Environmental sustainability and the carbon emissions of pharmaceuticals

Environmental sustainability and the paradox of prevention

The carbon emissions of global healthcare activities make up 4%-5% of total world emissions, with the majority coming from industrialised countries. The solution to healthcare carbon reduction in these countries, ostensibly, would be preventive healthcare, which is less resource intensive than corrective healthcare in itself and, as a double benefit, reduces carbon by preventing diseases which may require higher healthcare carbon to treat. This leads to a paradox: preventive healthcare is designed to give humans longer, healthier lives. But, by extending life spans, the carbon emissions of a person increase both over a lifetime and in the medical industry overall. At the same time, the need for higher carbon end-of-life care does not disappear, particularly in resource intensive countries. This article will first identify sources of healthcare carbon, focusing on the industrialised world, and explain various efforts towards healthcare carbon reduction, which include preventive healthcare. Second, it will develop the 'paradox of prevention'-that preventive healthcare may save healthcare carbon by proximally reducing the need for medical treatments, but also, paradoxically, result in more healthcare carbon both in an individual's life and in the medical industry. The third section will offer ethical principles for approaching the paradox of prevention. The conclusion will emphasise the need for institutional approaches to healthcare carbon reduction in the industrialised world, which will relieve some of the tensions of healthcare industry decarbonisation and individual healthcare carbon use.

The role of planetary health in urologic oncology

INTRODUCTION

Climate change and global warming are an omnipresent topic in our daily lives. Planetary health and oncology represent two critical domains within the broader spectrum of healthcare, each addressing distinct yet interconnected aspects of human well-being. We are encouraged to do our part in saving our planet. This should include the decisions we make in our professional life, especially in uro-oncology, as the healthcare sector significantly contributes to environmental pollution.

AREAS COVERED

There are many aspects that can be addressed in the healthcare sector in general, as there are structural problems in terms of energy consumption, water waste, therapeutic techniques, transportation and drug manufacturing, as well as in uro-oncology specific areas. For example, the use of different surgical techniques, forms of anesthesia and the use of disposable or reusable instruments, each has a different impact on our environment. The literature search was carried out using PubMed, a medical database.

EXPERT OPINION

We are used to making decisions based on the best outcome for patients without considering the impact that each decision can have on the environment. In the present article, we outline options and choices for a more climate-friendly approach in urologic oncology.

Green bioethics, patient autonomy and informed consent in healthcare

Green bioethics is an area of research and scholarship that examines the impact of healthcare practices and policies on the environment and emphasises environmental values, such as ecological sustainability and stewardship. Some green bioethicists have argued that healthcare providers should inform patients about the environmental impacts of treatments and advocate for options that minimise adverse impacts. While disclosure of information pertaining to the environmental impacts of treatments could facilitate autonomous decision-making and strengthen the patient-provider relationship in situations where patients have clearly expressed environmental concerns, it may have the opposite effect in other situations if makes patients feel like they are being judged or manipulated. We argue, therefore, that there is not a generalisable duty to disclose environmental impact information to all patients during the consent process. Providers who practice green bioethics should focus on advocating for system-level changes in healthcare financing, organisation and delivery and use discretion when bringing up environmental concerns in their encounters with patients.

Defending and Defining Environmental Responsibilities for the Health Research Sector

Six planetary boundaries have already been exceeded, including climate change, loss of biodiversity, chemical pollution, and land-system change. The health research sector contributes to the environmental crisis we are facing, though to a lesser extent than healthcare or agriculture sectors. It could take steps to reduce its environmental impact but generally has not done so, even as the planetary emergency worsens. So far, the normative case for why the health research sector should rectify that failure has not been made. This paper argues strong philosophical grounds, derived from theories of health and social justice, exist to support the claim that the sector has a duty to avoid or minimise causing or contributing to ecological harms that threaten human health or worsen health inequity. The paper next develops ideas about the duty's content, explaining why it should entail more than reducing carbon emissions, and considers what limits might be placed on the duty.

Generational Exploration on Aesthetic Medicine Products: Influence of Social Media, Reviews, and Brand Identity-GEMS Bond Survey

INTRODUCTION

The study investigates the impact of social media reviews and brand identity on consumer preferences in the non-surgical aesthetics products across different generations. It highlights the evolving landscape of aesthetic medicine and surgery, driven by technological advancements and a cultural shift towards individual well-being. The research aims to explore the interplay between generational preferences, the influence of social media, and the role of brand identity in shaping consumer decisions.

METHODS

A cross-sectional study design was employed, with a sample size of > 5000 participants stratified across various generational cohorts. The study utilized an online questionnaire to capture both quantitative and qualitative insights into consumer behaviour, with statistical analysis performed to identify patterns and relationships.

RESULTS

Analysis of 5850 responses revealed distinct generational preferences and behaviours. Social media engagement varied significantly across generations, with younger cohorts placing a higher emphasis on online reviews. The study also found that brand identity's influence is diminishing in decision-making processes, with consumers increasingly relying on peer reviews and social media content.

CONCLUSION

The findings highlight a pivotal shift in the non-surgical aesthetics consumer market, emphasizing the growing importance of social media and peer reviews over traditional brand identities. Importantly, the study underscores the critical need for integrating patient safety and evidence-based practice within marketing strategies. As consumer preferences evolve towards valuing transparency and authenticity, non-surgical aesthetics providers must prioritize these elements, ensuring that their services are not only appealing but also grounded in safety and scientific validity.

LEVEL OF EVIDENCE IV

"This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ."

Are Physicians Obligated to Recommend a Plant-Based Diet? A Response to Maximilian Storz

Maximilian Storz argues that physicians have an ethical obligation to recommend a plant-based diet to patients because such a diet: relieves certain chronic conditions, outperforms the Western diet (e.g. a diet containing animal products, among other things), and is ecologically sustainable. Contrary to these claims, I argue that a plant-based diet alone may not relieve chronic conditions, but potentially does so in combination with other lifestyle factors. With respect to the environment, I illuminate the landscape by discussing agricultural factors consistent across animal and plant farming such as energy and water. I conclude that physicians ought to recommend a diet that follows the science; such a diet as I have claimed is exclusionary: it excludes processed foods, especially added sugars. Lifestylfe factors also deserve to be discussed in the medical encounter as their incorporation may lead to even better health outcomes.

A sustainable scheduling system for medical equipment: Towards net zero goals for green healthcare

Shortages of medical equipment, growth in medical waste and carbon emissions have increased healthcare pressures and has a huge impact on the environment. An efficient scheduling of medical equipment will effectively reduce the pressure on healthcare and improve the healthcare system's ability to respond to unexpected disasters. A medical equipment scheduling system was established to improve the sustainable utilization of medical equipment within the healthcare network and to reduce the carbon emissions of the healthcare process. First, this paper combines medical equipment information to establish a medical equipment scheduling decision model that considers pollution to filter qualified medical equipment for scheduling. Then, this paper constructs and solves a multi-objective robust optimization model by collecting the patient's travel information and the medical pressure information of each region. In addition, to meet dynamic healthcare needs, a dynamic medical equipment configuration framework was constructed to enhance the flexibility of equipment scheduling and the resilience of the healthcare network. Combined with case studies, the results show that the medical equipment scheduling system can help decision makers make quick scheduling decisions and achieve sustainable use of medical equipment, with a corresponding increase in medical equipment utilization of 12.25% and a reduction in carbon emissions of 26.50%. The study will help enhance healthcare resource utilization and contribute to the net-zero goal of green healthcare.

Expanding health justice to consider the environment: how can bioethics avoid reinforcing epistemic injustice?

We are in the midst of a global crisis of climate change and environmental degradation to which the healthcare sector directly contributes. Yet conceptions of health justice have little to say about the environment. They purport societies should ensure adequate health for their populations but fail to require doing so in ways that avoid environmental harm or injustice. We need to expand our understanding of health justice to consider the environment and do so without reinforcing the epistemic injustice inherent in the field of bioethics. This paper considers what work in philosophy related to the environment should be applied to help build that understanding and develops ideas about the healthcare sector's responsibilities of justice to the environment. It first introduces the dominant multivalent environmental and ecological justice (EJ) concept in philosophy and each of its dimensions: distribution, participation, recognition and well-being. It then shows why applying that conception alone to broaden our understanding of health justice will reinforce epistemic injustice within bioethics. Drawing on EJ literature from the global South, the paper demonstrates that different ontological and experiential starting points identify additional EJ dimensions-power and harmony-and give rise to a nuanced understanding of the recognition dimension relative to the dominant EJ conception. The paper concludes by applying them to articulate healthcare sector responsibilities of justice to the environment, demonstrating they ground responsibilities beyond reducing its carbon emissions.

Carbon footprints in minimally invasive surgery: Good patient outcomes, but costly for the environment

Advancements in technology and surgical training programs have increased the adaptability of minimally invasive surgery (MIS). Gastrointestinal MIS is superior to its open counterparts regarding post-operative morbidity and mortality. MIS has become the first-line surgical intervention for some types of gastrointestinal surgery, such as laparoscopic cholecystectomy and appendicectomy. Carbon dioxide (CO2) is the main gas used for insufflation in MIS. CO2 contributes 9%-26% of the greenhouse effect, resulting in global warming. The rise in global CO2 concentration since 2000 is about 20 ppm per decade, up to 10 times faster than any sustained rise in CO2 during the past 800000 years. Since 1970, there has been a steady yet worrying increase in average global temperature by 1.7 °C per century. A recent systematic review of the carbon footprint in MIS showed a range of 6-814 kg of CO2 emission per surgery, with higher CO2 emission following robotic compared to laparoscopic surgery. However, with superior benefits of MIS over open surgery, this poses an ethical dilemma to surgeons. A recent survey in the United Kingdom of 130 surgeons showed that the majority (94%) were concerned with climate change but felt that the lack of leadership was a barrier to improving environmental sustainability. Given the deleterious environmental effects of MIS, this study aims to summarize the trends of MIS and its carbon footprint, awareness and attitudes towards this issue, and efforts and challenges to ensuring environmental sustainability.

Pharmaceuticals in the Water: The Need for Environmental Bioethics

Pharmaceuticals are present in various water sources used by wildlife and as drinking water for humans. Research shows that certain pharmaceuticals, sold over the counter and by prescription only, can harm wildlife. Moreover, the human ingestion of water contaminated by polypharmacy presents a potential cause for concern for human health. Despite the wide scope of this problem, environmental bioethics has not adequately engaged with this topic and, instead, has concerned itself with healthcare waste products more generally. The present essay calls for more ethical investigation on the topic.

Technical Difficulties: Teaching Critical Philosophical Orientations toward Technology

Issue: Technological innovation is accelerating, creating less time to reflect on the impact new technologies will have on the medical profession. Modern technologies are becoming increasingly embedded in routine medical practice with far-reaching impacts on the patient-physician relationship and the very essence of the health professions. These impacts are often difficult to predict and can create unintended consequences for medical education. This article is driven by a main question: How do we prepare trainees to critically assess technologies that we cannot foresee and effectively use technology to support equitable and compassionate care? Evidence: We translate insights from the philosophy of technology into a proposal for integrating critical technical consciousness in medical curricula. We identify three areas required to develop critical consciousness with regard to emerging technologies. The first area is technical literacy, which involves not just knowing how to use technology, but also understanding its limitations and appropriate contexts for use. The second area is the ability to assess the social impact of technology. This practice requires understanding that while technification creates new possibilities it can also have adverse, unintended consequences. The third area is critical reflection on the relationship between 'the human' and 'the technical' as it relates to the values of the medical profession and professional identity formation. Human and technology are two sides of the same coin; therefore, thinking critically about technology also forces us to think about what we consider 'the human side of medicine'. Implications: Critical technical consciousness can be fostered through an educational program underpinned by the recognition that, although technological innovation can create new possibilities for healing, technology is never neutral. Rather, it is imperative to emphasize that technology is interwoven with the social fabric that is essential to healing. Like medication, technology can be both potion and poison.

Production and possible reduction of greenhouse gases produced during GI endoscopy activity: a systematic review of available literature

BACKGROUND AND AIMS

Greenhouse gases (GHGs) that trap heat in the atmosphere are composed of carbon dioxide (CO2), methane, nitrous oxide and fluorinated gases (synthetic hydrofluorocarbons, perfluorocarbons and nitrogen trifluoride). In the USA, the health sector accounts for 8.5% of total GHG emissions. The primary objective of this systematic review was to critically analyse the carbon emissions data from GI endoscopic activity.

DESIGN

The GI endoscopy carbon cycle was evaluated at preprocedural, intraprocedural and postprocedural levels. We performed a systematic literature search of articles published on these issues until 30 June 2022 and discussed these available data on endoscopy unit GHG carbon cycle, barriers to reduce GHG emissions and potential solutions. The inclusion criteria were any full-text articles (observational, clinical trials, brief communications, case series and editorials) reporting waste generation from GI endoscopy. Abstracts, news articles and conference proceedings were excluded.

RESULTS

Our search yielded 393 records in PubMed, 1708 in Embase and 24 in Google Scholar. After application of inclusion and exclusion factors, we focused on 9 fulllength articles in detail, only 3 of them were cross-sectional studies (all from the USA), the others reviews or position statements. Therefore, the quality of the studies could not be assessed due to heterogeneity in definitions and amount of emissions.

CONCLUSIONS

Recognition of carbon emissions generated by GI endoscopy activity is critical. Although multiple limitations exists for quantification of these emission, there is an urgent need for collecting proper data as well as examining novel methods for reduction of these emissions for a sustainable endoscopic practices in the future.

Reducing the environmental footprint of gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement

Climate change and the destruction of ecosystems by human activities are among the greatest challenges of the 21st century and require urgent action. Health care activities significantly contribute to the emission of greenhouse gases and waste production, with gastrointestinal (GI) endoscopy being one of the largest contributors. This Position Statement aims to raise awareness of the ecological footprint of GI endoscopy and provides guidance to reduce its environmental impact. The European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) outline suggestions and recommendations for health care providers, patients, governments, and industry. MAIN STATEMENTS 1: GI endoscopy is a resource-intensive activity with a significant yet poorly assessed environmental impact. 2: ESGE-ESGENA recommend adopting immediate actions to reduce the environmental impact of GI endoscopy. 3: ESGE-ESGENA recommend adherence to guidelines and implementation of audit strategies on the appropriateness of GI endoscopy to avoid the environmental impact of unnecessary procedures. 4: ESGE-ESGENA recommend the embedding of reduce, reuse, and recycle programs in the GI endoscopy unit. 5: ESGE-ESGENA suggest that there is an urgent need to reassess and reduce the environmental and economic impact of single-use GI endoscopic devices. 6: ESGE-ESGENA suggest against routine use of single-use GI endoscopes. However, their use could be considered in highly selected patients on a case-by-case basis. 7: ESGE-ESGENA recommend inclusion of sustainability in the training curricula of GI endoscopy and as a quality domain. 8: ESGE-ESGENA recommend conducting high quality research to quantify and minimize the environmental impact of GI endoscopy. 9: ESGE-ESGENA recommend that GI endoscopy companies assess, disclose, and audit the environmental impact of their value chain. 10:  ESGE-ESGENA recommend that GI endoscopy should become a net-zero greenhouse gas emissions practice by 2050.

A pediatrician's guide to climate change-informed primary care

Despite the urgency of the climate crisis and mounting evidence linking climate change to child health harms, pediatricians do not routinely engage with climate change in the office. Each primary care visit offers opportunities to screen for and support children burdened with risks to health that are increasingly intense due to climate change. Routine promotion of healthy behaviors also aligns with some needed-and powerful-solutions to the climate crisis. For some patients, including those engaged in athletics, those with asthma and allergies, or those with complex healthcare needs, preparedness for environmental risks and disasters worsened by climate change is a critical component of disease prevention and management. For all patients, anticipatory guidance topics that are already mainstays of pediatric best practices are related closely to needed guidance to keep children safe and promote health in the setting of compounding risks due to climate change. By considering climate change in routine care, pediatricians will be updating practice to align with evidence-based literature and better serving patients. This article provides a framework for pediatricians to provide climate-informed primary care during the structure of pediatric well child and other visits.