Health care without harm: an ethical imperative. A consensus statement from Biomedical Ethicists in Support of Environmentally Sound Healthcare Practices.

Abstract

Bioethics is the formal discipline concerned with ethical and broader issues arising in the practice of medicine and the other health care professions and science as a whole. Bioethicists are concerned not only with the impacts and quandaries faced by individual patients and their caregivers, but also with the impacts of health care on society and the broader natural world. Although bioethicists approach such issues from many different theoretical perspectives, most, if not all, agree that the health care professions and industry should seek to minimize any real or potential health risks associated with providing health care. Modern healthcare is often a high-technology undertaking, using the services of hospitals with their myriad of materials. As the technology of healthcare continues to explode in complexity, so do by-products in terms of wastes and potential pollutants. Some of these can enter the environment through health care waste incineration, which is a leading source of dioxin and mercury pollution (as identified by the UnitedStates Environmental Protection Agency).1,2 Dioxin is a known humancarcinogen,3and it has been linked to birth defects,4 impaired fertility,5,6 immune system suppression,7 and hormonal disruption.8,9 Mercury can interfere with the development of the fetal brain and is directly toxic to the central nervous system, kidneys, and liver.10,11 An international campaign called Health Care Without Harm was created in 1996 and now has been endorsed by a growing list of more than 250 organizations, includingthe American Public Health Association, American Nurses Association,Physicians for Social Responsibility, more than 40 hospitals, and other leading health care and environmental organizations. The aim of this coalition is to eliminate the pollution in health care practices without compromising safety or quality of care. This mission is pursued by promoting comprehensive pollution prevention practices; supporting the development and use of environmentally safe materials, technology, and products; and educating and informing health care institutions, providers, consumers, and all affected constituencies about the environmental and public health impacts of the health care industry and solutions to its problems. Some of the means to those goals include eliminating the nonessential incineration of medical waste, phasing out use of polyvinyl chloride plastics and persistent toxic chemicals, phasing out use of mercury, and improving standards for medical waste management (including aggressive waste reduction, segregation, and recycling). Some of these goals are readily attainable and have been shown to be both practical and economically efficient in hospitals where they have been adopted.12,13 Others are more difficult to achieve, even though the reasons to work for them are well supported in the scientific literature. The argument that “not enough isknown” to justify altering current practices is the primary obstacle to pursuing such goals. Health Care Without Harm, however, subscribes to the “precautionary principle,” a fundamental tenet of public health practice. This principle holds that, in this regard: people have a duty to take anticipatory action to prevent harm; the burden of proof of harmlessness of a chemicallies with the proponents of use of that chemical, not with patients and the general public; and people using a toxic chemical have an obligation to examine a full range of alternatives. We note the similarity of some of these principles to well-accepted medical, public health, and bioethical codes. It must also be noted that, in some ways, the application of the precautionary principle could reverse current practices, such as the existing de facto“system” of approving the use of chemicals in commerce and society until they are proven unsafe. This status quo, from an ethical perspective, appears unacceptable when there is serious debate about risks. Therefore, the signatories of this statement, working in the diverse international field of health care ethics, hereby endorse the principles of Health Care Without Harm and the application of the precautionary principle to the use of potentially toxic substances in health care delivery and research. We urge any interested clinician,administrator, regulator, or other concerned person to visit theHealth Care Without Harm web site (www.noharm.org) for moreinformation and practical suggestions for “cleaning up”the healing professions.