Parker’s article is a welcome attempt to address the importance of environmental sustainability in the realm of clinical ethics.1 We support the recent movement to seriously consider the environmental impact of healthcare institutions in bioethics.2 3 Still, we find two partly linked weaknesses of Parker’s analysis and guideline suggestion. These relate to a need in ‘green’ bioethics to see beyond the normal healthcare ethical focus on health-related values related to individual patients, and to primarily adopt institutional ways of framing central (...) decision problems. Traditional bioethics applies a restricted scope of values to assess clinical decisions: primarily health-related patient well-being (including life) and patient autonomy. If a decision improves (or, as in Parker’s inhaler case, maintains) a patient’s health-related well-being, this supports it. However, if a decision improves a patient’s non health-related well-being, say, winning a beauty contest or securing a job by having cosmetic surgery, it is not supported. And so on. This idea of healthcare as, in Michael Walzer’s classic terminology, a separate ‘sphere of justice’ has two interrelated limitations: it reflects a bias towards individual patients over other people, and it restricts the scope of values allowed to influence healthcare ethical judgements. These limitations appear once we see that the issue addressed by Parker can be framed either as prescription decisions taken by individual doctors against the background of …. (shrink)

How should scarce healthcare resources be distributed? This is a contentious issue that became especially pressing during the pandemic. It is often emphasised that studies exploring public views about this question provide valuable input to the issue of healthcare priority setting. While there has been a vast number of such studies it is rarely articulated, more specifically, what the results from these studies would mean for the justification of principles for priority setting. On the one hand, it seems unreasonable that (...) public values would straightforwardly decide the ethical question of how resources should be distributed. On the other hand, in a democratic society, it seems equally unreasonable that they would be considered irrelevant for this question. In this paper we draw on the notion of reflective equilibrium and discuss the relevance and roles that empirical studies may plausibly have for justification in priority setting ethics. We develop a framework for analysing how different kinds of empirical results may have different kinds of implications for justification. (shrink)

Environmental pollution and greenhouse gas emissions that contribute to climate change have adverse impacts on global health. Somewhat paradoxically, health care systems that aim to prevent and cure disease are themselves major emitters and polluters. In this paper we develop a justification for the claim that solidaristic health care systems should include sustainability as one of the criteria for determining which health interventions are made available or reimbursed – and which not. There is however a complication: most adverse health effects (...) due to climate change do occur elsewhere in the world. If solidarity would commit us to take care of everyone’s health, worldwide, it might imply that solidaristic health system cannot justifiably restrict universal access to their own national populations. In response we explain health solidarity is to be considered as a moral ideal. Such an ideal does not specify what societies owe to whom, but it does have moral implications. We argue that ignoring sustainability in political decision making about what health care is to be offered, would amount to betrayal of the ideal of solidarity. (shrink)

There is a need for all industries, including healthcare, to reduce their greenhouse gas emissions. In anaesthetic practice, this not only requires a reduction in resource use and waste, but also a shift away from inhaled anaesthetic gases and towards alternatives with a lower carbon footprint. As inhalational anaesthesia produces greenhouse gas emissions at the point of use, achieving sustainable anaesthetic practice involves individual practitioner behaviour change. However, changing the practice of healthcare professionals raises potential ethical issues. The purpose of (...) this paper is twofold. First, we discuss what moral duties anaesthetic practitioners have when it comes to practices that impact the environment. We argue that behaviour change among practitioners to align with certain moral responsibilities must be supplemented with an account of institutional duties to support this. In other words, we argue that institutions and those in power have second-order responsibilities to ensure that practitioners can fulfil their first-order responsibilities to practice more sustainably. The second goal of the paper is to consider not just the nature of second-order responsibilities but the content. We assess four different ways that second-order responsibilities might be fulfilled within healthcare systems: removing certain anaesthetic agents, seeking consensus, education and methods from behavioural economics. We argue that, while each of these are a necessary part of the picture, some interventions like nudges have considerable advantages. (shrink)

Addressing distributive justice issues in health policy—ranging from the allocation of health system funding to the allocation of scarce COVID-19 interventions like intensive care unit beds and vaccines—involves the application of ethical principles. Should a principle of sustainability be among them? I suggest that while the value of temporal neutrality underlying such a principle is compelling, it is already implicit in the more basic principle of equal treatment. Munthe et al imagine sustainability accompanying four other principles: need, prognosis, equal treatment (...) and cost-effectiveness. Some are spelled out, however, in ways that are ambiguous or incomplete. (shrink)

This paper contributes to the growing discussion about how to mitigate pharmaceutical pollution, which is a threat to human, animal, and environmental health as well as a potential driver of antimicrobial resistance. It identifies market approval of pharmaceuticals as one of the most powerful ways to shape producer behavior and highlights that applying this tool raises ethical issues given that it might impact patients’ access to medicines. The paper identifies seven different policy options that progressively give environmental considerations increased priority (...) in the approval process, identifies ethically relevant interests affected by such policies, and makes explicit tensions and necessary tradeoffs between these interests. While arguing that the current European regulation gives insufficient weight to environmental considerations, the paper highlights concerns with the strongest policy options, on the grounds that these may very well endanger patients’ access to effective medication. (shrink)

Christian Munthe, David Fumagalli and Erik Malmqvist argue that well-known healthcare resource allocation principles, such as need, prognosis, equal treatment and cost-effectiveness, should be supplemented with a principle of sustainability.1 Employing such a principle would entail that the allocation of healthcare resources should take into account whether a specific allocation causes negative dynamics, which would limit the amount of resources available in the future. As examples of allocation decisions, which may have such negative dynamics, they mention those who cause a (...) lack of vaccines, anti-bioethics resistance and drug shortages. Thus, the overall thought is that we can spend and allocate healthcare resources in a certain way at t1, which means that we will have fewer resources available at a later point, t2. The authors argue that we should include a principle of sustainability to justify allocations, which avoids or diminishes the negative dynamics. The authors argue that existing principles cannot sufficiently include proper regard for how our current decisions affect future allocation decisions and, therefore, the people who need healthcare resources in the future. I am sympathetic to the developed argument and believe that the authors are correct that negative dynamics provide reasons to take our ability to meet future health needs …. (shrink)

John Rawls’s ‘just savings’ principle is among the better-known attempts to outline how we should balance the claims of the present with the claims of the future generations on resources. A central element of Rawls’s approach involves endorsing a sufficientarian approach, where our central obligation is to ensure ‘the conditions needed to establish and to preserve a just basic structure’.1 This engaging paper by Christian Munthe, Davide Fumagalli and Erik Malmqvist (‘the authors’) does not explicitly mention Rawls’s work on this (...) issue.2 Still, there are parallels in their aim to generate a ‘sustainability principle’ for healthcare systems. The authors defend the broadening of our focus to the relations between rounds—particularly, how decisions in one period can affect our choice range in the next, whereas current principles for allocating healthcare resources operate within ‘allocation rounds’. Where Rawls is concerned about future generations, the authors’ concern is with future sets of patients. Our present decisions may generate system ‘dynamics’ which are either positive—where ‘more resources per health need’ become available—or negative—where (otherwise justified) decisions taken now leave us with less bang for our buck in the future. The paper’s important and compelling central claim is that we have an obligation …. (shrink)

Maybe you only have 1000 units of some resource, but 10,000 people need the resource or would benefit from it. One question: why do you control the resource? Leave that aside for now. A second question: how should you allocate the resource? If you are a decision-maker in a health system, and if the resource has to do with medicine or public health, we are in the world of the ethics of scarce resource allocation decisions in healthcare. Munthe et al (...) 1 note that the ‘operational norms that guide actual decision making in this area tend to be similar across health systems’ and include principles concerning need, prognosis, equal treatment and cost-effectiveness. Even with just these principles, there are hard questions of how they ought to be specified, operationalised and balanced against each other when they conflict. They do not focus on this. Instead, they identify a concern: paying attention only to these principles in making allocation decisions may lead decision-makers to miss ‘negative dynamics’ that result from their decisions. They aim to rectify this by suggesting a ‘sustainability’ principle that would sit alongside these other ethical principles, serving as a side-constraint that rules out certain allocation choices or as a distinct reason to be weighed in the decision-making calculus (or a reason to save or insure against negative dynamics). I agree that the downstream effects of our allocation decisions matter, …. (shrink)

Munthe et al 1 argue for an asymmetry between positive and negative dynamics that justifies a new sustainability principle among the operational principles for ethical healthcare resource allocation. The purported asymmetry is that while positive dynamics are ‘taken into account in present applications of the operational principles…, negative dynamics are not’.1 Positive dynamics occur when allocations in the present lead to there being more healthcare resources per health need in the future (than are available in the present), whereas negative dynamics (...) occur when present allocations lead to there being less future healthcare resources per health need.i Munthe et al 1 are correct that we have ethical reason to reduce negative dynamics—all other things being equal, having less future healthcare resources per health need is worse than having more. Furthermore, this ethical reason ought to be accounted for by operational principles. However, using current examples from the COVID-19 response, I argue that allocation policies guided by existing operational principles already take into account negative dynamics and thus obviate the need for a new sustainability principle. Nevertheless, Munthe et al 1 make a valuable contribution to the literature by opening up new lines of important research regarding the mitigation of allocation policies’ negative dynamics. As Munthe et al 1 cogently argue, existing healthcare allocation policies (eg, of vaccines) take positive dynamics into account. However, when they do so, they also often implicitly or …. (shrink)

This paper argues that as we move to redefine global bioethics, there is a need to be attentive to the ethical issues associated with the environmental sustainability of data and digital infrastructures in global health systems. We show that these infrastructures have thus far featured little in environmental impact discussions in the context of health, and we use a case study approach of biobanking to illustrate this. We argue that this missing discussion is problematic because biobanks have environmental impacts associated (...) with data and digital infrastructures. We consider several ethical questions to consider these impacts: what ethical work does the concept of environmental sustainability add to the debate; how should this concept be prioritised in decision-making; and who should be responsible for doing so? We call on global bioethics to play a role in advancing this dialogue and addressing these questions. (shrink)

An anthropocentric scope for clinical medical ethics (CME) has largely separated this area of bioethics from environmental concerns. In this article, we first identify and reconcile the ethical issues imposed on CME by climate change including the dispersion of related causes and effects, the transdisciplinary and transhuman nature of climate change, and the historic divorce of CME from the environment. We then establish how several moral theories undergirding modern CME, such as virtue ethics, feminist ethics, and several theories of justice, (...) promote both a flourishing of human medical practice and the environment. We conclude by defining an expanded the scope of CME as inclusive of not only patients, families, physicians, and other health professionals but other humans, non-humans, and their shared environment. We then apply this scope and theory to a widely used framework for applying CME, the Four Topics model, to construct a climate conscious approach to CME. (shrink)

Healthcare systems produce significant greenhouse gas emissions, raising an important question: should healthcare be treated like any other polluter when it comes to reducing its emissions, or is healthcare special because of its essential societal role? On one hand, reducing emissions is critical to combat climate change. On the other, healthcare depends on emissions to deliver vital services. The resulting tension surrounds an idea of healthcare exceptionalism and leads to the question I consider in this paper: to what extent (if (...) any) should the valuable goals of healthcare form an exception to the burdens of reducing greenhouse gas emissions? The goals of this paper are twofold. One is to think about how to address the issue of healthcare exceptionalism. Second is to discuss the extent of healthcare’s climatic responsibilities. I examine two perspectives on healthcare exceptionalism. The first treats a responsibility to reduce emissions and the delivery of healthcare as separate issues, each governed by its own principle. I reject this view, proposing instead that we consider healthcare’s environmental responsibilities in conjunction with its essential functions. I defend an “inability to pay” principle, suggesting that while healthcare should indeed contribute to mitigating climate change, its obligations should be constrained by the necessity of maintaining its core goals like protecting health and preventing disease. Healthcare should be treated differently from other sectors, but not to the extent that it is entirely exempt from efforts to reduce emissions. (shrink)

Antimicrobial resistance (AMR) is increasingly recognised as a threat to human, animal and environmental health. In an effort to counter this threat, several intervention plans have been proposed and implemented by states and organisations such as the WHO. A One Health policy approach, which targets multiple domains (healthcare, animal husbandry and the environment), has been identified as useful for curbing AMR. Johnson and Matlock have recently argued that One Health policies in the AMR context require special ethical justification because of (...) the so-called least restrictive alternative principle. This article analyses and rejects two assumptions that this argument relies on. The first assumption is that One Health policies are generally more restrictive than their alternatives because they target more domains and impact more people. The second assumption is that the least restrictive alternative principle has a special normative importance in that it establishes a systematic presumption in favour of the least restrictive policy options. Once these assumptions are rejected, the use of One Health policies on AMR can be justified more easily than Johnson and Matlock argue. (shrink)

We proposed adding a sustainability principle to the operational ethical principles guiding public healthcare resources allocation decisions. All our commentators acknowledge our core message: healthcare needs to pay attention to the future. They also strengthen our proposal by offering support by luck egalitarian and Rawlsian arguments, and helpfully point out ambiguities and gaps requiring attention in the further development of the proposal, and its practical implementation.

In this issue of the Journal of Medical Ethics arguments are cogently made that sustainability and solidarity should be considered as core medical ethical principles, and that more explicit attention should be given to the complex context in which a decision is made.