Climate change and health: time to adopt environmental probity?

Whether we like it or not, doctors have a peculiar relationship with the societies which they serve. This peculiar relationship, however, comes at a price.

In the January edition Trevor Thompson and I reviewed the background to the mounting challenge that climate change presents to global health. Here I would like to explore the moral and ethical challenges that face GPs in particular At the 2010 RCGP annual conference in Harrogate I was heartened by the general attitude of most of the delegates that I spoke to.

There is firm evidence that our patients trust doctors, both in their individual care for them and more widely as a whole profession. Doctors in the UK are consistently rated highly for their professionalism. The findings of an IPSOS MORI poll in 2007 demonstrated that the UK population trusted doctors most highly among the professions.¹ This is in stark contrast with the public perception of our politicians who are tasked by us to strategically plan for our future wellbeing.

The trust that society places in doctors is based on individual patient contact experiences and the perception within society that they can be trusted with their personal health as well as speaking out about issues that threaten the health of individuals and their families. The 2005 Royal College of Physicians report² described medical professionalism as ‘a set of values, behaviours, and relationships that underpins the trust the public has in doctors.’ In part, this trust and high esteem is a product of the values assimilated and described in the GMC document Duties of a Doctor.³ To justify the trust of patients the recommendation within this document is that doctors should ‘Make the care of your patient your first concern and protect and promote the health of patients and the public’.

Doctors in the UK seem to relate easily to these expected values and behaviours that uphold the ideal of probity in the eyes of their patients. Perhaps, given the enormity of the health impacts of climate change it is time to incorporate the concept of environmental probity within this framework.

There is little doubt that the currently projected patterns of world climate change will have unprecedented adverse effects on morbidity and mortality. This is likely to widen health inequalities still further.⁴ To paraphrase Margaret Chan, director general of the World Health Organization, climate change presents the biggest single threat to health in the 21st century. In the face of this doctors have protected themselves from the dilemma by constructing an ethical framework that raises their work, actions, and attendant costs above these concerns. We seem to have adopted a moral imperative that our work should be insulated from the environmental impact that it has. This may be true, in part, but we have a real need to think critically about our activities and their environmental consequences. So what should the response of doctors be?

The 1962 report from the College of Physicians on smoking gave us clear evidence that tobacco consumption seriously affected health.⁵ Following this report there was a change in the relationship between doctors and society.⁶ Given the evidence and the importance of the message, the medical profession felt empowered to take a stance and speak directly with society and to lobby the government for political action aimed at minimising the effects of tobacco consumption. Doctors were in the vanguard of behaviour change by stopping smoking and advocating the same for their patients. There is evidence that this had a direct impact on the beneficial behavioural change of wider society^7–9 There can be immediate co-benefits to an individual's health, related to behavioural change leading to decreased CO2 production. The bigger prize in health terms though is the collective mitigation of longer-term adverse environmental change. The behaviour change by doctors in relation to tobacco was obviously driven by their personal self-interest in light of the evidence. With this agenda the change needs to be driven by the inter-generational self-interest that we have for the health of our children and grandchildren, as well as for patients both present and future. For our populations to take the concerns about the health impact of climate change seriously we need to be seen to decrease our personal and professional carbon footprints as well as speaking out and lobbying for political change. It may well be that the profession is not yet ready to take on these challenges in their personal lives but there does seem to be an increasing appetite to respond to them professionally. The leading role that GPs will have in the commissioning process gives us an ideal opportunity to bring about system change relatively quickly.

In the US there has been a continuous erosion of the moral authority of the medical profession. This has been in no large part due to the perception that the American population can no longer trust their physicians.^10–12 In the face of the mounting evidence linking climate change to major adverse health consequences, silence and a lack of action by doctors, both personally and institutionally, has the future potential to seriously threaten and undermine the moral authority and relationship that we have with our patients and society.

We are now in a position where we can make a reasonable assumption that, unchecked, carbon usage will have dramatic effects on the health of our patients and their families. Whether we like it or not, patients have a rightful expectation that doctors will use their unique position in society to help to protect the health of our population. We have a duty to respond to this expectation by not only informing patients about the likely health impacts of climate change, but by using our special relationship with society to empower our politicians to make difficult choices to plan for mitigation and adaptation in relation to the effects of climate change.