Cristian Timmermann¹, Frank Ursin²

¹ Institute for Ethics and History of Health in Society (IEHHS), School of Medicine, University of Augsburg

²Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School

Climate change and environmental damage are becoming among the greatest threats to human health. Dealing with anticipated threats involves averting or mitigating them through changes in behaviour in the present. As more and more healthcare professionals and bioethicists recognise the importance of reducing the healthcare sector’s ecological footprint, there has been a growing need to reassess the suitability of the four classical principles of biomedical ethics. One obvious response is to supplement the classical principles – respect for autonomy, non-maleficence, beneficence and justice – with a new principle: ‘sustainability’. This would ensure that ecological, social and economic dimensions are always systematically taken into account. In the context of the four classical principles, ethical conflicts would be weighted differently and brought into a coherent framework. However, this extension raises four questions: (a) Which understanding of sustainability should form the basis? (b) How does this new principle interact with the established duties of doctors towards individual patients? (c) Can environmental protection concerns already be addressed using the established biomedical principles, rendering a new principle superfluous? And (d) is such an extension even necessary, from a conceptual point of view, in order to systematically evaluate ethical considerations regarding the health of the population and the planet? In this lecture, we identify concepts of sustainability that unite the professional duties of healthcare professionals with those of institutions and other professional groups. We then examine how sustainability goals can be advanced within the framework of the four classical principles, for example through a broader understanding of the principle of harm prevention, which takes into account both direct and indirect harms outside the doctor–patient relationship. We propose a refinement of the principle of justice that also takes into account the interests of distant individuals and future generations. Finally, we advocate the introduction of ‘sustainability’ as a fifth principle, as the current environmental crisis and emergency compel us as a society to use every available means to recognise the urgency of the situation and translate it into principles that guide our actions.