Dual duties to patient and planet: time to revisit the ethical foundations of healthcare?

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. Doctors have a protanto duty to switch from a highcarbon metereddose inhaler (MDI) to a lowcarbon drypowdered 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 and avoiding harm coexists with our responsibilities towards the planet and one another, independently of national borders. This leads to a radically different starting point for considering the implications of the climate crisis for medical ethics and priority setting. An important overarching challenge relevant to the climate impacts of healthcare is how to balance the interests of individual patients with the population at large. This problem has long been discussed in terms of dual duties (or dual loyalties), which considers how doctors should balance duties to individual patients, their employer and the interests of other individuals within the healthcare system. 3 While a useful starting point, a significant limitation of this framing for our purposes is that it does not consider the interests of all the affected parties: healthcare can harm individuals outside the health system as well. A few examples include the dangerous working conditions for many people making surgical tools and equipment, the overseas export of contaminated clinical waste infecting individuals bordering refuse sites, and the hoarding of vaccines during intense global scarcity early in the COVID19 pandemic. In each case, efforts to address these harms have been piecemeal, where acknowledged at all; in practice, harms occurring beyond a country’s borders are routinely ignored in the moral and economic calculus. A key question is, therefore, not only whether carbon emissions cause harm (or expected harm), but whether climaterelated harms merit special attention? At one level, we can imagine that all significant negative externalities of healthcare production and delivery, including carbon emissions, would be embedded into the healthcare resource allocation criteria. The relative value of carbon emissions in this revised equation would, in turn, be contingent on many other ethical factors, including risk aversion (since the harms of a given quantity of emissions are uncertain), discount rates (since the negative impacts are concentrated in the future) and whether the population of concern is national or global (since climate impacts are largely imposed on people far away). This is not only difficult to quantify but value laden and morally complex to implement in practice. 9 Crucially, Parker is singling out climate impacts, rather than advocating a more general principle of taking all relevant externalities into account, thus sidestepping this problem. This is fully in accordance with the claim we are exploring here that respect for environment could be considered a fundamental and distinct ethical concern; moving closer to indigenous perspectives on sustainability and further from an anthropocentric world view. By taking this ethical starting point, the benefits and harms of carbon emissions do not directly become part of the distributional tradeoffs in healthcare resource allocation, nor do climate impacts have to be considered more important than other negative externalities. A further issue to consider briefly is cost. Parker states that the estimated drug costs of switching to DPIs is £12.7 million per 10% of inhalers switched, assuming the same brand profile of MDIs today. If the NHS target of a 50% reduction is achieved (a target Parker believes is ‘too modest’) this could cost £63.5 million per year or ~0.05% of the NHS annual budget. While an apparent solution would be to switch inhalers to same cost or ideally lower cost alternatives (to offset nondrug costs as well), Parker’s argument goes a step further: ‘the NHS should be prepared to accept these costs... insofar as this does not significantly threaten the NHS ability to protect and promote health.’(pg. 5). It is not clear how great a cost would be considered to ‘significantly threaten’ this ability; however, Parker is clear that where there is a tradeoff, health maximisation does not win out as a matter of course. Again, this can be tested as more comprehensively justified according to the broader foundational ethics approach we are suggesting. Understanding what it means to treat the climate impacts of healthcare as an ethical constraint will require cuttingedge normative work to see how parallel arguments emerging from the respect for autonomy and healthcare entitlements on the one side, and respect for the environment and the interests of all affected parties on the other, relate to each other. Parker’s work is a valuable contribution to this emerging debate. With the climate emergency now on us, it is imperative that the ethical implications of healthcare’s carbon footprint receives the wider scholarship it deserves.