Andrew Jameton

“Moral distress” was introduced in nursing ethics to describe the experience of having the moral conviction about the right thing to do while having limited agency to enact it. It exists at the intersection of moral philosophy, moral psychology, and moral communities that influence our desires to act. Although moral distress has significantly impacted bioethics scholarship, it has had almost no presence in business ethics scholarship. We argue that moral distress is useful for understanding important problems of business ethics. We claim it may be missing from business ethics discourse not because it is not present but rather because it is ever-present, an existential condition brought on by the tension between profit maximization and other moral purposes. We consider how the moral communities of medicine and business can be morally supportive or distressing and set forth a taxonomy of moral conditions involving the relationship between knowledge, action, and desire.

About 1970, Van Rensselaer Potter coined the term bioethics to bring under one heading broad questions of human survival, environment, and biology. In 1971, Potter outlined a statement of principles that linked the ethics of the biological sciences with the ethics of environmental concern. Regrettably, the field that adopted his rubric bioethics immediately diverged from Potter’s interests. Bioethics has become for the most part identified with medical ethics or health care ethics and in so doing has developed few ethical principles and analyses in relationship to environmental ethics. Similarly, environmental ethics seldom touches on clinical or health care issues, even though the field of environmental health has grown greatly in recent decades. It is the purpose of this article to indicate briefly some of the topics that could be treated effectively as part of a project to reconnect medical ethics and environmental ethics into what may be called sustainable bioethics.

At the September 1992 Birth of Bioethics conference observing the 30th anniversary of the Seattle kidney dialysis program, Warren Reich discussed the “bilocated” birth of the term bioethics. He showed that the term bioethics was coined in Michigan by Van Rensselaer Potter and that the term was also apparently conceived of independently at about the same time in 1970–1971 in Washington, D.C., by Andre Hellegers and Sargent Shriver. Potter's work, like many similar works in the early 1970s, was concerned with the growing global biological crisis of human overpopulation, the destruction of species, and how to respond to these. He prefaced his book Bioethics with a “Bioethical Creed for Individuals,” outlining duties to respond to this crisis in a meaningful and scientific way. Hellegers and Shriver used the neologism to name the new Joseph and Rose Kennedy Institute for the Study of Human Reproduction and Bioethics. The Center was to study concerns somewhat different from Potter's: the technological revolution in healthcare and its impact on reproduction, investigator-patient relations, and medical ethics.

In addition to good medical services, all aspects of an economy must work together to ensure a high level of public health. However, the abundant economies of the North are contributing heavily to global environmental disaster, with increasing concomitant damage to human health. Environmental health problems result from toxicity (i.e., pollution), scarcity (i.e., poverty), and energy degradation (i.e., entropy). Common to these three factors in environmental demise are the limits of the Earth. Production has evolved to a point where the Earth is no longer safe from radical depletion. Therefore, simple living is a necessary feature of global public health. Rarely do readers of this journal see these limits first hand, but they are real. Our limited perceptions and efforts hinder our ability to understand how to reduce the impact of production on natural ecosystems. Contrary to standard media portrayals, growth and technology cannot solve our public health problems, because they are unequally distributed across the world and neither can they solve the problem of limits. The need for modest consumption in developed nations is an essential and almost completely ignored element of the answer to environmental and associated health problems. A radical and rapid change to public health is needed in order to avoid abysmal global health consequences during the next century. These changes involve a restructuring of our economy, including the health care industry. In the short run, this is an ethical demand. In the long run, this is an inevitability. The actual and appropriate role of bioethicists in championing these changes is unclear. (Abstract by Bruce R. Smith)

The concept of moral distress can be extended from clinical settings to larger environmental concerns affecting health care. Moral distress—a common experience in complex societies—arises when individuals have clear moral judgments about societal practices, 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 necessary 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

The article by Jessica Pierce and Christina Kerby, raises some important but seldom asked questions about the use of natural resources in healthcare. They take for their example latex gloves, which are in wide everyday use, especially since the establishment of principles of universal precautions in infection control as a reaction to the spread of HIV. They trace the production of latex gloves back through rubber processing to their origins in Malaysian rubber plantations and elsewhere. They then ask, but do not answer, some hard questions about the ethics of our relationship as patients to the impact of the materials we use on communities and the environment. To draw out their theme more starkly, consider the rumor widespread in South America that some babies purportedly adopted by Northerners are sold and cut up for their organs. Suppose this story were true; suppose your donated organ were obtained in this way. You would probably be so revolted by the immorality of its acquisition that you would refuse to accept it. But now take a morally more ambiguous case, as Pierce and Kerby intend. Suppose that the process of obtaining latex gloves is part of the gradual erosion of the Malaysian environment, and that workers in latex factories are poorly paid. Now, should or would you refuse to use latex gloves? Should or would you even be more selective in their use? The practice of universal precautions presumes a virtually unlimited supply of gloves; yet to react to resource scarcity with selective precautions hazards discrimination. Is there any way philosophically to balance the local justice issue of discrimination in comparison to injustice on a global scale and to future generations?