AMA Journal of Ethics^®

Abstract

Clinicians and organizations in the health sector have healing missions, and physicians, specifically, take oaths to “do no harm.” Yet, paradoxically, health care operations contribute to pollution and exacerbate environmental disease burden. This article offers a view of how health sector actions exacerbate climate warming and iatrogenically harm global public health and argues that clinicians and organizations have ethical responsibilities to respond.

Lessons From the Syringe Tide

Medical waste management ethics came into focus in the late 1980s, when HIV-contaminated syringes, needles, and other medical trash washed up on East Coast beaches.¹ Known as the Syringe Tide,¹ this environmental disaster led to awareness of improper disposal of sharps and infectious waste as exacerbating pollution and increasing pathogen exposure and needlestick injuries and prompted passage of the Medical Waste Tracking Act of 1988.² A movement to properly segregate and dispose of medical waste to protect human and planetary health had begun.

As this example illustrates, the health sector’s waste management practices can have health impacts. Despite the age-old, ethical code of medicine to “do no harm,” the health sector, through its direct and indirect emissions and waste management practices, contributes to many conditions that clinicians that aim to treat. Professionals and organizations have responsibilities to reconcile such ethical inconsistency and to better align their commitment to nonmaleficence with the consequences of their actions. In what follows, we discuss how health sector actions exacerbate climate warming and iatrogenically harm global public health and argue that clinicians and health organizations have ethical responsibilities to respond to the health sector’s contribution to the climate crisis.

Organizational Nonmaleficence

In the 1990s, the US Environmental Protection Agency (EPA) identified medical waste incineration as a major source of emissions of carcinogenic dioxins³ and mercury,⁴ a potent neurotoxin. In response, 28 organizations came together to form Health Care Without Harm (HCWH), founded on the health sector’s responsibility to reduce its environmental impact on health.⁵ In 1998, the American Hospital Association, HCWH, and the EPA signed a memorandum of understanding agreeing to virtually eliminate mercury from waste streams by 2005.⁶ Leveraging the do-no-harm message, HCWH led campaigns to eliminate mercury-containing thermometers and devices from hospitals and pharmacies and to close thousands of medical waste incinerators while promoting non-incineration technologies (eg, autoclaves, microwaves) to decontaminate infectious waste.⁵ The campaigns led to near-elimination of the market for mercury-based measuring devices in the United States and eventually culminated in the Minamata Convention on Mercury, a global agreement to phase out mercury.⁷ The coalition also identified ways to reduce waste and pollution,⁵ and a sustainable health care movement was born.

Global Irony Management

Just as incineration of mercury-containing medical waste ironically poses a risk to public health, so does the industrialization of health service delivery, which contributes to the climate crisis and indirectly harms human health. US hospitals produce over 5 million tons of waste per year.⁸ Fossil fuels are required to move regulated waste to facilities (eg, for incineration, chemical mitigation, or other energy-intensive treatment) before being landfilled, and the magnitude of such fossil fuel-dependent transportation and treatment contributes to health care’s climate footprint. The World Health Organization has identified climate change as the “single biggest health threat facing humanity.”⁹ The global health community is united in its concern about the climate health crisis, delivering an unprecedented and powerful message calling for urgent climate action to protect health in an editorial simultaneously published in more than 200 journals¹⁰ and in an open letter signed by more than 600 organizations representing 46 million health workers that urged world leaders at the Conference of the Parties (COP26) to commit to aggressive climate goals to avert the impending health catastrophe.¹¹ Health care leaders, in addition to policymakers, would be wise to heed such stark warnings from the world’s doctors and nurses. Despite COVID-19 and the numerous challenges currently facing health care, the sector does not get a pass on climate action. Instead, it must urgently leverage its moral, political, and economic influence to lead climate solutions.

Resultant indirect public health harms of US health care emissions, which constitute 27% of the global health care footprint¹² and 8.5% of US greenhouse gas (GHG) and other toxic pollutant emissions,¹³ are on the same order of magnitude as medical errors,¹⁴ directly undermining the sector’s aim to avoid harm. One must question why the sector has not addressed harms caused by its operations with the same urgency with which it has responded to some iatrogenic harms, such as medical errors.¹⁵ To appreciate the myriad ways that health care activities generate emissions, it is important to understand the sources of GHG emissions, which are classified into 3 scopes. Scope 1 refers to emissions generated directly from a facility (eg, from on-site energy generation or fleet vehicles or from operating rooms’ generation of waste anesthetic gases, such as desflurane and nitrous oxide^16,17). Scope 2 refers to indirect emissions generated from energy purchased from a utility provider, such as electricity or steam.¹⁸ The greatest source of emissions (62% in the National Health Service¹⁶ and 82% in the United States¹³) are indirect Scope 3 emissions generated by activities such as product transport, employee commutes, business travel, waste generation, food and pharmaceuticals, and investments.¹⁸ Every health care activity—from nonclinicial services, such as cooking, cleaning, and maintaining facilities, to performing surgeries—consumes energy, requires materials, and generates waste, all of which add to health care’s climate impact.

Clinical Care and Emissions

Clinical care is the single largest contributor to health care emissions.¹⁴ Clinicians order tests and treatments, perform procedures and surgeries, and prescribe pharmaceuticals daily. However, such interventions can be overused and may not always add value, with a low-value test or procedure delivered to an older adult every 80 seconds in a US hospital.¹⁹ Factors that promote low-value care include fear of litigation, payment systems, pharmaceutical and device production, and a culture of intention to do everything possible for a patient.²⁰ While previous calls for reducing low-value care have focused on cost reduction and patient safety, reducing overdiagnosis, overprescribing, and overtreatment can also help reduce emissions. Clinicians have an ethical responsibility to evaluate clinical care choices through a climate lens and to minimize unnecessary surgeries, tests, interventions, and medications to help reduce health care’s environmental impact without compromising patient safety and quality.

Resultant indirect public health harms of US health care emissions are on the same order of magnitude as medical errors.

Clinicians also have an ethical responsibility to reduce the demand for health care services and keep people out of the hospital. Our current health care system functions as a “sick care” system,^21,22 with a reimbursement model designed to incentivize resource-intensive health care utilization, not prevention. The result is an unsustainable cycle: acute and chronic illness lead to health care utilization, which leads to emissions and pollution, which in turn leads to increased burden of disease. For health care to become more sustainable, there must be a focus on preventive care, which would reduce the demand for health care utilization, lessen emissions, and help realign health care with its mission.

Slow Response

Given the toll that climate is having on human health and that extreme weather events can impair health care access and delivery, one would think that health care would be at the forefront of climate solutions. Ironically, that isn’t the case, and while some health systems are making significant progress, US health care emissions overall rose between 2010 and 2018.¹³ Thus, the medical community has been slow to recognize connections among climate, health, and health care. Perhaps the health harms from climate change feel distant and abstract compared to the immediacy of patient care. Quite possibly, health professionals believe they are already doing enough “good” and don’t need to do more. The majority of health professionals haven’t received education on health care emissions or training on how to implement sustainable solutions,²³ and there has not been enough research conducted to understand the magnitude of the problem or enough data disseminated to allow health professionals to make evidence-based interventions. Finally, there is often a lack of awareness of the strong business case for sustainable health care and a misperception that “greening” is costly.²⁴

There are currently no comprehensive regulatory or sector-wide mandates for sustainable health care or sustainability reporting, and health care organizations lag behind other sectors in sustainability reporting, a common practice among large businesses.²⁵ Moreover, there is a stark contrast between traditional and sustainability hospital committees. Hospital committees related to quality, value analysis, and ethics are often required by regulators or hospital administration. Such committees play a critical role in management and decision making and are bolstered by oversight, staffing, and resources. In contrast, hospital sustainability committees or “green teams” are often initiated by employees, led by volunteers, and without oversight or accountability. While a few health systems have staffed sustainability programs, most do not have a full-time employee dedicated to the role, and some sustainability leaders have been charged with embedding an entire facility’s sustainability work within another role, such as facilities director or executive chef (Janet Howard, personal communication, November 2021).

Oversight and Transformation

Historically, the nation’s guiding bodies that provide oversight of the health sector have neglected to meaningfully account for environmental performance and emissions in metrics or reporting requirements. However, in November 2021, the Biden administration committed to decarbonizing US health care through the COP26 Health Programme,²⁶ with Assistant Secretary for Health for the US Department of Health and Human Services (HHS), Admiral Rachel Levine, announcing that the United States would start by decarbonizing federal health care facilities.²⁷ This announcement was followed by President Biden signing an executive order in December 2021 requiring all federal facilities to decarbonize in alignment with the national GHG reduction commitment by achieving a 50% reduction in federal building emissions by 2032 and net-zero federal buildings by 2045, including Veterans Health Administration and Defense Health Agency facilities.²⁸ Moreover, in 2021, the National Academy of Medicine formed the Action Collaborative on Decarbonizing the US Health Sector, a partnership of health sector leaders—including leaders from the Joint Commission, HHS, and the Centers for Medicare and Medicaid Services²⁹—committed to reducing the sector’s climate impact while strengthening its resilience.³⁰ Finally, on Earth Day 2022, HHS and the White House issued a call to action to the health care sector to commit to tackling the climate crisis by reducing its GHG emissions and increasing its climate resilience.³¹ They asked health organization stakeholders to sign a pledge committing to reducing their organization’s emissions by 50% by 2030 and to net zero by 2050, completing an inventory of Scope 3 emissions, developing climate resilience plans, and designating an executive lead for this work.^31,32

Creating a low carbon, climate-smart health care sector will require transformational change. A climate lens must be applied to every aspect of health care decision making: facility operations, food services, supply chain, employee commutes, waste management, clinical care, and financial investments (see Table for suggestions). Moreover, we must move toward preventive health care and efficient, value-driven care. To avert the most devastating health effects of climate change, the health sector must join other sectors in halving emissions by 2030 and achieving net-zero emissions by 2050. If the sector continues on a business-as-usual path, health care emissions are predicted to triple by 2050.³³ Health care has 2 choices: urgent mitigation or further contribution to suffering. Only one choice is moral. The only ethical future is one in which health care does not cause harm to patients and the planet.