By Joshua Parker, Nathan Hodson, Paul Young & Cliff Shelton.
If asked what an anaesthetist does, most would picture a doctor placing a mask on a patient’s face and asking them to count backwards from ten to one. As they count, they inhale a colourless gas and before passing the halfway mark their countdown stops as they are asleep.
This image of anaesthesia is changing, and with good reason. Those seemingly innocuous anaesthetic gases are actually powerful greenhouse gases. The most notorious, desflurane, is thousands of times better than carbon dioxide at trapping heat energy from the sun, thereby causing global warming. This adds up. One back of the envelope calculation suggests that switching from anaesthetic gases could save an average anaesthetist the equivalent of two return transatlantic flights per year.
This is concerning because anaesthesia is an important pillar in modern medicine. Anaesthesia is essential to facilitate various surgeries, procedures and investigations. Fortunately, most of the time, alternatives are available to anaesthetists. Intravenous anaesthesia can achieve at least as good results and anaesthetists are increasingly using nerve blocks to numb just the necessary area. As these alternatives have a much smaller carbon footprint, you might expect that a green revolution in anaesthetic practice has taken place.
Granted, there has been change. But change has been patchy and inconsistent. The revolution is pending.
In fairness, deciding between various anaesthetics, not on the basis of typical considerations like the interests of the patient, but on green credentials is potentially a radical step. In our JME paper we make two main claims. The first clarifies what moral responsibilities anaesthetists have when their practice contributes to global warming. We argue that, at a minimum, when two or more anaesthetic options are equally suitable for a patient, the one with the fewest emissions should be preferred. The second claim is that it is not enough to argue that anaesthetists should change their practice. If we are serious about a radical change in anaesthetic practice, then any behaviour changes need to be supported and enabled by institutions and those in power.
Anaesthetic practice needs to move away from inhalational anaesthesia opting instead for total intravenous and regional techniques. Ideally all anaesthetists would unanimously agree to use alternatives where inhalational anaesthesia isn’t necessary for patient safety. However, as many environmentally minded anaesthetists can attest, obtaining departmental consensus can be particularly challenging. Furthermore, if change requires consensus, waiting to achieve this could derail the project of greener anaesthesia. Three options remain for institutions to help make the necessary behavioural change: remove inhalational anaesthesia, provide education and nudges.
Taking inhalational anaesthetics off the anaesthetic menu might appear bold, but in some areas the NHS has committed to do this already. There are plans to phase out and eventually remove desflurane from practice. Knowing that desflurane has an enormous carbon footprint and isn’t particularly special as an inhaled anaesthetic does justify removing this. But wholesale removal of all anaesthetic gases faces a handful of concerns. First is that it may undermine professional autonomy. Second, and building on this, as anaesthetists enjoy particularly high levels of professional autonomy, removing medicines from their armoury may backfire. Finally, there are a few cases where volatiles are necessary, and volatiles are an important backup as a safety mechanism.
Education has been the mainstay of attempts to change anaesthetists’ practice. It’s easy to see why. If anaesthetists don’t realise the impact they are having and how easily they can change, we can’t expect them to practice differently. Furthermore, education doesn’t threaten professional autonomy; you can always ignore the information provided. This is also the main problem with education. For years we have been informed of the impact our behaviours have on the climate and yet there hasn’t been comprehensive individual change across high-emitting societies. Why would we expect anaesthesia to be any different? Where our habits are entrenched and changing requires effort, a vague and distant problem like climate change is hardly motivating, even when we are told the consequences. We don’t want to overstate the deficiencies of education. Education can play a role. Yet, it would be quixotic to think that education alone will shift anaesthetic practice in the necessary ways.
If anaesthetic gases are ‘bad’, we could make it easier to choose alternatives. Strategies like this are a type of nudge: changes to the context in which decisions take place to make some decisions easier. Surprisingly, vaporisers which contain desflurane are typically left attached to machines for giving anaesthesia. Why not store these away from the anaesthetic room, forcing anaesthetists to go and fetch them if they want to use them? Similarly, equipment for intravenous anaesthesia could be made easily accessible and widely available. Some teams have put information on vaporisers reminding users of the environmental impact of using these, making key information available at a critical time of decision-making. The crucial advantage of nudges is that they can be effective in bringing about change but don’t force anaesthetists to make certain decisions and they can be implemented without consensus.
Reducing the carbon footprint of anaesthesia is essential in light of the threats posed by climate change. Achieving this requires behaviour change. We have various options to bring about change, however it is important to pay attention to the ethical issues that arise in bringing about a revolution in anaesthetic practice.
Authors: Joshua Parker1, Paul Young2, Nathan Hodson3, and Cliff Shelton4,5
1 Doctoral Candidate, 5 Senior Clinical Lecturer, Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, Lancaster, UK.
2 Specialty Trainee, North West School of Anaesthesia, Health Education England North West, Manchester, UK.
3 Academic Clinical Fellow, Unit of Mental Health and Wellbeing, University of Warwick, Coventry, UK
4 Consultant, Department of Anaesthesia, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
Competing interests: None declared