AMA Journal of Ethics^®

Case

Ms. Chen had been going to Dr. Patel’s outpatient gynecology practice for several years for her annual well-woman exam. The rural clinic was understaffed, and it was all the few participating physicians could do to manage the patient load.

A few months before Ms. Chen’s yearly check-up, Dr. Patel’s small group practice instituted a policy to stop using plastic specula for gynecological exams. The clinic-wide policy was an effort to reduce waste and avoid the increased shipping costs of plastic specula. Signs were posted in the clinic waiting area that informed patients of the practice’s decision to “go green,” and thanking them for their understanding and continued support.

Ms. Chen preferred the single-use plastic speculum, however, for hygiene reasons. She did not want to get a sexually transmitted disease from an improperly sterilized instrument and requested a single-use plastic speculum for her exam. Dr. Patel informed her that the clinic no longer stocked them and reassured Ms. Chen that measures had been taken to guarantee the metal specula were properly sterilized.

Commentary 2

Hospital mission statements emphasize healing environments, community, wellness, respect, and quality care. Yet, in the process of providing that care, hospitals simultaneously have a negative impact on human health and the environment through intensive energy and water consumption, use and disposal of toxic materials, and waste headed to landfills and incinerators. With the increased understanding of man’s impact on global climate and public health, physicians and health care administrators must demonstrate leadership in addressing health care’s role in environmental sustainability [1].

Over the last several decades, numerous reusable medical devices have been replaced with disposable ones in the name of infection control and ease of use. These decisions are coming back to bite us in the form of reduced landfill space and overuse of red bags—disposal of which costs at least five times more than disposal of nonregulated or regular waste. The sheer volume of waste has prompted health care professionals to look closely at inefficient practices and consider the value of going back to reusables in a number of areas—sharps containers, dishware, drapes, isolation gowns, and hard cases for sterilizing instruments, to name a few. Hospitals are working to reduce red-bag waste generation through staff education, standardized receptacles, and signage, and to cut the overall volume of waste through decreased use, reuse, and recycling.

Waste regulations and segregation practices have sometimes been based on perceived risk associated with a certain item, device, or practice, and not on science. This is precisely why, in the early 1990s when medical waste washed up on the eastern shores, IV bags were regulated in certain states and had to be handled as potentially infectious—not because they were infectious—but because they resembled blood bags. It proved to be a huge mistake costing hospitals hundreds of thousands of dollars to treat noninfectious wastes as if they were potentially harmful. Several years later, this perception-based regulation was changed to reflect scientific reality, but these poor habits have persisted in many facilities, where unnecessary red bagging is commonplace.

Health care professionals are in the best position to demonstrate their leadership through evidence-based approaches in sustainability initiatives and by correcting misinformation. In some cases, where scientific evidence is not yet available or difficult to study (for example, acceptable levels of exposure to multiple chemicals or the timing of fetal exposure), facilities are urged to take the precautionary approach [2]. The Precautionary Principle presumes an ethical imperative to prevent rather than merely treat disease, even in the face of scientific uncertainty. This principle can be understood as: “when an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically” [3].

In the case at hand, Ms. Chen is concerned about the possibility of infection from a reusable speculum. Dr. Patel can step in here to educate her on the safety and environmental benefits of reusable medical device use. Dr. Patel could ask the facility sustainability officer, safety director, or infection-control practitioner to demonstrate the sterilization or high-level disinfection of the reusable speculum recommended by the Centers for Disease Control and Prevention’s Guideline for Disinfection and Sterilization in Healthcare Facilities. Cold-sterilant and high-level disinfectant manufacturers back up their disinfection claims through rigorous study and offer quality assurance controls through protocol of staff training, cleaning and disinfection, and other quality control measures [4]. The quality assurance protocol includes infection control with standardized methodology, staff training, posted policies, verification testing, and periodic, unannounced inspections by safety and infection-control staffers. Joint Commission (on Accreditation of Healthcare Organizations) inspections often include a close review of protocol, including staff interviews and documentation review.

Taking a leadership role on sustainability does not mean cutting corners on safety, quality, or infection control. A diverse team with clinician participation considers all criteria for sustainability interventions, and implementation is preceded by pilot testing, evaluation, policy development, research review, and sign-off from leadership.

Some physicians are not fully engaged with the specific environmental sustainability programs in their health care facilities. “Higher-ups,” for example, sometimes don’t enforce basic training requirements and participation in sustainability programming for all staffers, so a physician may not receive specific training on recycling or red-bag segregation. Health care delivery is a complex organism, and the more engaged staffers (on every level) are in sustainability, the faster and stronger it develops and the more embedded it becomes in the culture of the organization. Having a separation between clinicians and other staffers creates a barrier that can lead to regulatory compliance violations, safety concerns, and reduced morale on the part of other staffers. When it comes to participation in sustainability programs, no one should have an opt-out clause.

Support staffers tend to feel greater respect when physicians and other clinical leaders take that extra step to maintain a safe and healthy environment. An individual who drops a needle should bend down and pick it up and properly discard it in a sharps container even if that individual is the division chief. A person who is rushing down a stairwell and tempted to drop disposable gloves on the ground should hold onto the gloves until a waste receptacle is found. Someone in a hurry after treating a patient at the bedside and tempted to leave the disposable kit with blood-stained material on the table for someone else to clean up should resist the urge. The generator of the waste material should be responsible for its proper segregation into the appropriate containers. Following these guidelines will go a long way in setting a tone of environmental excellence and respectful work environments. The next time someone complains, “Well, those doctors won’t participate”—someone will speak up, “Yes they will; they’re on board and want to participate.”

While new medical students may not feel powerful as they venture into the health care environment, they are the future of health care and have a voice and role in clinical leadership on sustainability. Clinical support of green building, energy and water conservation, and toxicity- and volume-reduction programs can help propel the initiatives to a new level. Clinical leadership has led to elimination of toxic cleaning chemicals and support for building with LEED certification as a goal. It can give a program the push it needs to attract the attention of senior leadership and help connect action with public health; purchasing with disease; materials with air quality; and management with illness.

Often staffers accustomed to a pre-ecoconscious work environment are the most difficult to convince, which is why the incoming clinicians are critical to the mission with their commitment to responsible procurement, training, use, and management of equipment and materials. The next generation of clinicians has greater knowledge of environmental sustainability and eco habits well established in their homes and personal belief systems; they will infuse health care with the enthusiasm, commitment, and determination it needs to move the entire sector.

How do these committed clinicians know where their facility falls on the greening spectrum, where to start, and what to do next? One option is the Green Guide for Health Care, a self-certifying toolkit that steers facilities through greener design, construction, and operations [5]. A project of the Center for Maximum Potential Building Systems, Health Care Without Harm, and Practice Greenhealth, the toolkit breaks greening the landscape into manageable chunks. Facilities can use this toolkit to assess where they are and plot their course to improvements over the long term. Version 3, currently in development, strives to identify the restorative visioning of health care. Concepts like restoring ecosystems; zero waste; renewable energy; collecting rain water; toxin-free purchases, building materials, furnishings, and finishings; and hosting farmers’ markets are part of this future. More and more hospitals and health systems are realizing the value of naming a sustainability officer to lead environmental activities. The activities are steered by a diverse committee—where clinical leadership is a must.

Physician leadership, knowledge, education, and ability to leverage authority are critical to environmental sustainability in health care. Increased physician involvement will help as we progress from a policy of “doing less harm” to one of “healing communities.”