Discussion 350 words minimum and 3 references

SYMPOSIUM

A Reflection on Moral Distress in Nursing Together With a Current Application of the Concept

Andrew Jameton

Received: 18 October 2012 /Accepted: 11 June 2013 /Published online: 20 September 2013 # Springer Science+Business Media Dordrecht 2013

Abstract The concept of moral distress can be extend- ed from clinical settings to larger environmental con- cerns affecting health care. Moral distress—a common experience in complex societies—arises when individ- uals have clear moral judgments about societal prac- tices, but have difficulty in finding a venue in which to express concerns. Since health care is large in scale and climate change is proving to be a major environmental problem, scaling down health care is inevitably a nec- essary element for mitigating climate change. Because it is extremely challenging to discuss these concerns in health care settings, those concerned about climate change and health care experience distress. This article outlines some philosophical concepts and perspectives that may be useful in mitigating this distress.

Keywords Nursing ethics . Climate change . Global warming . Moral distress . Health care costs . Bioethics history. Environmental ethics

The main purpose of this paper is to adapt and extend considerations of moral distress to issues of moral choice and action in relationship to major environmental issues affecting health care. The discussion here particularly draws attention to the problematic nature of health care’s excessive environmental footprint, especially its carbon footprint. As climate change worsens over decades, the scale of U.S. health care—and that of other developed nations—is becoming ethically increasingly awkward.

Although the outlines of the moral problems of health care overconsumption in the context of global justice and environmental decline over generations are clear enough, it is difficult to find appropriate venues in health care to express these concerns. This paper identifies some of the hindrances to needed discussion and then suggests some shifts in the perspectives of clinical ethicists on bioethics as a theoretical field that may be helpful in finding a helpful role in moving the discussion ahead during a period in which the political, economic, technical, and societal complications of climate change are hindering efforts to meet speedily its urgent challenges.

Moral Distress in Bioethics

The concept of moral distress has origins in nursing ethics in the 1970s and 1980s. During this period, shortly after medical schools began to establish bioethics courses, ethics faculty recognized that nurses and nurs- ing students displayed a strong interest in the study of ethics. At the University of California, San Francisco, for

Bioethical Inquiry (2013) 10:297–308 DOI 10.1007/s11673-013-9466-3

The comments to this article are available at doi:10.1007/ s11673-013-9458-3 and doi:10.1007/s11673-013-9461-8.

A. Jameton (*) Department of Health Promotion, Social and Behavioral Health, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198-4365, USA e-mail: [email protected]

example, bioethics pioneer Albert R. Jonsen made elec- tive bioethics courses available to health professions students campus-wide. Although the courses were usu- ally labeled “medical ethics,” many more nurses enrolled in them than students from medicine and other health professions programs. Nursing professors Anne Davis and Mila Aroskar recognized this need and in 1978 published one of the first modern textbooks in the field, Ethical Dilemmas and Nursing Practice (Davis, Aroskar, and Fowler 2009).

During that period, many of the philosophers turn- ing freshly to bioethics as an area of study tended to direct their teaching to exploring major ethical theo- ries, such as utilitarianism and Kantian deontology. They predominantly employed the technique of setting students to work on ethical dilemmas, that is, case studies that stimulated exploring direct conflicts among basic theoretical principles.

They also tended in their cases, analyses, and chosen audience to foreground the physician, often male, as the central or representative clinical character in the clini- cian–patient relationship. These narratives tended to edit out nurses. In part because of the predominance of nurses in ethics classes, this began to change. Ethicists began to explore a range of nursing ethics issues of which nursing students and professionals were aware but which had heretofore tended to pass beneath the radar of physicians and medical students.

Nursing students typically displayed concerns that seemed less theoretical, more practical, and more feeling (Belenky et al. 1997). In addition to the nurse–patient relationship, the nurse–physician relationship was an absorbing area of reflection, rich with potential issues of cooperation and conflict and marked by professional viewpoints reliably different from those of physicians.

Although not yet prominent in the bioethics schol- arly literature, feminist ethics was on the rise in society and in philosophy. Nursing students tended to focus on issues of power, inequality, and assertiveness that characterized the feminist literature. Attention to nurs- ing ethics exposed bureaucratic details and institution- al concerns to view. While for many philosophers the important and primary concerns remained with the initial dilemmas of patient care, for many others the more significant and challenging ethical concerns lay in the dilemmas of institutional life—delegation, ne- gotiation, scope of discretion, managerial responsibil- ity, role of the board, mission, fairness among em- ployees, public relations, and so on.

Some of the nursing students were clinicians with several years of experience. Often, when reflecting on clinical moral problems they had faced, they expressed little confidence in their own views, even though it seemed clear that they had relatively strong views on what needed to be done. One problem seemed to be that they expected to receive little support from phy- sicians or nursing administrators. Being professional, and since feminism had not yet swung into nursing with force, they tended to avoid direct conflict and expressed their views in ways designed to cloak, sometimes unconsciously, their professional disagree- ment with some medical practices.

The concept moral distress was thus useful in pro- moting a more direct discussion of the moral problems nurses were facing. The 1984 book Nursing Practice: The Ethical Issues (Jameton 1984) characterized mor- al distress as a challenge that arises when one has an ethical or moral judgment about care that differs from that of others in charge, in contrast with a dilemma, which is more concerned with ethical conflicts among the larger and abstract aims and principles of care (Jameton 1977).

The more standard dilemmas remained relevant, but the dilemmas of distress shifted issues from the region of what is right for the patient to the dilemmas of putting a nursing perspective across in a stratified bureaucratic environment where it was not the nurse’s place to determine the direction of patient care, nor to assert moral declarations ex cathedra about the goals of hospital care.

The treatment of moral distress in Nursing Practice was not the first time that the concept of moral distress had appeared in the nursing ethics literature. In other meanings, it appeared, for instance, in 1909 and 1887 publications (Elmer 1909; Fouillée 1887). Job-related distress, including disagreements with physicians about patient care, had been widely observed more than 80 years before in the work of Isabel Hampton Robb (Robb 1900) and Florence Nightingale (Skretkowicz 2010) and continuing in various works from there on. Nursing burnout deriving in part from challenges to nurses’ idealism was a common concern in the 1970s nursing literature, as for example in Marlene Kramer’s 1974 book Reality Shock: Why Nurses Leave Nursing (Kramer 1974).

Since the concerns of moral distress fit neatly into discussions about gender, the status of women, and participation in decision-making that were appearing in

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feminist philosophy of that period, Nursing Practice had the opportunity to cover a variety of concerns that had not been well covered to date in the medical ethics literature, especially the emotive experience of ethical issues.

The affective dimension arose partly from the nurs- ing role being one that included emotional aspects of patient care. Nurses labored in the hospital, among other purposes, to comfort patients, to build trusting relation- ships, and to reward patients’ compliance with the med- ical plan. To use the language of Arlie Hochschild in The Managed Heart: Commercialization of Human Feeling (Hochschild 1983), as a professional group in the hospital nurses were doing much of the emotional labor that preserves hospitals as humane places and not the cold, technological, profit-trolling, computer-driven Frankensteins they have the capacity to be.

In addition, a key work that inspired the development of moral distress predated the feminist turn in bioethics. This was a thin volume in business ethics by Alfred O. Hirschman entitled Exit Voice and Loyalty: Responses to Decline in Firms, Organizations, and States (Hirschman 1970). This book developed some interesting and com- plex economic arguments about dissatisfaction in occu- pations, some of which center on ethical disagreement, such as aspects of patient care to which a clinician may have moral objections. Hirschman asks: Should the cli- nician quit work? That is, should he or she exit? He argued that this choice is worthwhile only if there are hospitals that practice differently down the street. But that is unlikely, since hospitals share highly similar practices which their professional and organizational cultures promote and on which many of their accredita- tion criteria depend.

The other two choices available to employees, as identified by Hirschman, are voice—speaking up to the issue—and loyalty, his term for quietly doing one’s job. Although many nurses at the time were choosing exit by leaving nursing altogether, most of the class- room discussion of nursing distress explored choices elaborating a range of subtly different problem-solving strategies falling between voice and loyalty.

The typical moral sticking point for nurses in those years was the medical potlatch of overtreatment of the dying, which is still a commonly regretted practice in academic health centers. In their position at the bed- side, when patients were overtreated and suffered for it, nurses were often hit hard with distress. Sometimes, they witnessed suffering they could not justify and

were hands-on in causing that suffering with suctioning, shots, transporting patients, adjusting ventilators, and so on. To nurses, up close physically and emotionally to suffering, unnecessary pain felt like abuse of patients, and in being complicit in and witnesses to abuse, they themselves experienced abuse. Meanwhile, they resent- fully saw physicians enter the patient’s room and write orders, only to depart quickly and leave the management of suffering to nurses.

Most classroom descriptions of moral distress at that time came from nurses who regretted being less vocal than they might have been. As time went on, something in the passivity and regret of that early feminist ethics period was displaced by more asser- tiveness and articulateness among nurses. As a result, the concept of moral distress retained a residue of ambivalence and regret characteristic of the period of its coining. Those who wrote about distress in subse- quent years rightly called attention to the somewhat passive character of the concept and urged nurses to be more vocal on behalf of the values of their profession. The energizing answer to the dilemma of moral dis- tress is to speak up (voice) and to struggle in and out of institutions for what one sees as right. The answer to passive distress is activism.

Besides reflecting the professional dominance of medicine (Freidson 1970), the medically centripetal tendency of bioethics at that time arose in part from a hope among philosophers that they might rise in the world through association with a powerful profession (Toulmin 1982). Other philosophers took a different direction. They chose to focus on nursing ethics and to disdain becoming too identified with the medical pro- fession. The 1970s was a decade of hope for re- form in health care. Since physician dominance was seen by many reformers as one of the prob- lems of health care and since nurses populated the clinical regions of the hospital, it seemed to some in bioethics that if the health care system were to progress, physicians would have something to lose and nurses might have much to gain. So, insofar as an ethicist aspired to be of service to health care in general, it made sense to work with those professions who had more to gain by strengthening their conscious- ness of ethics and idealism. Backing nurses seemed a modest way for a philosopher to support health care reform and thereby to bet on the victory of, in the view of some, the more virtuous, if currently less powerful, profession.

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Once nurses emerged from the background of the ethics discussion, a host additional of characters came forward as part of the clinical cast of players, includ- ing pharmacy, dentistry, health administrators, and diverse allied health professions, each bearing its own code of ethics and particular moral perspective on clinical goals and relationships with patients.

It became immediately evident that moral distress is not confined to nursing but is an experience common to many professionals, workers, and citizens broadly. Almost everybody is sometimes in a similar position of moral distress. Nurses were able to articulate it and worked in circumstances arousing intense experience of it. But most people work in organizations. Managed and served by various staff, supervisors, and subordinates, organizations have functions and missions about which staff experience conflicting feelings. In typical cases, an institution may have a stated mission that it is, in the view of some, fulfilling poorly. Or, in the detailed oper- ations of institutions, it may seem that principles of fair treatment, cultural competence, conviviality, or respon- sible delegation have gone astray. Indeed, since its use in nursing ethics, the concept of moral distress can be found in articles on the ethics of a variety of clinical profes- sions, including medicine, and in nonclinical areas, such as business and engineering ethics.

Extending Moral Distress

This section of the paper relates one story of the enlargement of the concept of moral distress to wider contexts than particular professions. The concept’s broadening is not meant to minimize its importance to intra-professional and intra-institutional contexts, but it does lend to them a useful perspective.

This broader application of moral distress began with a funded project conducted at the University of Nebraska Medical Center (UNMC) related to greening hospitals and medical centers. Health care greening is the process of redesigning medical technologies and architecture, resetting clinical priorities, and reinventing the health care delivery system into something more environmen- tally sound and sustainable—less toxic and less intensive in its use of resources (Whitehouse et al. 2010).

The UNMC greening project was stimulated partly by the 1992 “World Scientists’ Warning to Humanity” published by the Union of Concerned Scientists, which opened:

Human beings and the natural world are on a collision course. Human activities inflict harsh and often irreversible damage on the environ- ment and on critical resources. If not checked, many of our current practices put at serious risk the future that we wish for human society and the plant and animal kingdoms, and may so alter the living world that it will be unable to sustain life in the manner that we know. Fundamental changes are urgent if we are to avoid the colli- sion our present course will bring about (Union of Concerned Scientists 1992, “Introduction”).

Jessica Pierce (2012), a philosopher and theologian, led the work at UNMC, which was generously sup- ported by The Greenwall Foundation during 1998 to 2004. The project produced several articles and a book titled The Ethics of Environmentally Sound Health Care (Pierce and Jameton 2004). The project quickly generated work and relationships that extended well beyond the bedside. For instance, hospital purchasing decisions are made institutionally by committees representing several groups of administrators and pro- fessions, many of whom have nonclinical disciplinary backgrounds. Commitments to purchase materials and equipment are made outside of the hospital by institu- tions far from the bedside, such as Group Purchasing Organizations. Methods and materials of manufacture are decided by the industries producing materials and equipment. Engineers, city planners, policy-makers, and architects often play an important role in setting the standards to which hospital supply chains and design must respond. Very little control can be exercised at the bedside.

The work at UNMC paralleled a rise in environmen- tal concerns regarding health care, driven in part by activists in such organizations as Health Care Without Harm, The Nightingale Institute, the Environmental Protection Agency, the United States Building Council, the American Hospital Association, and many others (Whitehouse et al. 2010). Initial environmental concerns tended to focus on the toxicity of hospital waste, such as the disposal of products containing mercury, red bag waste, incinerator emissions, dioxins, and pharmaceuti- cals. The sheer bulk of waste volume going to landfills was also an early concern.

Involvement of clinical ethicists in these areas was novel, both for the organizations and the ethicists them- selves. As with bedside bioethics, ethics research in- volved an exciting learning adventure concerning the

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complex chemistry, components, manufacturing process- es, disposal, and origins of supplies, tools, and equipment. This resulted in an exciting transformation in perception for the bioethicists involved.

Ethicists learned that the hospital purchased from a catalog of around 85,000 distinct products in addition to pharmaceuticals. Participants began to see aspects of hospital buildings and architecture they had neither seen nor noticed before. The hospital loomed into view as a massive industrial object. Its structure emerged as a complex container of the clinical areas—the pipes in the ceilings, the basements of fuse boxes, the floors of buildings devoted entirely to air handling and water processing, the loading docks, the storage rooms with forests of IV stands, the stacks of disposable supplies, and so on.

And the off-campus activities linking hospitals to the external world of laundry, warehousing, and transportation made a larger world still. Beyond these lay mining, petro- leum, coal, the chemical industry, international trade, and more. Crucially encompassing these appeared the im- mensely important regions of the living world—biomes, species, atmosphere, ocean, and so on.

The clinical gaze intensely directed to the patient and caregivers began in this context to seem strangely over-focused, almost microscopic like medical science itself, as though like horses in harness, ethicists had been wearing blinders.

Yet the novelty, complexity, and extent of these environmental terrains were also awkward for clinical ethicists. And with that awkwardness came feelings of moral distress. Ethicists were seeing a significant mor- al problem—excessive environmental impact. That is why the ethicist has entered this realm. But in what institutional context can this be discussed? This is the same challenge that nurses and environmental activists in these institutions face. The key values of safety, efficiency, low cost, therapeutic efficacy, finance, and marketability drive most decisions in this realm. Although their numbers are increasing, only a few health care organizations have a “sustainability offi- cer” or the like. The morality of environmental con- cern usually falls under the rubric of organizational omissions, so it is hard for activists and ethicists to find the right moment and office in which to voice concerns, and if these concerns are voiced and heard as legitimate, it may well be difficult for individuals and organizations to find feasible and pragmatic solu- tions to the problems raised.

Meanwhile, back at the Ethics Consultation Service and the Medical Ethics Committee, these concerns fall well outside clinical ethics. Bioethics consultation nor- mally responds to the questions asked by patients and clinicians. If patients and clinicians are not asking envi- ronmental questions, it seems inappropriate for the con- sultant to raise them. Questions about the incinerator or the laundry hardly feel relevant.

Presenting environmental issues to patients raises especially awkward ethical issues. Sick patients are unlikely stewards of environmental costs. While the normal anxiety of environmentalists is, “Are we using too much?” the anxiety of patients is, “Will they provide me all that I need?” Since environmental costs are incurred primarily distant from the hospital, pa- tients don’t see the material inputs and outputs, many of which are generated by manufacturers far upstream from clinical end-users. If it is already difficult for a patient to appreciate the significance of medical and physiological concepts, it is even more complex and challenging to add a burden of supply chain science to patient education.

If, in order to accommodate patients with environ- mental concerns, hospitals were to tailor environmen- tal costs to patient preferences and supply green care for patients who choose it and conventional care for others, costs would rise significantly. Hospitals would need to stock both conventional and green models of the same item, such as both reusables and disposables. Dual stocking would entail dual packaging and additional accounting and storage space. And since seldom are two distinguishable items handled the same way, expen- sive staff training is needed for each item. The “patient choice” model does not work here. The environment is a common institutional and societal responsibility not han- dled by the ethics of patient-centered care.

Emergence of Over-Scale

As ethicists explored this new realm, it began to become clear that a major factor in the environmental conse- quences of health care is the extensive scale of health care. This was already apparent from a monetary or financial perspective. Health care in the United States is expensive as measured by dollar costs, and its modest impact on improving public health in ratio to its finan- cial expense in proportion to Gross Domestic Product is something of an embarrassment as compared with other

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developed countries. Worse, the U.S. health care system uses close to half of all the money spent worldwide on health care (World Bank 1993; WHO 2007). Even though major portions of health care’s environmental costs are externalized, its disproportionate monetary cost is an approximate reflection of its considerable environmental cost.

As Paracelsus is said to have remarked, “the dose makes the poison” (Borzelleca 2000, 3). So, health care scale determines the degree of its environ- mental toxicity and impact. Moreover, it costs lots of energy to clean up pollution. Thus, solving problems around pollution and toxicity result in increasing energy costs, wherein lie, as we shall see, the key over-scale challenges.

Since the gains of substituting out toxics with less toxic materials and increasing efficiency are modest, little can be done to reduce the total environmental footprint of health care without substantially down- scaling its technologies, architecture, and services.

Cutting back on medical services is psychologically challenging. It is difficult enough to shift from auto- mobiles to bicycles and public transit, to make hous- ing and urban design more efficient, and to cut back consumption of ordinary consumer goods. It is even more difficult, arguably inhumane, to cut back health care. Yet, if these other realms are scaled down, so much more must health care be cut back, if it is not to occupy an even larger share of the economy.

Enter Climate Change

The challenge of health care over-scale is now being amplified by the threat of global climate change. This section outlines how climate change is aggravating the environmental problems of health care.

Although the basic geophysical and scientific foun- dations of concern about climate change were well established by the 1980s, a convenient date at which to set the formation of a full scientific consensus on the issue is 2001, when the Intergovernmental Panel on Climate Change issued its Third Assessment Report (IPCC 2001). The report contained the most definite statement the IPCC had made to date on the reality of human-caused climate change and the possibility of devastating consequences for humans and other species. The Fourth and Fifth Assessment Reports of 2007 and 2013 underlined and detailed the conclusions of 2001.

The bottom line of climate science is that, if the global output of fossil fuel wastes is not rapidly re- duced to a level that sounds like science fiction to policy-makers and economists focused on wealth, jobs, and profits, the global consequences of human-produced atmospheric carbon dioxide and related greenhouse gas- es are likely to mount through the next several decades into a global public health and economic catastrophe of the first order.

Although the U.S. press and leadership are just be- ginning to catch up with the science and global opinion on this issue, the bulk of scientists who study climate fear the worst (Anderson and Bows 2011). In the words of the climate scientist Lonnie Thompson:

Why then are climatologists speaking out about the dangers of global warming? The answer is that virtually all of us are now convinced that global warming poses a clear and present danger to civilization (Thompson 2010, 153).

The debate among scientists is largely over the degree and pace of devastation, not over its causes and dynamics. Climate change is a very serious threat to the environment and health.

Because the health benefits of the goods and services supplied by ample and easy energy from fossil fuels are so evident, few in health care and bioethics realize how devastatingly adverse the ratio of fossil fuel-driven en- vironmental damage globally and into the future is to the good achieved through such fuels.

Most clinical ethics work frames issues within days, weeks, months, and a few years of a life span. In contrast, species extinctions and human health catastro- phes being generated by climate change will span de- cades, centuries, and millennia. Current use of fossil fuels commits the earth to damage far into the future. As David Archer points out, when I drive my car, the CO2 emissions from the gasoline absorb enough energy from the sun to produce 40 million units of unwanted global warming during the 10,000-year life span of CO2 in the atmosphere in ratio to the units of energy used to move the car and me in it (Archer 2009, 174). At these ratios, even when the time frame is confined to the next century or so, using any fossil fuels is a form of reckless driving.

As it is practiced in the United States, medicine is a fossil fuel hog—through its lengthy supply lines, 24–7 schedule, power plants, technologically complex prod- ucts, fossil fuel-based pharmacology, and extensive

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panoply of services. Climate change makes the material scale of U.S. health care highly problematic. An ethicist conscious of the industrial framework of health care cannot help but be concerned about its ample dependen- cy on a high level of energy consumption.

Health care makes its own substantial contribution to global warming. Ironically, its energy-intensive ef- forts to save lives is incurring global warming costs that will destroy, over the decades, many million more human lives, individual animals, species, and biomes than saved by health care. In the big picture, fossil fuel-based, technological health care is a losing game.

Knowingly living in a time and as part of a process of likely ultimate destruction generates moral distress. Two of the elements that characterize this distress with regard to climate change arise from the nature of the problem itself: (a) warming unfairly and unethically harms people globally and will harm even more peo- ple in the future; and (b) its consequences are exten- sive and grave. Additional factors that make the moral wrong fit the distress paradigm are: (c) each of us as individuals is implicated in causing anthropogenic warming; and (d) finding an effective voice is highly challenging.

There are of course many distressing things going on in the world which we as individuals are powerless to change even if we have strong and well-justified ethical judgments about them. For many, however, moral distress regarding climate change is moving to the foreground. One reason for this is that many of the environmental challenges that the public recognized before becoming aware of climate change cannot be solved without also addressing and resolving the chal- lenge of climate change.

Moreover, some prized activities that at one time were highly valued despite the expense, medicine primary among them, must be reevaluated.

Bioethics and Climate Change

In addition, while climate change puts citizens gener- ally in moral distress, its consequences for health care raises some particular challenges to the roles of bio- ethicists, in much the same way as does the economic over-scale of health care.

Some of this distress experienced by bioethicists in the Midwest and High Plains of the United States is likely related to the fact that, as of this writing, few

clinicians, like many among the American public, appreciate the potential scale of the climate change catastrophe, nor do they realize how much needs to be done to mitigate it (Parker 2011). So, the climate conversation is generally not only seemingly irrele- vant, it is also hardly acceptable within the halls of health care. In the clinical setting, discussion of cli- mate change by ethicists carries an unwanted and disempowering undertone of egregious criticism.

Part of the moral awkwardness for bioethicists re- sponsible for drawing attention to larger moral ques- tions arises from the conflict of this responsibility with the dominant forces and philosophies of public health and health care that are far from coming to terms with the need to downscale health care even as the clock on catastrophe is running out. And, as will become evi- dent in the next section, these challenges suggest the need for changes in how many bioethicists view and use philosophical moral theory.

New Perspectives on Bioethics

At this point, it might be best to consider routes to resolving moral or ethical distress: If moral distress is representative of the situations of people caught up in institutions and social phenomena that are headed in the wrong direction, like a poorly chosen intensive therapy, how should it be resolved?

As suggested in the first section, moral distress expresses a decision point, a moment of emotive im- mobility, where ambivalence needs to be resolved toward a choice. Once the choice is made and action is undertaken, the psychological elements of distress tend to diminish. Without offering immediate and concrete answers, bioethics can help to suggest some of the ethical terms or principles that can help to resolve the ambiguity. Thus, this section reflects on some aspects of bioethical thinking that may help to adjust some common concepts to our predicament.

Exploiting Transparency

One of the achievements of health care ethics has been to show that clinical practices are transparent to larger ethical considerations. Ethicists have successfully brought general principles to bear on the local, focused details of patient care. For instance, respect for pa- tients and their choices reflects what some have called

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“side constraints”—respect applies to all clinical situ- ations and none are insulated from it. General norma- tive moral theories, such as utilitarianism that sets no boundaries on relevant consequences, have won re- spect as legitimate perspectives from which to judge clinical practices. As a result, the conventions of insti- tutional procedure and professional ethics are now open to critique from a broad set of considerations.

Environmentalists are inclined to express this trans- parency more strongly as a sense of interconnection. To environmentalists, not only are larger environmen- tal considerations relevant, environmental philosophy and activism presume a strong sense of physical, bio- logical, and moral connection among all people and creatures globally over decades and even centuries. So, environmental concerns as well as such concepts as respect are eligible for consideration as they affect bedside care.

Physical and Abstract Principles

An implication of the applicability of environmental connections to patient care is that we in philosophy need to accept more material elements in our accounts of rights and duties. Much of the moral philosophy applied to health care has been highly abstract in content and almost wholly focused on humans. This is typical of many traditions of ethical philosophy going back for thousands of years. But this approach is not adequate to our present global circumstances. Ethics must include material considerations that go well beyond abstract duties, money-only financial cost accounting, and intra-human issues. We need to know from which of Earth’s renewable and nonrenewable sources health care materials and equipment come, what goes into making them, and how they got here. We need to know where the waste goes when we are through with them. And we have to account for the greenhouse gas costs of every- thing we do, because the potential ultimate price for these costs is the destruction of everything health care is striving to accomplish.

Justice

The challenges of interconnection and materiality for health care ethics are greatly aggravated by including justice in the issue of climate change and health care impact. Although justice in access to health care pol- icy has been a standard element of the bioethics canon,

its environmental aspects are seldom addressed either in policy or clinical settings. Moreover, the justice conversation is usually framed within the borders of the United States, while a broad sense of global justice has been held up in the hallway. There are good reasons for this, but they are far from conclusive.

We rightly want to and should protect patients. In the typical treatment of clinical ethics, as exemplified in Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, justice is the last con- cern of the clinician (Jonsen, Siegler, and Winslade 2010). The focus on the patient dominates the scene and any harmonization of resources with the larger picture takes a back seat to patient care.

But climate change is telling us that we have not yet been able to strike an ethically justifiable balance between the scale of patient therapies and long-term global environmental costs affecting billions of people and future generations. Our challenge is to reevaluate the priority of justice in clinical settings with a better sense of the unintended environmental harm generated by technologically intensive therapies.

Theoretically, for instance, if we consider John Rawls’ (1971) theory of justice, he presupposes that we are living in an expanding economy, where pro- viding for the worst off dominates our concerns and offering rewards to those who contribute to society is based on their capacity to expand our overall resources to serve the vulnerable. Indeed, we are only to give advantages to some if that works to protect the worst off. But if we are living in a contracting or strictly limited economy, we must reconsider granting anyone privileges; instead, we should think like Rawls “in reverse.” We need to consider taking from the best off in order to protect the worst off.

However, the struggle for justice is highly institu- tionalized in academic health centers and is largely focused on traditional forms of discrimination against women, people of color, the poor, the sick, refugees, and so on. Efforts toward justice at the UNMC, for instance, include a gender equity commission, a diver- sity committee, pipelines to recruit minority students, cultural competence requirements and programs, clas- ses on justice and culture for students, and so on. At the same time, the UNMC hosts a greening project with a number of excellent programs, but there is not yet an established campus commission for the adapta- tion of the medical center to climate change and its participation in mitigating global warming.

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Climate change is beginning to shift who in the world is most vulnerable. Indeed, the poorest of the world are already suffering the most from climate warming. But none of the groups standardly discussed under the social justice rubric, as important and exten- sive as current and historical injustices to them are, is in the new context of climate change the most dis- criminated against nor the most vulnerable.

Children and grandchildren, already born, in addition to unborn future generations, are the most threatened. In 2052, children born in 2012 will enter their 40s in mid- career and family life. But, by then, decades of climate change—health disasters, droughts, storms, floods, fires, heat waves, increasing food prices, conflict over water, declining air quality, and migration—will have likely substantially transformed the health and suste- nance needs of populations (Randers 2012). And what medical center committee now devotes its attention to the lifelong and long-term health needs of to the young?

Part of the moral challenges is the need to reduce the per capita consumption of the billion or so people in the developed world in order to limit the overall environ- mental damage by consumer economies (Athanasiou 1998; Durning 1992). The historical form of justice most passionately supported in modern times is the claim of those who have little and need more. But the limited capacity of the atmosphere to accept more in- dustrial output tends, regrettably, to define limits which, if transgressed, spell catastrophe in the long-term. This means that globally and in time, as far as fossil fuels are concerned, we are playing a zero-sum game at best. Climate change is thus all about limits. Can those in the first world find a passion for justice in aspirations to abnegation and reduced consumption required by jus- tice for developed world consumers, especially when that abnegation applies to such a sensitive and needed commodity as health care?

Downscaling Health Care

Only a few short steps of reasoning bring one to the conclusion that, in the context of climate change, U.S. health care stands out as extraordinarily unsustainable and that most policies needed to cope with climate change challenge its wealth, power, and modes of effi- cacy. Climate change is global in nature and the effects of North American consumers are planet-wide. Since the frame of equity must now include seven billion people, together with those to come, any proportionate

allocation of health care resources must entail a steep reduction in the scale of U.S. health care. It is hard to champion downscaling health care as little as 10 per- cent; harder still to discuss eliminating the approximate- ly one-third to half of services deemed by many inef- fective or harmful.

Downscaling to a level anywhere near the fair and climatologically necessary 20 percent or less seems psychologically highly unlikely, except possibly among nurses and younger practitioners with strong environ- mental commitments (Jameton 2007). It is therefore difficult to choose a framework for justice that works psychologically for a clinical audience.

Bioethicists can be helpful here. One helpful action is to press for discussion of these issues in the most suitable health care venues one can find. Another is to recognize that pointing out an obligation makes it easier for people to act on it. Reduction in health care scale may seem at first to be an impossibility, but once the topic comes under discussion and an obligation is stated, new possibilities of activity are opened.

Historical Connection

Concern for climate change and hospital greening helps to restore one of the initial motives for the field of bioethics. It reverberates with the coining of the term “bioethics” around 1970 by the cancer biologist Van Rensselaer Potter out of his environmental concerns and his search for an approach to deserving human survival (Potter 1971, 1988).

This larger perspective faded from prominence as the Georgetown school of thought in medical ethics and the foundation of bioethics centers in several academic health science centers drilled the locus of concern down from the larger human biological situation in the natural world to the more focused and intellectually manageable world of the bedside and the laboratory.

However, concern for climate change and environ- mental costs helps to recover bioethics’ more transdis- ciplinary nature concerned with such issues as ten- sions between human nature and technological inno- vations, the moral standing of nature, the concept of the human, and human overpopulation.

Generalizing the Clinical Bioethics Role

Since the broad societal changes needed to cope with climate change involve many professions and skills,

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philosophers can make a contribution by moving among the wide range of professions who have skills relevant to needed changes. They can play a “glue” or “bridge” role in encouraging inter-relationships among professions broadly.

Most immediately, ethicists need to be working more with the nonclinical occupations of the hospital world, such as environmental services, the kitchen, building and grounds, administrative services, and security, where many of the moral problems of health care, as discussed here, reside.

Philosophers can help encourage health professionals to work with professions in the broader world as well. Outside of the hospital, engineers, architects, chemists, wildlife biologists, agriculturalists, urban planners, and soon have key roles in maintaining human health and preventing disease and frailty. Just as a clinical focus dims the perception of health professionals of larg- er environmental problems, the foci of the engi- neers and others tend similarly to overshadow human health concerns. To address the larger problems of the moral distress of health professionals, ethicists, clini- cians, and public health professionals need to be cooperating more actively and regularly with these broader professions.

Working With Activists

In particular, it is important for those in bioethics to engage with activists. Since activism mitigates moral distress, health professionals and ethicists must also join with activists in speaking to shifting health care to alternate sources of energy and scaling it in proportion to global resources. There are plenty of people and organizations with whom to work. Indeed, a major benefit to and support for ethicists is involvement with a wide community of concerned and dedicated people in many walks of life.

One need only to attend one of the annual CleanMed conferences (Practice Greenhealth 2012), visit the Centers for Disease Control and Prevention’s website on its Climate and Health Program (CDC 2012), or read some of the 18,000 or so articles listed in PubMed on global warming and climate change to appreciate that much work is being done. Major health professional organizations, such as the American Nurses Association, the American Medical Association, and the American Public Health Association, have made statements stimulated by the activists within these

organizations. Many health professionals and scientists are involved in documenting the potential health prob- lems of climate change. Avariety of new energy options for hospitals is being undertaken and evaluated (WHO and Health Care Without Harm 2009).

Nurses have served prominently in reawakening en- vironmental concerns in health care. Many were involved in the founding of Health Care Without Harm, which was the leading activist group in the 1990s on green- ing health care technology. Holly Shaner-McRae, a nurse, founded the Nightingale Institute in Burlington, Vermont, to work on environmental concerns and championed recycling at Dartmouth’s Fletcher Allen Health Care in 1989 (Long 2009). With others, she has pioneered work on such environmental concerns as mercury, incinerators, food waste, red bag waste, reprocessing, and so on.

Conclusion

The intention of this discussion has been to suggest ways in which those in bioethics can find useful roles: to move beyond the moral distress generated by the traditional focus of the discipline on clinical matters and to extend our work to essential health-related moral problems in the larger global and temporal universe. Hopefully, ethicists and philosophers have something unique to contribute. Behind the practical issues expressed by activists concerned with climate change, there exists at least one key philosophical obstacle to making needed changes.

If a philosopher were to say just one thing about climate change (Kierkegaard 1956), it is this: Without a fundamental revolution in the values of people and institutions in the developed world, the problem of greenhouse gas-driven global warming cannot be solved. What will happen, and must inevitably happen under present and general societal philosophical com- mitments, is that the development and expansion of alternative sources of energy (wind, solar, tidal, etc.) will be futile in winding down the use of fossil fuels and the emission of greenhouse gases. Alternatives will almost certainly only be used to supplement the use of fossil fuels. Without profound changes in the philosoph- ical commitments of developed economies, even as fossil fuels become economically and environmentally more expensive to produce, pipe, and process, virtually all of the economically valuable fossil fuels are likely to

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be mined. And in that case, as James Hansen has put it, it is “game over for the climate” (2012, ¶2).

As long as the developed world, and the developing world entrained by it, continues to commit to a high- energy civilization, there is no way to stop climate change. Ultimately, the problem of climate change is a problem of values. Modern Western culture needs to convert to a system of thought that encourages us to abnegate from the exploitation of economically valuable fossil fuels. We have to stop new petroleum and oil shale fields, pipelines, refineries, and coal and methane mining.

To move society toward the modesty and abnega- tion required to mitigate climate change, it is neces- sary also to solve the problem of over-scale in health care. My concern for nursing moral distress and my own arises from being haunted by the likely big death of this century and the next, symbolized by techno- logically intense dying in health care institutions.

Both my hopes and fears are expressed by Tillie Olsen in her prayer ending the short story “I Stand Here Ironing,” based on the moments she was nursing her baby in August 1945, while at the same time listening to a radio news report of the bombing and burning bodies of Nagasaki:

Only help her to know—help make it so there is cause for her to know—that she is more than this dress on the ironing board, helpless before the iron (Olsen 1956, 14).

Changes in philosophical perspective, with the as- sistance of philosophers, ethicists, and health profes- sionals, can help to generate the great material and social changes needed to keep safe the next genera- tions of children and grandchildren, together with their living environment.

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