Explore the medical ethics associated with the case of Held v Montana.
To most of us, the self-evident truths found in the Declaration of Independence—that Americans are “endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty, and the pursuit of Happiness”—are very precious words. Too often, however, we do not hold sacred the connection to life and nature in which these rights are grounded; even so, the Declaration of Independence urges us to “assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature’s God entitle” us to claim them. Our nation is founded in our place among the powers of the earth. Without protecting these natural forces to ensure a healthy planet and our place upon it, we cannot enjoy our inalienable rights as Americans.
This is what the group of young plaintiffs in the landmark decision of Held v Montana managed to make clear in law. This courageous action by young individuals at the state level succeeded because there was unconstitutional pro-fossil fuel Montana law that demonstrably threatened the rights, health, and future of the plaintiffs as guaranteed by the Montana constitution. Those who worked on this case have emboldened action on other cases.
Psychiatrists are guided in our care of patients by medical ethics that overlap with the democratic and climate ethics that supported the outcome of this case. Psychiatrists and other physicians are obligated under the American Psychiatric Association’s Principles of Medical Ethics to seek changes in laws that do not protect the health interests of their patients.1
Held v Montana calls out this obligation for psychiatrists because it brings together these ethical and legal duties in relation to global warming, establishing precedent for psychiatrists to seek legal remedy for climate change based on their ethical obligations to protect the health of their patients. This legal obligation is founded in principles of medical ethics that include the duty of care, duty of stewardship, and duty of rescue, in addition to the principles of nonmaleficence, sustainability, solidarity, respect for life, and accountability in relationships. Among these, respect for life, solidarity, and accountability overlap with those values demanded of a democratic government and its citizens, and these were affirmed in Held v Montana.
Courage in a Moral Storm
Climate-aware psychiatrists have long expressed the idea that climate abuse is child abuse. Held v Montana gives us precedent to act on this awareness, linking legal precedent on intergenerational rights to our psychiatric ethics regarding child mistreatment. As psychiatrists, we have a particular legal duty to protect children from mistreatment and neglect. The young plaintiffs, aged 5 to 22 years, articulated a wide range of threats to their mental and physical well-being in the lawsuit, including deprivation of food and shelter and exposure to life-threatening fires, all ultimately resulting from institutional and adult failure to control use of fossil fuels. We have the duty to care for a protect children from such neglect and trauma both in statute and because of our obligation to prevent harm in the form of the legacy of posttraumatic stress, hopelessness, despair, rage, and distrust that overwhelms psychic health when elders misuse their power, as well as the impediment of normal maturation into adult roles and responsibilities that comes along with these reactions.2
Climate change has been called a perfect storm for human moral behavior because it is global and intergenerational, crosses species boundaries, disperses cause and effect, occurs in a setting where our theories and institutions are weak, and undermines the belief that personal agency is effective—all tempting unethical action. Held v Montana gives us courage in this moral storm. On a national and international level, increasing legal precedent and expert opinion assert that climate inaction also creates conditions injurious enough to children’s well-being that they may be conceptualized as intergenerational injustice. Intergenerational justice is legally protected by the Convention on the Rights of the Child and the US Constitution’s posterity clause and the Fifth Amendment, which states that no one shall be deprived of “life, liberty, or property without due process of law” and that these basic rights are secured for the benefit of future generations as well. International courts have recognized that the burden to address climate change cannot be placed disproportionately on youths (Neubauer et al v Germany, 2021), and national courts have used dissents to give voice to intergenerational rights, as Alaska Supreme Court justices Peter J. Maassen and Susan L. Carney did when they explicitly recognized a constitutional right to a livable climate in their dissent in a youth climate change case before the state’s Supreme Court, (Sagoonick v Alaska, 2022).3
Engaging the Climate Crisis
In our awareness of the intergenerational abuse that is climate change, we must not only acknowledge what is happening and validate the distress of younger generations, but we must also stop it. Psychiatrists have many ways to engage the climate crisis: advocacy, research, activism, care, and education. But it is through the legal system that we can best address the institutional betrayal of our youth in a way that reassures them about adult capacities for integrity and justice.
Any federal or international policy that continues to support the use of fossil fuels in the face of mounting environmental devastation is a potential injurious action toward the public and its younger generations. In Juliana v United States (2020), a national lawsuit alleging violation of these constitutional and international rights, the majority opinion of the Ninth Circuit Court of Appeals supported this position: “A substantial evidentiary record documents the federal government has long promoted fossil fuel use despite knowing that it can cause catastrophic climate change, and that failure to change existing policy may hasten an environmental apocalypse.”4 This is not only institutional betrayal—it is criminal neglect. The more you are aware of the consequences of your actions, the more forensic culpability you have.
This is also true in psychiatric ethics: We are more obligated to act where we have more expertise and proximity to the problem, and where we can most be effective; prevent more severe consequences; and earn the public trust in so doing. As we await the outcome of Juliana and similar cases around the country, may we act in the words of Maya Angelou: “Do the best you can until you know better. Then when you know better, do better.” And knowing better, we must do better—to protect the Constitutional rights and mental health of our patients and our future. The powers of the Earth are on our side.
Dr Haase is physician director for Carson Tahoe Regional Center and chairs the climate committee for the Group for the Advancement of Psychiatry. She is also the climate editor for Psychiatric Times.
1. American Psychiatric Association. The Principles of Medical Ethics with Annotations Especially Applicable for Psychiatry. APA Press. 2013. Accessed August 23, 2023. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Ethics/principles-medical-ethics.pdf
2. Mandatory reporters of child abuse and neglect. Child Welfare Information Gateway. 2019. Accessed August 23, 2023. https://www.childwelfare.gov/pubPDFs/manda.pdf
3. Rogers A, Dunn K. The need for science-based legal remedies to respond to young peoples’ climate distress. In: Haase E, Hudson K, eds. Youth Climate Distress: Multiple Disciplines Respond. Cambridge University Press. In press.
4. Gardiner SM, Weisbach, DA. Debating climate ethics. Oxford University Press; 2016.