In the Wake of Katrina: Has “Bioethics” Failed?
by Jonathan D. Moreno
2005. The American Journal of Bioethics 5(5):W18

Hurricane Katrina and its sequelae will force policymakers to revisit previous assumptions; the same should be true of bioethics as it has come to be understood.

The catastrophe in New Orleans and the Gulf Coast was three-fold: the original hurricane, the breaching of the levees, and – perhaps most shocking and distressing – the transparent failure of institutions to provide security and succor to the victims in the immediate aftermath. But history will bear witness that the medical and public health crisis rested on decades of exploitation of the geology of New Orleans and the ecology of the Gulf of Mexico by energy, gambling and real estate interests. Government at all levels failed to enforce prudence over self-interest. While the levees were designed to withstand a flood that could occur once in 200 years, the Dutch dikes are hundreds of times more resilient.

In 1970, Van Rensselear Potter coined the term bioethics to refer to, in Peter Whitehouse’s recent concise formulation, the “integration of biology and values…designed to guide human survival” (Whitehouse 2005). Nearly two decades later, exasperated by the adoption of his language by a field that underwent explosive growth without acknowledging his contribution, Potter wrote of global bioethics to signify a broader understanding that encompassed medicine, environmentalism, public health and spirituality.

Although Whitehouse, Al Jonsen, Warren Reich and a few others have kept Potter’s contribution in memory, on the whole he has been at best a marginal figure in the minds of most who work and study in the field. Potter is often not included in the pantheon of bioethics’ founders, and those of us who got our start while he was still professionally active mostly did not know him. Yet it was arguably his felicitous term that captured the imagination of physicians, theologians, philosophers, journalists and the educated lay public in the 1970s. “Bioethics” has a far sharper edge than clunky early descriptors like “human values in medicine” or “society, ethics and the life sciences.” In immediately calling forth both science and morality “bioethics” is a sexy conjunction.

Katrina and its aftermath have caused epidemic disease and shocking levels of death; what little morbidity and mortality the hurricane did not cause, it gravely complicated. This disaster painfully illustrates Potter’s conception of the nexus of human values in medicine and the environment. And who better to appreciate the delicate balance of nature, exemplified by land reclaimed from the sea, than a Dutchman? This tragedy also may be the shock that wakens the field of bioethics from a false consciousness and moves it closer to Potter’s vision.

It is no secret that bioethics has followed popular trends rather than led them. In the past 40 years, as the wider society lurched from controversy to controversy and case to case - organ transplants, artificial organs, resource allocation, gene therapy, Karen Quinlan, HIV/AIDS, Baby Doe, Nancy Cruzan, “Debbie,” Jack Kevorkian, Dolly, Jesse Gelsinger, cloning, biosecurity, Terri Schiavo and on and on - American bioethics has been there. This is not to deny that much important and enduring work has been done in clinical and research ethics and public policy, but more often as not the field in general has rushed to the scene of the hot topic.

How to account for these developments? Francis and colleagues (2005) observed that bioethics emerged just as the era of infectious disease seemed to be ending and - I would add - as the valorization of personal autonomy was beginning. Reviewing early bioethics texts, they note that “systematic discussion of infectious disease is manifestly absent … even cases and examples involving infectious conditions are rare at best.” The central doctrine of bioethics, informed consent, instead has emphasized the consequences of treatment decisions for individuals and virtually ignored the consequences for the health of others. Even discussions of distributive justice fail to take into account public welfare beyond our rather-porous borders. If the paradigmatic medical problems that stimulate ethical debate are infectious diseases, rather than acute conditions, the commonly cited principles of biomedical ethics would have been recited in a different order or even formulated quite differently.

Followers of bioethics in much of the rest of the world are familiar with this conclusion. They tend to see American bioethics as anomalous in this regard, as just another manifestation of the land of plenty. This point was personally driven home in March of 2005, when I spent a week in Karachi teaching a bioethics course. The pressing ethical issue in Pakistan is the dire shortage of facilities and organs for end-stage kidney patients while villagers simultaneously take payment from foreigners in exchange for their healthy organs, leaving them sicker and poorer. Pakistani bioethicists and their allies in the health care system are pressing the government to establish a national allocation network for cadaveric organs, using arguments from both distributive justice and Islamic law to support their case.

In the U.S. academic world, offerings in ethics and public health are beginning to make their appearance but the literature is still disgracefully sparse. A modest foundation-sponsored project to develop a model curriculum for public health ethics was completed a few years ago, although these efforts have been somewhat distorted by the widespread American preoccupation with bioterrorism (Childress et al., 2002). The issues raised by the prospect of a biological attack are important but the contribution that biodefense preparedness can make to a oft-neglected public health system is controversial. Public health professionals have complained that government investment in biodefense is, on the whole, a distraction from the need to rebuild the public health infrastructure after years of negligence. Nor do discussions about responses to a terrorist attack necessarily lead to more general discussions about ethical issues in public health.

The Katrina disaster partly resulted from a failure of public institutions, and bioethics must shoulder its share of the blame. Many commentators have observed that the field has wrapped itself in the embrace of the privileged and their problems. What contribution have we made to the debate about access to health care since the President’s Commission in the early 1980s? The failure to create and execute an escape plan for New Orleans’ impoverished residents is part of a continuum of inadequate services that often prove deadly even under ordinary circumstances.

More transparent is the lack of intellectual exchange between bioethics and environmental ethics, either in the literature or within academic institutions. We shouldn’t exaggerate the influence of bioethicists’ voices, but the media does provide many of us with a soapbox that should be exploited for purposes other than simply to comment on the ethics crisis de jour. The American environmental movement is in its own period of self-examination, following a series of regulatory setbacks. Two influential environmentalists recently roiled the field when they pronounced “the death of environmentalism” (Shellenberger and Nordhaus, 2004). Bioethicists could help reinvigorate their own field by providing new voices and fresh ideas, helping enrich our understanding of the reach and significance of our own work.

In the short run, the reconsideration of the scope of bioethics that is proposed could even unite opposing voices in the culture wars. While conservative and liberal thinkers might continue to disagree about familiar ethical issues like suitable limits on enhancement technologies, they should find common cause in the need to care for a fragile and increasingly ailing planet. In some ways, such a discourse would return us to the insight that gave rise to both fields – namely, that human happiness and well-being is dependent upon a complex ecological system in which we are all inextricably linked, a system in which we are all actors and patients, doers and sufferers. We ignore these brute facts at our peril.

Or, to adapt another insight attributable to the notorious 1960s, you don’t need a hurricane to know which way the wind blows.

References
Childress, J.F., R.R. Faden, R.D. Gaare, L.O. Gostin, J. Kahn, R.J. Bonnie, N.E. Kass, A.C. Mastroianni, J.D. Moreno, and P. Nieburg. 2002. Public health ethics: mapping the terrain. The Journal of Law, Medicine and Ethics 30(2):162-169.

Francis, L.P., M.P. Battin, J.A. Jacobson, C.B. Smith, and J. Botkin. 2005. How infectious disease got left out – and what this omission might have meant for bioethics. Bioethics 19(4):307-322.

Shellenberger, M., and T. Nordhaus. 2004. The death of environmentalism: global warming politics in a post-environmental world. Website

Whitehouse, P.J. 2003. The rebirth of bioethics: extending the original formulations of Van Rensselear Potter. American Journal of Bioethics 3(4):W26-W31.