doubt: How a Handful of Scientists Obscured the Truth on Issues from Tobacco Smoke to Global Warming. New York: Bloomsbury Publishing; 2010. 12 D. LaFramboise. Warming Up for Another Climate-Change Report. Wall St J. New York: Dow Jones & Company, Inc. 2013. Available at: http://online.wsj.com/article/SB100014241278873239813045790790307 50537994.html [Accessed 24 Dec 2013]; R. Darwall. The Political Science of Global Warming. Wall St J. New York: Dow Jones & Company, Inc. 2013. Available at: http://online.wsj.com/news/articles/ SB10001424052702303464504579106993839343868 [Accessed 24 Dec 2013]. 13 Saad, op. cit. note 9. 14 B. Williams. Moral Luck. Cambridge: Cambridge University Press. 1981. 11
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MacPherson, op. cit. note 1, p. 305. E.W. Maibach et al. Reframing Climate Change as a Public Health Issue: an Exploratory Study of Public Reactions. BMC Public Health 2010; 10: 299. 16
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This is an extensive and powerful list of reasons, but an additional and especially encouraging piece of evidence is that public health framing is effective for a wide array of audiences, ranging from audience segments that are dismissive of climate change to those that are alarmed by it. When a related study examined audience reactions to three messages about climate change, ‘emphasizing either the risks to the environment, public health, or national security;’ it found, ‘across audience segments, a public health focus was the most likely to elicit emotional reactions consistent with support for climate change mitigation and adaptation’.17 A positive public reaction to a public health-centered climate change message is a very promising finding, but unfortunately public health messages are not the norm in climate change discourse. Instead, 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”.18 That is, climate change is widely understood as a matter of saving the environment, even though evidence now suggests: 1) climate change is an enormous health problem, and 2) switching to a health-centered frame would be more pragmatically effective. As health behavior psychologists have long known, motivating people to concrete health-promoting actions involves a complex network of beliefs. In the case of climate change, ‘proximal climate threats against which individuals feel highly susceptible, such as heat waves, droughts, or forest fires, are acted upon’.19 In other words, when climate risks (health or otherwise) are seen as menacing and immediately present in one’s life then those risks motivate changes in behavior. The problem is that a recent survey indicated that American respondents, even more than other respondents in other sampled countries, ‘viewed distant people elsewhere (in the United States, in other countries, and in future generations) as more likely to be harmed’.20 It seems that much public action could be catalyzed if only the public were made aware of accessible versions of the information being produced by climate health specialists, such as the complex model projections indicating ‘climate change exacerbates air pollution and increases associated health risks globally’.21 17 T.A. Myers et al. A Public Health Frame Arouses Hopeful Emotions about Climate Change. Climatic Change 2012; 113: 1105–1112: 1105. 18 E.W. Maibach et al. op. cit. note 16. 19 J.C. Semenza et al. Climate Change and Climate Variability: Personal Motivation for Adaptation and Mitigation. Environmental Health 2011; 10: 46. 20 K. Akerlof et al. Public Perceptions of Climate Change as a Human Health Risk: Surveys of the United States, Canada and Malta. Int J Environ Res Public Health 2010; 7: 2559–2606: 2574. 21 Y. Fang et al. Impacts of 21st Century Climate Change on Global Air Pollution-Related Premature Mortality. Climatic Change 2013; 121: 239–253: 250.
Attending to the public health framing research suggests multiple reasons for why bioethicists would have good reason to become more involved in bioethics deliberations. First, as one of many groups with biomedical expertise, there is the rather obvious reason that climate change is a growing health risk and thus is directly or indirectly relevant to all healthcare experts. Second, and more specific to bioethicists, since climate change framing is fundamentally about understanding and communicating medical risk, bioethicists have a particular role to play because understanding and communicating medical risk is one of the discipline’s greatest strengths. For example, bioethicists including Arthur Caplan have fostered an active public dialog about infectious disease risks and the ethics of seasonal influenza vaccinations.22 Bioethicists have multiple roles to play in climate change deliberations. Fortunately, the discipline already includes a large number of experts in a range of public engagement and transdisciplinary collaboration contexts. Bioethicists serve as public advocates in debates over priorities and goals in psychiatry,23 coauthor work with multidisciplinary teams24 and advise government officials in official capacities. Climate change’s health risks will require contending with immensely difficult concepts such as individual liberty, local and global justice, economic constraints and the welfares of various populations. It so happens that these are concepts with which bioethicists have considerable experience as analysts and communicators, especially when combinations of these concepts must be dealt with simultaneously. And, while public health practitioners can assess and predict health impacts, bioethicists have particular expertise and prima facie legitimacy when the time comes to make strong normative claims. While many scientists are reluctant to make strong normative claims or policy recommendations, it would be in the purview of a bioethicist to assert, hypothetically: ‘The US government has been unacceptably slow in providing elderly Americans with access to air conditioning as a means of protecting this vulnerable population from heatwaves brought on by climate change. Immediate legislative action to guarantee such access is ethically necessary.’ There are already various efforts underway to develop climate change arguments that shift focus away from the familiar messages about environmental protection, 22
A. Caplan. Don’t Be Selfish: Get a Flu Shot and Protect the Most Vulnerable, Bioethicist Says. New York: NBCNews.com 2013. Available from http://www.nbcnews.com/health/dont-be-selfish-get-flu-shot -protect-most-vulnerable-bioethicist-1B7944163 [Accessed 4 Jan 2014]. 23 A. Dreger. Gender Identity Disorder in Childhood: Inconclusive Advice to Parents. Hastings Center Report 2009; 39: 26–29. 24 L.G. Aspinwall, T.R. Brown & J. Tabery. The Double-Edged Sword: Does Biomechanism Increase or Decrease Judges’ Sentencing of Psychopaths? Science 2012; 337: 846–849.
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Bioethics and the Framing of Climate Change’s Health Risks such as eco-pragmatism25 and some forms of anthropocentrism.26 Internal debates about the proper focus (Human interests? Non-human interests? Both?) of environmental philosophy and activism can be rather vitriolic, but it seems that bioethicists would be able to promote health-centered concerns without giving offense to those who wish to keep environmental scholarship focused on the intrinsic value of entities such as forests. Meanwhile, Dwyer has explicitly called for a tighter linking of environmental ethics and bioethics, drawing attention to the relationship between sustainability and justice.27 In the bioethics literature, Daniels has called for a ‘broader bioethics agenda’, one that pays greater attention to population-level health and global-level ethical challenges.28 It seems that portions of both the climate change community and the bioethics community have been undergoing similar processes of self-reflection about their priorities, simultaneously making room for healthcentered approaches to climate change.
THE CLIMATE (RE)FRAMING PROCESS NEEDS ETHICAL GUIDANCE As argued above, bioethicists are well positioned to serve as communicators of climate change health risks, including explicit discussions of ethical dimensions of those risks. There is also a second and separate role that bioethicists can play, as expert evaluators of the ethical issues in climate change framing and communication. The framing of climate change dialog has happened and will continue to happen with or without bioethicists’ input. But, as research into the efficacy of various sorts of climate messages and rhetoric advances, there are important questions raised about when the framing of climate change messages might enter into ethically dubious territory. As Matthew Nisbet, a leading climate change communication expert, argued in 2009, there are quite serious ethical challenges and responsibilities in the framing of scientific information.29 If framing effects are powerful tools for shaping and influencing audiences’ perceptions then this power must be wielded in an ethical manner. Nisbet proposes some guiding principles, including man25
M. Shellenberger & T. Nordhaus. Break Through. New York: Houghton Mifflin; 2007. 26 K. McShane. Anthropocentrism vs. Nonanthropocentrism: Why Should We Care? Environ Values 2007; 16: 169–186. 27 J. Dwyer. How to Connect Bioethics and Environmental Ethics: Health, Sustainability, and Justice. Bioeth 2009; 23: 497–502. 28 N. Daniels. Equity and Population Health: Toward a Broader Bioethics Agenda. Hastings Cent Rep 2006; 36: 22–35. 29 M.C. Nisbet. The Ethics of Framing Science. Communicating Biological Sciences: Ethical and Metaphorical Dimensions Nerlich B. et al., editors. Burlington, VT; Ashgate Publishing: 2009. pp. 51–74.
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dates to be accurate and to not use framing to ‘attack a particular social group’ or ‘in the service of partisan or electoral gains’.30 Nisbet’s early steps toward the creation of ethics guidelines for science framing are a clear location where bioethicists can aid in refining and applying standards for the communication of climate change risks. Even Nisbet’s sensible ‘guiding principles,’ such as the prohibition against using framing to promote partisan positions, will inevitably lead to more complex and less obvious ethical choices. For example, while the sociological factors related to climate denialism are complex, acceptance or rejection of climate science’s consensus predictions has become a partisan issue in political discourse.31 Thus, while Nisbet is right to be wary of partisan politics becoming enmeshed with scientific communication, it is also hard to escape the fact that communicating climate change as a serious risk (in any specific framing) serves some partisan goals and clashes with others. Nisbet expresses a great deal of concern over the damage done to science communication when one political or social faction simplistically claims that science is on its side. This is hardly new territory to bioethicists, who have a long record of carefully defending particular positions in politically or religiously contentious topics such as heath care reform policies32 and compulsory vaccination.33 Nisbet is correct that an ethics of framing is needed, and bioethicists have expertise that would be immensely valuable in helping to develop it. Even this article’s basic assertion, that bioethicists should bring climate health risks to the public’s attention, requires ethical scrutiny. Empirically sound data on climate change’s health risks could serve to push some people into fearful compliance with suggested policy changes (e.g. ‘go ahead and tax carbon emissions as much as you want, just stop it all from poisoning my family!’). There is enormous potential for abuse, as Nisbet suggests in the discussion above. But there is also more than enough room for bioethicists to responsibly discuss information about climate health risks with the public. Public health crises often require experts to communicate with the public about deadly and unpredictable hazards. The literature on communicating health hazards, such as pandemics, to the public stresses the importance of ‘building and maintaining trust’, which in turn is founded upon ‘judgments about the competence, fairness, honesty, caring, accountability, and transparency of leaders or 30
Ibid: 53. A.M. McCright & R.E. Dunlap. Cool Dudes: The Denial of Climate Change among Conservative White Males in the United States. Global Environmental Change 2011; 21: 1163–1172. 32 L.M. Fleck. Just Caring: Health Care Rationing and Democratic Deliberation. Oxford: Oxford University Press; 2009. 33 L.O. Gostin. Public Health Law: Power, Duty, Restraint. Berkeley, CA: University of California Press; 2008. 31
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risk managers’.34 So, manifesting qualities such as fairness, caring and transparency facilitates communication while also promoting behaviors that are valued by bioethicists. But, as bioethicists know all too well, the nuances of building caring and trusting relationships in the healthcare world are extraordinarily complex and delicate. In sum, the good news is that there is actually a great deal of overlap between effective health risk communication and ethical health risk communication; the bad news is that there is nothing simple about the business of actually acting in accord with standards for ethical and effective health risk communication. The high stakes and unavoidable complexities of communicating climate health risks with large groups of people require bioethical vigilance.
HEALTH RISKS AND MOVING PAST SKEPTICISM: LEARNING FROM THE SUCCESSES OF THE CASE OF ANTIBIOTIC RESISTANCE IN THE US The potential benefits of shifting the public discourse about climate change are apparent in an analogous case, one in which a socially and politically divisive science’s predictions have found widespread acceptance in the face of a serious public health risk: the evolution of antibiotic resistance. Climate change and antibiotic resistance will be posited as analogous problems. In the latter case the public’s focus on the problem’s health risk has been impressively effective in sidelining skepticism about the scientific basis. And bioethicists have begun engaging with the issue without needing to first pause and carefully justify their engagement in the dialog. The case of antibiotic resistance is an illustration of the power of framing problems in terms of health risks, and adds further support to the proposal that bioethicists should assist in the ongoing process of understanding and communicating the health risks in the analogous climate change case. Despite Americans’ deep-seated skepticism about evolutionary biology, there is broad public acceptance of the seriousness of antibiotic resistant pathogens, so-called ‘superbugs.’ Inside environments where natural selection favors antibiotic resistance (host patients with antibiotics in their systems), microbes have evolved defenses against humans’ continuous reliance on a handful of forms of antibiotics since the 1940s.35 This is a social problem with a global scope and constitutes a clear health risk. 34 E. Vaughan & T. Tinker. Effective Health Risk Communication About Pandemic Influenza for Vulnerable Populations. Am J Public Health 2009; 99: S324–S332. 35 H.F. Chambers & F.R. DeLeo. Waves of Resistance: Staphylococcus Aureus in the Antibiotic Era. Nature Reviews Microbiology 2009; 7: 629–641.
The emerging phenomenon has motivated an accompanying bioethics literature on the subject, attempting to answer related ethical questions: Should public responses to antibiotic resistance stipulate that being free of infectious diseases is a public good?36 Would a global antibiotics treaty be an ethical solution to the problem?37 Must the ethics of antibiotic use be incorporated into broader discussions of justice issues in social determinants of health?38 To what extent are the ethical challenges of antibiotic policies/practices in the developed world and the developing world separable?39 This literature meshes with the literature in environmental/agricultural ethics, which asks related questions, such as: Is existing knowledge about agricultural antibiotic resistance sufficient to make ethical policy decisions?40 Unlike the case of climate change, there seems to be no ambiguity about whether antibiotic resistance qualifies as a bioethics problem. Scientific denialism plays strikingly different roles in the antibiotic resistance discourse and the climate change discourse, which should serve as a reason for optimism among those who advocate for health-framed climate messages about climate change. Evolutionary biologists’ messages about antibiotic resistance are not incessantly rebuked in the opinion pages of newspapers, quite unlike climate scientists’ experiences. Rather, antibiotic resistance is a topic that appears in countless news stories without featuring any input from anti-evolution leaders to see whether antibiotic resistance hypotheses would or would not conflict with their interpretations of the Bible.41 There seems to be little or no public interest in ‘teaching the controversy’ or in presenting ‘both sides of the debate’. Meanwhile, healthcare professionals have had the management of antibiotic resistance incorporated into everyday clinical practice. For example, hospital workers are always on watch for the dreaded MRSA (methicillin-resistant Staphylococcus aureus). According to a survey of clinical faculty and residents in the US, 97% agreed ‘inappropriate [antibiotic] use causes 36
M.J. Selgelid. Ethics and Drug Resistance. Bioethics 2007; 21: 218– 229. 37 J. Anomaly. Combating Resistance: the Case for a Global Antibiotics Treaty. Public Health Ethics 2010; 3: 13–22. 38 M. Millar. Can Antibiotic Use Be Both Just and Sustainable . . . or Only More or Less So? J Med Ethics 2011; 37: 153–157. 39 C. Olivier, et al. Containing Global Antibiotic Resistance: Ethical Drug Promotion in the Developing World. Antimicrobial Resistance in Developing Countries. A.d.J. Sosa et al. editors. New York, NY: Springer; 2010. pp. 505–524. 40 B. Rollin. Ethics, Science, and Antimicrobial Resistance. J Agric Environ Ethics 2001; 14: 29–37. 41 The perplexing position of the influential Answers in Genesis group is that antibiotic resistance exists but that the proliferation of resistant bacteria does not qualify as evolution. G. Purdom. Antibiotic Resistance of Bacteria: An Example of Evolution in Action? Hebron, KY: Answers in Genesis; 2007. Available at: http://www.answersingenesis .org/articles/am/v2/n3/antibiotic-resistance-of-bacteria [Accessed 23 Dec 2013].
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Bioethics and the Framing of Climate Change’s Health Risks antimicrobial resistance’.42 The combination of scientific consensus and serious public health risks, communicated as a public health problem, has bypassed a network of (evolution) denialists far older and more experienced than the climate change denialist network. It may seem obvious that the healthcare community would take antibiotic resistance and the science of its causes quite seriously, but it is important to bear in mind that skepticism about evolution runs deep in the US, including among physicians. A 2005 survey found that 54% of Protestant physicians ‘agree[d] more with intelligent design’ than with evolution.43 The distinction between the two theoretical systems is important, as the leading intelligent design organization, the Discovery Institute, portrays antibiotic-resistant bacteria as lineages that are irreversibly enfeebled by the mutations that provide their resistance.44 This is quite the opposite of the ‘superbug’ rhetoric that has taken hold in the US public discourse, or for example, a mainstream biology paper’s characterization: ‘[Staphylococcus] aureus is an extraordinarily adaptable pathogen.’45 It is difficult to pinpoint the exact mechanisms for how antibiotic resistance discussions have remained largely unaffected by evolution skepticism. It seems that what happened is that no external agents were able to derail the basic public message of antibiotic resistance as a medical risk. This is a powerful message and it took hold in the minds and policies of clinical professionals. Creationists and intelligent design advocates may have wished to reframe the message about what antibiotic resistance is or signifies, but a powerful message framed in terms of grave medical risk is not easily pushed aside. And so, evolution denialists never succeeded in re-framing the issue as a matter of faith in the supernatural or as an extension of long-standing debates over biology textbooks, political opposition to secularism, etc. By contrast, climate change denialists have proven much more successful at framing climate change discourse as a matter of partisan affiliation. The antibiotic resistance case and the aforementioned climate communication research suggest that health risk messages are more robustly able to get past the denialist messages that cloud the issue, and get taken seriously by audiences. 42
L. Abbo et al. Faculty and Resident Physicians’ Attitudes, Perceptions, and Knowledge about Antimicrobial Use and Resistance. Infect Control Hosp Epidemiol 2011; 32: 714–718: 714–715. 43 H.C.D. Research. Majority of Physicians Give the Nod to Evolution over Intelligent Design. Flemington, NJ: HCD Research; 2005. Available at: http://www.hcdi.net/news/PressRelease.cfm?ID=93 [Accessed 23 Dec 2013]. 44 A. Smith. Is Antibiotic Resistance Evidence for Darwinian Evolution? Seattle, Washington: Discovery Institute; 2010. Available at: http://www.idthefuture.com/2010/03/is_antibiotic_resistance_evide_1 .html [Accessed 23 Dec 2013]. 45 Chambers, DeLeo, op. cit. note 35, p. 638.
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The case of antibiotic resistance also shows bioethicists and climate scientists a positive example of the possibility of communicating nuanced proposals for how to respond to medical risks. In climate change and in antibiotic resistance there is need for ‘mitigation’ and ‘adaptation’ strategies to be coordinated. A 2004 paper by Gardiner on the ‘Ethics of Climate Change’ pays special attention to the problem of climate change policies that strongly favor adaptation (e.g. helping farmers to switch to crops appropriate for the new local climate) over mitigation (e.g. reducing greenhouse gas emissions).46 Meanwhile, antibiotic resistance management policy already combines both types of strategies; mitigation through the prevention of over-prescription and adaptation through modified treatment guidelines for infected patients work in concert.47 In all, the professional community and the public at large have received the health-framed message that antibiotic resistance must be contended with forcefully and urgently, and pseudoscientific skepticism has been sidelined. Meanwhile, bioethicists have joined the debate without even needing to explain why doing so is appropriate.
INCORPORATING HEALTH IMPACTS INTO CLIMATE ETHICS DELIBERATIONS Having established that bioethicists have important roles to play in climate change discourse, it is necessary to consider how existing climate ethics deliberations should incorporate considerations of health impacts. MacPherson’s article optimistically cites examples in which changed behaviors or policies can mitigate greenhouse gas emissions, ‘without compromising health or socioeconomic development’, such as expanding public transportation systems.48 But, ethical interests do not always fortuitously align and univocally support one solution; in her article’s abstract, MacPherson makes clear that there are tradeoffs involved in climate deliberations and responses. For instance, health goals and economic goals can conflict. Even MacPherson’s example of expanding public transportation, despite its many benefits, has serious negative health and socioeconomic development impacts for certain populations. Replacing the need for personal automobiles with public transportation options will economically harm employees in the automobile industry, devastate the economic structure of 46 S.M. Gardiner. Ethics and Global Climate Change. Ethics 2004; 114: 555–600. 47 Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2013. Atlanta, GA: Centers for Disease Control and Prevention; 2013. Available at: http://www.cdc.gov/ drugresistance/threat-report-2013/pdf/ar-threats-2013–508.pdf [Accessed 24 Dec 2013]. 48 MacPherson, op. cit. note 1, p. 306.
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related factory towns, and expose those affected to the health risks that accompany sudden loss of income and decreased socioeconomic status. When policy deliberations about transportation take place, then it would be valuable to have bioethicists sitting alongside labor economists, climatologists, urban planners, and the other experts trying to determine what is at stake, what tradeoffs are involved and which options are ethically acceptable. This article’s goal is not to decisively settle individual climate ethics cases, but rather to point to a productive role for bioethicists in deliberations about such cases. In the public transportation case there are many competing interests and considerations, and only some of those considerations are health issues. The economic dimensions of climate change must be deliberated seriously, the full range of non-human environmental impacts of climate change must be deliberated seriously, etc. Climate change’s scope is global and its impacts are complex and variable. As such, it would be unethical for bioethicists to monopolize climate ethics deliberations. No one perspective or type of expertise should dominate the rest. What sets the health impacts apart is that they are serious and growing hazards, but have been poorly communicated to the public and given limited attention by the bioethicists in this journal’s readership. Bioethicists should have seats at the table during climate change deliberations so that they, in turn, can put the ethics of climate change’s health impacts on the table.
CONCLUSION There is still far more research that must be done on the effectiveness and ethics of health-framed climate change communication, which has implications for bioethicists as communicators. The antibiotic resistance analogy gives some reason for optimism, but also points out challenges. First, it is difficult to get individuals to see how their own actions contribute to a larger problem. Physicians seem to take antibiotic resistance quite seriously, but while 62% of respondents accuse others of overprescribing, only 13% are willing to accuse
themselves of doing the same.49 Second, it is unclear how an individual’s beliefs about climate change’s health risks affects his or her longterm behaviors. If someone accepts the seriousness of climate change framed as a health problem then how does that generate new consistent habits? Why? Despite compelling and wide-ranging evidence of negative health impacts from climate change, the climate change discourse is still entrenched in rhetoric dominated by vague imperatives to ‘be green’ or ‘protect the environment’, accompanied by visual strategies characterized by photos of the globe taken from space, or of polar bears perched on ice flows. Given the evidence, it is odd that images of climate change do not more commonly include housebound asthmatic children or families dismayed by the price of (healthy) vegetables at the grocery store. The more-pictures-of-polar-bears rhetorical strategy has thus far been inadequate to motivate the American public to action on climate change, and it has crowded out attention to climate change as a global health crisis. New empirical evidence suggests that a health-focused approach would be more successful. In sum, bioethicists are conspicuously late to the climate change conversation, but there is substantial reason to believe that they can help the world to respond to ‘the biggest global health threat of the 21st century’.50
Acknowledgements This project began as an October 2013 entry for the Michigan State University Bioethics in the News blog series, written for a lay audience (http://msubioethics.com/2013/10/25/climate-change-and-medical-risk). It was subsequently revised, rewritten and expanded. I am thankful for the comments on the earlier project, provided by Tom Tomlinson, Elizabeth Bogdan-Lovis and Kyle Whyte. I am also indebted to Kevin Elliott for comments on this later project, and to two anonymous reviewers for their helpful comments. Sean Valles is Assistant Professor at Michigan State University, joint appointed to the Lyman Briggs College and the Department of Philosophy. He is also an affiliated faculty member in the Ecology, Evolutionary Biology and Behavior program. 49 50
Abbo et al., op. cit. note 42. Costello et al., op. cit. note 2, p. 1693.
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