Integrative Bioethics is a Bridge-Builder Worth Considering to Get Desired Results

In “A Bridge Back to the Future: Public Health Ethics, Bioethics, and Environmental Ethics,” Lee (2017) advocated a return to Leopold’s and Potter’s concepts of bioethics to unite the fields of biomedical ethics and environmental ethics. She proposed public health ethics as the bridge, arguing that three things are required: (1) recognition of the ways that human health is connected to that of animals and the environment, (2) awareness of the theory and practice of public health ethics, and (3) application of the problem-solving methods used by public health. She opined that efforts such as “health in all policies,” stakeholder engagement, and structural change are essential for informing policymakers of the interconnectedness of health and well-being (Lee 2017). We submit that the idea of bridge-building and the methods proposed by Lee are attractive, but not unique to public health ethics. This idea and the methods that support the desired outcomes are features of the integrative bioethics we have employed to promote social justice, deliberative decision making, and ecosystem mindfulness (Powers and Faden 2006) at the Tuskegee University National Center for Bioethics in Research and Health Care (President’s Council on Bioethics 2003; Sodeke 2012).

Drawing on the works of others (Jahr 1927; Leopold 1949; Potter 1971), the author highlighted the theoretical formulation of Leopold’s vision of bioethics focused on the “land ethic” and Potter’s vision of joining science and the humanities. As Potter posited, “ethical values cannot be separated from biological facts.” An inclusive vision of bioethics that could serve as a bridge to connect science and humanities would include a “Land Ethic, a Wildlife Ethic, a Population Ethic, a Consumption Ethic, an Urban Ethic, and International Ethic, a Geriatric Ethic, and so on” (Potter 1971). The author of the target article noted that this broad concept of bioethics has never gained traction (Jones 1993; Resnik 2009). We agree. Lee also admitted the need for biomedical ethics and environmental ethics in the work and practice of public health, but she equated biomedical ethics to mainstream bioethics when she stated, “Public health ethics, a relatively new subfield of bioethics, emerged initially from the belly of contemporary biomedical ethics” (Lee 2017, 5). This is problematic, given the early struggles on the meaning of bioethics (Reich 1995). Nevertheless, Lee claimed that as public health ethics evolves, “it is well positioned to reconnect biomedical ethics and environmental ethics in a practical and meaningful way to improve our collective experience on this planet” (Lee 2017, 5).

The tools needed to build such a bridge are already in use, as evidenced by our experiences with integrative bioethics at Tuskegee. In our view, rather than “down the tools and methods” of bioethics in exchange for those of public health ethics, we suggest movement toward the original broad concept of bioethics by integrating disciplinary fields and perspectives in ways that remove boundaries that have impeded progress and prevented realization of desired outcomes.

To support her argument for making public health ethics a bridge, Lee focused on health as the common denominator. We contend that such a focus is limiting and argue that it is only within the context of our respect for and love of life that the discussion of health arises. Bioethics is about “life”—all life, meant to coexist harmoniously in a balanced ecosystem. For human life, it means life lived fully, not just biologically or physiologically, but socially, culturally, economically, politically, and spiritually in ways that support sustainability, not in isolation or in ways that cause damage to other beings (President’s Council on Bioethics 2003). Fox opined that, pursued to its logical conclusion, bioethics brings ethics to life and life into ethics (Fox 2001). What affects one being affects others (Resnik 2009; Jennings 2016). There is a moral sense in which bioethics promotes this interconnection and interdependence. This is the essence of integrative bioethics. We substantiate the soundness of bridge-building by sharing our experiences.

In relation to the apology for the U.S. Public Health Service Study of Untreated Syphilis in the Negro Male conducted in Tuskegee, AL, President Clinton gave an executive order to establish a bioethics center in Tuskegee to assure that such egregious acts do not happen again. The visionary leaders of the Tuskegee University National Center for Bioethics in Research and Health Care (TUNCBRHC) decided that it would be confining to adopt mainstream bioethics. As communicated in the founding document, “an approach to bioethics which attempts to utilize abstract ethical theories alone to develop moral guidelines to action in health and life events is insufficient … effective moral reasoning requires us to employ an interdisciplinary account” (“Establishment of TUNCBRHC”: Tuskegee University Archives 1998).

Since the problems of bioethics are evident in the lives of people who live in a pluralistic society structured by the powerful and majority-defined norms, the founders advocated a more robust view of bioethics in concept, scope, and practice that honors their heritage and their sense of community, solidarity, and compassion for those similarly situated. Integrative bioethics is holistic, interdisciplinary, multidisciplinary, and transdisciplinary. In spanning boundaries and building bridges, it employs deliberative decision-making in ensuring moral progress. At Tuskegee, it has been used to shape the justification for university and community support of local, national, and international scholarly presentations; ethics across the curriculum; discussion of the draft curriculum for public health ethics by a campus-wide interdisciplinary faculty group; the integration of bioethics into health disparities, business ethics, veterinary medicine, and engineering ethics and society courses; a public health ethics course; and the first bioethics conference held at Tuskegee (Sodeke 2012).

Integrative bioethics is evident in the curriculum and practices of the university and community. The approach embraces ethical methods for resolving issues of individual and population health; it incorporates Leopold’s and Potter’s broad view of bioethics and Jahr’s view of respect for the interconnectedness and interdependence of all forms of life. In response to a community-identified issue, we used integrative bioethics to garner community support and prevent the dumping of environmental wastes in Macon County. Sensitivity to our ethical obligations to one another, promoted by knowledge of integrative bioethics, made possible establishment of a food pantry on the Tuskegee campus, which provides food for food-insecure households (Wilson 2013). The university also helps sustain the local farmer’s market and participates in recycling programs.

A Public Health Ethics course is offered to various individuals across the nation. Use of deliberative decision making builds competencies in the theory and practice of public health ethics, health care ethics, bioethics, and research ethics, and their influence on race, ethnicity, sex, gender, and class. In resolving these challenges, discussions have included consideration of the dimensions and roles of environmental justice, agriculture and food security, poverty, economics, social structures, communications, human relations, research, health, health care, and the humanities. Another course, Special Topics in Bioethics and Research Ethics, allows students to interact with community members and facilitates understanding of basic concepts and issues raised in mainstream bioethics, integrative bioethics, public health ethics, environmental ethics, health disparities, health equity, and media and communications ethics. Its aims are to enhance awareness of basic ethical theories and principles; hone skills for ethical analysis and reasoning; highlight the connection between science, ethics, politics, and media; and demonstrate how behavioral, communications media, and biomedical research involving vulnerable populations should be conducted and reported.

Another component of Tuskegee’s bioethics program was the five-day Train the Trainer workshop conducted in 2013. The objective was to “embed bioethics concepts into the fabric of science and integrate them across the spectrum of research.” It aimed to broaden understanding of bioethics and attendant concepts to be integrated across research spectrum; demonstrate an awareness of how bioethics concepts can be delivered to target research communities; practice the delivery of concepts in an experiential and supportive environment; and create plan to engage the knowledge and experience gained to enhance bioethics education in home institutions and new environments (Sodeke et al. 2015).

Lee is right. We concur that mainstream bioethics should make a turn to a broader concept of bioethics. As demonstrated at Tuskegee, it could do so through integrative bioethics, a boundary spanner characterized by an understanding of the connectedness of human health and its challenges with, and its interdependence on, the health of animals and that of the ecosystem; knowledge of the ethical theories that ground inclusivity of diverse views; and application of deliberative ethical problem solving (Whitehouse 2003; Buchannan 2007; Sodeke 2012).

Integrative bioethics, which engages diverse audiences and disciplines in addressing real life issues, and of which mainstream bioethics and public health ethics are parts, is worth considering. It provides an opportunity for integration of broadly construed bioethics, which can address ethical challenges in individual, community, environmental, and animal health, and identify options that will guide development of policies and laws. Social justice demands for the use of scientific and technological advancements for the benefit of all necessitate a return to Potter’s injunction, “Ethical values cannot be separated from biological facts.” We have the necessary tools and methods for facilitating this return (Presidential Commission for the Study of Bioethical Issues 2016).