AMA Journal of Ethics^®

Case

Ms. Chen had been going to Dr. Patel’s outpatient gynecology practice for several years for her annual well-woman exam. The rural clinic was understaffed, and it was all the few participating physicians could do to manage the patient load.

A few months before Ms. Chen’s yearly check-up, Dr. Patel’s small group practice instituted a policy to stop using plastic specula for gynecological exams. The clinic-wide policy was an effort to reduce waste and avoid the increased shipping costs of plastic specula. Signs were posted in the clinic waiting area that informed patients of the practice’s decision to “go green,” and thanking them for their understanding and continued support.

Ms. Chen preferred the single-use plastic speculum, however, for hygiene reasons. She did not want to get a sexually transmitted disease from an improperly sterilized instrument and requested a single-use plastic speculum for her exam. Dr. Patel informed her that the clinic no longer stocked them and reassured Ms. Chen that measures had been taken to guarantee the metal specula were properly sterilized.

Commentary 1

Dr. Patel and her small group practice should be commended for “going green”—a movement that has become common in both large academic centers and public hospitals. Experts estimate that U.S. hospitals produce an average of 6,600 tons of waste per day. Over the past 10 years, waste production has increased as much as 15 percent with the escalating use of disposable, single-use products such as plastic specula [1]. Much of our medical waste is incinerated, with the resultant release of noxious gases that many argue are detrimental to the environment [2]. Movement toward recyclable materials should be encouraged not only as a cost-saving measure for hospitals and clinics but also as a necessary change to alleviate some of the burden of medical waste.

At the same time, Ms. Chen should not be faulted for expressing a fear, however unwarranted, that a change to a metal speculum would expose her to infectious disease. She is most likely unaware of the inherent safety of sterilization procedures. Perhaps Dr. Patel could educate her about this, which may or may not alleviate her fears. Ultimately, if Ms. Chen refuses an exam with a sterilized speculum, as the case asks, must Dr. Patel provide her choice of speculum? The answer is probably no.

As a question of principle, Dr. Patel should enforce the new green policy uniformly. Making exceptions in individual cases opens the door to an untenable situation. If enough patients demand specific nonreusable materials, this small practice might end up with a large stock room full of alternative materials. Even assuming one could charge the patient the cost of the speculum or other material, maintaining a room of alternative materials would be cost-prohibitive. More importantly, it would violate the group’s new commitment to green practices, not only by including nongreen materials it had decided to exclude, but also by providing a market, albeit small, for them.

An argument might be made that Ms. Chen suffers from mysophobia (i.e., germaphobia) and that this condition could be recognized as a disability. Certainly no physician can refuse necessary medical care to a patient because of a disability, and the case implies that Ms. Chen cannot easily find another source of medical care. It is even possible that this rural clinic receives federal funding, which might oblige staff to consider making a reasonable accommodation for patients with special needs. This does not automatically mean, however, that ordering plastic specula is a reasonable accommodation for Ms. Chen’s impairment.

Assuming a small, federally funded rural center might be required by law to consider accommodating Ms. Chen’s mysophobia, the accommodation would not stop with the regulation for a plastic speculum. If Ms. Chen needs a biopsy of her cervix, for example, a Tischler biopsy forceps will be used. There is no plastic single-use equivalent. Much of the equipment in physicians’ offices and operating rooms has no single-use equivalent. Ms. Chen might be surprised to learn this, since the process for obtaining consent to treat in either office or operating room does not include a specific description of the materials that will be used.

This raises a broader question. As offices and hospitals move forward to “green” their practices, what form of notification and consent is required? This clinic attempted to make patients aware of the change with a posted sign. But this sign did little to educate Ms. Chen about the relative safety of sterilized metal equipment, and there was no formal process to ensure she consented to this change in practice. It is unlikely that a formal consent process is legally necessary, based on the standard test of what a reasonable person in the patient’s position would want to know; there is no inherent change in the risk of using a metal speculum as opposed to a plastic one. Both pieces of equipment are considered standard of care, and a strong argument can be made that a patient need not be informed of each piece of equipment that will be used for treatment. That said, educating patients on the need for multiple-use equipment and addressing their concerns regarding safety is an important part of the process of “going green.” Perhaps in some instances, merely offering patients a handout that details the problem with medical waste and the process and safety of sterilization will suffice.

There may be situations, however, in which physicians should consider a formal consent process. One example is the trend toward sterilization of devices originally marketed for single-use in the operating room. A reprocessing industry has emerged that collects single-use products—such as laparoscopic trocars or skin staplers—sterilizes, and returns them to the hospital for reuse [3]. The process is inherently safe and does not pose any additional risk to the patient on whom the product is reused. These products, however, are being used in a way not originally intended. An argument can be made that patient consent must be sought specifically for reuse of these products and that they be allowed to opt out. This would make recycled products less attractive to hospitals and would severely hamper an important effort to make our hospitals “green.”

In sum, as hospitals move toward environmentally sound practices, the public must be educated about the safety of new “green” products. This education may take various forms, but without it the public is unlikely to accept alternatives that, at first blush, seem to put them at risk. There is no legal or ethical requirement, however, that physicians adhere to a patient’s request to use single-use products. A physician does not violate any duty to a patient by enforcing green policies in a practice.