The Concise Argument
====================

* Lucy Frith

*   health care for specific diseases/groups

This issue of the Journal of Medical covers a range of ethical issues and care settings making the task of beginning to summarise these papers challenging. They reflect the diversity of our field, representing different branches of bioethics focussing on specific areas or topics using a variety of methodologies: but how do we categorise these branches of bioethics? What demarks one branch from another? And what function do such categorisations fulfil? From the early days of medical ethics we now have a growing proliferation of different branches, from those with a more specific focus: clinical ethics, global ethics, nursing ethics, public health ethics for example, to a widening out, in terms of bioethics becoming the broader usage and medical ethics sitting within that. More recently, a new area of ethical focus has arisen, One Health, the subject of Johnson and Degeling’s article in this issue. They define One Health as follows: ‘One Health is generally construed as an integrated approach to understanding and managing disease. Although primarily associated with the prevention and control of Emerging Infectious Diseases, the approach is also relevant to dealing with endemic and zoonotic animal diseases, as well as securing food safety. In its most comprehensive form, it extends to fostering the health of humans, animals and their shared environments.’

This raises, in many ways, a different set of ethical concerns from those usually encountered in bioethics and medical ethics and this leads Johnson and Degeling to ask whether One Health merits having its own ‘ethical framework’. They use ethical frameworks in two senses: as value neutral deliberative tools and as embodying values, and consider how each  usage could be applied in One Health. In terms of the first usage they state: ‘When ethical frameworks are regarded as a procedural tool then, the One Health perspective can broaden and strengthen considerations to be included in the mix within existing ethical frameworks deployed in bioethics and public health.’ In terms of the second usage of ethical frameworks, as embodying values, they note that One Health could generate its own framework, ‘with additional premises, central tenets from One Health can support normative claims, and further, One Health is suggestive of change in the ethical and public health policy status quo.’ They present a number of arguments for generating this kind of framework and point out that by not adopting its own normative framework, One Health is not living up to its potential: ‘There is much productive work that can be done by philosophers in teasing out and working up the hitherto underexplored values of One Health and in trying to work out how it might be possible to sort through and prioritise the completing claims of a One Health ethics.’ However, ultimately, they remain agnostic about the project of developing a specific normative framework for One Health.

One Health encourages us to think more broadly about the effects of our behaviours and the implications of and on the wider eco sphere and the links between human and animal health, and this is an exciting development in bioethics. It also raises interesting questions of where it sits in the field of bioethics, and applied ethics more broadly, and what, if any, distinct contributions it might make to bioethical inquiry.

There has been a long-standing debate over what constitutes a particular sub-set or branch of applied ethics and what does and should differentiate particular areas of focus. As Verweij & Bovenkert1 note bioethics has become increasingly specialised. An argument for needing these discrete branches, or communities of practice, such as clinical ethics or global ethics is, taking Lillehammer’s2 ‘division of intellectual labour argument’ and reworking it: that having an expertise in a particular area and developing this through sustained work gives any resulting ethical analysis a texture and closeness to the realities of practice that it might otherwise lack. This is clearly necessary to say sensible things that those working in the area will find useful. One of the reasons that Verweij & Bovenkert1 see for this increasing specialisation in bioethics is the rise in more empirical perspectives that require a more finely tuned appreciation and understanding of the subject matter. Thus, an argument for One Health being a distinctive area of bioethics could draw on this kind of justification - it pays attention and develops expertise in an area, although broad and inter-disciplinary, of scientific development, practice and policy. One Health raises distinctive ethical concerns from those usually addressed in bioethics. It takes a much wider approach to the context of ethical issues, bringing in not only animals, and how they interact with humans, but also the natural environment. These concerns could link into animal ethics and environmental ethics and debates over wider responsibilities to future generations and the global eco sphere. For people working in this area, a detailed knowledge of the context in which these issues and dilemmas play out would be necessary, as they are a long way away from traditional medical ethics debates located in the narrow confines of medical practice. This is one of the reasons the authors give for thinking in these terms: ‘One of the strengths of One Health is that the approach draws attention to an environmental dimension which may be relevant in ethical decision-making but which, despite initial prominence in domains like bioethics, appears to have slipped off the disciplinary agenda.’

While prima facie it seems sensible to develop context-based expertise, how we categorise this focus, whether it be a clinical area such as reproductive medicine or a level of clinical interaction, such as the doctor-patient relationship, determines and predetermines the scope of the inquiry. By basing ethics around established medical categories, such as psychiatric ethics or paediatric ethics, we may already be closing off ways of seeing and conceptualising the issues. For instance, we may become bound by biomedical disease categories that foreclose avenues of analysis and certain types of solutions. Further, focussing on a particular level of encounter, like  the doctor-patient relationship, may mean that certain questions do not become apparent. This has been the impetus for new branches of bioethics, such as organisational ethics and public health ethics. For example, by having the organisation as the focus of ethical analysis, organisational ethics is able to open up new questions and areas that might not otherwise be considered. An example of this is the recognition that individual healthcare professionals’ actions and decision-making take place within a prescribed organisational context – while they can react to this context – the context shapes the options available and how ‘appropriate’ responses are constructed and delineated. Spencer *et al* 3 point out that the construction of this context, the hierarchical structures of the healthcare organisations, power relations, finance, personnel issues and the ethical implication of these are often not addressed by medical or clinical ethics and hence: ‘There is a dramatic need for a broader conception of ethics in Healthcare Organisations.’ Public health ethics has similarly sought to focus attention on populations rather than individuals and reconceptualise concepts of the human good.4 One Health ethics could perform a similar role of opening up areas for ethical consideration, re-orientating existing ‘ethics’ towards the relationship between humans and animals, and broader ecological considerations. The development of One Health ethics could be seen as part of Robert Lyman Potter’s5 stages in the evolution of bioethics. He argues that bioethics needs to be expanded to consider the wider sociological context of healthcare systems and this is, a ‘turn towards a broader ecological version of bioethics.’ This version of bioethics sees issues in their broader context – an ecological vision that constructs individuals as biosocial organisms operating in a wider ecosphere – elements that are crucial for a thorough ethical analysis. These levels are not a progression or a set of steps, but ‘one must move back and forth from the various levels to maximise interaction of the various levels.’5 

A further reason for dividing areas of ethical concern into categories is that different areas might need different kinds of theoretical tools to approach them. To use the previous example of organisational ethics, it has been argued that the theoretical tool kit of medical and clinical ethics, often focused on patient autonomy, does not have the theoretical resources to consider the ethics of organisations. Werhane has argued that different theories are needed to think through organisational ethics and makes the case for using stakeholder theory: ‘Stakeholder theory provides a moral framework for evaluating not only stakeholder relationships but also evaluating organisations, their missions, and their value-creating activities. Thus stakeholder theory initiates thinking about organisation ethics for healthcare, while including the stakeholder dimensions of professional, clinical, and managerial ethics.’6 Work in public health ethics has also sought to draw on different theories and theoretical framings, such as social justice, solidarity, reciprocity, contractarianism, welfare forms of consequentialism, accounts of human flourishing and capabilities, and ideas of public and common goods.4 One Health ethics might also need to draw on a different kind of theoretical cannon, that can more adequately cope with considering ethical issues across human, animal and environmental domains. Using developments in systems and complexity theory that are able to theorise how different systems interact and co-evolve could be one area to explore.7 As Verweij & Bovenkert1 note the, ‘One Health perspective implies that evaluating health policies merely from a (human) public health ethics view will not be sufficient.’ Whether this means that One Health should develop its own ethical framework, in the normative sense, and what kinds of theoretical tools are best suited to examining the ethical issues raised by this  perspective, are areas that need more debate and discussion. One Health could prompt the development of moral theories that might enable us to think more constructively about how to address the ethical issues and challenges raised by this inter-disciplinary area. Whether this area becomes a new branch of bioethics and how it develops remain to be seen, but this kind of debate needs to  happen so that bioethics can continue to evolve and be responsive to new societal challenges.

## Footnotes

*   Competing interests None declared.

*   Provenance and peer review Not commissioned; internally peer reviewed.

*   Patient consent for publication Not required.

## References

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3.   Spencer E , Mills A , Rorty M , et al . Organizational ethics in healthcare. Oxford University Press: Oxford, 2000.
    
    

4.   Dawson A . Public Health Ethics. Cambridge: Cambridge University Press, 2011.
    
    

5.   Potter RL . From clinical ethics to organizational ethics: the second stage of the evolution of bioethics. Bioethics Forum 1996;12:3–12.
    
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6.   Werhane PH . Business ethics, stakeholder theory, and the ethics of healthcare organizations. Camb Q Healthc Ethics 2000;9:169–81.[doi:10.1017/S0963180100902044](http://dx.doi.org/10.1017/S0963180100902044) 
    
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7.   Walby S . Complexity theory, systems theory, and multiple intersecting social inequalities. Philos Soc Sci 2007;37:449–70.[doi:10.1177/0048393107307663](http://dx.doi.org/10.1177/0048393107307663) 
    
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