Barriers to green inhaler prescribing: ethical issues in environmentally sustainable clinical practice

Abstract

The National Health Service (NHS) was the first healthcare system globally to declare ambitions to become net carbon zero. To achieve this, a shift away from metered-dose inhalers which contain powerful greenhouse gases is necessary. Many patients can use dry powder inhalers which do not contain greenhouse gases and are equally effective at managing respiratory disease. This paper discusses the ethical issues that arise as the NHS attempts to mitigate climate change. Two ethical issues that pose a barrier to moving away from metered-dose inhalers are considered: patients who decline an inhaler with a smaller carbon footprint and increased cost. I argue that while a patient is not morally justified in refusing a more environmentally sustainable inhaler due to the expected harms, a doctor may still prescribe a metered-dose inhaler if they believe that switching without consent might undermine trust or substantially worsen the patient’s health. Turning to cost, I argue that the imperative to combat climate change means the NHS should accept small increased financial costs for lower carbon inhalers, even though this provides no additional direct benefit for the patient. I then go on to consider the implications of the preceding analysis for policy and practice. I argue for a policy that minimises the impact of inhalers on the climate by advocating for a principle of environmental prescribing and explore decision-making in practice. While the arguments here pertain primarily to inhalers, the discussion has broader implications for debates around healthcare’s responsibility to be environmentally sustainable.

Green prescribing is good, but patients do not have a duty to accept it

“…Parker’s broad view is that, because metered-dose inhalers (MDIs) emit far more greenhouse gases (GHG) than do dry powder inhalers (DPIs), and the two are equally effective for most patients, the healthcare system should switch most patients on MDIs to DPIs, and the patients have a pro tanto duty to accept this change 1. The problem is that no individual inhaler use causes harmful climate change, and so it is difficult to explain a duty not to use MDIs.…”

Environmentally friendly inhalers: issues for the general practice consultation

“…Elsewhere, I summarise the discussion so far into a 'principle of environmental prescribing' 8 to try and guide clinical practice. In essence, the principle says: in the first instance, if two treatments are clinically equivalent then doctors and patients should opt for the one with the lowest carbon footprint, unless it might undermine trust or significantly worsen health.…”

Taking a moral holiday? Physicians’ practical identities at the margins of professional ethics

“…If this obligation conflicts with the ethical duty of protecting the environment, there is a tension between professional norms and ethical demands directed to everyone and not only to professionals. As an example, a critical situation might occur if a physician wants to prescribe a dry powder inhaler to a patient for the treatment of their respiratory disease, as this inhaler does not contain greenhouse gasses, but the patient refuses 33. Here the physician needs to decide between their duty to respect the autonomy of the patient as well as protecting the patient’s trust in the treatment and lessening the negative impact on the environment.…”