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Planet Earth and its growing human population are challenged by the health impacts of industrial policies that drive global emissions production and cause climate change. The health-care industry has capacity and responsibility to adopt environmentally sustainable policies and practices. Bioethicists have a responsibility to support environmental sustainability through their clinical, research, educational, and policy work. They communicate complex ideas to diverse stakeholders and can communicate similarly to improve understanding about emissions and the value of environmentally sustainable policy. A growing bioethics literature addresses climate change in collaboration with human and veterinary medicine and other disciplines. Pursuing environmental sustainability with the vigor that made autonomy a norm would help to reduce global emissions production in health care and make it a role model for other industries. Making environmental sustainability a health-care norm would be as significant an accomplishment as doing so for individual autonomy.

Health promotion involves social and environmental interventions designed to benefit and protect health. It often harmfully impacts the environment through air and water pollution, medical waste, greenhouse gas emissions, and other externalities. We consider potential conflicts between health promotion and environmental protection and why and how the healthcare industry might promote health while protecting environments. After probing conflicts between promoting health and protecting the environment we highlight the essential role that environmental resources play in health and healthcare to show that environmental protection is a form of health promotion. We then explore relationships between three radical forms of health promotion and the environment: (1) lowering the human birth rate; (2) transforming the food system; and (3) genetically modifying mosquitos. We conclude that healthcare and other industries and their institutions and leaders have responsibilities to re-consider and modify their priorities, policies, and practices.

This article outlines challenges to benefitting developing countries that are hosts of international research. In the context of existing guidance and frameworks for benefit-sharing, it aims to provoke dialog about socioeconomic factors and other background conditions that influence what constitute benefits in a given host setting, and about the proportionality between benefits to hosts and benefits to sponsors and researchers. It argues that capacity-building for critical thinking and negotiation in many developing country governments, institutions, and communities is a benefit because it can help to overcome background conditions that impinge on equitable international research negotiations, partnerships, and benefits. Enhancing the capacity for both critical thinking and negotiation can, like other targets of capacity-building, nurture respectful and trusting partnerships that benefit all stakeholders in international research.

BackgroundPalliative and end-of-life care development is hindered by a lack of information about the circumstances surrounding dying in developing and resource-poor countries. Our aims were to develop and obtain face and content validity for a self-administered questionnaire on end-of-life care provision and medical decision-making for use in population-based surveys.MethodsModelled on validated questionnaires from research in developed countries, our questionnaire was adapted to the cultural sensitivity and medico-legal context of Trinidad and Tobago. Two sets of semi-structured face-to-face cognitive interviews were done with a sample of physicians, sampling was purposive. Phase 1 assessed interpretation of the questions, terminology and content of the questionnaire. Phase 2 was tested on a heterogeneous group of physicians to identify and fix problematic questions or recurring issues. Adjustments were made incrementally and re-tested in successive interviews.ResultsEighteen physicians were interviewed nationwide. Adaptations to questionnaires used in developed countries included: addition of a definition of palliative care, change of sensitive words like expedited to influenced, adjustments to question formulations, follow-up questions and answer options on medications used were added, the sequence, title and layout were changed and instructions for completion were included at the beginning of the questionnaire.ConclusionA new instrument for assessing and documenting end-of-life care and circumstances of dying in a small, resource-poor Caribbean country was developed and validated, and can be readily used as a mortality follow-back instrument. Our methods and procedures of development can be applied as a guide for similar studies in other small developing countries.

Context Empirical information on circumstances of dying from advanced illness in developing countries remains sparse. Evidence indicates that out-of-hospital end-of-life care can have significant benefits such as increased satisfaction for the patient and caregivers and cost-effective for a health-care system. Services that are aimed to deliver care at private homes may be a good model for low- and middle-income countries or other low-resourced settings. Objectives To examine specialized, generalist, and informal palliative care provision and to describe the end-of-life care goals and treatments received. Method A mortality follow-back study with data obtained from general practitioners certifying a random sample of death certificates of adult decedents who died between March and August 2018. The questionnaire inquired about the characteristics of care and treatment preceding death. Results Three hundred nine questionnaires were mailed, and the response rate was 31% (N = 96), of which 76% were nonsudden deaths. Of these cases, 27.4% received no palliative care, 39.7% received it from a general practitioner, and 6.8% from a specialized palliative care service. Comfort maximization (60.3%) was the main goal of care in the last week of life, and analgesics (53.4%) were the predominant treatment for achieving this goal. In addition, 60.3% received informal palliative care from a family member. Conclusion The largest part of end-of-life care at home in Trinidad and Tobago is provided by family members, whereas professional caregivers feature less prominently. To ensure quality in end-of-life care, better access to analgesics is needed, and adequate support and education for family members as well as general practitioners are highly recommended.

To identify common themes documented in the literature on palliative and end-of-life care in English-speaking Caribbean small island developing states (SIDS), and to describe barriers, improvement strategies, and suggested ways forward.In 2015, we conducted a systematic scoping review of relevant literature identified through the MEDLINE and Web of Science databases. We supplemented that with searches of other electronic and hard-copy sources to map key concepts and summarize themes.Primary data and other literature from and about English-speaking Caribbean nations are relatively scarce. The available literature offers an overview of the existing situation in the region and explores why palliative and end-of-life care is limited there. This review identified barriers in five main areas recurring across this literature: i) culture and attitudes of health care providers, patients, and those close to them towards terminal illness and death; ii) opioid availability and use; iii) limited development of palliative care services; iv) unmet palliative care needs; and v) limited research on palliative or end-of-life care.Our analysis helps to document the need for palliative and end-of-life care in Caribbean SIDS and highlights suggestions for moving forward with related practice, policy, and research.Establecer los temas comunes documentados en la bibliografía sobre los cuidados paliativos y al final de la vida en los pequeños estados insulares en desarrollo del Caribe de habla inglesa, y describir los obstáculos, las estrategias de mejora y los pasos futuros que se sugieren.En el 2015, realizamos un examen sistemático exploratorio de la bibliografía pertinente encontrada por medio de MEDLINE y las bases de datos de Web of Science. Complementamos el examen con búsquedas de otras fuentes electrónicas e impresas para esquematizar los conceptos fundamentales y resumir los temas.Los datos primarios y otra bibliografía sobre las naciones del Caribe de habla inglesa o provenientes de ellas son relativamente escasos. La bibliografía disponible ofrece un panorama de la situación existente en la región y explora las razones por las que los cuidados paliativos y al final de la vida son limitados en estas naciones. La presente revisión detectó obstáculos en cinco áreas principales, recurrentes en toda la bibliografía:Nuestro análisis ayuda a documentar la necesidad de cuidados paliativos y al final de la vida en los pequeños estados insulares en desarrollo del Caribe de habla inglesa, y pone de relieve sugerencias para avanzar en la práctica, la política y la investigación relacionadas.Identificar temas comuns documentados na literatura científica sobre cuidados paliativos e de pacientes terminais nos pequenos Estados insulares em desenvolvimento do Caribe e descrever barreiras, estratégias de melhoria e rumos a serem tomados.Em 2015, foi realizada uma revisão sistemática do tipoOs dados primários e outros dados da literatura provenientes e acerca dos países de língua inglesa do Caribe são relativamente escassos. A literatura disponível oferece um panorama geral da situação da região e examina por que os cuidados paliativos e dos pacientes terminais são limitados. A revisão permitiu identificar barreiras em cinco áreas principais recorrentes nos estudos: i) cultura e atitudes dos profissionais da saúde, dos pacientes e das pessoas próximas que acompanham o paciente com doença terminal e morte; ii) disponibilidade e uso de opioides; iii) progresso restrito dos serviços de cuidados paliativos; iv) necessidades da atenção paliativa não atendidas e v) pesquisas pouco extensas sobre cuidados paliativos e dos pacientes terminais.Nossa análise contribui para documentar a necessidade de cuidados paliativos e dos pacientes terminais nos pequenos Estados insulares em desenvolvimento do Caribe e sugere o rumo a ser tomado com relação a práticas, políticas e pesquisas.

Should physicians take action in the political realm to address climate change? There are many historical examples of physician advocacy in the political sphere, both individually and as a collective, and many have argued that it is important for health professionals to advocate on a variety of issues. But which criteria should be used to determine when and how health professionals should take on particular advocacy issues, and is climate change an appropriate-or even obligatory-arena for physician advocacy? We propose a seven-part deliberative framework for making this determination.

Climate change threatens health, health care, and the industries and resources upon which these depend. The growing prevalence and severity of its health consequences and economic costs are alarming health professionals and organizations as their professional obligations, grounded in the core value of health, include protecting against these harms. One means of fulfilling these obligations is to lead or support sustainability initiatives that are built upon current, reliable, accurate, and unbiased evidence and collaboratively tailored to meet specific needs and respond to specific contexts. We consider why and how health professionals and organizations should lead or support such initiatives.

Decisions about environmental health policy often deal with contentious issues. David Resnik and colleagues (2018) highlight some such issues, arguing that the accountability for reasonableness (AF...

Decades of evidence from a range of disciplines shows that industrial energy releases greenhouse gas emissions and contributes extensively to climate change. Energy delivers water, food, and other goods to billions of people, but through emissions it also harms health and environments that support health. These harms vary and have different practical and ethical significance for different populations and environments. A public health ethics concerned with whether and how to respond to conditions that harm health must address these harms. This chapter reviews evidence that the primary cause of climate change is emissions released during industrial production and use of energy. It highlights the health impacts of climate change, defines emissions as health determinants with ethical implications, and discusses how and why ethically informed health policy and other interventions should integrate social justice and social responsibility.

L’histoire de James Dwyer au sujet d’une Commission GAIA fictive met en évidence les préoccupations concernant la portée de la bioéthique, en particulier en ce qui concerne la répartition de la responsabilité au niveau international face aux impacts des changements climatiques sur la santé. Ce commentaire traite de l’impact potentiel d’un individu sur les émissions de gaz à effet de serre et l’importance des réponses institutionnelles afin d’avoir un impact significatif., James Dwyer’s story about a fictional GAIA Commission highlighted unresolved concerns about the scope of bioethics, specifically regarding the global distribution of, and responsibility for, the health impacts of climate change. This commentary discusses the potential impact of an individual on greenhouse gas emissions and the importance of engaging institutional responses in order to have meaningful impacts., Commentaire / Commentary

Climate change has substantial impacts on public health and safety, disease risks and the provision of health care, with the poor being particularly disadvantaged. Management of the associated health risks and changing health service requirements requires adequate responses at local levels. Health-care providers are central to these responses. While climate change raises ethical questions about its causes, impacts and social justice, medicine and bioethics typically focus on individual patients and research participants rather than these broader issues. We broaden this focus by examining awareness among health-care providers in the Caribbean region, where geographic and socioeconomic features pose particular vulnerabilities to climate change. In focus groups, Caribbean providers described rises in mosquito-borne, flood-related, heat-related, respiratory and mental illnesses, and attributed these to local impacts of climate change. Their discussions showed that the significance of these impacts differs in different Caribbean nations, raising policy and social justice questions. Bioethics and public health ethics are situated to frame, inform and initiate public and policy dialog about values and scientific evidence associated with climate change. We urge readers to initiate such dialog within their own institutions about the context-dependent nature of the burdens of climate change, and values and policies that permit it to worsen.

For decades, scientists from many disciplines have documented changes in earth’s atmosphere, oceans, soil, weather patterns, and ecosystems that collectively reflect climate change. The websites of national and international health organizations, and other influential institutions, document their concerns about health impacts of climate change. These are seldom addressed in bioethics, despite bioethics practical and scholarly dedication to medicine, health, and wellbeing. The premise of this book is that medical and research ethics, and other disciplines, can and should embrace Van Rensselaer Potter’s global bioethics. This bioethics is concerned with dependencies and relationships between humans and other living things, and extends beyond environmental ethics and public health ethics to human health and wellbeing and other realms. Integrating it into medical and research ethics, and related practical and scholarly activities will facilitate studies of, deliberation about, and deeper understanding of the causes and impacts of climate change; and help to identify and implement the most promising, effective, and fair responses to it. This Chapter develops and supports this premise; introduces some readings for understanding the ethics of climate change; and provides an overview of the book’s aims, contributors, and contents.

The production of even small quantities of greenhouse gas emissions worsens climate change and accentuates the unequal, and often unfair, distribution of emission-associated benefits and harms. The relative inattention of bioethics to climate change is surprising given its roots and concern with health, wellbeing, and autonomy. Bioethics could improve understanding among policymakers and others that autonomy is expressed and health is experienced within natural environments and ecosystems. Such understanding could strengthen efforts to reduce emissions and help make Western lifestyles more accessible globally. Processes of globalization and socioeconomic development sometimes improve health determinants and indicators, but simultaneously increase production of emissions that harm health. Bioethicists have the capacity, influence, and responsibility to deepen understanding that emissions harm health, health systems, and natural resources on which these rely; and to inform related analyses and policies.

The Polar Regions (PR) and Small Island Developing States (SIDS) are distant and relatively undeveloped. They differ in cultures, socioeconomics, geographies, flora and fauna, and annual average temperatures. Despite their differences, they are similar in having small percentages of global population, limited economic and political influence, growing reliance on imported food and goods, and producing relatively small amounts of greenhouse gas emissions. The Arctic encompasses about four million people and 30 different Indigenous Peoples. There, warming has increased exposure to infectious, vector-borne, and mental illnesses; reduced food and water security; and displaced communities through scarcity, rising sea levels, and melting permafrost that damages infrastructure. Combined, the Small Island Developing States (SIDS) have over 60 million people. Their extensive and low lying coastal areas make them particularly vulnerable to sea level rise and extreme weather. Changes in temperatures and precipitation patterns in Caribbean SIDs contributed to outbreaks of infectious diseases including cholera in Haiti, malaria in Jamaica, and H1N1 influenza virus in Barbados. Previously confined to SIDS of the Indian Ocean, Chikungunya (CHIKV) appeared across Caribbean SIDS in 2013, causing significant morbidity. We review health impacts of climate change in the PR and SIDS, contrast the environmental contexts in which these are occurring, and discuss regional and global causes and consequences.