Environmental and clinical ethics support decarbonising end-of-life care
Authors: Cristina Richie, Forbes McGain
Journal: The Lancet Planetary Health (2024)

The Viewpoint by Myles Sergeant and colleagues1Sergeant M Ly O Kandasamy S Anand SS de Souza RJ Managing greenhouse gas emissions in the terminal year of life in an overwhelmed health system: a paradigm shift for people and our planet.Lancet Planet Health. 2024; 8: e327-e333Summary Full Text Full Text PDF PubMed Google Scholar makes an important contribution to both environmental bioethics and clinical ethics, although the authors do not highlight their research as such. Environmental bioethics examines the intersection of environmental ethics, carbon emissions of health care, and climate effects on human health. Clinical ethics assesses the moral rightness or wrongness of actions within health-care settings, usually at the point of the therapeutic relationship: the patient and clinician. In environmental bioethics, we find that health care is predicated on the ethical principle of non-maleficence: primum non nocere. Yet, health care itself pollutes, contributing to climate change, ecosystem collapse,2Whitmee S Haines A Beyrer C et al.Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health.Lancet. 2015; 386: 1973-2028Summary Full Text Full Text PDF PubMed Scopus (1614) Google Scholar and systemic environmental racism,3Gutschow B Gray B Ragavan MI Sheffield PE Philipsborn RP Jee SH The intersection of pediatrics, climate change, and structural racism: ensuring health equity through climate justice.Curr Probl Pediatr Adolesc Health Care. 2021; 51101028PubMed Google Scholar thereby harming people and the planet.4MacNeill AJ McGain F Sherman JD Planetary health care: a framework for sustainable health systems.Lancet Planet Health. 2021; 5: e66-e68Summary Full Text Full Text PDF PubMed Scopus (109) Google Scholar The excessive carbon emissions of health care in the developed world are, often, forms of so-called wicked problems: multifaceted ethical issues that are interconnected. For instance, the Viewpoint by Sergeant and colleagues highlights the connections between end-of-life care, chronic disease, and polypharmacy, stating, "it is plausible therefore that hospitalisation during the terminal year might be responsible for a large portion of avoidable emissions". In clinical ethics, we see that health care harms individual patients and their families when treatments are given without concomitant clinical benefit or without regard for patient preferences due to an absence of informed consent. As the authors indicate, only "67% of older people have talked … about their care wishes" for advanced care and at-home palliation.1Sergeant M Ly O Kandasamy S Anand SS de Souza RJ Managing greenhouse gas emissions in the terminal year of life in an overwhelmed health system: a paradigm shift for people and our planet.Lancet Planet Health. 2024; 8: e327-e333Summary Full Text Full Text PDF PubMed Google Scholar The principle of respect for patient autonomy is the foundation of informed consent.5Richie C Greening the end of life: refracting clinical ethics through an ecological prism.in: Lysaught T McCarthy M Catholic Bioethics and social justice: the praxis of US health care in a globalized world. Liturgical Academic Press, Collegeville2018: 129-142Google Scholar Discussions about advanced care planning need to occur early and should not be limited to older people. Chronic and acute diseases and unforeseen medical emergencies affect people of all ages. The traditional goals of medicine—a foundation for clinical ethics—include "the care and cure of those with a malady, and the care of those who cannot be cured".5Richie C Greening the end of life: refracting clinical ethics through an ecological prism.in: Lysaught T McCarthy M Catholic Bioethics and social justice: the praxis of US health care in a globalized world. Liturgical Academic Press, Collegeville2018: 129-142Google Scholar In this way, carbon emissions are wisely and ethically expended and within heath-care ethics. When health care is overused, misused, or mismanaged, excess carbon emissions occur—contrary to environmental bioethics—and clinical standards are unmet. Steps can be taken by clinicians, and patients, to minimise the environmental impact of end-of-life care—as Sergeant and colleagues show—without compromising clinical care or clinical ethics. This ethical framing both complements and strengthens the arguments for decarbonising end-of-life care. FM reports grants or contracts from the Australian National Health and Medical Research Council, Medical Research Future Fund, Australian and New Zealand College of Anaesthetists, and College of Intensive Care Medicine, all paid to their institution; royalties or licences from The McMonty Hood (licenced to Medihood); patents for The McMonty Hood (owned by Medihood) and ReResp (owned by the University of Melbourne); and being the co-lead of the Sustainability Working Party for the College of Intensive Care Medicine. CR reports no competing interests.