Healthcare Resource Allocation and Environmental Sustainability

Our healthcare systems are responsible for delivering essential, often life-saving care to patients within the society that they serve. It has long been recognised that healthcare systems, as basic social institutions, have duties of health and social justice.1 Healthcare systems should help ensure people are free of preventable morbidity and mortality2 and able to function normally3 such that they can achieve either a normal lifespan of decent quality4 or an optimal lifespan of high quality.5 As such, healthcare systems must provide equal access to high-quality healthcare and services for their society's population and ensure protection against financial hardship due to out-of-pocket healthcare expenditures, especially for the poor and disadvantaged.6 Healthcare systems, however, as they currently operate, are also substantial contributors to environmental damage through, among other things, greenhouse gas emissions, air pollution, toxic and nontoxic waste production, consumption of nonrenewable resources and changes to land-use that may damage existing natural environments.7 Some of these effects of healthcare provision are directly or indirectly detrimental to human health and well-being, such as pollution and greenhouse gas emissions, and others may irreparably harm the environment, such as threatening the survival of a particular species. Thus, the (ideally but not always in practice) equitable delivery of healthcare generates harm to the environment that has an adverse effect on the health of those that healthcare systems are trying to serve.

For that reason, healthcare systems across the world are endeavouring to reduce their environmental impacts. At COP26, 50 countries pledged to transition to climate-resilient and low-carbon health systems, with 14 countries setting a target date of reaching net-zero emissions by 2050.8 Yet this leaves healthcare as an enterprise with a conundrum: How should it allocate its resources in a way that accounts for the environment? How should it make decisions about allocating its resources to the equitable delivery of healthcare versus to minimising that healthcare's negative environmental impacts? The problem arises because allocating resources to measures to minimise environmental impacts seems to compete with healthcare's core mission of saving lives.

These resource allocation questions can also be posed at multiple levels of healthcare decision making: for example, from international and national policy makers, through hospital leaders and managers, and finally to individual healthcare practitioners in a clinical setting.

In this special issue, we present several contributions that explore those questions. They were each developed and refined through a series of webinars hosted by the Queensland Bioethics Centre at Australian Catholic University, during which the contributors to this issue were able to present and workshop their contributions through robust conversation, first with an assigned respondent, and then with the other contributors to the special issue. The contributions in this issue offer different approaches, both in where they see the problem, and in how they seek to address it.

In part, this reflects differences in the way in which moral reasoning is employed to solve the problem in the various contributions. Those who favour a deontological approach emphasise particular duties or rules, though this leaves open the question of which ones, who sets them, and on what grounds. Those with a more teleological approach will focus on the positive outcomes of a decision, but this leaves open questions of the conception of the good that is to be promoted and the relative value of different goods. And finally, those with a more virtue-based approach argue that the virtues of the individual actors are what matter, though this might raise the question of how they actually solve the moral problems. This map of different ethical approaches is no doubt familiar territory for those involved in applied ethics.

Beyond different ethical approaches, it is also possible to take different positions on at least three axes that, in turn, generate different answers as to how the resource allocation problem should be addressed.

In terms of the nature of healthcare's responsibilities, at one end is a position that says that healthcare has no environmental obligations; its purpose is solely to pursue acute therapy or care for humans in need. This has been called the ‘absolute healthcare exceptionalist’ position.9 At the other end is the ‘non-exceptionalist’ biocentric view that environmental goods should always override acute healthcare needs since the future of all life as we know it on the planet is otherwise in jeopardy. In terms of who is responsible, views might be mapped between those who see lawmakers as the only relevant decision makers and those who see individual healthcare practitioners as the only relevant decision makers. Finally, in terms of conceptions of health and healthcare, views could be mapped between those that seek to address the problem by redefining the terms and frame of reference that underpin it and those that seek to double-down on status quo conceptions of key terms.

The above map of the moral landscape of the problem serves a useful guide to the contributions in this special issue. We believe that, with this map in mind, the strength of the collection of contributions in this special issue is that it demonstrates how various ethical approaches to the problem say we should address it, which will, hopefully, encourage and empower those who are actually making these kinds of decisions every day.

The first contribution by Luca Valera, ‘Time to Expand a Paradigm: Healthcare Sustainability and Eco-ethical Assessment’, takes an approach to the problem that leans towards the category of redefining the terms and frame of reference to give a more prominent place to environmental considerations. Valera seeks to reinvigorate Van Rensselaer Potter's view of bioethics as necessarily including concern for the environment as an antidote to overly individualised medical ethics that Valera sees in the ‘Georgetown approach’. He combines Potter's view with the deep ecology of Arne Naess to reframe the problem of allocation of healthcare resources as one that is fundamentally relational and environmentally embedded. Based on this alternative framing, he derives a set of (deontological) pragmatic considerations for the future of healthcare: wellbeing rather than cure, shared responsibility rather than individual responsibility, environmental community rather than merely individual, environmental stewardship rather than merely anthropocentricism or biocentrism, and epistemic humility.

In contrast to Valera, the second contribution by James Hart, Sapfo Lignou, and Mark Sheehan, ‘Environmental sustainability and the limits of healthcare resource allocation’, sticks to status quo definitions and argues that, at the level of hospitals and healthcare practitioners, there is no ‘duty’ to the environment. They argue that trade-offs are inevitable and complex, and so are beyond the remit of healthcare decision makers and should be made by policymakers at a ‘higher’ level. The responsibility of hospitals is limited to provide the best healthcare they can within the rules (again a deontological approach) set by the ‘higher level’. Perhaps this could be described as a moderate healthcare exceptionalist position, since they still acknowledge the problem and the responsibility of healthcare to enact what policymakers decide.

The third contribution by Joshua Parker, ‘Sufficiency and healthcare emissions’, offers a window into what such a policy-driven healthcare landscape might look like. Focussing on the problem of emissions, he argues that sufficientarianism provides a way to both set an emissions target for healthcare systems, and share the burden of mitigation fairly. Decisions are made about what constitutes ‘enough’ healthcare, and then, based on this, thresholds are established for permissible emissions. Healthcare or certain kinds of healthcare may be permitted more emissions in the interests of fairness to achieve ‘sufficient’ health. It thus reflects a ‘moderate healthcare exceptionalism’, rather than absolute healthcare exceptionalism or non-exceptionalism, as its environmental obligations are constrained by the necessity of maintaining its core goals like protecting sufficient health. The approach is also interesting because, like Valera's, it requires a redefinition of health and healthcare, in this instance defining what is sufficient health, from which flow rules that aim to secure the good ends of sufficient health and emissions reduction. It is like Hart et al. in that it seems to put the decision in the hands of a ‘higher level’. At the same time, it leaves open a range of possible decisions about resource allocation under this threshold.

Alistair Wardrope's contribution, ‘Thinking like a mountain: A land ethical approach to healthcare resource allocation’, is like Valera's in that he uses Leopold's Land Ethic to reframe what is meant by healthcare so that the problem is approached from a diachronic, holistic and biocentric perspective. Wardrope, likewise, argues for a set of rules to govern resource allocation in healthcare, but in this case, they are the planetary boundaries that act as a ‘side constraint’ on decision making. So, like Parker's sufficientarian approach, this leaves a lot of scope for different approaches to actual decisions, but, contra Parker, the thresholds are set not by concerns for human health but for planetary health. Yet, though this appears at first to lean towards a stronger ‘healthcare exceptionalism’, it is probably more moderate than at first sight. Wardrope contends that the Land Ethic's ‘ethical sequence’ does not call for the total subjugation of individual interests to the needs of the biotic community. Unlike Hart et al., it seems Wardrope's approach would allow for decisions at a variety of levels of healthcare decision making.

What none of the contributions introduced so far has addressed is the problem of how to allocate resources between environmental goods (minimising healthcare's environmental impacts) and health goods (equitable healthcare delivery). We focus on the level of hospital decisions in our article in this issue, ‘In hospital resource allocation conflicts between health goods and environmental goods, a relational, co-benefits frame, rather than a dualistic, competing goods frame, is key’. Our contribution, like others, also seeks to redefine what is meant by health and healthcare. Our point of departure for this, however, is a relational personalist anthropology that situates the human person as meaning-making subject in relationship to all that is. The result is that environmental goods are now considered within rather than as opposed to health considerations, and decisions are made with reference to a relational personalist criterion. The use of this personalist criterion means that our position could also be characterised as moderate healthcare exceptionalism. This means that decision-makers (and we considered particularly hospital level decisions, though such an approach could also work for health system policymakers) should think beyond their defined roles in hospital operation and administration to find creative solutions that can result in co-benefits for both human health and the environment, rather that adopting zero-sum thinking that gives rise to a competing goods dilemma. Where no co-benefits are possible, this relational approach to health means that classical resource allocation methods of proportional benefit and burden can still be used to make decisions (about a now wider range of goods, that is, health and environmental, rather than merely health goods) in cases of health/environmental or even environmental/environmental goods conflicts.

It must be acknowledged that for any of the approaches discussed so far, absolute certainty that a decision about resource allocation is the morally right one would be difficult to guarantee. Certainly, establishing rules as proposed by Hart et al., Parker, and Wardrope can provide an external ‘performance indicator’. Still, like in research ethics, there is arguably a moral difference between monitoring whether a rule has been broken and promoting the moral integrity of the actors. The final contribution to this special issue offers an angle that takes the question of moral integrity seriously. Xavier Symons, in ‘The virtues of limits and environmental sustainability in healthcare’, shows how, given the complexity of the situation, a turn to virtues may offer a solution. The virtuous healthcare decision maker, according to Symons, will appreciate the value of healthcare and environmental resources and so employ stewardship (echoing Valera) to carefully manage these resources rather than waste them. Symons's contribution is useful because, in the context of the other contributions, it reiterates something about which there can be little doubt, namely that promoting virtuous decision-making in this area is crucial.

For us, two things stand out after consideration of the problem of healthcare's contributions to environmental damage and the various approaches to solving it set out in the articles in this special issue.

First, as is to be expected, a range of ethical approaches give rise to a range of positions on how to allocate healthcare resources to account for the environment. These positions fall mostly into the moderate healthcare exceptionalism category.

Second, the moral nature of the decisions being made seems inescapable. By that, we mean that there is no mathematical solution to the problem that enables one to know with absolute certainty that one is doing the right thing. Choices about the underlying worldview we use, what rules we apply (or obey), the goods we pursue, the relative value we place on them and the virtues we cultivate are all choices of a moral or ethical nature, not a mathematical or empirical one. Since making these kinds of moral decisions is something that is fundamental to our nature as free and rational beings who seek to realise the Good, we can only ask that people inform themselves of the facts to the greatest degree reasonable given their roles in healthcare decision making, and make the best moral decisions they can based on reasons and reasoning that can be ethical reasons for other people,10 such that they can reach a conscientious judgement about the ‘right thing to do’ and so be prepared to bear personal responsibility for it.