An ethical investigation into environmental sustainability in healthcare

Parker, Joshua and Appleby, John and Wilkinson, Stephen and Allinson, Sarah (2025) An ethical investigation into environmental sustainability in healthcare. PhD thesis, Lancaster University.

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Abstract

As we witness the effects of a changing climate, with more extreme weather events and broken records for global surface temperatures, societies are scrambling to address climate change. Healthcare organisations are increasingly being called upon to reduce their greenhouse gas emissions, including the National Health Service (NHS). But this creates a puzzle. On the one hand, healthcare systems globally account for around 5% of global emissions and under the threats, including health threats, posed by climate change it seems obvious that healthcare systems should minimise their emissions. On the other hand, a common intuition is that healthcare is special. Where healthcare systems have relied on emissions to provide the manifold benefits associated with technologically advanced healthcare, we may worry about what a low-carbon agenda means for healthcare. As such, the thought that healthcare is special could be taken to ground the idea that in global efforts to address climate change healthcare systems should be treated differently from other polluters. The overarching question for societies when it comes to addressing climate change is who should do what to minimise the threats posed by climate change? Theorists have tended to answer this at a global level thinking about nations and states. But the same question of distributive justice can be asked of an organisation like the NHS: how should we determine what a fair share of the burdens (and benefits) of climate change mitigation for complex, modern healthcare systems like the NHS should be? Primarily, this thesis focuses on addressing this question of distributive justice. In determining the NHS’ fair share of national and global efforts to tackle climate change, the issue of whether healthcare is special becomes relevant. Should the NHS’ responsibilities to reduce greenhouse gas emissions be sensitive to its role in social justice through its function in protecting and promoting health, or is this irrelevant? In response to the primary research question, this thesis defends an ability to pay IV principle, understood as a sufficientarian concept where healthcare emissions above and below a threshold of enough are treated differently, to determine healthcare’s fair share of the burdens of climate change mitigation. This approach is sensitive to healthcare’s primary goal of protecting and promoting health and integrates this role with mitigation. However, healthcare is not exempt from mitigating emissions. The final part of the argument shows how ability to pay allocates responsibilities to reduce healthcare emissions within healthcare, to for example policy makers, professionals and patients. The thesis is divided into three main parts. The first part is concerned with introducing the topic and relevant background, explaining the method and providing an overview of the main body of work. The second section presents the five papers that form the main body of this work. Paper one takes up the idea of ‘healthcare exceptionalism’ to answer whether healthcare should be treated differently when it comes to mitigating greenhouse gas emissions. In this paper the main argument that healthcare is exceptional but not exempt is provided and ability to pay is introduced. A polluter pays principle is a common and intuitive way to determine healthcare’s fair share of addressing climate change and so paper two is devoted to this. I argue against polluter pays. Papers three and four are dedicated to refining ability to pay and detailing the circumstances in which healthcare does, or does not, have capacities to reduce emissions. The final paper focuses on the issue of how ability to pay can be used to determine who should do what within healthcare to minimise emissions. The thesis is concluded in part three.