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ANALYSIS: A J McMichael, S Friel, A Nyong, and C Corvalan Global environmental change and health: impacts, inequalities, and the health sector BMJ 2008; 336: 191-194 [Full text]

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Will medical ethics undergo a climate change?

John C Chambers   (27 January 2008)

Without family planning, famine, disease, and war will return

James G Danaher   (28 January 2008)

Vacuum in Population Debate

Rebecca M Gait   (30 January 2008)

The BMJ should commission a paper on demography, environmental change and poverty

Colin D Butler   (3 February 2008)

Please get the priorities right

Thomas Sandeman   (8 February 2008)

Will medical ethics undergo a climate change? 27 January 2008
John C Chambers, Macmillan Consultant and Medical Director Katharine House Hospice, East End, Adderbury, Oxon, OX17 3NL Send response to journal: Re: Will medical ethics undergo a climate change?	The potentially devastating health consequences of manmade global climate change are perhaps understated (1). If and when they hit home, will they have an ethical impact on health care? It is widely accepted that ethical medical actions are beneficent, non-maleficent, just and dignified. Furthermore, the medical professionals concerned must be honest and respect the patient’s autonomy. I suspect that none of us factor in the global consequences of our medical actions as much as we might in the future. At present, medical ethics is taken very seriously by us all, but with the focus almost completely on the patient and their most immediate environment. Autonomy arguably takes centre-stage, with the other considerations being subservient to it. In contrast, the good of the community is obscured within the ethical principle of justice. This might be perfectly reasonable in a climate of unlimited resources, particularly if the subsequent activities are not considered to harm others. However, in a climate of limited resources, and particularly when one’s self-interest has the potential to disadvantage others, autonomy can become selfish and arguably something not to be respected so much. (Of course, rationing already takes place in the NHS today, but the most important decisions in this area take place hypothetically and economically at national committee level, leaving the doctor at the patient’s side able to apologise for it and claim no personal involvement in the decision if they so wish). Let us turn a blind eye to the present awful global inequalities and simply look to the future. The human population is presently doubling every 40 years. The depletion of the world’s practically accessible oil, gas and possibly coal reserves is occurring at such a rate that these fuels are likely to become scarce commodities during the lifetime of our children, if not ourselves. On a worldwide scale, fertile land for growing food will be lost to rising sea levels; salination by over-irrigation; desertification; and use in the manufacture of biofuels. Fresh water supplies will become scarcer, the world will become warmer, and communicable diseases will increase in prevalence and territory. More people will want their fair share of less. Saturation will presumably be reached at some indeterminate point, after which the situation will become increasingly awful for us all. Instability and death on a large scale will not be unreasonable consequences. How might medical ethics change when this happens? There will almost certainly have to be a shift away from autonomy towards the good of the community. For example, it will become harder to justify fertility treatments that bring more life into an overpopulated world. The expensive, resource-intensive treatment of an individual will become harder to justify if it prevents the cheaper and easier treatment of larger numbers of people. An individual’s right to life-prolonging treatment when vast numbers of the population they live in are dying will become harder to justify. I anticipate that all of these changes will evolve naturally as the resources to run high-tech healthcare services dwindle away. These ideas alone might be unpalatable for many, but things could get even worse than this. For example, those in relatively safe communities might decide that it is for the benefit of humanity as a whole to let the most vulnerable communities in the world die out rather than provide them with the charitable relief that they need to survive. Let us hope that nothing like this ever happens. I anticipate that ethical medical actions will always be beneficent, non-maleficent, just and dignified, no matter what the climate. However, one day when rationing bites hard and unrelentingly at us all, non- maleficence as it applies to the individual will assimilate something of the Socratic notion that it is better to be a victim than a perpetrator of injustice. Medical professionals will remain honest, but the good of the community will become more important than the principle of autonomy. The former will be highlighted as a principle in its own right whilst the latter will become obscured within the ethical principle of justice. In the intervening years, it might be appropriate to give autonomy and good of the community a more obviously equal footing than they presently have. It might be our biggest medical challenge and prove to be highly unpopular with many, but such an approach applied across the spectrum of all human activity is surely the right medicine to counteract manmade global environmental change. References 1. McMichael AJ, Friel S, Nyong A, Corvalan C. Global environmental change and health: impacts, inequalities, and the health sector. BMJ 2008;336:191-194 Competing interests: None declared
Without family planning, famine, disease, and war will return 28 January 2008
James G Danaher, Retired NHS GP 33 Ashby Road, Ravenstone, Leicestershire, LE67 2AA Send response to journal: Re: Without family planning, famine, disease, and war will return	AJ McMichael and colleagues, though noting population pressures, do not mention the urgent need for the provision of effective family planning in developing countries in their wide-ranging review of global environmental change and health. (BMJ 26 January 2008). This is curious, as the population explosion is probably the major cause of poverty, conflict, environmental damage, large-scale migration, and therefore of poor health, in those countries of the developing world which are failing to control rapid population growth. Since 1945, death rates have fallen right across the world, especially the developing world. In most regions of the world, action has been taken to reduce birth rates as well as death rates. In these regions, slowly but surely, as populations stabilise, prosperity, peace, and good health are spreading, first in developed regions, now in the Far East, soon in Latin America. However, in one region of the world population problems remain. This region is Africa and the Middle East to Pakistan. The United Nations Population Division (http://esa.un.org/unpp) gives the following figures for the 1950 and 2000 populations, and the predicted 2050 populations, of some countries in this region: Afghanistan 8 million, 20 million, 70 million. DR Congo 12 million, 50 million, 164 million. Ethiopia 18 million, 69 million, 159 million. Kenya 6 million, 31 million, 72 million. Pakistan 36 million, 144 million, 249 million. Palestine 1 million, 3 million, 8 million. Rwanda 2 million, 8 million, 19 million. Somalia 2 million, 7 million, 18 million. Sudan 9 million, 33 million, 62 million. Uganda 5 million, 24 million, 80 million. In many of these countries, population control by effective family planning is treated dismissively, and the aid agencies have little interest in the subject. Inevitably, if this approach continues, the millennium goals will become unattainable, and population control will be left to the ancient methods of famine, disease, or war: probably all three together. If this is to be avoided, our enthusiasm for death control needs to be matched by an equal enthusiasm for birth control. Gerald Danaher (Retired NHS GP) Ravenstone, Leicestershire LE67 2AA jgd@gerrydanaher.com Competing interests: None declared
Vacuum in Population Debate 30 January 2008
Rebecca M Gait, SpR Public Health Lothian NHS, EH8 9RS Send response to journal: Re: Vacuum in Population Debate	McMichael et al succinctly describe the dual challenges to the planet of population expansion and the acromegaly of economic growth. However, human population control is notably absent from the solutions they offer. While discussions about carbon footprints, food miles and renewable energy are now common place, population control has failed to make the leap from academic research to public consciousness. There are at least three reasons for this. Most importantly population has become a taboo topic, synonymous with eugenics, the one child policy and Indira Ghandi. The emergence of very strong individual rights-based societies has helped to compound our fears. Secondly, the issue does not register on the short term radar screens of companies or politicians. There are no fast returns or political gains to be made. Thirdly, like many difficult issues, individuals feel powerless to make a difference. None of these barriers are easily overcome, yet overcome they must be if population is to take its proper place at the forefront of public debate. The medical profession, and in particular the global public health community, are well placed to play a leading role in elevating the population debate. Perhaps a dedicated BMJ issue on the topic would be a good starting point? Competing interests: Mother of two
The BMJ should commission a paper on demography, environmental change and poverty 3 February 2008
Colin D Butler, Visiting Fellow Australian National University Australia 0200 Send response to journal: Re: The BMJ should commission a paper on demography, environmental change and poverty	Population pressure was twice identified in this paper, but the scope of this commissioned piece is likely to have excluded consideration of ways to slow human population growth. The authors cannot blamed, but it is again time that opinion leaders such as the BMJ commission papers on the links between climate change, poverty, violence and unsustainability. Indeed, in 1995 the BMJ bravely published such an editorial - by AJ McMichael.1 The authors of this paper identify the crisis in Darfur as having roots in climate change and population pressure, as does the economist Sachs.2 The current crisis in Kenya, following the disputed election, may also be worsened by climate change. This crisis is undeniably due in part to ethnic violence and poverty. But beneath these factors are resource scarcity and the perception of worsened future resource scarcity, triggering pre-emptive murder and “ethnic cleansing”, when other conditions permit.3 In many parts of Africa the size of the human population has exceeded the wealth-generating capacity of its eco-social system. Most simply, this complex system refers to the climatic, water, mineral, ecological and human resources of a given area.4 High birth rates further snare these populations in poverty, misery and violence, as concluded in 2007 by the UK parliament.5 Slowing population growth, through contraception rather than famine, disease or violence is crucial if Africa is to escape this predicament, whether called poverty, Malthusian or demographic entrapment. Of course, entrapment is not solely the product of African behaviour. Centuries of exploitation by Europeans and others have also contributed. But while rich populations should provide aid to reduce poverty, the leaders of poor populations have a duty of care to acknowledge and to seek to address demographic factors when seeking ways out of poverty. Blaming rich populations may be necessary but is insufficient. Climate change can also be conceptualised as another assault from the rich world upon Africa. Population size and growth in the rich world also contributes to this. It is time for the BMJ to commission a paper on population size, population growth, environmental change and poverty. 1. McMichael AJ. Contemplating a one child world. Falling grain stocks and rising population spell disaster and demand debate BMJ 1995 311: 1651-1652 2.Sachs J. Poverty and environmental stress fuel Darfur crisis. Nature 2007 449:14-15. 3. Butler CD and Oluoch-Kosura W. Linking Future Ecosystem Services and Future Human Well-being. Ecology and Society 2006 11 (1): 30. http://www.ecologyandsociety.org/vol11/iss1/art30/ 4. All Party Parliamentary Group on Population Development and Reproductive Health, "Return of the Population Growth Factor: Its Impact on the Millennium Development Goals" (HMSO, London, 2007) 5. Butler CD. Human carrying capacity and human health. Public Library of Science Medicine 2004;1(3):192-194. Competing interests: None declared
Please get the priorities right 8 February 2008
Thomas Sandeman, Retired Radiation Oncologist None Send response to journal: Re: Please get the priorities right	I can only echo several of the rapid responses that point out that our population growth over the past century is responsible for all of the current concern about our planet's and our species' future. I would add that I think its is disgraceful that the medical profession has not kicked up far more of a fuss about this since a substantial reduction in human numbers will solve most of the crises that the international community is willing to spend billions on, while ignoring the contrary pressures by religion, political expediency and the commercial value of children in the third world where they are a saleable commodity. Here we are saving lives when we should be restricting their appearance. Long term hormonal contraception in women would at least let them enjoy intercourse without adding to their burden. This is far more of an emergency than global warming which it would go a long way to alleviate. Competing interests: None declared