Green inhaler prescribing and the ethical obligations of physicians

In an accompanying feature article, Parker argued that general practitioners should support efforts by the National Health Service to reduce greenhouse gases by avoiding metereddose inhalers and by prescribing similarly effective inhalers with smaller carbon footprints. 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. 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 for patients to consider other ways in which they can protect the environment. Doctors should not stop at advising about inhaler use but advise about other personal behaviours related to their potential roles in mitigating climate change such as dietary modifications, the use of transportation and the use of energy in the home. This information can be provided by a variety of supplemental sources including pamphlets and other educational materials. Patients will be receptive to advice from their doctors on how to protect the planet and will be empowered when they act to do so. After all, patients with respiratory diseases have a special stake in reducing air pollution given how they are likely disproportionately affected by it. Counselling about inhaler use and other methods for mitigating climate change should become a habit for doctors in concert with broader public health initiatives, not dissimilar to other strategies such as curbing gun violence, reducing cigarette smoking, reducing unintentional poisoning and improving motor vehicle safety. Second, the behaviours of doctors should align with those expected of patients. That is, to be effective counselors, doctors should demonstrate that they are serious about climate change. Patients will notice subtle factors and behaviours after all that may suggest otherwise. How doctors behave, not only in their professional roles but outside of work, is a critically vital component of professional identity when responding to the urgent challenges posed by climate change. Doctors as behavioural role models should strive to act with integrity in all aspects of their lives. Third, how doctors counsel and how they behave will have consequences for how patients trust them. Parker commented on the role of trust in the context of patients’ refusal to change from a metered inhaler to a more environmentally friendly dry powder inhaler, in part because failing to respect a patient’s refusal undermines the contribution of informed consent to trust. Trustworthiness is the cornerstone professional virtue in the practice of medicine. Patients will trust doctors who are sincere, ethical and committed to social causes. Patients will also be more likely to comply with their doctor’s recommendations when they are trusted and when their counsel is effectively presented. Individual doctors, therefore, need to learn about the science of climate change. And doctors will need to know how to become effective educators about the climate. Medical schools and healthcare organisations should support these initiatives. This education should start in medical schools and primary care specialty training programmes. Practising doctors and medical school educators, however, might not be familiar with the related sciences. One educational challenge is that many of the scientific advances on climate change are published in science and nature journals that are not routinely read by doctors. Moreover, those scientific methodologies are not necessarily familiar to doctors. How many general practitioners, for example, know about the potential effects of the different classes of inhalers on the climate, and then alter their prescribing habits accordingly? Furthermore, the medical profession should be transparent about any efforts to mitigate climate change. One excellent development is that health organisations in the UK have been ranked based on their sustainable policies on procurement and waste, transport and food, divestment from fossil fuels, as well as on actions taken to prepare their members for clinical practice in a climatechanging world. When members of the profession are working in close collaboration with each other and with their professional organisations, and in synchrony with the best science, their efforts are more likely to be effective and to be trusted. Doctors and their professional organisations should seize this opportunity to inform patients and the public about how to mitigate climate change and how to protect the environment. It is unethical not to do so and there is no time to lose. As Parker has shown, even when choosing what inhalers to prescribe, the stakes are very high indeed.