Sustainable development in healthcare causes and consequences. Signification, research and teaching

Healthcare activities are not only affected by global warming, but also by changes in nosography associated with environmental changes in the Global North and in the Global South. More than half of all known pathologies could be modified by climate change. Climatic hazards and changes in biodiversity are security threats that are forcing populations in the Global South to migrate. These population displacements have implications not only for health, but also for the social and political organization of health care.

More intriguingly, we are discovering that the practice of medicine itself may be contributing to environmental change. Far from being limited to carbon dioxide, healthcare infrastructures emit specific pollutants: xenobiotics, bacteria, viruses and radioisotopes. Pollutant production in hospitals is mainly related to the consumption of pharmaceuticals, energy and mobility. Some of the pollution associated with healthcare is unavoidable and could be managed with the appropriate techniques. Another part is caused by an inappropriate use of techniques and should be reduced.

Inappropriate medical prescribing impacts health, the economy and ecosystems. Overuse of medical services is estimated to be between 30% and 80% worldwide. It affects the Global North as much as the Global South and coexists with unmet medical need. For example, physicians in the Global North would quickly resort to the use of Computed Tomography (CT) scans for screening purposes or Positron Emission Tomography CT scans outside of formal indications, leading not only to radiation exposure but also to overdiagnosis. Overuse is also known in the context of inappropriate prescription of therapeutic agents. Antibiotic consumption in Southern Europe is three times higher than in Northern Europe, with no difference in overall survival, suggesting irrational consumption that contributes to the emergence of antibiotic-resistant microbes and their spread in the environment. This is just one example of a common bias in medicine in the Global North: that more diagnostic tests, more treatments, more procedures are better care. Unfortunately, we know that overtreatment can coexist with undertreatment because, for example, wasteful care can be very costly to national health services and prevent other important investments. In addition, overtreatment can have spillover effects into other therapeutic classes because the more you test, examine or treat, the more the risk increases.

These problems related to the way care is provided cannot be separated from the economic and regulatory environment in which the activity develops. Waste of medicines due to inappropriate packaging or use represents a significant cost to national health services. Hidden sources of pollution such as pharmaceutical manufacturing are other indirect sources of social and environmental concern. Fee-for-service medicine and fear of medical-legal repercussions encourage overuse of medical resources.

The overuse of medical resources presents a multifaceted challenge encompassing iatrogenic effects that escalate the demand for medical interventions, thereby compromising both patients' quality of life and life expectancy. Simultaneously, this overconsumption strains the availability of resources, exacerbating disparities in healthcare access. Additionally, it gives rise to pollution, which detrimentally affects essential societal needs, both directly and indirectly. Reducing such overuse and waste in health care offers multiple benefits, known as health - environments co-benefits. Healthcare practices contribute only a fraction of this pollution, while the pharmaceutical industry, veterinary medicine and agriculture are significant contributors. Nevertheless, healthcare providers should set an example by considering the cross-cutting nature of their impact on the natural environment.

Almost paradoxically, rather than encouraging the refinement of indications, the concern generated by pollution is encouraging the development of superfluous technologies designed to “clean up” what has been “polluted”. Such solutions create hyper-technological “islands of purity”, without any real consideration of the global environmental costs or of access to basic care for all humans. Faced with these facts, it seems necessary that medical doctors and, more generally, caregivers, consider environmental protection as one of the parameters on which they can intervene to prevent or even cure disease.

CO2 emissions from medical practices are a significant contributor to the ongoing environmental crisis. Reducing these emissions is essential for sustainable development in healthcare. But it cannot be the only focus. A significant change in the ideology of caregiving seems necessary. Reducing medical overuse, identifying unmet medical needs and medical prevention should be considered as non-subordinate actions to reducing greenhouse gas emissions. The medical ethics of the future needs to recognize the limits of the scope of individual practices in order to prevent collective harm from environmental change.
Such an ethical framework already exists and is encapsulated in the concept of "bioethics", first articulated by Van Rensselaer Potter. He presented it as the wisdom necessary for the use of technology. Similarly, Fritz Jahr advocated for “bioethics” as a moral obligation towards all living beings.
Awareness of the risks associated with our endangered environment is an opportunity to emerge from successive crises by reviving the original insights of bioethics' pioneers: an irrational use of technology is a risk for the individual as well as for the natural environment.

The UN's sustainable development objectives are applicable to the practice and teaching of medicine.