Joshua Parker’s article on green inhaler prescribing is important and timely. I agree with much of it, specifically regarding the institutional duty to make climate-friendly changes (from environmentally expensive prescriptions to ‘greener,’ similarly effective ones). The challenge, however, comes in determining how that institutional obligation impacts the rights and duties of patients. In this commentary, I want to offer a friendly alternative to Parker’s view of individual patient obligation, which I suggest is important for reasons that go beyond this one (...) case. Parker’s broad view is that, because metered-dose inhalers (MDIs) emit far more greenhouse gases (GHG) than do dry powder inhalers (DPIs), and the two are equally effective for most patients, the healthcare system should switch most patients on MDIs to DPIs, and the patients have a pro tanto duty to accept this change.1 The problem is that no individual inhaler use causes harmful climate change, and so it is difficult to explain a duty not to use MDIs. It seems that my individual behaviour ‘makes no difference’ to climate change, so familiar more principles have a difficult time justifying a prohibition of such behaviour. Parker’s response to this worry fits into the consequentialist tradition,2 3 as he argues that each individual contribution to climate change causes some amount of ‘expected harm,’ because it contributes a little bit to future climate changes which will cause harm. And since we have a duty to minimise expected harm, we have a duty not to make such small contributions to climate change. I think we should be sceptical of this sort of argument. It makes the most sense if we endorse a bathtub metaphor, in which the atmosphere is like a bathtub, and once it is full, every …. (shrink)

Green bioethics is an area of research and scholarship that examines the impact of healthcare practices and policies on the environment and emphasises environmental values, such as ecological sustainability and stewardship. Some green bioethicists have argued that healthcare providers should inform patients about the environmental impacts of treatments and advocate for options that minimise adverse impacts. While disclosure of information pertaining to the environmental impacts of treatments could facilitate autonomous decision-making and strengthen the patient–provider relationship in situations where patients have (...) clearly expressed environmental concerns, it may have the opposite effect in other situations if makes patients feel like they are being judged or manipulated. We argue, therefore, that there is not a generalisable duty to disclose environmental impact information to all patients during the consent process. Providers who practice green bioethics should focus on advocating for system-level changes in healthcare financing, organisation and delivery and use discretion when bringing up environmental concerns in their encounters with patients. (shrink)

I am grateful for these four wide-ranging and incisive commentaries on my paper discussing the ethical issues that arise when we consider the carbon footprint of inhalers.1 As I am unable to address every point raised, instead I focus on what I take to be the common thread running through these papers. Each response has something to say regarding the scope of healthcare’s responsibility to mitigate climate change. This can be explored at the intuitional or structural level, or at the (...) individual patient and practitioner level leading to a further issue of the relationship between these perspectives. Coverdale argues for broadening the scope of individual responsibilities regarding the climate.2 Discussing inhalers does not go far enough and doctors, argues Coverdale, are well placed to draw attention to the various behaviour changes patients can undertake both through role modelling and in the clinic. While Coverdale makes some excellent points, I have three worries about his proposal. One is relevance. Climate concerns may not always be pertinent in the clinical encounter; think of counselling a bereaved patient or somebody needing a fit note. Related to this is opportunity. General practitioners capacity to cover an inordinate amount in a 10 min consultation …. (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)

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)

Arguably one of the strengths of the discipline of medical ethics is its close attention to the context in which ethical dilemmas, questions and issues play out. As a discipline that is concerned with helping and supporting practitioners, policy-makers and the public to address the ethical aspects of healthcare provision and practice in the best way they can, context is crucially important. As McMillian puts it, ‘ethics should be grounded’ in the practical realities of the situation.1 What, where and who (...) are important questions that set the parameters of the debate and, to some extent, frame the subsequent solution or decision. What is happening in a particular case, what is the source of controversy, is it a conflict of values, regulations or professional viewpoints? Where does it take place, under which rules, jurisdiction or in which professional setting? And who does it involve? Whose rights, interests or decision-making capacity do we prioritise? All these contextual questions need to be carefully articulated before it is possible to draw any normative conclusions. The importance of context is clear in this issue’s ‘Engagement without entanglement: a framework for non-sexual patient–physician boundaries’ by Appel.2 What might be seen as entirely appropriate behaviour in one context, for example, when I help out a friend and let them stay in my house for a few weeks while they recover from an operation, is entirely inappropriate in another—in …. (shrink)

In an accompanying feature article, Parker argued that general practitioners should support efforts by the National Health Service to reduce greenhouse gases by avoiding metered-dose inhalers and by prescribing similarly effective inhalers with smaller carbon footprints.1 He also argued that patients are not morally justified in declining to use dry powder inhalers which do not contain greenhouse gases and when judged to be readily available and similarly effective, unless, when patients resist that option, their trust in the professional relationship is (...) undermined.1 Prescribers should, therefore, take account of factors not only concerning the benefits and costs to individual patients including the strength of the professional relationship, but broader social considerations including potential effects on climate change and planetary health. In this commentary, I present three additional factors to broaden the context of Parker’s excellent analysis. The first is that a discussion with patients on the effects of various forms of inhalers on the environment may bring to their attention the seriousness of anthropogenic climate change and open opportunities …. (shrink)

When weighing up which inhaler to prescribe, a doctor may prioritise a patient’s preferences over the expected harms from the associated carbon emissions. Parker argues that this is wrong.1 Doctors have a pro-tanto duty to switch from a high-carbon metered-dose inhaler (MDI) to a low-carbon dry-powdered inhaler (DPI)—even though this provides no direct patient benefit—unless switching would undermine trust or significantly worsen a patient’s health. He goes on to state that even if DPIs are more expensive for the National Health (...) Service (NHS) then this is justified so long as it does not ‘significantly threaten’ the NHS’ ability to protect and promote health. This may appear to be a radical proposal, challenging the ethical principles of autonomy, health entitlements and justly distributed resources. However, we will claim that it is only radical in so far as one perceives (A) patient autonomy and healthcare entitlements as existing within a vacuum, unrelated to other foundational ethics concerns and (B) the health consequences of a given healthcare budget are limited solely to the designated recipients rather than all affected parties. Here, we test the claim that our responsibility for promoting patient autonomy …. (shrink)