Joshua Parker

This paper addresses the critical issue of decarbonising healthcare systems to help combat climate change. I focus on identifying the ‘agents of justice’ responsible for this transformation. Beginning with the claim that healthcare's greenhouse gas emissions cause injustice, the paper assumes that achieving a net zero healthcare system is essential for climate justice. The discussion centres on two prevailing perspectives: one that primarily assigns responsibility to healthcare organisations and another that holds individual healthcare professionals accountable. The paper advocates for a pluralistic approach to responsibility, contending that the complexity and scale of reducing healthcare emissions necessitate allocating responsibilities based on effectiveness. This leads to the identification of two types of responsibility: first‐order responsibilities, which involve direct actions to reduce emissions, and second‐order responsibilities, which involve supporting and ensuring the fulfilment of first‐order duties. The paper clarifies how mitigation responsibilities should be allocated across organisations and individuals by expanding the scope of responsibility to include a broader range of agents, both within and beyond the healthcare sector. By distinguishing between first‐order and second‐order responsibilities, the paper offers a clearer framework for understanding the distribution of obligations in achieving climate justice in healthcare. Ultimately, it underscores that focusing solely on direct mitigation efforts by organisations or clinicians is inadequate, and a more comprehensive, multi‐agent approach is required to effectively decarbonise healthcare systems.

Often lurking below the surface of many clinical ethical issues are questions regarding background metaphysical, epistemological, meta-ethical, and political beliefs. In this issue, authors critically examine the effects of background beliefs on conscientious objection, explore ethical issues through the lenses of particular theoretical approaches like pragmatism and intersectional theory, rigorously explore the basic concepts at play within the patient safety movement, offer new theoretical approaches to old problems involving decision making for patients with dementia, explicate and explore the problems and promises of machine learning in medicine, and offer us a non-rights-based argument for the just distribution of healthcare resources.

This issue of The Journal of Medicine and Philosophy is dedicated to topics in clinical ethics with essays addressing clinician participation in state sponsored execution, duties to decrease ecological footprints in medicine, the concept of caring and its relationship to conscientious refusal, the dilemmas involved in dual use research, a philosophical and practical critique of principlism, conundrums that arise when applying surrogate decision-making models to patients with moderate intellectual disabilities, the phenomenology of chronic disease, and ethical concerns surrounding the use of artificial intelligence in medicine. Throughout the issue, the themes of conceptual and moral boundaries in bioethics, critiques of current clinical ethics paradigms, and the importance of transparency are prominent.

In this paper, I am concerned with how healthcare systems ought to transition away from the greenhouse gas emissions that they have historically relied on to provide care. I address two questions in relation to this issue. The first is what emissions target should healthcare systems adopt? Second, is how should the burdens of mitigation be shared fairly in light of that target? I argue that sufficientarianism offers an attractive way to answer both of these questions because it is better situated to strike the right balance between healthcare benefits and the costs of mitigation than rivals. Sufficiency describes the view that what is important from the perspective of distributive justice is that individuals have enough. I argue that this ideal can be used to set a threshold of enough health from which an emissions threshold can be set. Once an emissions threshold is in place, this can be used to demarcate permissible from impermissible emissions in healthcare. In turn, the emissions threshold provides guidance on which emissions are liable to mitigation and when it would be fair for healthcare to shoulder the associated burdens. Permissible emissions, on the other hand, are necessary to secure sufficiency and so healthcare's mitigation responsibilities should be altered in light of this. I also discuss various alternative methods of setting an emissions target like net zero, zero emissions, emissions grandfathering and emissions egalitarianism. I point to several issues with these approaches.

Healthcare systems produce significant greenhouse gas emissions, raising an important question: should healthcare be treated like any other polluter when it comes to reducing its emissions, or is healthcare special because of its essential societal role? On one hand, reducing emissions is critical to combat climate change. On the other, healthcare depends on emissions to deliver vital services. The resulting tension surrounds an idea of healthcare exceptionalism and leads to the question I consider in this paper: to what extent (if any) should the valuable goals of healthcare form an exception to the burdens of reducing greenhouse gas emissions? The goals of this paper are twofold. One is to think about how to address the issue of healthcare exceptionalism. Second is to discuss the extent of healthcare’s climatic responsibilities. I examine two perspectives on healthcare exceptionalism. The first treats a responsibility to reduce emissions and the delivery of healthcare as separate issues, each governed by its own principle. I reject this view, proposing instead that we consider healthcare’s environmental responsibilities in conjunction with its essential functions. I defend an “inability to pay” principle, suggesting that while healthcare should indeed contribute to mitigating climate change, its obligations should be constrained by the necessity of maintaining its core goals like protecting health and preventing disease. Healthcare should be treated differently from other sectors, but not to the extent that it is entirely exempt from efforts to reduce emissions.

Healthcare practitioners have access to a range of ethical guidance. However, the normative role of this guidance in ethical decision-making is underexplored. This paper considers two ways that healthcare practitioners could approach ethics guidance. We first outline the idea of deference to ethics guidance, showing how an attitude of deference raises three key problems: moral value; moral understanding; and moral error. Drawing on philosophical literature, we then advocate an alternative framing of ethics guidance as a form of moral testimony by colleagues and suggest that a more promising attitude to ethics guidance is to approach it in the spirit of ‘critical engagement’ rather than deference.

Burnout among health professionals is at epidemic proportions. In response, many health institutions have emphasised the importance of self-care, relying particularly on the idea that doctors who are burned out provide worse care for their patients. Although not made explicit, this suggests that doctors might have a responsibility to their patients (and perhaps others) to practice self-care. This chapter explores the potential grounds for such an obligation. We suggest that while there is potential for a limited obligation of self-care, institutional emphasis on this risks instrumentalising doctors' well-being, minimising institutional responsibilities and workers' rights, and being excessively demanding for individuals.

There is a need for all industries, including healthcare, to reduce their greenhouse gas emissions. In anaesthetic practice, this not only requires a reduction in resource use and waste, but also a shift away from inhaled anaesthetic gases and towards alternatives with a lower carbon footprint. As inhalational anaesthesia produces greenhouse gas emissions at the point of use, achieving sustainable anaesthetic practice involves individual practitioner behaviour change. However, changing the practice of healthcare professionals raises potential ethical issues. The purpose of this paper is twofold. First, we discuss what moral duties anaesthetic practitioners have when it comes to practices that impact the environment. We argue that behaviour change among practitioners to align with certain moral responsibilities must be supplemented with an account of institutional duties to support this. In other words, we argue that institutions and those in power have second-order responsibilities to ensure that practitioners can fulfil their first-order responsibilities to practice more sustainably. The second goal of the paper is to consider not just the nature of second-order responsibilities but the content. We assess four different ways that second-order responsibilities might be fulfilled within healthcare systems: removing certain anaesthetic agents, seeking consensus, education and methods from behavioural economics. We argue that, while each of these are a necessary part of the picture, some interventions like nudges have considerable advantages.

The shift towards "empirical bioethics" was largely triggered by a recognition that stakeholders' views and experiences are vital in ethical analysis where one hopes to produce practicable recommendations. Such perspectives can provide a rich resource in bioethics scholarship, perhaps challenging the researcher's perspective. However, overreliance on a picture painted by a group of research participants—or on pre‐existing literature in that field—can lead to a biased view of a given context, as the subjectivity of data generated in these ways cannot (and should not wholly) be escaped. In response, we propose the implementation of a complementary approach of ethno‐immersion in bioethics research. By positioning oneself in the context being researched, the researcher can better understand the realities of that context. The researcher's understanding will, naturally, be subjective too. However, it will act as a better developed and more informed outsider view, when considering the picture painted by participants and previous studies, thus enabling the researcher to introduce more nuance when analysing data. We introduce this approach after examining what we call the context detachment problem, whereby some bioethics scholarship—empirical or otherwise—fails to reflect the reality of the healthcare setting it concerns. Our proposed ethno‐immersion (which differs from formal ethnography) is then explored as a response, highlighting its benefits, and answering the question of timing within a research project. Finally, we reflect on the applicability of our proposal to non‐empirical bioethics scholarship, concluding that it remains important but may require some adjustments.

In their paper ’Too much medicine: not enough trust?' Zoë Fritz and Richard Holton explore the connection between trust and overtreatment and overinvestigation. Whilst their paper is insightful, here I argue that much more could be made of a doctor’s (mis)trust and how this exacerbates overtreatment and overinvestigation. By taking Fritz and Holton’s view of trust as having ‘our best interests at heart’ as my starting point, I argue that doctor’s do not always trust that patients or the system has their interests at heart and so use overtreatment and overinvestigation to protect themselves. I also point to the tensions created by a lack of trust on the doctor’s part as a focal point for much needed sustained ethical analysis.

I am grateful for these four wide-ranging and incisive commentaries on my paper discussing the ethical issues that arise when we consider the carbon footprint of inhalers.1 As I am unable to address every point raised, instead I focus on what I take to be the common thread running through these papers. Each response has something to say regarding the scope of healthcare’s responsibility to mitigate climate change. This can be explored at the intuitional or structural level, or at the individual patient and practitioner level leading to a further issue of the relationship between these perspectives. Coverdale argues for broadening the scope of individual responsibilities regarding the climate.2 Discussing inhalers does not go far enough and doctors, argues Coverdale, are well placed to draw attention to the various behaviour changes patients can undertake both through role modelling and in the clinic. While Coverdale makes some excellent points, I have three worries about his proposal. One is relevance. Climate concerns may not always be pertinent in the clinical encounter; think of counselling a bereaved patient or somebody needing a fit note. Related to this is opportunity. General practitioners capacity to cover an inordinate amount in a 10 min consultation …

In this paper I argue that junior doctors are morally exploited. Moral exploitation occurs where an individual’s vulnerability is used to compel them to take on additional moral burdens. These might include additional moral responsibility, making weighty moral decisions and shouldering the consequent emotions. Key to the concept of exploitation is vulnerability and here I build on Rosalind McDougall’s work on the key roles of junior doctors to show how these leave them open to moral exploitation by restricting their reasonable options. I argue that there are a number of ways junior doctors are morally exploited. First, their seniors can leverage their position to force a junior to take on some discreet decision. More common is the second type of moral exploitation where rota gaps and staffing issues means junior doctors take on more than their fair share of the moral burdens of practice. Third, I discuss structural moral exploitation where the system offloads moral burdens onto healthcare professionals. Not every instance of exploitation is wrongful and so I conclude by exploring the ways that moral exploitation wrongs junior doctors.

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.

How should we respond to patients who do not wish to take on the responsibility and burdens of making decisions about their own care? In this paper, we argue that existing models of decision-making in modern healthcare are ill-equipped to cope with such patients and should be supplemented by an “appointed fiduciary” model where decision-making authority is formally transferred to a medical professional. Healthcare decisions are often complex and for patients can come at time of vulnerability. While this does not undermine their capacity, it can be excessively burdensome. Most existing models of decision-making mandate that patients with capacity must retain ultimate responsibility for decisions. An appointed fiduciary model provides a formalized mechanism through which those few patients who wish to defer responsibility can hand over decision-making authority. By providing a formal structure for deferring to an appointed fiduciary, the confusions and risks of the informal transfers that can occur in practice are avoided. Finally, we note how appropriate governance and law can provide safeguards against risks to the welfare of patients and medical professionals.

In this response article, we challenge a core assumption that lies at the centre of a round table discussion regarding the Pharmacogenetics to Avoid Loss of Hearing trial. The round table regards a genetic test for a variant (mt.1555A>G) that increases the risk of deafness if a carrier is given the antibiotic gentamicin. The idea is that rapid testing can identify neonates at risk, providing an opportunity to prevent giving an antibiotic that might cause deafness. We challenge the assumption that a positive test unequivocally guides antibiotic choice because, aside from the risk of deafness, all antibiotics for neonatal sepsis are equivalent. We argue that this assumption is faulty and has particularly troubling moral consequences. We claim that giving an alternative to gentamicin is potentially providing inferior treatment and thereby may increase the risk of death. Parents and doctors are faced with a terrible choice as a result of positive point-of-care testing (POCT): give gold-standard treatment and risk deafness or give second line care and risk death. While we do not indicate an answer to this choice, what we do argue is that such a deep and difficult choice is one that may make parents wish genetic testing was never undertaken, and therefore, contra some authors in the round table, provides a reason to gain specific consent for POCT.

In our paper ‘The ethical case for non-directed postmortem sperm donation’ we argued that it would be ethical for men to donate sperm after death for use by strangers. In their thoughtful response Fredrick and Ben Kroon lay out practical concerns regarding our proposal. They raise issues regarding the quality of sperm collected postmortem based on empirical studies. Second, they claim that concerns about quality would make women unlikely to use sperm collected after death. In this response we explore issues of sperm quality in both living and dead donors. We consider whether there might be ways to ensure quality in both. Finally, we question whether quality should be a barrier to women choosing to use sperm donated after death.

In this article we outline and defend the concept of voluntary non-directed postmortem sperm donation. This approach offers a potential means of increasing the quantity and heterogeneity of donor sperm. This is pertinent given the present context of a donor sperm shortage in the UK. Beyond making the case that it is technically feasible for dead men to donate their sperm for use in reproduction, we argue that this is ethically permissible. The inability to access donor sperm and the suffering this causes, we argue, justifies allowing access to sperm donated after death. Moreover, it is known that individuals and couples have desires for certain sperm donor characteristics which may not be fulfilled when numbers of sperm donors are low. Enacting these preferences contributes significantly to the well-being of intended parents, so we argue that this provides apro tantoreason for respecting them. Finally, we explore the benefits and possible disadvantages of such a system for the various parties affected.

Healthcare systems need to consider not only how to prevent error, but how to respond to errors when they occur. In the United Kingdom’s National Health Service, one strand of this latter response is the ‘No Blame Culture’, which draws attention from individuals and towards systems in the process of understanding an error. Defences of the No Blame Culture typically fail to distinguish between blaming someone and holding them responsible. This article argues for a ‘responsibility culture’, where healthcare professionals are held responsible in cases of foreseeable and avoidable errors. We demonstrate how healthcare professionals can justifiably be held responsible for their errors even though they work in challenging circumstances. We then review the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, we argue that a responsibility culture has significant advantages over a No Blame Culture due to its capacity to enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors.