Energy, Emissions, and Public Health Ethics
Abstract and Keywords
Decades of evidence from a range of disciplines shows that industrial energy releases greenhouse gas emissions and contributes extensively to climate change. Energy delivers water, food, and other goods to billions of people, but through emissions it also harms health and environments that support health. These harms vary and have different practical and ethical significance for different populations and environments. A public health ethics concerned with whether and how to respond to conditions that harm health must address these harms. This chapter reviews evidence that the primary cause of climate change is emissions released during industrial production and use of energy. It highlights the health impacts of climate change, defines emissions as health determinants with ethical implications, and discusses how and why ethically informed health policy and other interventions should integrate social justice and social responsibility.
(p. 739) Introduction
A public health ethics concerned with whether and how to respond to conditions that harm health must address the public health impacts of climate change. This chapter reviews evidence that the primary cause of climate change is industrial production and energy use that helps billions of people access water, food, and other goods, but also generates, as byproducts, greenhouse gas emissions, abbreviated herein as “emissions.” As emissions concentrate within Earth’s finite atmosphere, they cause climate change and harm health by disrupting seasonal weather patterns; average global temperatures and sea levels; and the quality and quantity of water, air, and other resources (Watts et al., 2015; Haines et al., 2007; Resnik, 2012).
Decades of evidence and a range of disciplines ground efforts around the world to reduce the range, severity, frequency, and number of people harmed by emissions (Watts et al., 2015; Patz et al., 2014; Frumkin et al., 2008). Drawing on evidence and ethics, this chapter defines emissions as health determinants with ethical implications, and it discusses how ethically informed policies can help reduce emissions to the benefit of everyone.
Energy used to obtain water, food, and other necessities comes primarily from the petroleum industry. For forty years that industry has contributed the biggest global increases in emissions (Patz et al., 2014), which is accompanied by deforestation that annually destroys 20 million acres of rainforest and generates 20 percent of emissions (Auerbach, 2008). Even successful carbon-neutral strategies are outweighed by emissions produced (p. 740) in meeting demands for energy from growing and socioeconomically developing populations (Haines et al., 2007; UNEP, 2005). This demand reflects global population growth from 2.5 billion in 1950 to 7 billion in 2014, which is expected to reach 9 billion before 2050 (Resnik, 2012, Fig. 9.4). Reducing this growth by making contraception more accessible in low- and middle-income countries (LMICs) would reduce global emissions and improve respiratory health in LMICs, where billions of people routinely burn biomass for household energy (Haines et al., 2007).
Growing populations need more food, along with more energy to produce, package, and transport that food. Industrial food production uses fifty times more petroleum than other approaches to meet those needs, and rising petroleum prices increase pressure to cultivate larger areas of land at lower levels of productivity (Harvey and Pilgrim, 2011). One-third of global land surface is already used for animal production, and meat and dairy consumption are rising significantly, even in LMICs (Popkin, 2009). Reducing animal production would reduce emissions and deforestation, and in wealthy nations it would reduce heart disease by reducing dietary animal fat (Roberts and Stott, 2010).
Globally, the agricultural industry produces about one-third of emissions and uses one-half of all chemical pesticides. Meat production alone causes over half of all soil erosion and antibiotic consumption and 20 percent of water use (Popkin, 2009). Global groundwater withdrawal has risen ten-fold annually since the 1960s, with agricultural use in the United States costing over 1 billion dollars annually, generating 6 percent of India’s total emissions, and intensifying needs for water regulations (Rothausen and Conway, 2011). For several reasons, however, water resists regulation (Scott et al., 2011; Resnik, 2012).
By marketing Western products and consumption patterns, globalization increases short-term (i.e., less than one year) socioeconomic gains for industries and governments and drives further demand and production. Globalization also consolidates industrial interests and enhances industry access to, and influence on, government decision-makers regarding how much energy to produce and use, and at what levels of efficiency (Global Policy Forum, 2016). Public interests should be central to such decisions and often parallel shareholder interests in long-term gains and viability, but industries today seem more focused on the short term and market share. Industrial emissions provide short-term benefits but, in the long term, undercut employee health and productivity, damage industrial and other infrastructure and natural resources, and shift consumer spending to essential goods. These impacts should be considered in policymaking involving health, natural resources, and trade.
Atmospheric concentrations of carbon dioxide barely changed for millennia but have risen steadily since 1950 (Resnik, 2012, Fig. 9.2). As inadvertent byproducts of energy production and use, emissions challenge determinations about responsibility that are (p. 741) necessary to fair and effective policy. Their harms are documented in thousands of peer-reviewed publications and include altered seasonal weather patterns (Herring et al., 2014) which affect geographic ranges of vectors and disease reservoirs; rates of development, survival, and reproduction for vectors, reservoirs, and pathogens; vector biting behaviors; prevalence of infections; and transmission to humans (Watts et al., 2015; Patz et al., 2014).
Weather changes contribute to outbreaks of meningitis, tick-borne encephalitis, cholera, and mosquito-borne and other illnesses, with substantial costs (Watts et al., 2015; Costello et al., 2009; McMichael et al., 2008). In 2006 an outbreak of mosquito-borne Chikungunya cost India over 5 million US dollars in lost income (Meason and Paterson, 2014). Chikungunya first reached the Western Hemisphere in 2013 in the Caribbean (Fischer and Staples, 2014), with untold costs to health care and lost income and tourism revenue.
Increased frequency and severity of heat waves, floods, droughts, wildfires, and other environmental changes also reduce quality and quantity of food and water, damage ecosystems that support health, and increase morbidity and death (Resnik, 2012). The 700 heat-related deaths annually in the United States between 1999 and 2009 will increase as the annual number of hot days (over 32°C or 90°F) triples by 2050 and increases respiratory and mental illness and substance abuse (Patz et al., 2014). Heat-related disasters usually involve floods that spread waterborne bacterial and viral illnesses and “trigger broad dislocations, often to places ill-prepared for refugees who are overwhelmed by undernutrition and stress” (Patz et al., 2014, 1571). Disaster, dislocation, and refugee conditions raise national security concerns and facilitate infectious disease transmission (Patz et al., 2014; Jarvis et al., 2011; McMichael et al., 2006) and mental illnesses that develop slowly while increasing aggression and suicide (Maughan, Berry, and Davison, 2014).
Over 1 billion people were injured or made ill by water-related disasters between 1992 and 2001 (McMichael et al., 2006). Global water needs will double by 2050 due to development and population growth (UNDP, 2015). Simultaneously, oceans that once absorbed 30 percent of emissions are losing that capacity through acidification and pollution from, among other things, 13,000 pieces of plastic per square kilometer of ocean (UNDP, 2015). Emissions are reducing access to safe water across the United States (Maibach et al., 2008). California’s population, now 80 percent larger than in the 1970s, imposed water restrictions due to a severe multiyear drought that began in 2012 (Mann and Gleick, 2015). In April 2017, California’s Executive Order B-40-17 declared that having threatened freshwater supplies, devastated agriculture, and harmed fish, animals, and environments, this drought had ended in all but four counties, and that conservation as a way of life will continue through the development of permanent restrictions on wasteful water use (such as hosing sidewalks and driveways) and requirements for reporting water use.
As land is degraded by deforestation, overcultivation, and overgrazing to support growing populations, wind-borne dust polluted with fertilizers and chemicals reduces air quality and increases respiratory illness (WHO, 2015). Rising ozone concentrations significantly increase asthma-related hospitalization and premature death (Kinney, 2008), although millions of respiratory illnesses and premature deaths would be prevented by (p. 742) implementing existing emission-reducing technologies (Frumkin and McMichael, 2008). Meanwhile, mainstream news reports describe poor air quality across Asia as driving a market for unproven filtration systems and canisters of North American air.
The extreme hurricanes Harvey and Irma in the United States in August and September 2017 indicate the growing health and economic dangers of emissions, climate change, and the associated extreme weather. The science and scientists that enabled accurate prediction and tracking of those hurricanes, and facilitated preparations that protected hundreds of thousands of people in their paths, also predict the impacts of emissions on climate change and health. Many American leaders, however, deny that human activities or emissions cause climate change.
Signed by nearly 200 nations in December 2015, the historic COP21 agreement to reduce global emissions emerged from scientific consensus that emissions harm health, are caused primarily by energy production and use, and can be significantly reduced by slowing production. Denial of the evidence and opposition to regulation are motivated by shortsighted self-interests, misunderstandings of science and peer review, and commitments associated with conservative political affiliations (Valles, 2015; Jamieson, 2014; Evans and Feng, 2013).
Corporately funded denial campaigns designed to polarize dialogue and delay policy responses have been successful and are being expanded (Farrell, 2016; Myers et al., 2015). Denial campaigns communicate authoritatively but misrepresent evidence by, for example, citing evidence of rising regional per capita food production (Zycher, 2015) while ignoring influences of obesity, food waste, and other confounding factors. Denial can sometimes be overcome through dialogue that fosters partnerships aimed at identifying shared political and ethical commitments to health across ideologies, and these commitments may promote a range of health goals, including emission reduction (Gruen and Ruddick, 2009).
Emissions are Health Determinants
The increasingly prevalent and visible harms of emissions deserve attention from everyone concerned with causes of disease, requirements for health, and ethics (Frumkin et al., 2008). Emissions are physical components of our environment, affect health and resources for health, and have ethical implications. Few individuals, communities, or populations have full control over their exposure to hazardous environmental components released into the air, water, or earth by human activities. This challenges fair and ethical management of public health and of environmental health determinants, some (p. 743) of which function at epigenetic levels (Dupras, Ravitsky, and Williams-Jones, 2014; Dupras and Ravitsky, 2016). Because physical environments and their components constitute health determinants (WHO, 2016), emissions are health determinants.
Public health ethics weighs the accuracy, relevance, and implications of evidence; and it uses evidence to elucidate ethical grounds for, and challenges to, public health programs and policies (Faden and Shebaya, 2015). These involve relationships within and between social structures, institutions, governments, and international and other entities, and these influence health and constitute health determinants that affect real people and populations (Macpherson and Akpinar-Elci, 2015; Jennings, 2015).
Relationships create practical and ethical issues and can hinder or enhance the success of public health interventions. Successful smoking reduction policies, for example, alter individual choices and social norms about the acceptability of smoking; this affects tobacco sales, and when sales drop, tobacco companies market more heavily in LMICs lacking such policies, exposing already vulnerable populations to rising rates of lung cancer (Dawson and Verweij, 2015). Policies governing tobacco sales and marketing, and accessibility and quality of tobacco, affect health through relationships between and within various entities.
Relationships are central to public health, and public health programs succeed best by using multiple levels of influence involving relationships among individuals, populations, and institutions (Wardrope, 2015). Using this approach, healthy eating programs can position healthy foods prominently and attractively in groceries or restaurants to facilitate individual choice, make healthy choice the default, cultivate temperance as a virtue, connect virtue with health, shift social norms about food, and reinforce all this with social structures (Rozier, 2015). Linking a specific behavior to its impact on others can improve the success of conservation programs (Schultz, 2011), and equally of emission reduction and other health programs.
Relationships form “an intricate web of cooperation and interdependence” with “tremendous significance for health and health care” (Jennings and Dawson, 2015, 37, 33). Public health ethics, like bioethics and medicine, is increasingly attentive to relationships and the environments and institutions in which relationships occur. These determine the impacts of emissions in different geographic regions, their local significance, and the effectiveness of interventions. Emission-related priorities center on air quality in China (Nielsen, 2016), agriculture in India (Gopichandran and Dawson, 2016), zoonotic diseases in Arctic and tropical regions (Macpherson, Bidaisee, and Macpherson, 2016), and drought and floods that disrupt migratory pastoralists in Africa and the Middle East who may misunderstand national and private borders (Metz, 2016).
Individual and collective actions, including emission-producing actions, manifest themselves through relationships. At personal and political levels, individual actions can be morally persuasive and can catalyze collective agreements, because other individuals (p. 744) sometimes emulate actions that protect the commons, like those aiming to reduce emissions (Hourdequin, 2010; Singer, 2011, 235). Individuals and their actions are inseparable from the communities and environments in which they exist, and relational approaches expose systemic patterns of injustice therein that threaten shared interests in health, safety, and survival (Baylis, Kenny, and Sherwin, 2008). Drawing from feminist theory, public health ethics can use relational approaches to illuminate connections between disadvantage and health, stakeholder involvement and power in health systems and processes, and social structures and norms that shape individual abilities to identify and express health-related preferences (Rogers, 2006).
Teasing apart these connections can enhance understandings of and responses to health threats, including emissions. Freedom and solidarity connect with well-being, for example, and are expressed through autonomous actions in here and now “places” in which populations, social structures, and other entities exist and health determinants function (Jennings, 2015; Jennings and Dawson, 2015; Eckenwiler, Straehle, and Chung, 2012). Policies affecting emissions influence health from within these places by shaping individual and collective understandings about, and preferences and capacities for, emission reduction. To succeed, these policies must target these places and relationships within and beyond them. Public health ethics can guard against systemic interests and moral indignation that confuse or mislead policymaking and other interventions, but this requires acknowledging its own internal biases (Schmidt, 2014).
The early bioethicist Van Rensselaer Potter recognized that relationships and interdependencies between living things influence impacts of biomedical and social advances (Potter, 1971, 1–12; ten Have, 2012; Whitehouse, 2002). Drawing from his work in biochemistry and oncology during the socially turbulent 1960s, Potter constructed a “global bioethics” that used humanities and social sciences to deepen understanding and guide medical, scientific, and technological advances in ways that would benefit, rather than undermine, health and survival (Potter, 1971, 1–12). Often overlooked, this relational approach is foundational to bioethics work on health, and particularly emissions (Macpherson, 2016, 202; Macpherson, 2013a; ten Have, 2012; Dawson, 2010).
Bioethics is often described as an umbrella encompassing public health ethics, medical and research ethics, and other ethics specialties. Many environmental or climate ethicists, however, do not identify themselves as bioethicists or address health in their work. What seems to be the first publication directly addressing emissions in a mainstream bioethics journal documents health harms associated with the production, transportation, and disposal of latex gloves; and asks whether the harms outweigh the benefits of using latex gloves in health care (Pierce and Kerby, 1999). This question remains salient given their steadily growing use nearly twenty years later.
Despite subsequent attempts to rekindle Potter’s bioethics (Whitehouse, 2002, 2003; Whitehouse and Fishman, 2004; ten Have, 2012) and increasingly visible impacts of (p. 745) emissions, climate change remains of peripheral interest within mainstream bioethics (Macpherson, 2013a, 2013b; Dawson, 2010; Dwyer, 2009). Exceptions include its integration into a few bioethics programs in the United States, United Kingdom, and Europe; published reflections prompted by Hurricane Katrina on health determinants that harm those least able to protect themselves and recover (Dwyer, 2005; Moreno, 2005); several peer reviewed articles in the Kennedy Institute of Ethics Journal, Journal of Bioethical Inquiry, and elsewhere; and proposals for specialties in ecoethics (Ehrlich, 2009), environmental bioethics (Pierce, 2009), green bioethics (Richie, 2014), and One Bioethics (Thompson and List, 2015) to overcome this disinterest.
One Bioethics aims to prevent or resolve ethical dilemmas like those associated with the 2014 Ebola outbreak by integrating the ethics of “complex issues involving human, animal, and environmental health” into One Health initiatives (Thompson and List, 2015, 98). One Health recognizes that ethics and relationships between humans, animals, and environments are central to the health of each and bear on the management of emerging and other diseases (Capps et al., 2015; Shomaker, Green, and Yandow, 2013).
Even in LMICs, where it is often culturally or economically inappropriate, medical technologies and Western conceptions of autonomy dominate bioethics, but bioethics would have greater relevance to, and better inform, health policy and practice everywhere if it embraced collective concerns (Dawson, 2010; Macpherson, 2013a). Bioethicists and health professionals have professional and civic responsibilities. For bioethicists, these involve public trust in their willingness and ability to inform policymakers and the public about risks and harms to health.
Recognizing emissions as one such harm, some health professionals are accepting this responsibility by making environmental sustainability an ethical priority in their institutions. Accordingly, they are reducing costs and energy use by increasing patient proximity to ambient light and green spaces, because doing so reduces pain, aggression, and fatigue while accelerating recovery and increasing cognition and longevity (Sadler, 2015; Gomez et al., 2013; Sadler et al., 2011). Medical curricula and practice are increasingly responsive to emissions (Walpole et al., 2016; Chivian, 2014; Roberts and Stott, 2010; Macpherson, 2009; Auerbach, 2008). Equally safe but less wasteful procedures for cannulation and intravenous antibiotic preparation are being taught (Bajgoric et al., 2014), and patient compliance and outcomes are improving in conjunction with strategies to reduce medication waste (Maughan, Berry, and Davison, 2014).
Packaging contributes greatly to medical waste. Britain’s National Health Service (NHS) produced nearly 6 kilograms of waste per patient per day from 2005 to 2006, while France produced under 2 kilograms, and Germany only 0.4 kilograms, per patient per day (Hutchins and White, 2009). Reprocessing rather than discarding medical devices prevented over 2,000 tons of landfill waste in the United States in 2008, saving hospitals nearly $1.5 million (Kwakye et al., 2010). Health care emissions in the United States, however, were thirty times higher than those of the NHS in 2007 (Richie, 2014). Legal and policy responses to emissions in the United Kingdom are moving the NHS toward carbon neutrality (NHS SDU, 2016).
(p. 746) Large quantities of emissions are produced by all medical institutions and industries because they use large amounts of energy and other resources for routine maintenance, procurement, disposal, and transportation. The assisted reproductive technology (ART) industry and the institutions in which it functions share responsibility for these emissions and may have additional responsibilities, given that their emissions are not produced while caring for patients with medical conditions (Richie, 2014). ART differs from other medical institutions and industries in that it does not treat, cure, or prevent disease; its ethical acceptability is contested by a range of stakeholders; and it increases, consumes, and disposes with the “sole purpose of creating more consuming humans” who will use more energy and resources in the future (Richie, 2014, 5).
Ethically Informed Policy
Ethically informed policies are needed to reduce emissions, adapt to emissions already present, apportion responsibility for their future production, and ensure accountability for present and future production. These policies will require well-defined goals built on strong and objective evidence, multiple targets with sensitivity to local environments and priorities, and resources for implementation and outcome measurement. They are challenged by disagreement about, among other things, how to fairly apportion responsibilities.
Responsibility for emissions is complicated because their sources and quantities vary over time, they are used to obtain both luxuries and necessities like potable water, and the extent to which knowingly producing them imparts obligations to reduce them is debatable (Singer, 2011, 236). Such complexities may be countered by framing emissions as an affront to the natural world, and the need to reduce them as a moral imperative, in order to evoke support across conflicting ideologies (Markowitz and Shariff, 2012). A responsibility to develop empathy for those harmed by emissions in distant places and times can be met by strategically circulating stories from individuals and entities about their experiences to unify and drive responses (Bushell, Colley, and Workman, 2015).
States and industries have moral responsibilities to reduce emissions, and because large-scale emission production violates human rights to life and health, signatories to human rights agreements also have legal responsibilities to do so (Levy and Sidel, 2014; Meason and Paterson, 2014; Singh, 2012). Human rights approaches are applicable because climate change jeopardizes the minimal moral threshold to “life, health and subsistence” through, for example, recurring storm surges and heat waves; they offer advantages over cost benefit analyses, which, in aggregating harms and needs, overlook the most vulnerable, like the elderly or economically disadvantaged; and they can inform policy development regarding the infliction of harm “on others and the role that compensation may play in our decision making,” because destroying someone’s property or health is a harm, wrong, and rights violation, regardless of whether it is compensated (Caney, 2010, 172). Human rights agreements support using resources to promote health (p. 747) and justice, but their influence is limited by the laws and capacities of states to uphold them (Syrett, 2015; Jennings, 2015; Daniels, 2006).
Globalization and development processes impose moral responsibilities because they elevate emissions and demand for energy, harm health and environments that sustain health, and connect us to future generations (Holland, 2006; Macpherson, 2016, 205–207). Globalization raises ethical questions about whom we, individually and collectively, are morally responsible and accountable to (Verkerk and Lindemann, 2011); and about the size of burdens created by emissions, how to apportion responsibility for creating those burdens, and what to do if that responsibility is not met (Kingston, 2014). What constitute dangerous, fair, and preferred responses to emissions are ethical, rather than scientific, determinations.
Ethically grounded policymaking respects diverse stakeholder goals even when these goals conflict with moral convictions of policymakers; it also ranks benefits and burdens fairly; exposes rationales for support, opposition, or neutrality that affect consensus-building; and delineates associated values (Churchill, 2002). Values pervaded the policy goals of former US president George W. Bush, who sought to protect the American way of life by promoting economic growth and emissions despite harms even within the United States (Singer 2011, 229). Had his values been different, he might have pursued this goal through other strategies, like promoting alternative energy. Similarly, development policies that fail by excluding local stakeholders from their design could succeed with different strategies (Ruger, 2015).
Values are apparent in the contrasts between policymaking, which occurs over months, and science, which accumulates evidence, wisdom, and authority over centuries; these values shape scientists’ responsibilities to participate in policymaking, clarify implications of evidence, and distinguish between fact- and value-based disagreements (Jamieson, 2014). Dialogue about the harms and benefits of proposed interventions would reduce policymaking conflicts and shift attention from values to evidence in decisions such as whether and when the benefit of reducing mosquito-borne disease outweighs the harms of using DDT, or the harms of deforestation outweigh economic benefits (Resnik, 2012). Such dialogue illuminates environmental differences that affect the fairness of policy goals and strategies (Macpherson, 2013a), and ensures that “reasonable people who disagree can view policies as fair and legitimate” (Daniels, 2006, 26).
Global population growth can be slowed to reduce emissions by improving women’s economic and health indicators and access to contraception (Resnik, 2012; Singer, 2011, 209; Haines et al., 2007). Slowing population growth raises contentious questions about reproductive freedom (Resnik, 2012; Callahan, 2009), such as where and when does freedom from overcrowding outweigh freedom to choose how many children to have; is it justifiable to manipulate birthrates or stipulate who may have children; and is it acceptable to provide sex education and with what specific information (Veatch, 1972)? (p. 748) It would also, however, protect the capacity of social structures to manage dwindling resources and infrastructure (Ehrlich and Harte, 2015). Natural resources that once seemed infinite cannot support 8 billion people living Western lifestyles, so new concepts of growth, development, and well-being are needed, with policies supporting them (Jamieson, 2014; Buchholz, 1998).
Emission-producing activities involve multiple sectors, nations, and stakeholders. Employing a range of targets will help ensure that infrastructure is designed and situated with sensitivity to extreme weather, carbon sinks, and indigenous populations; cost-benefit calculations incorporate the entire cost of producing and consuming a unit of energy; and carbon-neutral technologies receive widespread investment and adoption (Jamieson, 2014). Political and financial commitment to such work depends largely on values and environmental conditions (Macpherson, 2013a), and bioethics capacity to frame and communicate medical risk could be used to enhance related dialogue (Valles, 2015).
The health implications of emissions should be prominent in climate deliberations and policy (Singh, 2012), and also integrated into legal frameworks and governance to improve public health infrastructure and mechanisms (Wiley, 2010). Shortcomings in these worsened Hurricane Katrina’s impacts on the most vulnerable in 2005, but bioethicists resisted probing interests in preserving our “fragile and increasingly ailing planet” (Moreno, 2005, W19). With few exceptions, mainstream bioethics continues to resist investigation of collective interests and common goods despite its grounding in the search, across diverse groups and conflicting ideologies, for common values and interests that bear on dynamics between environments and health (Whitehouse, 2003).
Activities involving industrial energy release emissions that cause climate change. Emissions are health determinants that affect individuals and populations through relationships of many sorts, and that impact and harm health differently in different environments. Public health ethics helps advance deliberations about whether, when, and how to reduce health harms and threats, including those of emissions. It can deepen understanding among policymakers and other stakeholders about values that influence policy goals and targets, and help nurture concepts of growth and development that are compatible with the preservation of natural environments that sustain health and wellbeing.
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