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Various meanings of sustainability point to complex, interlocking challenges for global bioethics. In global bioethics, sustainability can refer to conditions necessary for maintaining particular health-care systems; to economic development, particularly for underserved populations; and to health care that does not damage the natural environment. This entry reviews the historical development of sustainability, the tensions between economic and environmental emphases in sustainability, and the import of sustainability for global bioethics. Sustainability comprises a norm that increasingly informs global bioethics, though the term itself can obscure thorny ethical issues.
In health care, the term sustainability can refer to the capacity to sustain programs or systems that provide preventative care or treatment. The terminology of sustainability also appears prominently in literature on economic development, public health, and in literature on human health and environmental issues. Economic and environmental sustainability are urgent, interconnected issues in global bioethics. They bear on and complicate the sustainability of health-care programs and systems, for example, affecting access to antiretroviral drug treatment for HIV/AIDS in resource poor contexts or straining already ﬁnancially burdened health-care sectors when climate-related natural disasters occur. Sustainable health care promotes human health without doing ecological damage and in concert with larger strategies for improving the lives of poor and marginalized persons in a globally interdependent context. Sustainability comprises a norm that increasingly orients and informs work in global bioethics. However, the meaning of sustainability is itself disputed in ways that highlight complex moral questions at the intersection of human health, economic development, and care for the environment.
Meanings Of Sustainability
There is no single deﬁnition of sustainability in global bioethics. The term itself can refer simply to the continuance of a given health-care initiative or the viability of a particular system or organization, and thus operate as a relatively nonmoral term. More often sustainability functions normatively. In global bioethics, the concept is often drawn from development discourse and environmental ethics. Sustainability can operate in moral discourse that is concerned primarily with development, referring to the eradication of poverty and promotion of economic growth. This principally economic version of sustainability can exhibit varying degrees of attention to and concern for the natural environment. Sustainability can also refer principally to environmental protection, conservation, and repair. Here, too, the concept permits a wide range of viewpoints regarding the intrinsic value of the natural environment, the moral status of nonhuman species, and attitudes toward trade-offs among human health, economic growth, and well-being of the natural environment. The concept of sustainability often joins economic development to environmental concerns (at least in the form of stewarding natural resources for future generations). One notable and often used example comes from Our Common Future, also known as the Brundtland Report, which was sponsored by the United Nations World Commission on Environment and Development (UNCED). The Brundtland Report deﬁned sustainability as “meeting the needs of the present generation without compromising the ability of future generations to meet their needs” (UNCED 1987). While the Brundtland Report as a whole does speak to morally relevant questions like whether the natural environment has intrinsic value, its deﬁnition of sustainability leaves such questions open. Following the Brundtland Report, the concept of sustainability in development discourse usually jointly refers to a goal of economic development that avoids, minimizes, or seeks to repair environmental harm (du Pisani 2006).
The Brundtland Report identiﬁes three pillars of sustainability: environmental protection, economic development, and social equity. These dimensions of sustainability intersect but do not overlap. Tensions arise between economic growth, for example, and environmental protection. The relationship between health and human development typically falls under the pillar of social equity. More recently, discussions of sustainable development have come to include a fourth pillar of sustainability, that of culture (UNESCO 2001). Appeals to culture resist the reduction of sustainable development to material benchmarks by explicitly acknowledging the importance of cultural diversity and intangible cultural heritage. Designating culture as a pillar of sustainability afﬁrms the indispensable role culture plays in providing a coherent basis for human participation in the development of material sustainability and motivation to support the changes that are necessary for that development (UNESCO 2001).
A variety of allied concepts appear in lieu of or in concert with sustainability, including but not limited to conservation, resilience, human security, and stewardship. With regard to environmental sustainability, conservation refers to the protection and preservation of natural resources, environments, and populations. It sometimes includes the repair of ecosystems or wildlife populations. Resilience increasingly appears in discussions of climate change; it refers to the capacity to undergo stress yet maintain function. Resilience can be a feature of natural and built environments, as well as ecological and anthropogenic organizations or systems. Resilience is also used to refer to capacities to adapt to changing conditions (Pierce and Jameton 2003). The concept of resilience increasingly appears in development discourse (Sustainable Development Solutions Network 2014). The concept of human security situates human health and well-being in a framework that includes attention to violence and peace, economic security, and environmental security (Lautensach and Lautensach 2015). It fosters an integrated, multidisciplinary approach to security risks and to paradigms of well-being (Lautensach and Lautensach 2015). Another concept allied with sustainability is stewardship (Resnik 2012). It appears in secular as well as religious literature on topics as diverse as biomedical research and land management. While it, too, is a contested idea, stewardship generally refers to the prudent management of resources entrusted to one’s care. It can complement the principle of sustainability by directing attention to the particular responsibilities of diverse moral agents.
Sustainability In Bioethics: A Brief History
The genesis of environmental bioethics is often attributed to Van Rensselaer Potter’s Bioethics: Bridge to the Future, in which he argued for a broad understanding of bioethics (Potter 1971). Rather than limit it to medical quandaries faced by individuals, Potter envisioned bioethics as a new philosophy that bridged disciplinary divides among medical, biological, and environmental sciences and between the sciences and humanistic inquiry. Globally, the environmental movement was already gaining traction. Rachel Carson’s Silent Spring, published almost a decade earlier than Potter’s Bioethics, raised awareness regarding the impact of pesticides and other toxins (Carson 1962). Garret Hardin and others voiced concerns about population growth (Hardin 1968). Indeed, Potter’s vision for bioethics as a ﬁeld concerned with the survival of the species was part of a larger global emergence of environmental awareness and advocacy. Nevertheless, bioethics developed principally as medical ethics, focused primarily on individual patients and their best interests. Potter later called his approach to bioethics “global bioethics” to further distinguish its scope and orientation from medical ethics (Potter 1988).
As recognition of environmental degradation grew in the 1970s and 1980s, so did awareness that high rates of economic growth and technological progress do not prevent economic disparity. Moreover, this disparity threatened prospects for continued rates of economic growth. Efforts to promote development in impoverished regions appeared at odds with environmental conservation, which seemed to limit acceptable forms of development (du Pisani 2006). In his historical study of the concept of sustainable development, Jacobus A. du Pisani argues that it emerged as a compromise between growth and conservation; the concept of sustainable development brought signiﬁcant elements from previous development discourse – notably themes of progress and growth – into relation with environmental degradation and growing economic inequality (du Pisani 2006).
In the 1980s, the concept of sustainability increasingly came to refer to human development undertaken in an environmentally mindful fashion. The Brundtland Report’s understanding of sustainability, with its pillar of environmental protection, provided a basis for a number of high proﬁle global initiatives, including the 1991 United Nations Environmental Program report, Caring for the Earth, the 1992 United Nations Conference on Environment and Development (UNCED), the emergence of Agenda 21 from UNCED, the Earth Charter in 2000, the World Summits on Social Development in 2002 and 2012, the UN Millennium Development Goals, and many others. With the 2015 deadline for the Millennium Development Goals at hand, work is under way to update targets and indicators for Sustainable Development Goals (Sustainable Development Solutions Network 2014). As the following section will show, however, the increasing use of sustainability as a concept belies serious disagreements of its meaning and scope.
While the concept of sustainability gained traction in development discourse, it also became more prominent in bioethics through engagement with economic and environmental issues. Scholarship focused on poverty and social determinants of health connected bioethics to public health and to development discourse. Paul Farmer’s Pathologies of Power revealed shortcomings in some development strategies, which can be imperialistic, by undertaking tuberculosis treatment in Haiti in a manner informed by liberation theology (Farmer 2005). Norman Daniels developed a framework for allocation of health-care resources that is indebted to John Rawls’ Theory of Justice (Daniels 2008).
Others have promoted bioethical concern for sustainability through research on the public health impact of environmental degradation and, conversely, the impact of health-care systems on the environment. Jessica Pierce, for example, advocates for environmentally sustainable practices in medical and hospital settings and for environmentally friendly health-care products. Pierce and Andrew Jameton coauthored The Ethics of Environmentally Responsible Health-Care, which not only explored the impact of environmental degradation on human health and health-care but also argued that aspects of medical practice contribute to the environmental harm that undermines human health (Pierce and Jameton 2004). More recently, David Resnik published Environmental Health Ethics, the ﬁrst English monograph devoted to environmental health (Resnik 2012). Resnik argues that environmental health ethics needs to supplement the traditional principles of health ethics with principles that expand the scope of our moral concern beyond humans to include other species and the natural environment. He identiﬁes six principles from environmental ethics for this task: utility, environmental justice, animal welfare, stewardship, sustainability, and precaution.
A growing concern for sustainability is evident in the variety of global initiatives, coalitions, and academic programs that marry health-care, development, and ecology. For example, the Earth Summit in Rio de Janeiro (1992) yielded Agenda 21, a voluntary program to promote sustainable development. In 2012, the United Nations Conference on Sustainable Development reafﬁrmed commitments to Agenda 21. Sustainable coalitions among health systems are emerging; the 2020 Healthcare Climate Challenge, for example, is a worldwide campaign intended to mobilize hospitals and other health-care systems to reduce their adverse environmental impact and protect public health from climate change. Academic programs facilitate collaboration among scholars, governmental leaders, and nongovernmental capacity builders. Examples include the United Nations University, the UNESCO/UNITWIN (University Twinning and Networking) Networks Programme, as well as degree programs at colleges and universities around the world.
While there is growing evidence that bioethics is seriously engaging issues of sustainability, bioethics focused on environmental issues and global economic inequality remain subﬁelds or niche interests. Bioethicists who are committed to doing bioethics in an environmental and economically sustainable fashion continue to call their colleagues to conversion, urging them to consider the participatory role bioethics can play in fostering sustainable public health programs and policies, “green” medical therapies, and sustainable research protocols (Lautensach and Lautensach 2015; Resnik 2012; Pierce and Jameton 2003; Valles 2015). Will global bioethics continue to integrate economic and environmental dimensions of sustainability? Will bioethical engagement with poverty and ecology remain subﬁelds, or will they transform bioethics more broadly?
Sustainability As A Moral Norm
Research on social determinants of health shows an undeniable correlation among poverty, other forms of social vulnerability, and poor health outcomes. Poverty is linked with higher rates of chronic disease, poor nutrition, inadequate access to clean water, and premature death, to name a few (Sustainable Development Network Solutions 2014; Daniels 2008; Farmer 2005). The maldistribution of vulnerability, access to social and material goods, and opportunity through social structures, policies, and cultural processes amounts to a structural form of violence against persons (Farmer 2005). Improving health outcomes requires nothing short of dismantling these structures. Sustainable development is often suggested as a solution to health disparities, though it is important to note that approaches to sustainable development can themselves contribute to rather than ameliorate structural violence (Farmer 2005).
Damage to the environment imperils human health in a variety of ways, including but not limited to exposure to toxins and pollutions, depleted natural resources, food insecurity, climate-related and vulnerability to natural disasters, and vulnerability to communicable diseases (Pierce and Jameton 2003; UNCED 1987). Environmental sustainability appears vitally important for human health (Sustainable Development Solutions Network 2014). Yet it is also important to note that environmental sustainability can conﬂict with the promotion of public health. For example, the World Health Organization has endorsed the limited use of DDT (dichlorodiphenyltrichloroethane) to combat malaria even though DDT use can cause environmental damage (Carson 1962; Resnik 2012). Granting that conﬂicts such as this will inevitably arise, sustainability in its economic and environmental dimensions designates a normative orientation to understand human health in its manifold relations to ecological and social systems and to improve health by addressing these systems.
Sustainability And Contested Moral Questions
The meaning and force of sustainability as a moral norm for global bioethics depend signiﬁcantly on several interrelated and contested moral questions. To begin, there is the question of what moral obligations we have to future generations. Using the Brundtland Report’s deﬁnition of sustainability, our obligation is to avoid compromising the ability of future generations to meet their needs. Understanding the scope of this obligation would require bioethicists to parse the term “needs,” particularly in relation to wants, and to consider different ways of conceptualizing quality of life. Potter identiﬁes ﬁve modes of life (mere, miserable, unjust, idealistic, and acceptable) that are relevant to such inquiry (Potter 1988). Even once an obligation to future generations is clariﬁed, there remains a question regarding its force vis-à-vis moral obligations to currently existing human persons and to the natural environment. On what grounds do we adjudicate conﬂicts between the needs of future generations and the needs of present human lives? Does sustainability place limits on certain medical endeavors, for example, weighing against the use of resources for nontherapeutic cosmetic surgery, in the interest of curtailing their environmental impact and reallocating those medical resources to programs that serve vulnerable populations? What is the import of sustainability for end of life care? Daniels develops an account of health as a special social good – one essential for pursuing and enjoying a host of other goods – in terms of normal species functioning; his theory of justice, indebted to John Rawls, endeavors to show when health inequalities are unjust and when limits on health are fair (Daniels 2008). Some limits on health can then be shown to be warranted in order to protect future generations’ equality of opportunity for health as normal species functioning (Daniels 2008). Under a strong formulation of sustainability, regard for future generations is an urgent moral question with the potential to overturn the received wisdom of bioethics on even the most basic matters. More modestly, sustainability can inform particular judgments regarding ordinary and extraordinary care.
In any case, the question of humanity’s debt to future generations is complicated by the massive economic inequality found within particular regions and globally. Research on social determinants of health clearly shows the interrelationship of poverty and poor health outcomes. Discussions of sustainability are variously optimistic or pessimistic regarding the compatibility of economic growth and environmental conservation. Development discussions of sustainability soberly note the scale of global economic inequality and the urgency of our ecological crisis, yet articulate development goals predicated on the ultimate feasibility of promoting both economic growth and environmental sustainability (Sustainable Development Solutions Network 2014). Lautensach and Lautensach, however, consider the fact that human beings currently consume natural resources at the rate of approximately 1.4 planets and that overconsumption permanently damages the biosphere thereby reducing the Earth’s capacity for supporting future generations; they argue that the terminology of sustainable growth is simply nonsensical from a scientiﬁc standpoint (Lautensach and Lautensach 2015).
A second contested question, related to the ﬁrst, concerns what we owe to nonhuman species. While this issue includes matters such as the use of nonhuman animals in biomedical research, its import is much larger. As Lautensach and Lautensach note, as many as several dozen nonhuman species disappear every day (Lautensach and Lautensach 2015). The cumulative extinction of so many species impacts the biosphere in which human beings are only one species along many others, threatening the very conditions necessary to sustain human life. The loss of agricultural biodiversity includes threats to food systems and nutrition, endangers resources for traditional medicinal treatments and pharmacological research for new therapies, and increases risks for infectious disease.
Bioethics can make consequentialist appeals to human self-interest to raise concern for biodiversity. However, instrumentalizing nonhuman species or planetary biodiversity may simply replicate anthropogenic moral patterns. So a third contested question is whether the natural environment has intrinsic worth. If so, what constraints does it place on particular human choices? Disagreements over the precautionary principle can illustrate differences regarding the intrinsic worth of ecosystems, nonhuman species, or biodiversity. The precautionary principle often ﬁgures in discussions of sustainability and global bioethics. The precautionary principle warrants a course of action, such as protective or preventative measures in order to avoid harm, even in the absence of scientiﬁc consensus about the risk of such harm (Resnik 2012; Jordan and O’Riordan 2004). The precautionary principle has been invoked, for example, to support a ban on genetically modiﬁed organisms (GMOs) as well as hydraulic fracturing for natural gas, although its application in both cases is challenged by supporters of these technologies.
As these contested questions indicate the normative force of sustainability depends greatly on the sort of moral commitments one builds into its meaning, such as commitments to social equity or distributive justice, the environment, and future generations. Even when a particular medical practice or health system is “green,” or environmentally sustainable, its overall moral quality could be problematic. A sustainable practice can be morally wrong on other grounds. Therefore, other norms must work in concert with sustainability. Norms like beneﬁcence, non maleﬁcence, autonomy, and solidarity can complement sustainability. If sustainability is not integrated with other bioethical norms, environmental bioethics and global bioethics will remain niche sub disciplines within bioethics more broadly. If growing calls for more sustainable bioethics are heeded and sustainability becomes a central norm, it has potential to transform bioethics.
Sustainability And Other Norms
Given this history, when sustainability is used normatively, it typically signals a commitment to social equity, to distributive justice, and to environmental protection, conservation, and repair where the latter is possible. Because appeals to sustainability in bioethics, environmental ethics, and development discourse entail the contested questions discussed above, and because the relative force of the concept’s economic and environmental dimensions is ambiguous, the application of sustainability in bioethics requires additional normative judgments. As a moral norm, sustainability must work in concert with other norms from bioethics, economic ethics, and environmental ethics (Resnik 2012). It is also important to note that a particular medical practice or system for allocating health-care resources could be sustainable yet still be morally problematic on other grounds. Sustainable health care is not equivalent to morally acceptable health-care.
Sustainability, Health Care Industry, And Research
Bioethicists are increasingly documenting the impact the health-care industry has on the environment (Pierce and Jameton 2003, Richie). Environmental impact includes energy use, pollution, hazardous chemicals, and waste management, along with participation in unsustainable services, for example, through overuse of disposable products and other purchasing practices. Sustainability, however, may require changes that go well beyond reducing the adverse impact of health-care systems. Once again, the question arises whether an emphasis on the environmental component of sustainability has the normative force to overturn, or at least seriously challenge, ostensibly settled moral convictions in bioethics. A controversial article that explores the idea of what an environmentally sustainable reproductive technology looks like provides an example (Richie 2014). All human births, whether or not they are facilitated by assisted reproductive technologies (ART), contribute to population growth and humanity’s carbon footprint. Cristina Richie, however, argues that the impact of fertility clinics on the environment differs morally from the impact that occurs through natural reproduction, since ART is undertaken as a commercial medical therapy. She argues that fertility clinics should be subject to carbon caps and that ART funding should be eliminated for those who are not biologically infertile. The argument is merely one example of the way commitments to sustainability can chafe against other moral commitments, in this case to reproductive liberty.
Sustainability also bears normatively on research and research ethics (Resnik 2012). With regard to economic development and human health, commitments to sustainable development include building capacity for research ethics committees in contexts where human subjects have been exploited (Resnik 2012). Commitments to sustainability in global bioethics also underscore the importance of research aimed at alleviating poverty, understanding the impact of environmental degradation and climate change on public health, and devising sustainable therapies and health-care systems (Pierce and Jameton 2003). However, a concern for sustainability increases ethical tensions regarding the funding of research projects. Pressure to accept funding from biotechnology and pharmaceutical corporations in the absence of robust governmental funding can create conﬂicts of interest in any case. Bioethicists could be more reluctant to speak against the adverse environmental impact of particular corporations or their products.
Bioethics And Advocacy
By its nature as a normative enterprise, bioethics seeks to impact the practice of medicine as well as the health systems in which medical practice is situated. This impact need not rise to the level of advocacy for social or structural change. A norm of sustainability, however, even in its weaker versions, beckons bioethicists to intervene against climate skepticism; to advocate for greener practices and infrastructures; to collaborate with a wider array of scientiﬁc, governmental, and nonproﬁt partners; and to engage in public intellectual activity necessary to build support for sustainable policies and practices. Increased advocacy by bioethics can beneﬁt from the work of health behavior psychologists and communications experts (Valles 2015). Research on scientiﬁc communication suggests that framing climate change risks in terms of public health risks better elicits emotional responses that correlate with support for action to mitigate climate change (Valles 2015). Collaboration with experts from a wide variety of sectors is a necessary component for morally responsible as well as effective advocacy. Consider a hypothetical example of such advocacy in which bioethicists urge for legislation to provide access to air conditioning for vulnerable populations to lower their risk of heat-related death during climate change-induced heat waves (Valles 2015). While this advocacy could be warranted by appeals to sustainability, a commitment to sustainability would also require bioethicists to understand the ecological footprint of air conditioning, including its impact on energy systems and ecosystems. Moreover, that impact assessment would need to morally evaluate the program in light of a debt to future generations. To the extent that the environmental dimension of sustainability is emphasized, bioethicists will need to expand the scope of their interlocutors as well as their range of vision. For some bioethicists, this expansion must include challenges to the very feasibility of global development goals that are premised on the legacy of development discourse from the Brundtland Report onward (Lautensach and Lautensach 2015).
Economic and environmental factors are crucially important determinants of human health. They also impact the health-care systems that are necessary for preventative care and treatment. Worsening economic inequality and the impact of climate change represent urgent public health challenges for health-care systems. Sustainability, in the threefold sense discussed here, comprises a positive norm for global bioethics, albeit one fraught with internal tensions. A normative commitment to sustainability challenges contemporary bioethics to develop new frameworks for bioethics, to undertake more interdisciplinary and cross-cultural collaboration, and to measure expenditures of human, social, economic, and environmental capital in terms of their impact on vulnerable human populations and our imperiled environment.
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