Ethical Dilemmas in Public Health

Order Instructions:

Ethical Dilemmas in Public Health

Public health leaders must grapple with, and lead their organizations through, any number of ethically challenging circumstances. In this Discussion you will select a case study and apply basic principles of ethical analysis to the issue.

Begin by identifying an ethical challenge you have faced in your work in public health. Alternatively, select one of the ethics case studies at the end of Modules 4, 6, 7, 8, or 9, in the ” Ethics and Public Health: Model Curriculum” (http://www.aspph.org/wpcontent/uploads/2014/02/EthicsCurriculum.pdf).??

I HAVE CHOSEN THE MODULES SEVEN

Reflect on the ethical dilemma posed by your selected case, and consider what ethical principles could guide you in dealing with the situation. What insights does the Public Health Code of Ethics (e.g., “Principles of the Ethical Practice of Public Health”) offer you in this instance?

IHAVE SELECTED CASE STUDY I: Environmental Injustice in Homer, Louisiana

ADDRESS THE FOLLOWING QUESTIONS:

1. Briefly describe the ethical dilemma or issue.

2.Referring specifically to the “Principles of the Ethical Practice of Public Health,” identify principles that should be applied.

3. Describe how you would apply these principles. What actions would be ideal to take in this situation? What are the barriers or costs of taking those actions?

4. Are these actions in alignment or in conflict with your personal values? Briefly explain your response.

PLEASE APPLY THE APPLICATION ASSIGNMENT RUBRIC WHEN WRITING THE PAPER.

I. Paper should demonstrate an excellent understanding of all of the concepts and key points presented in the texts.

II. Paper provides significant detail including multiple relevant examples, evidence from the readings and other sources, and discerning ideas.

III. Paper should be well organized, uses scholarly tone, follows APA style, uses original writing and proper paraphrasing, contains very few or no writing and/or spelling errors, and is fully consistent with doctoral level writing style.

IV. Paper should be mostly consistent with doctoral level writing style.

MODULE 7

Ethical Issues in Environmental and Occupational Health
Kristin Shrader-Frechette, PhD University of Notre Dame

Issue Essay

US physicist Alvin Weinberg (1988) claims that today’s environmental-health problems are relatively trivial. Although many aspects of human well being are influenced by the environment, Weinberg says that environmental-health problems (such as liquid and airborne wastes, stresses in the workplace, and unsafe food) are sensationalized by the hypochondria of laypeople. Weinberg believes that these contemporary hypochondriacs are driven by an hysteria analogous to the irrationality that drove fourteenth- and fifteenth-century witch hunts. Just as people eventually learned that witches did not cause misfortunes, Weinberg claims that the public must learn that various environmental problems do not cause the public-health problems often attributed to them. He says the public needs to come to its senses, just as those who killed more than a million alleged witches eventually came to their senses.
Public-interest activist and attorney Ralph Nader, however, thinks Weinberg is wrong (Nader 2000). He believes that many of today’s public-health problems are substantial, increasing, and largely environmentally induced. The culprit behind this “corporate cancer,” Nader believes, is the profit motive. Labor leader Sheldon Samuels (1988) agrees with Nader and claims that workplace health problems are increasing, largely because of an “industrial cannibalism,” industries’ killing their own workers in order to save money on pollution control.

Background

Who is right about environmental-health threats, the Alvin Weinbergs or the Ralph Naders of the world? Are environmental-health risks minimal, but fueled by public ignorance and hypochondria? Or are environmental-health risks massive, but covered up by vested interests attempting to reduce manufacturing costs? To answer these questions, it is important to examine environmental-health problems faced by at least three distinct groups–workers, the public, and the poor or members of minority groups.

Medical doctors long have realized that workers face special public-health threats as a consequence of workplace exposure to various environmental hazards. In 1472 a German booklet warned goldsmiths how to avoid poisoning by mercury and lead. And in 1556, the mineralogist Agricola wrote the first known review of miners’ health problems. He noted that some women who lived near the mines of the Carpathian Mountains in Eastern Europe had lost seven successive husbands to mine-related accidents and diseases. Pleading with employers to make workplaces safer, in 1700 Italian physician Ramazzini wrote Diseases of Workers (Shrader-Frechette 2002, ch. 7).

More than two centuries ago, Percival Pott linked coal tars to the scrotal cancer that killed young chimney sweeps in England. Yet today thousands of coke-oven workers in steel mills around the world continue to inhale the same deadly substances, and they are dying of cancer at 10 times the rate of other steel workers (Leigh 1995). Even in nations like the US, annual occupation-related deaths are approximately five times greater than those caused by the illegal drug trade and approximately four times greater than those caused by AIDS (Leigh 1995). A later case study will examine whether occupational health is getting better or worse and whether the current state of occupational health raises any important ethical issues, such as consent to higher workplace risks, that ought to be addressed.

In the area of public health, obviously environmental threats are being reduced, as compared to several centuries ago. In the middle 1800s communities in most nations established Departments of Public Health to monitor and regulate the health effects from environmental contamination such as polluted water. While progress in environmental health is obvious, it is less clear that some areas of environmental health are improving. For example, the World Health Organization claims that pesticide poisonings, especially in developing nations, annually cause about 50,000 deaths (Matthews et al. 1986). And the US Office of Technology Assessment asserts that up to 90 percent of all cancers are “environmentally induced and theoretically preventable” (Lashoff et al. 1981, pp. 3, 6 ff.). Experts agree that roughly one third of all cancers are caused by cigarette smoking (National Cancer Institute 1994), but they disagree about the causes of the remaining cancers. Some say a major culprit is industrial pollution, given that the cancer rate tends to track the rate of industrialization throughout the world (Epstein 1998; Walker 1998). Others say the greater culprit is lifestyle, such as eating too much fat, while still other medical experts say the predominant cause of cancer is genetic (Ames and Gold 2000). They point to the BRCA1 and BRCA2 genes thought responsible for 5 to 10 percent of all breast cancers. Whoever is right, the stakes are high. According to the National Institutes of Health, more Americans die each year from environmentally induced cancer than from murder. Cancer incidence in the US is increasing six times faster than overall cancer mortality is decreasing (National Institutes of Health 2000). A later case study will examine whether the cancer rate can be attributed, in large part, to environmental factors and whether there are ethical grounds, such as the right to life, and the right to equal protection, for additional investigation and regulation of these factors.

The environmental health of minorities and poor people is perhaps even more problematic than that of either workers or the public generally. A recent article (Navarro 1990) in Lancet pointed out that on average whites live 6 years longer than African-Americans in the US. The essay also noted that, for most causes of death, the mortality differentials between the two groups is increasing, not decreasing. Even worse, the article charged, is that the US is the only western developed nation whose government does not collect mortality statistics by class, that is, by income and education. When the author looked at class-based mortality data for the only diseases (heart and cerebrovascular ailments) on which the US government collects class-related information, the class data showed an even wider disparity than the race data. If the author is correct, then the public health of poor and minorities is getting worse and may point to crucial inequities in society. A later case study will examine allegations of greater numbers of environmentally-induced health threats among poor and minorities, that is, instances of alleged environmental racism or environmental injustice. It will also investigate whether there are ethical grounds for additional investigation and regulation of factors affecting the health of poor people and minorities.

State of the Debate

The current debate over environmental threats to occupational, public, and minority health focuses both on the scientific facts (the magnitude of health risk) and on the ethical issues associated with those facts. Normative controversies concern both the content of the ethical principles that should govern policy and decisions about environmental health and the scientific and evaluation methods that are most ethically defensible. Conflicts over the content of ethical norms focus on issues such as (1) rights to know, (2) autonomy and free informed consent, (3) equality, especially equal protection from environmental-health risks, and (4) due process. Controversies over the methods appropriate to ethical evaluation of environmental health focus on (5) the burden of proof, (6) stakeholder representation in environmental-health decisions, and (7) the legitimacy of using risk assessment and benefit-cost analysis in ethical evaluation of environmental-health problems.
Debates over (1) rights to know particular environmental threats to public health usually pit commercial interests against medical interests. On the one side, market proponents, like advocates of the World Trade Organization, argue that requirement of full labeling of food products, for example, regarding the presence of possible pesticides or growth hormones, amounts to an infringement on free trade (Hoekman and Mattoo 2002). They also claim that such labels put some manufacturers (who use more pesticides or growth hormones, for example) at an unfair competitive advantage, relative to manufacturers who do not use the pesticides or hormones. On the other side, public-interest groups, like the nongovernmental organization (NGO), Public Citizen, argue that all consumers have the right to know exactly what they are purchasing (Wallach and Sforza 1999). They also maintain that even Adam Smith argued that markets could be free and competitive only if there were full information available to consumers.

With respect to (2) autonomy and free informed consent, often the debate focuses on what serves the common good, versus what serves some private good or an individual’s right to self-determination. On the one hand, many people (like businessman Peter Drucker (1991)) maintain that allowing free informed consent to every potential victim of an environmental health threat would be extraordinarily inefficient and might even lessen economic progress and thus harm the common good. They say that if most residents had to give free informed consent to siting a polluting facility nearby, then very few needed facilities could ever be sited, and the consequences would economically disastrous, would harm the common good.

On the other hand, medical ethicists, like Tom Beauchamp and James Childress (1994, pp. 142 ff.), point to the fact that, as a result of the Nuremberg Accords, it is not permissible to experiment on anyone without his consent, and involuntary exposure to pollution may amount to an experimentation on people and to a potential violation of their rights to life. Arguing for free informed consent, advocates also note that typically pollution can be reduced to a level according to which it is easy to obtain free informed consent of exposed people, but that often industry is unwilling to pay the costs of reducing pollution. In such cases, some ethicists argue for expanding regulations that might help guarantee free informed consent to environmental-health risks (Cranor 1994).

Controversies over (3) equality, especially equal protection against threats to environmental-health risks, typically focus on whether decisions about environmental health should aim to maximize overall welfare, as utilitarians might propose, or on whether they should aim to ensure equal treatment among people, as egalitarians claim. Those, like economist John Harsanyi, who would likely find nothing reprehensible about siting most hazardous waste dumps in consenting minority communities, for example, typically maintain that the overall welfare of such communities can be improved because of such decisions (Harsanyi 1975, pp. 594-600). They say that increased support for the local tax base and growth in jobs, available at the dumps, could offset any alleged inequality in the imposition of environmental health risks. They note that a bloody loaf of bread is better than no loaf at all.
However, those who are worried about equal protection, like philosopher John Rawls (1971), maintain that any choice (about siting most dumps in consenting minority communities) is unethical if it forces people to jeopardize their health, relative to others, because of factors that are largely beyond their control. Such inequality in imposing environmental-health risks, say egalitarians, also is inequitable because people are not really free to reject it, if they are powerless politically and economically, or if they must jeopardize their health in exchange for other basic necessities of life. Moreover, egalitarians argue that because rights to life, and to equal protection from environmental-health threats, are necessary for the exercise of civil liberties and for fulfilling the conditions of human life, people ought not be forced to give up such rights and protections.
If people are put at risk by an environmental threat to their health, ethicists also are divided on the issue of (4) due process and what, if anything, they deserve as compensation. On the one hand, more utilitarian (those who maximize overall average welfare) thinkers, like physicist Harold Lewis (1990), maintain that if people were allowed to exercise their due-process rights and were able to sue every source of potential health problems, then many societal resources would be wasted in lawsuits, and overall societal good would not be served. Moreover, they say that the burden of environmental health threats already is spread rather evenly to citizens, and therefore no one is put substantially more at risk than others are. Therefore, they claim, no one really needs to be compensated or to have his due- process rights enforced in this area.

On the other hand, medical and public-interest groups, like Public Citizen, assert that environmental- health threats are not distributed equally. They say often such threats are covered up and are more serious than people believe; that when people are harmed, they have due-process rights to redress (such as compensation) under the law. Moreover, without such redress, they say those who threaten environmental health have no incentives to improve their modes of behavior (Wallach and Sforza 1999).

One important area of due-process concerns, related to environmental health, is that of US weapons production. Under US law, defense operations that cause harm to citizens are typically not threats concerning which citizens can seek compensation. Because of the doctrine of sovereign immunity, according to which one cannot sue the sovereign or government, citizens have no rights to seek court action to protect their due process rights that may be jeopardized by the US government or its contractors. Yet current (year 2001) estimated costs to clean up the weapons-production facilities in the US, where thousands of communities are endangered because of chemical and radiological pollution, are approximately a trillion dollars. And US military contractors, such as Raytheon, McDonnell- Douglas, Westinghouse, Bechtel, Martin Marietta, and so on, are typically held not liable, by US law, even for intentional violations of public- and environmental-health standards at the facilities they run (US GAO 1999).

On the one hand, the rationale for exempting government contractors from responsibility for violations of citizens’ due-process rights, to seek redress from injury caused by defense operations, is national security. Proponents of exemption also charge that everyone benefits from national security and defense, so everyone must be willing to pay the price (US Congress 1999). In addition, they argue that the health costs of defense are borne fairly equitably, across regions of the nation.

On the other hand, opponents of military violations of public-health and environmental standards argue that something is wrong when US defense activities harm the very people they are designed to protect (Rush and Geiger 1997-1998). They also point out that the US defense establishment is, by far, the largest and most serious violator of US public-health and environmental standards, and that the US has to be held accountable, on grounds of fairness, for obedience to its own laws. Critics of those who want to hold the defense establishment not responsible for threats to citizens’ due-process rights, also argue that failure to hold it responsible has caused many needless threats to public and environmental health. For example, the US could have tested all nuclear weapons below ground, instead of above ground, and it could have avoided hundreds of thousands of additional US cancers caused by above-ground weapons testing. Because of the absence of liability and due-process claims against the government, the critics note that the US pursued the cheaper path of above-ground testing, of not warning civilians to stay indoors after the tests, and of not testing the weapons on the east coast, so that the fallout could drift over the Atlantic, instead of over the US.

Just as there is great debate over the content of the norms (e.g., individual rights versus common good) that ought to govern environmental-health decision-making, as in cases of weapons testing, so also there is controversy over the methods appropriate to ethical evaluation of environmental health. Primary among these debates is the focus on (5) the burden of proof. On the one hand, attorneys like Sander Greenland (1991) argue that, given US law, people ought to be presumed innocent until proved guilty, and therefore the potential victim of an environmental-health threat ought to bear the burden of proof in establishing his injury. Otherwise, they say that many innocent people and groups would face the impossible obstacles of trying to prove their innocence.
On the other hand, philosophers like Carl Cranor (1994) argue that, because the damage from environmental-health threats is so great, and because it is so difficult and expensive to prove causality in such cases, therefore the burden of proof should be on the “deep pocket,” the party with the most resources and the party least likely to be vulnerable. According to Cranor, this least-vulnerable party is the person or group causing potential environmental-health threats. Such conflicts over who should bear the burden of proof in environmental-health disputes focus mainly on the common good, on equal treatment, and on fairness.
In debates over ethical strategies for decisions about environmental-health threats, many conflicts arise over (6) the necessity of stakeholder representation. (Stakeholders are those who stand to gain or lose as a result of particular environmental health threats. Often stakeholders are primarily potential public- health victims. ) On the one hand, groups like the US National Academy of Sciences, in its classic 1983 discussion of societal health threats, argue that decisions about the magnitude and importance of such risks ought to be made by experts, since only scientific experts have the requisite technical expertise (NRC 1983).

On the other hand, later committees of the US National Academy of Sciences, like the 1996 group studying democratic constraints on risk imposition, (NRC 1996) argue that environmental-health decisions are not mainly about technical matters. They say such decisions are mainly about whether the potential victim community believes the risks are worth the benefits. Hence the citizens’ groups maintain that stakeholder representation is essential to democratic control of public health. Otherwise, they say, vested interests likely would dominate decisions about environmental health.
Ethicists concerned about environmental health also disagree over (7) the legitimacy of using risk assessment and benefit-cost analysis in ethical evaluation of environmental-health problems. That is, they disagree over the degree to which analytic methods ought to be used to resolve these problems. On the one hand, many economists and policy-makers argue in favor of such analytic techniques on the grounds that they systematize the problem under investigation, clarify it, and make it more tractable (Shrader-Frechette 1991). They also argue that, because society does not have infinite resources to correct environmental-health problems, therefore techniques such as risk assessment are necessary both to quantify the risk and to determine how to evaluate it. On the other hand, many environmentalists are opposed to any use of analytic methods in environmental-health decision-making (O’Brien 2000). They say that such techniques err both because they give control of public health to vested interests, rather than to potential victims, and because it is not possible to put a price on the value of life. They also say that the techniques fail to take account of many important ethical considerations such as consent and equity. Finally they complain that the techniques unfairly presuppose a largely utilitarian account of public policymaking.

Policy Issues

In each of these areas of environmental-health debate, there are a number of concrete policy proposals that have been developed to address ethical aspects of environmental health. For example, one policy issue, regarding (1) rights to know, concerns whether the World Trade Organization ought to have the right to define accurate labeling on potentially dangerous foods as “impediments to trade.” With respect to (2) autonomy and free informed consent, a crucial policy issue is whether representative democracy can adequately guarantee the free informed consent of potential environmental-health victims, or whether the victims themselves have the right to give or withhold free informed consent. For example, in the case of the proposed Yucca Mountain Nuclear Waste Repository, the US Nuclear Regulatory Commission, as a federal executive agency appointed by the President, claims the right to give free informed consent to the repository, whereas the residents of Nevada, 80 percent of whom oppose the facility, claim the right to withhold consent (Shrader-Frechette 1993).
On the issue of (3) equality and equal protection against environmental-health threats, one important current policy issue is whether all areas of the nation have equal rights to a liveable environment, or whether some people ought to have the right to trade the equal protection of their community health or environmental health for money. Is there a right to a liveable environment? Or is it a good that can be traded when necessary? Another policy issue is whether the US ought to require the same environmental-health standards for products manufactured abroad as for those manufactured in the US. Currently US manufacturers are held to higher standards of occupational health and environmental health than are the manufacturers from whom the US often imports goods and foodstuffs. Do these other nations have sovereignty over such decisions, or does the US have the right to demand the same safety standards of everyone who wishes to sell its products in the US (see Wallach and Sforza 1999)?

With respect to (4) rights to due process, an important policy issue is whether the US government ought to repeal the Price-Anderson Act. This law gives utilities protection against 99 percent of the costs of worst-case nuclear accidents, including costs and damages likely to threaten public health. Is the act is constitutional, as the Supreme Court alleged, because no violations of actual due process, in the face of catastrophic accidents, have actually occurred? Or is the act a violation of due-process rights, rights that ought to be guaranteed in principle (Shrader-Frechette 1993, pp. 15-23, 96-98)?

With respect to (5) the burden of proof, an important policy issue is whether those who threaten environmental health, because of their products, ought to be held liable on grounds of considerably weakened evidentiary standards for proof of harm, or whether the current standards ought to be maintained. These current standards place the burden of proof on the potential victim. In the case of cancer, for example, it often is extraordinarily difficult for victims to prove what caused their disease, and most cancer outbreaks are recognized because of statistical associations that preclude proving that an individual cancer had a particular environmental-health cause (Cranor 1994).

In the area of (6) stakeholder representation in environmental-health decisions, one of the crucial policy decisions is whether all federal agencies who assess health risks ought to be mandated to change and therefore to follow the US National Academy of Sciences recommendation to give stakeholders equal weight (to experts) in decision-making regarding environmental health (NRC 1996). Many ethicists argue that justice requires not merely equal consideration of interests and equal treatment, but also equal voice in the decision about how to give equal consideration and equal treatment (Rawls 1971).

Finally, one of the crucial policy issues regarding (7) the legitimacy of using risk assessment and benefit-cost analysis in ethical evaluation of environmental and health-related problems is whether all federal health-related decisions require a cost-benefit justification, as the Bush Administration proposes, or whether justifications instead can be based purely on ethical criteria, such a rights to equal protection (O’Brien 2000).

References

Bruce N. Ames and Lois Swirsky Gold, “Paracelsus to Parascience: The Environmental Cancer Distraction,” Mutation Research 447, no. 1 (January 17, 2000), pp. 3-13.

Tom Beauchamp and James Childress, Principles of Biomedical Ethics, New York, Oxford University Press, 1994.

Carl Cranor, Regulating Toxic Substances, New York, Oxford University Press, 1994.

Peter Drucker, “Saving the Crusade,” in Kristin Shrader-Frechette (ed.), Environmental Ethics, Pacific
Grove, CA, Boxwood Press, 1991, PP. 201-207.

Samuel Epstein, The Politics of Cancer Revisited, Fremont Center, NY, East Ridge Press, 1998.

Sander Greenland, “Science versus Public Health Actions,” American Journal of Public Health, 133, no. 5 (1991) pp. 435-436.

John Harsanyi, “Can the Maximin Principle Serve as a Basis for Morality? A Critique of John Rawls’s Theory,” American Political Science Review 69, no. 2 (1975), pp. 594-602.

Bernard Hoekman and Aaditya Mattoo (eds.), Development, Trade, and the WTO, New York, World Bank, 2002.

J.C. Lashoff et al., Health and Life Sciences Division of the U.S. Office of Technology Assessment, Assessment of Technologies for Determining Cancer Risks from the Environment, Washington D.C., Office of Technology Assessment, 1981.

J. Paul Leigh, Causes of Death in the Workplace, London, Quorum, 1995. Harold W. Lewis, Technological Risk, New York, Norton, 1990.

Ralph Nader, The Ralph Nader Reader, New York, Seven Stories Press, 2000.

National Cancer Institute (NCI), Surveillance, Epidemiology, and End Results, Cancer Statistics Review 1973-1994, Bethesda, MD, NCI, 1994.

National Institutes of Health, Cancer Rates and Risks, http://seer.cancer.gov/publications/raterisk/ (US Government: US National Institutes of Health and US National Cancer Institute, 2000).

National Research Council, Risk Assessment in the Federal Government, Washington, DC, National Academy Press, 1983.

National Research Council, Understanding Risk, Washington, DC, National Academy Press, 1996.

Vincente Navarro, “Race or Class versus Race and Class: Mortality Differentials in the United States,” Lancet, 336 (1990), p. 1238-1240.

Mary O’Brien, Making Better Environmental Decisions, Cambridge, MIT Press, 2000. John Rawls, A Theory of Justice, Cambridge, Harvard University Press, 1971.

D. Rush and J. Geiger, “NCI Study on I-131 Exposure from Nuclear Testing,” Physicians for Social Responsibility 4, no. 3 (1997-1998):1-5.

Sheldon Samuels, “The Arrogance of Intellectual Power,” in Phenotypic Variations in Populations: Relevance to Risk Assessment, ed. A. Woodhead, M. Bender, R. Leonard, New York, Plenum Press, 1988, pp. 115-116.

Kristin Shrader-Frechette, Burying Uncertainty: Risk and the Case Against Geological Disposal of Nuclear Waste, Berkeley, University of California Press, 1993.

Kristin Shrader-Frechette, Environmental Justice: Creating Equality, Reclaiming Democracy, New York, Oxford University Press, 2002.

Kristin Shrader-Frechette, Risk and Rationality: Philosophical Foundations for Populist Reforms, Berkeley, University of California Press, 1991.

U.S. Congress, Worker Safety at DOE Nuclear Facilities, Washington D.C., U.S. Government Printing Office, 1999.

U.S. General Accounting Office, DOE: DOE’s Nuclear Safety Enforcement Program Should Be Strengthened, Washington D.C., U.S. Government Printing Office, 1999.

Martin Walker, “Sir Richard Doll: A Questionable Pillar of the British Cancer Establishment,” The Ecologist (March/April 1998), pp. 82-92.

Lori Wallach and Michelle Sforza, Whose Trade Organization, Washington, DC, Public Citizen, 1999.

A. Weinberg, “Risk Assessment, Regulation, and the Limits,” in Phenotypic Variation in Populations, ed. A. Woodhead, M. Bender, and R. Leonard, New York, Plenum, 1988, pp. 121-128.

Fact Sheet on Environmental Health

In evaluating the extent of environmental-health threats, it is important to realize that factual information, often used as a basis for ethical decisions about environmental health, may fall victim to a number of biases and values. For example, threats to environmental health may be described in problematic ways as a consequence of at least 4 factual difficulties, (1) framing problems, (2) low-power studies, (3) alternative statistical-epidemiological methods, and (4) arbitrary decision rules.

Any ethical decision about the magnitude of an environmental-health threat is subject to considerable uncertainty as a consequence of different frames. For example, if one evaluates environmental-health threats to coal miners in terms of the “frame” of tons of coal mined, the health of miners appears to be improving. That is, coal-mine deaths, per ton of coal mined, have been decreasing since 1950 in the US. However, if one evaluates environmental-health threats to coal miners in terms of the “frame” of numbers of coal miners, the health of miners appears to be diminishing. That is, coal mine deaths, per thousand coal-mine employees in the US, have been increasing since 1950. Note that the number of deaths remains the same in both cases, but the significance of the number changes, on the basis of the frame that is used to view the deaths (see NRC 1996, pp. 50-52).

One of the most common ways in which a polluter is able to claim that there is no environmental-health threat that results from his activities is by using small sample sizes or low-power studies. For example, if an excess of 1 in 10,000 workers exposed to y amount of vinyl chloride dies, within 5 years of exposure, of liver cancer, and if the epidemiological studies investigating this health effect employ a sample size of only 200, there is only a very small probability that the test will reveal a 1 in 10,000 chance of cancer for a 5-year study, given the low incidence of the excess cancer. The sample size is too small to be likely to reveal the risk. Similarly with low-power studies. For example, when John Todhunter of the US EPA in 1982 reassessed the data alleging the carcinogenicity of formaldehyde, he concluded that the data did not show the carcinogenicity of formaldehyde. These negative statistical results, this failure to show a statistically significant increase in cancers, as a result of formaldehyde exposure among DuPont workers, however, appears to be merely an artifact of the low power of the statistical tests that Todhunter used. The DuPont study had only a 4 percent chance of rejecting the null hypothesis (and therefore inferring excess cancers), even if there were a twofold increase in cancer of the pharynx or of the larynx in those exposed to formaldehyde. That is, the DuPont study had only a power of 4 percent to detect twofold increases in cancers. As this example shows, failing to reject the null hypothesis does not rule out excess environmental cancers unless the epidemiological tests are reliable. (For the DuPont and Todhunter assessments and discussion of these problems in the formaldehyde case, see Mayo, 1991).

Other statistical-epidemiological methods also can cause environmental-health threats to be overestimated or underestimated. For example, many industries are likely to claim that their employees are more likely to die at home than on the job, that their homes are less safe than the workplace. They often make such claims on the basis of the “healthy worker effect.” This effect typically is exhibited when an epidemiologist compares the cancers per x workers in a particular industry, for example, to the cancers per x members of the total population. However, there is a selection bias in comparing worker health statistics to those of the general population. The general population includes very young people, very old people, highly sensitive people, people too sick to work, and so on, whereas the worker population is in the middle-age group, a group which is generally freer of highly sensitive people or sick people (or else they would not still be working). As a consequence, even workers with higher rates of occupationally-induced illness may appear healthier than the general population, simply because epidemiologists use a selection bias in comparing their health rates to those of the general population, a population that includes many more at-risk people than does the work population (Moeller 1997, pp. 43-44.)

Still another common difficulty that arises in evaluating environmental-health threats is caused by use of different decision-theoretic rules for evaluating the same data. For example, according to the US government’s Rasmussen Report, the probability of a nuclear core melt, in a US reactor, is about 1 in 4 for all US reactors, assuming a 30-year lifetime for the reactors. Assessments conducted by the Ford Foundation and by the Union of Concerned Scientists (UCS), however, disagreed on the environmental- health risks associated with using nuclear fission, even though both studies used the same data about reactor-accident probabilities and about accident consequences. What accounted for the difference in the health assessments? The Ford research was based on the widely accepted Bayesian decision criterion that it is rational to choose the action with the highest expected utility, where “expected utility” is defined as the weighted sum of all possible consequences of the action, and where the weights are given by the probability associated with the consequence. The UCS recommendation followed the maximin decision rule that it is rational to choose the action that avoids the worst possible consequence of all options. Thus, for identical data, the chosen decision rule–with particular ethical presuppositions–determined the calculated environmental-health threat associated with nuclear power. (For discussion of the Rasmussen Report, the Ford Foundation Report, and the UCS assessment, including these decision-theoretic rules, in areas of environmental health, see Shrader-Frechette, 1991, pp.100- 130.)

As the preceding paragraphs reveal, it is important to evaluate the factual-scientific basis on which the environmental-health threats are assessed, prior to engaging in ethical evaluation, because decisions about the acceptability of a particular environmental-health risk are a function of many subtle factors. These include the actual magnitude or seriousness of the risk. Moreover, this magnitude and seriousness can be underestimated or overestimated, purely on the basis of considerations such as framing, the power of the studies, statistical-epidemiological methods, and decision rules.

References

Deborah Mayo, “Sociological Versus Metascientific Views of Risk Assessment,” in Acceptable Evidence, ed. Deborah Mayo and Rachelle Hollander, New York, Oxford University Press, 1991, ch. 12.

Dade Moeller, Environmental Health, Cambridge, Harvard University Press, 1997.

National Research Council, Understanding Risk, Washington, DC, National Academy Press, 1996.

Kristin Shrader-Frechette, Risk and Rationality: Philosophical Foundations for Populist Reforms, Berkeley, University of California Press, 1991.

Four Case Studies on Environmental-Health Controversies

In order to determine how the preceding ethical debates, policy options, and scientific methods play respective roles in controversies over environmental health, it is useful to examine, in more detail, several important environmental-health disputes. These concern, respectively, (1) environmental injustice in Homer, Louisiana; (2) escalating cancer rates, (3) endocrine disruptors, and (4) occupational health in the US.

For each case study, the issues of debate are introduced, and then readers are invited to consider various arguments, possible counterarguments, the need for additional information, the frames employed in the debate, relevant ethical values, and the interests of various stakeholders involved. References and citations for additional resources are provided. In addition, readers will find that every issue of the journal, Environmental Health Perspectives, provides additional information and potential case studies for discussion.

Case Study 1: Environmental Injustice in Homer, Louisiana

Do all citizens have equal rights to protection against threats to environmental health? This question arises both because minorities and poor in developed nations bear greater-than-average environmental- health risks and also because those in developing nations bear greater health risks than those in the developed world, in large part because of the policies of developed nations. For example, according to the US General Accounting Office, roughly one-third of all US pesticide exports are products that are banned or not registered for use in the US because they are deemed too dangerous. Instead the US ships them abroad. As already mentioned, the World Health Organization estimates that approximately half a million cases of accidental pesticide poisoning occur annually, with a death-to-poisoning ratio of 1 to 10. This means that each year, about 50,000 people die annually from pesticide poisoning, most in developing nations. One person is poisoned every minute from pesticides in developing nations (Mathews et al. 1986).
Such disproportionate environmental-health impacts also affect those in the developed world. In 1983, African-American sociologist Bob Bullard largely began the whole area of study known as “environmental injustice” when he showed that (1996), from the 1920s through the 1970s, Houston placed almost all its city-owned landfills in African-American neighborhoods. Although they represented only 28 percent of the city’s population, African-American communities received 15 of 17 landfills and 6 of 8 incinerators. Bullard showed not only that minorities across the US faced disproportionate environmental-health threats from incinerators and toxic-waste dumps, but also that these added risks increased other public-health problems–such as crime, poverty, and drugs–in minority communities. Comparing pollution in different California ZIP codes, researchers likewise showed that in the dirtiest US ZIP code, in Los Angeles, industries release 5 times as much pollution as in the next-worst ZIP code. They concluded it is no accident that the dirtiest ZIP code is 59 percent African-American. Thus African-Americans appear to be victims of a special public-health problem, environmental injustice.
To understand alternative perspectives on the issue of environmental injustice, disproportionate environmental risks’ being imposed on poor people and minorities, consider a recent case, a proposal to build a multinational, highly-polluting, uranium-enrichment facility in an African-American community in Homer, Louisiana. One of the poorest towns in the US, Homer has a per capita income of only about $ 5,000 per year. Members of the local community were able to oppose the proposed Claiborne Enrichment Center facility only because of help from outside experts, and their stopping the facility in 1997 became the first major environmental-justice victory in the US.

Questions for discussion:

• Why would various parties want to locate a uranium-enrichment facility in Homer? Why might a multinational corporation want to build such a facility there? Why might residents welcome or oppose such a plan? Why would local businessmen or politicians welcome or oppose such a plan? Why would teachers, school administrators, and others concerned with public services welcome or oppose the building of such a facility?

• Why would “outsiders,” like environmental activists take an interest in Homer and the Claiborne facility? Who are the outsiders and insiders in cases of potential environmental pollution, and which should have the greater “say” in decisions about building a potential polluter? Why?

• What data should inform a decision about whether to build? In addition to scientific data about the facility and its environmental impact, what other data are relevant? How certain or uncertain are these data? In the presence of scientific, economic, social, or other uncertainty, who should bear the burden of proof and why?

• Can a community give informed consent to the initiation of a project like building the Claiborne facility? How would such consent be similar to a process of individual informed consent, and how would it differ? Consider what is discussed in Module 4 on community-based practice and research and on the process of sharing power within communities. Which methods discussed in that module might be useful in Homer?

• What would need to be disclosed and to whom in order for the community of Homer to make an informed decision about building the Claiborne facility? Are all of the issues to be disclosed factual, or are there ethical assumptions that need to be disclosed as well? Who represents the community in such a decision? Is it the community’s decision to make?

• Consider some of the issues raised in Module 2 on the Tuskegee Syphilis Study and issues of race. What role does the predominant race of the residents of Homer play in the siting of the Claiborne facility there? Would you argue that the facility will benefit those of a minority group, African-Americans, or would you argue that they are being singled out to bear an environmental burden?

Case Study 1: Discussion

Henry Payne (1997) argued that the proposed Claiborne Enrichment Center, in Homer, Louisiana, would have been desirable for the local African-American community but that outside environmental activists misled the community into criticizing the facility, which actually would be in the community’s best interests. Payne argued that these activists prevented Homer citizens from getting the industry and the jobs that they want and need. He argued that the proposed facility would bring jobs and an improved economy to a poor area, and yet that it would cause no serious environmental harm. Payne takes, as facts, (1) that the facility would have benefited minorities nearby, (2) that these minorities wanted it, (3) that outside activists did not want the facility, (4) that the proposed plant would help the local economy, and (5) that the facility would cause no serious public health or environmental harm. In claiming (5), Payne assumed (a) that in a situation of uncertainty, with little scientific study, ethics does not require people to be “safe rather than sorry.” He also assumed (b) that the absence of positive evidence of harm from the facility, or ignorance about the facility, was the same as a guarantee of safety about the facility. Thus he made the ethical assumption (c) that public health advocates bear the burden of proof in alleging harm from a proposed plant. Finally, Payne assumed (d) that the requirements (see Beauchamp and Childress 1994) of free informed consent (disclosure, understanding, voluntariness, and rationality) were met in the Louisiana case and that the minority community therefore actually consented to the proposed facility.

In assessing the adequacy of the Payne account, one would need to evaluate his factual assumptions (1)- (5) and his ethical assumptions (a)-(d). One also would need to take account of the fact that, in arguing for both his ethical and factual claims, Payne cited neither any scientific analyses nor any ethical and legal analyses to support his position. Instead, he relied on a commonsense assumption that manufacturing facilities bring economic benefits.
Addressing Payne’s points, Daniel Wigley and Kristin Shrader-Frechette (1996), argued that both Payne’s factual and ethical assumptions are wrong, and they therefore claimed that siting the Louisiana facility is not justified. Shrader-Frechette and Wigley challenged both the factual assumption (1) that the plant would have benefited minorities and (5) as well as the ethical assumption (a) that ignorance about the facility justified believing it was safe. Analyzing the required environmental impact assessment (EIA) for the plant, they showed that its proponents failed to consider a number of costs of the facility and that these costs were likely to exceed the associated benefits. In particular, they argued that the jobs created by the plant would go to skilled white labor and professionals, not to unskilled blacks, and that the EIA included no probabilistic risk assessment of threats posed by the facility. Instead they revealed that the EIA made purely subjective judgments about site safety.
Much of the Wigley and Shrader-Frechette (1996) analysis was devoted to showing that the EIA performed by the enrichment corporation (wishing to site the proposed facility) employed procedures that actually violated minority rights to free informed consent. In particular, Shrader-Frechette and Wigley showed, first, that the corporation did not disclose the actual nature of the facility to anyone, and instead asked citizens if they would like to have a manufacturing facility nearby. The company violated the disclosure requirement (for free informed consent), second, by covering up the radiological risks and health threats to be imposed by the facility and by failing to reveal that the onsite radiological wastes would not be covered by US government regulations. Third, the company did not reveal that the products of the multinational facility would likely be used abroad, not in the US. Nor did it reveal that these multinational products would compete with higher quality US products, while Louisiana residents would bear the health risks of the facility. In addition, Shrader-Frechette and Wigley argued that the site EIS violated the criterion of voluntariness (for free informed consent) because the corporation polled only white residents living a great distance away from the proposed facility. It did not even seek the opinions of any of the minority residents who make up the entire population living within 5 miles of the plant. Thus, Shrader-Frechette and Wigley concluded that the Louisiana facility siting amounted to environmental racism or environmental injustice and that neither factual nor ethical arguments, given in the EIA, were capable of supporting it.

References

Robert Bullard, Confronting Environmental Racism, Boston, South End Press, 1996.

Tom Beauchamp and James Childress, Principles of Biomedical Ethics, New York, Oxford University Press, 1994.
J.T. Mathews et al., World Resources 1986, New York, Basic Books, 1986.

Henry Payne,” Environmental Injustice,” Reason 29, no. 4 (September 1997), pp. 53-57.

Daniel Wigley and Kristin Shrader-Frechette, “Environmental Justice: A Louisiana Case Study,” Journal of Agricultural and Environmental Ethics 9, no. 1(1996), pp. 61-82.

Additional resources

Ruth Faden and Tom Beauchamp, A History and Theory of Informed Consent, New York, Oxford University Press, 1986. (on informed consent, voluntariness)

David Newton, Environmental Justice, Oxford, England, ABC-CLIO, 1996.

Iris Marion Young, Justice and the Politics of Difference, Princeton, Princeton University Press, 1990. (on the ways in which policies and practices affect differently situated people differently)
SAMPLE ANSWER

A proposal was developed to build a uranium-enrichment facility in Homer, Lousiana. This facility was known to cause high levels of pollution in the surrounding environment following its establishment. Homer was selected as the appropriate site for location of the facility since its occupants were African-Americans, and it was one of the poorest towns in the US. Members of this city had no power to oppose this decision because they were poor and belonged to the minority group. Experts from outside offered to help the Homer inhabitants in stopping the establishment of the facility.

The appropriate principles of ethical practice and public health that would apply in the above cause would be the fifth principle. According to the principle,” public health should seek the information needed to implement effective policies and programs that protect and promote health”. Regarding this principle, it will be vital to collect several data on the level of uranium that will be emitted into the surrounding, the anticipated effects, and the approximate size of the population that will be affected. Upon careful review of the information revealed by the analysis of data, it would be imperative to choose to locate the facility in a place that is not occupied by people (Burke and Friedman, 2011).

Establishing this facility in a place that is not occupied by people would mean additional expenditures. Additionally, there will be several barriers including inaccessible transport and communication lines, lack of electricity and sufficient water supply. Other costs may be warranted in order to overcome these obstacles and successful establishment of the facility (Burke and Friedman,2011).

In conclusion, these actions align with my personal views regarding community health. Every person in the community, despite of their ethnic backgrounds, social and economic status, should occupy a physical environment that assures them of good health. Setting up a uranium-enrichment facility in Homer, Lousiana would be against the “Principles of the Ethical Practice of Public Health” since the health of the occupants of Homer will be compromised.

References

Burke, R. E., & Friedman, L. H. (2011). Essentials of management and leadership in public health. Sudbury, MA: Jones and Bartlett Publishers.