First do no harm? The ethics of sustainable health and social care

• Is it legitimate for health and social care professionals to conserve natural resources for future unknowable gain?
• What values should we apply in determining the costs and benefits of healthcare with high environmental impact?
• How can we ensure that ‘greening’ public services won’t have unintended consequences for health inequalities if specific activities are curtailed?
• Should environmental impact be taken into account in assessing the effectiveness of drugs?

These are among the questions posed in our report – The ethics of sustainable health and social care:  towards a framework for decision-making (Cox and Max, SCIE 2011) - recently published by the Social Care Institute for Excellence.

The report is the first ever attempt to tackle the potential ethical dilemmas associated with factoring environmental outcomes into different levels of health and social care decision-making, for example resource allocation and treatments.  It doing so, it challenges assumptions about health inequalities and environmental justice, intergenerational equity, and measurements of effectiveness.

Our aim was to inform the development of a new sustainable health and social care ethical decision-making framework. The report reviews the environmental and climate change ethics literatures in conjunction with health and social care ethical principles; it also summarises the deliberations of two expert seminars convened to help devise and review these principles and propose a way forward.

Addressing health and climate change together

From the Lancet UCL Commission on Climate Change and Health to the Marmot Review of health inequalities (cited in the Government’s public health white paper, Healthy Lives, Healthy People) to the Royal College of Physicians, there are powerful voices supporting action which promotes health and tackles climate change simultaneously. All this at a time of unprecedented fiscal challenge, radical transformation of the NHS and whole-scale review of social care funding.

Against this backdrop, we have a duty to consider the ethical ramifications of applying sustainable development principles to health and social care and ensure there are no unintended consequences for health and health inequalities.

In October 2010, the Social Care Institute for Excellence (SCIE), in partnership with the King’s Fund and the Ethox Research Centre at the University of Oxford, convened a multi-disciplinary expert seminar Valuing the Environment. The event stimulated discussion about the tough but necessary economic and ethical questions posed by steps to factor environmental outcomes into all levels of health and social care decision-making. The starting point was climate change and measures to reduce carbon emissions, but we also touched on wider environmental impacts such as waste and water use.  Questions considered in the seminar included:

• What are the ethical and economic implications of costing environmental impacts properly in allocative, treatment and priority-setting decisions in health and social care?
• If health and social care costs are to include costs to the environment, what should the benefits include?
• What ‘currencies’ can we use to account for environmental impact and is it sufficient to use carbon emissions?

Developing principles

SCIE has taken forward this thinking forward through a number of work streams within or associated with its Sustainable Social Care Programme.

On ethics, further work was undertaken to research the environmental, climate change and health and social care ethics literature and the themes that emerged from the seminar.  These findings formed the basis for a set of potential principles for ethical decision-making which were then tested in a second expert seminar, with a different but overlapping set of stakeholders.  The expert group debated to what extent health and social care professionals should take environmental sustainability into account in decision-making about the care of patients and clients.  Key themes to emerge were

• Distributive justice, including protecting the vulnerable and the relevance of the concept of ‘fair chore division’ for tackling climate change in this context.
• The challenge of weighting different social values and the interplay between them (such as: ‘not all carbon emissions are morally equal’).
• Opportunities and risks associated with the current health and social care reforms (which include a renewed emphasis on prevention and a drive towards increased integration of health and social care systems as productivity and efficiency requirements).
• Democratic legitimacy, procedural justice and choice:  when and how to involve patients and people who use services in decision-making.
• The need to broaden the discussion beyond climate change mitigation to adaptation and other environmental impacts, including costs and benefits (e.g. other forms of air pollution, biodiversity, use of natural resources).

Next steps

The deliberations of this seminar are discussed in the final section of our report, which also proposes ways forward. Our plan now is to develop a suite of scenarios that present particular challenges regarding integrating this thinking into every day practice. These scenarios will be designed to test and refine the principles with a wider range of stakeholders and, ultimately, produce a tool or tools to assist with decision-making in different contexts.

In due course, we hope to influence policy, advice and guidance such as the National Institute for Health and Clinical Excellence (NICE) social value judgements.

Further reading

• The ethics of sustainable health and social care: available to download.