Doctors, Medical Students and the Environment

Connecting doctors and medical students with their role in environmental protection and stewardship using the language of medical ethics and human rights
by Jen Moran, 1st Year Medical Student, ANU Many doctors and medical students appear hesitant to become advocates for environmental protection and sustainable development. This is not to say they do not care, but that they may not see the connection between the practice of medicine and the health of the environment. But this does beg the question, if our role in the doctor-patient relationship is the commitment to the relief of suffering, then how can we deny our responsibility to contribute to a healthy environment? Human suffering and the state of our environment are intrinsically linked. By ensuring that our environment is healthy—our water is clean, our soil is fertile, our exposure to harmful chemicals is minimal, and our ecosystems are in good working order—we are in essence providing the ultimate public health intervention.

In theory, this makes sense. Why then does this argument not galvanize doctors and medical students into action? The answer is complex and, among other things, probably contains elements of fear, denial, complacency, limited time, lack of knowledge or exposure to environmental issues, and disbelief. Perhaps, despite our education, we do not grasp the gravity of these issues or see their relevance to the practice of medicine because they do not resonate with us. In other words, we know that the health of the environment is important, but we do not see that we have a role in fixing it. If this is the case, part of the solution may be to present the argument in the context and language of medical ethics and human rights. This is language that we are introduced to early in medical school and it continues to be used to shape our professional conduct throughout our careers. Possibly it is not the message that is the problem, but the way the message is being delivered. To this end, I suggest we try to place the argument in favour of doctors for the environment in the lexicon of medical education as a way to connect doctors with their responsibility for environmental stewardship.

For example, the concepts of virtue ethics are well known to all of us. We are introduced to them early in our medical education and it is hoped that we will assimilate these virtues to a point where they will govern our conduct in all aspects of our lives. We are expected to be mindful of the virtues of beneficence, non-maleficence, autonomy and justice. If this is the case, the role of doctors as environmental stewards is contained in these virtues.

In essence, beneficence encompasses many moral virtues such as charity, kindness and mercy. Beauchamp and Childress (2001) apply the term in its broadest sense as an action done to benefit others. They go on to assert as doctors we have a moral obligation to act for the benefit of others. For the most part, we apply this concept to our patients with little difficulty. We seem, however, to limit our professional application of beneficence to our human interactions. But why limit it in this way when we could incorporate it into our argument in favour of environmental stewardship. We could use it to illustrate that if we support a lifestyle that encourages environmental degradation we may be adding to our patients’ ill health by exposing them to a foul environment wrought with pathogens. In this way, we are supporting an environment that would increase the incidence of many diseases such as cancer, autoimmunity, allergy and atopy. We could argue that this is not an act of beneficence. Sitting idle while our patients live in a world of depleted resources and polluted ecosystems is not charitable or kind. The beneficent alternative is to get involved in environmental advocacy.

The same argument can be phrased using the virtue of non-maleficence. We accept that it would be wrong to do harm to another, especially in the trusted position our patients place us in. We do not, however, seem to apply this virtue in the broader sense. If non-maleficence means to do no harm, then it holds that we should not only do no harm to our patients, but also the environment they live in. Since the earth is a closed system, it is impossible to act independently of the consequences of our actions. The things we each consume and the choices we make with respect to how many resources we use have an impact on all of us. If we choose to live in a consumptive manner that results in excessive resource depletion or pollution, we are indirectly causing harm to our patients.

As a manifestation of the virtues of beneficence and non-maleficence we are committed to the relief of suffering. We cannot claim to be committed, however, unless we take steps to resolve the source of suffering. If one source is an unhealthy environment then that is a place where our efforts need to focus.

The moral norm of autonomy can be regarded as respect for the individual and their ability to make decisions with regard to their own health and future (Beauchamp and Childress, 2001). Actions that enhance autonomy are thought of as desirable and actions that dwarf an individual and their autonomy are undesirable. Thus it follows that if we live in a degraded and unhealthy environment, we may be unable to make uninhibited decisions with respect to our health and our future. For example, if previous generations have soiled our air and water, or damaged our ecosystems we will not have all the tools necessary to live in health. As a result, the unsustainable lifestyle of those who have come before us may have diminished our autonomy. As doctors who respect our patients’ autonomy it is therefore part of our responsibility to try to prevent this. Thinking about virtue ethics in this way broadens its application from the traditional one-on-one doctor-patient interaction to a cross-generational one where we have a responsibility to become environmental stewards out of respect for our patients’ autonomy now and in the future. Thus as doctors, we are bound to strive for a healthy environment, not only for its intrinsic value, but also out of respect and commitment to that autonomy.

Justice refers to a group of norms for distributing benefits, risks and costs fairly (Beauchamp and Childress, 2001). In other words, it is concerned with being fair or just to the wider community in terms of the consequences of an action. Similarly, the most frequently quoted definition of sustainable development is “development that meets the needs of the present without compromising the ability of future generations to meet their own needs (UNCED 1987).” Based on these definitions, both justice and sustainability are concerned with fair decision making with a mind for the future. Sustainable development focuses on improving the quality of life for everyone without increasing the consumption of natural resources beyond the capacity of the environment to supply them. It requires an understanding that inaction has consequences and that we must find innovative ways to affect social and individual change, goals not dissimilar from those of the virtue of justice.

In more practical terms, virtue ethics can be seen to be at the heart of human rights where they form a “common morality (Beauchamp and Childress, 2001).” This “common morality” is expressed in the Universal Declaration of Human Rights (UN 1948). Of the 30 articles in the Declaration, four can be applied to the argument in favour of a doctor’s obligation to work toward environmental protection and sustainable development:
* Article 1 states “all human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.”
* Article 5 states “no one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.”
* Article 25 states “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”
* Article 30 states “nothing in this Declaration may be interpreted as implying for any State, group or person any right to engage in any activity or to perform any act aimed at the destruction of any of the rights and freedoms set forth herein.”
Again, these rights can be interpreted in such a way that they may underscore the sentiment of sustainable development.

Once we have raised our collective conscience the possibilities for involvement are immense. We can lead by example, get involved in local conservation programs, lend financial support to environmental research and protection organizations, educate others, or become a voice in politics. There is no one role for all of us other than to be involved. The role we each choose is a personal one consistent with who we are and where our strengths lie. Our unifying goal should be to achieve environmental protection and a sustainable future for our patients, holding true to our ethical obligation to ensure they have every opportunity to live healthy lives.

The language of virtue ethics is one tool we can use to connect doctors to their role in environmental stewardship. We can use the language of ethics to enable this change and get more doctors and medical students to make the connection between human health and the health of the environment. We can show that there is a connection between commitment to patient care and support for environmental protection and sustainable development, and more importantly, we can use our professional commitment to these virtues as an impetus to get involved.