Volume 11, Number 2, July 2000

The Complexity of Bioethics, the Bioethics of Complexity

Jason Scott Robert, PhD
Department of Philosophy, McMaster University

Introduction

With the recognition over the past three decades that health is multiply determined and that medicine is presently (and by necessity) less efficacious in increasing our health than a wide range of alternative (e.g., social) interventions, one would have expected a broadening of bioethical attention beyond medicine. Yet just the opposite has occurred: the more narrow sub-specialty of clinical ethics now dominates the field. Further, since its inception, bioethics has faced a backlash from physicians as representing an unwelcome intrusion into properly medical affairs. In response, philosophers have absorbed as much medical knowledge as possible, and so have attempted to become participant-observers in the biomedical milieu. While such behaviours have facilitated the emergence of a more medicine-friendly clinical ethics, contemporary bioethics is nonetheless inadequate to addressing the complexity of health beyond the confines of individual medical encounters. As a result, bioethicists have been discouraged from asking appropriately 'big' questions with nevertheless deeply practical implications. Consequently, bioethics is less a force with which to be reckoned than it could, and should, be. In this paper, I offer some suggestions about how to revitalize bioethical inquiry.

Bioethics

Thirty years ago - almost concurrently with the foundation of what is now the Kennedy Institute of Ethics at Georgetown - the word 'bioethics' was invented, with two different meanings. There was at once a broad interpretation (Van Rensselaer Potter's) referring to the intersection of biology and ethics, which would have considered such issues as species survival, biodiversity, and planetary overload as comprising the moral matter of bioethics. There was as well a more narrow interpretation (Sargent Shriver's) referring to the intersection of biomedicine and ethics, which would have - and in fact has - restricted 'bioethics' to the application of ethical principles in the context of clinical decision-making. As the environment too rarely enters into clinical consciousness, it is consequently not a stock concern of bioethical inquiry (but see Jameton 1994; Darragh and McCarrick 1998; Beauchamp and Steinbock 1999; and Whitehouse 1999).

As is well known, Georgetown's Kennedy Institute of Ethics has been associated with two dominant trends in bioethics, to wit: (1) the principles approach to bioethics as epitomized in Beauchamp and Childress's classic text, Principles of Biomedical Ethics; and (2) a simple and straightforward focus on medical ethics primarily at the level of individual cases. An appropriate Georgetown response to whatever kind of medical situation would ensure that the patient gave informed consent to treatment, and that his/her physicians acted in his/her best interests without causing undue harm. These are important considerations, to be sure - but they do not go nearly far, or deep, enough.

Such a notion of 'bioethics' is at odds with the broad understanding advanced by Potter, whose basic concern was for the long-term survival of the human species. Potter saw bioethics as embracing long-range environmental concerns as a central component of its mandate. He took the additional step of urging that clinicians should be both individually and corporately concerned with environmental well-being (Reich 1995:21). But since the early 1970s, when both bioethics and environmental ethics were born as academic disciplines (or, at least, as respectable areas of academic inquiry), the path between bioethics and environmental ethics has been seldom traveled. Moreover, the dominance of clinical ethics offers neither opportunity nor motivation for broadening the bioethical horizon to include, well, the horizon, the land, the complex ecosystems which are prerequired for our very existence.

Reconciling bioethics and environmental ethics is, to be sure, no easy task; numerous obstacles stand in the way of rapprochement. The most obvious of these is the reigning biocentrism of environmental ethics as antagonistic to the reigning anthropocentrism of bioethics. I will not attempt to work out the details of such a reunion here, but a forthcoming issue of Ethics and the Environment makes some moves in this direction. I require only a weak concession: if it is reasonable to believe that the health concerns of humans are inextricably tied up with the health concerns of the environment - that is, that human health and environmental health are mutually determining and interdependent, - then it is also reasonable to believe that of the "two kinds of bioethics" (Potter 1987), it is preferable to cultivate a variation on its original meaning. Hence the proposal for a bioethics adequate to the complexity of health: a radical reorientation of the field to include sustained, multileveled attention to the complex positive and negative interrelations between economic, industrial, political, social, medical, ecological, evolutionary and other biological determinants of health.

Ecology

In establishing this link between human health and ecosystem health, of central import is the notion of 'embeddedness'. As against proponents of theses about the autonomy of nature, and about the putative independence of human and nonhuman nature left over from our Baconian worldview, many scholars have recently committed to exploring and underscoring the utter interdependence of human and nonhuman nature. In this regard, Plumwood (1994) has argued that the concepts 'human' and 'nature' have been constructed oppositionally in a value hierarchy. In terms of human moral self-understanding, one consequence has been the privileging of our rational capacities while, simultaneously, we have been able to generate no strong prescriptive ground for ethical obligations toward (presumably a-rational) non-human nature. Accordingly, both humans and nature have suffered: as humans, we have been abstracted (and have abstracted ourselves) from our bodies in their natural environments and relationships, while nonhuman nature has been both commodified and exploited. But in order to achieve both human and ecosystem health, it would seem that we must rethink both humans and nature and the interdependent, complex, relations between them.

This reconceptualization can proceed in a variety of ways, on either - or both - empirical and theoretical grounds, especially in the context of considerations about health. For instance, Kettel (1996) cites the biophysical environment as both a determinant of health and a locus for health policy intervention. She argues that women are the primary health managers within families and communities, and many of the caring practices, processes, and products that they provide are derived from the biophysical 'space' within which they live. Moreover, women tend to have quite extensive knowledge about how to use the resources found within their biophysical life-spaces in sustainable, healthy ways.

Yet, as well as being an important resource, the biophysical environment can, of course, pose serious risks to health. Digestive, respiratory, and reproductive illness - major causes of morbidity and mortality in developing countries, - are directly affected by the quality of air, water, and nutrition available. In industrialized countries, where the primary causes of death are heart disease and cancer, links to the environment, particularly to toxic contamination, are finally being well-established, despite the difficulties involved in making causal claims in contexts of complexity. Toxic waste, tobacco use, global warming, pesticides - all have overwhelmingly negative effects on human health, and on the health and well-being of the larger ecosystems of which we are but one integral part.

Despite the demonstration of such important links between humans and ecosystems, and between human health and ecosystem health, some writers, such as LaBossiere, have resisted 'naturalizing' humans (as it were). Although he has argued that "it is morally wrong to pollute human bodies if and only if it is morally wrong to pollute the environment" (LaBossiere 1994:411), he nonetheless insists that his argument goes through regardless of the relationship (equality, identity, hierarchy, e.g.) that exists between humans and environments. In particular, he thinks that "arguing that humans are part of the environment turns out to be more difficult than it appears" (412); as evidence, he offers examples of both environmentalists and non-environmentalists who insist on some rigid separation of humans from environments. Given the current state of our biological knowledge, however, the independence of humans and nonhuman environments is an entirely untenable position. Of course, philosophers have never taken awfully seriously the biological plausibility of their descriptive or prescriptive proposals - much to the detriment of academic, public, and practical philosophy. We too easily forget that humans are not just persons, but also, and primarily, organisms. And while we may imagine the existence of 'abstract individuals', there could be no such (organic) being.

In a recent attempt to generate an 'ecosocial' model of health, Levins and Lopez (1999:284) confirm the complex interdependency of organisms and environments: "Organisms select, transform, and define their environments; the environments thus created form the organisms and therefore the next round of selecting, transforming, and defining processes. The inseparability of social, ecological, physical, chemical, and biotic environments is a crucial framework for a whole-system approach to health". Such a framework forces us beyond dichotomous thinking about human-environment interactions, proposing in its place a model based on the deep interpenetration of humans and environments. In other words, it demands a focus on complexity; that is, a focus on elucidating interactions rather than abstracting putatively independent variables (265).

Thus, notwithstanding LaBossiere's (misplaced) reticence, it must be admitted that humans and the nonhuman environment, while distinguishable, are nonetheless deeply interrelated and, in some respects, mutually constituting. In order to capture the complexity of these mutual interpenetrations and interrelations between diverse and putatively disparate elements of an ecosystem, I shall adopt the language of 'symbiosis' in an effort to unlock the bioethical imagination.

Recently, Peacock has endorsed what he refers to as Aldo Leopold's "extraordinary", even "outrageous", claim that all ethics is ecological; that is, that ethics "flows from the recognition of symbiotic interdependency". Despite his sense of relatively widespread animosity toward this sort of view, Peacock refers to it as the "obvious conclusion" to be drawn from the recognition of human-environment interdependency: once we refuse the abstraction of humans from our organismal-biological nature, we can no longer pretend that we're mere "linguistic interlocutors, economic units, pure volitional entities, [or] utility maximizers" (Peacock 1999:703). The condition of possibility of ethics is neither social nor political nor rational, but ecological. Once we recognize the ecological context of ethics, then - to return to my original point - we see that the Georgetown approach to bioethics is evidenced as inadequate. And, suddenly, some new logical and practical space opens up for philosophical bioethics to have an impressive real-world impact.

Conclusion

The appropriate scope of bioethics cannot be just clinical medical research and practice. Neither biomedical research nor therapeutic practice and innovation can be meaningfully, successfully, plausibly abstracted from its ecospheric context. As bioethicists, we cannot settle for an ethics ignorant of or antithetical to the basic relation of symbiosis. Recognition of human-environmental symbioses in the context of health suggests a reorientation of bioethical inquiry, away from medical practice and clinical research per se, and instead toward health more generally. Such a reorientation can be accomplished, I suggest, under the banner of complexity. Levins and his colleagues (1994:60) have recently suggested that "the study of complexity is perhaps the central general scientific problem of our time" - I should like to urge that the study of complexity ought also to be our central bioethical problem. In this regard, we can take our lead from recent inter- and trans-disciplinary research on complexity in the understanding and achievement of health (Albrecht, Freeman, and Higginbotham 1998). But the path is not, by any means, an easy one to navigate.

Too many of our models of health are either overly reductionistic or unduly holistic and so are unable to attend to interactions and intricate feedback and feedforward loops between pathogenic and healthful factors located at multiple levels and operative on different time scales. A more adequate approach would be premised on neither reductionism nor holism but rather on 'systemism', the view that the interrelations between a system's composition, structure, and environment are integral to any attempt at understanding, explaining, and predicting that system's behaviour (Mahner and Bunge 1997; Robert 2000). Moreover, we tend to focus too much on individual health, at the expense of attention to considerations about the health of populations (Barer et al. 1994; Callahan 1999). And when we do focus on populations, too often we construe them as strict aggregates of (atomistic) individuals, instead of recognizing the emergent dynamics of populations as such (Krieger 1994; McMichael et al. 1999). The limitations of our standard approaches to health have an immense practical fallout.

For instance, we are often told that if we could only adopt healthier lifestyles, the health profile of the population would increase. Three observations: first, whether many people can in fact change their lifestyle in the appropriate ways is by no means obvious; secondly, whether governments ought to shirk their responsibility for the public's health (by, for instance, pretending that health and disease are largely matters of individual choices or genetic bad luck) is therefore not clear either; and, thirdly, the solution proposed fails to recognize the deep interconnections between human health and environmental health that by themselves may undermine the solution unless addressed head-on. Just as our getting ill does not take place in a context-free void, so too is our getting healthy bound up with social, economic, and ecological determinants and consequents. In Canada, we have spent much of the past twenty-five years identifying the broad determinants of health. We are, that is, at least aware of them, though we have done pitifully little to alter them. Instead, the focus has been on medical research and intervention, and health prevention-as-lifestyle-alteration. So we have been encouraged to stay healthy, and then have had access to a very good health care system just in case we get sick. All else being equal, it is a convenient and relatively equitable arrangement, and Canadians are, on the whole, quite healthy people. So whence does my concern arise? It has two primary sources: (1) the economic and psychological unsustainability of current medical practice in the Western world (Callahan 1999); and (2) our ignorance of a crucial additional dimension: that we cannot in our pursuit of health ignore the complex environmental context of our very existence, in sickness and in health.

Allow me to conclude, therefore, with two challenges for bioethics as it enters the 'global era': the first is to recognize and confront not only the sociopolitical context of medicine but also its ecological context, which will require productive interactions and collaborations with environmental philosophers, philosophers of biology and of medicine, and social and political philosophers as well. The second challenge is to cultivate a greater critical distance between bioethics and medicine and health care, so as to facilitate the adoption of a broad framework within which asking and addressing big questions - what is the value of health? what are the goals of medicine? what are the ecological limits of modern health care? - is possible, desirable, and commonplace.

Acknowledgments

This article is abstracted, with revisions, from my 26 May 2000 presentation to the Canadian Society for the Study of Practical Ethics, Edmonton. For funding support, I am grateful to the Social Sciences and Humanities Research Council of Canada, the Fulbright Foundation, the Department of Philosophy at McMaster University, and the McMaster Institute of Environment and Health. I am thankful as well for having been awarded the CSSPE Peter Miller Student Essay Prize for this article.

Jason Scott Robert recently completed his PhD at McMaster University. He will begin a SSHRC and Killam Postdoctoral Fellowship in the Department of Philosoph,y at Dalhousie University, in September 2000.

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