Medical ethics in the Anthropocene: how are €100 billion of German physicians' pension funds invested?

[Sustainability in private surgical practice-A narrative review]

Background

Surgery is contributing to the climate crisis, not least in the outpatient sector. The present publication aims to identify the challenges this poses, and to provide clear, preferably evidence-based recommendations on environmental protection while simultaneously reducing costs.

Method

Narrative review with a non-systematic search and selection in PubMed/MEDLINE and grey area literature as well as expert interviews.

Results

Numerous primary articles, evidence syntheses, practical recommendations for action and checklists were identified and two experts were interviewed. Environmental issues were identified in the production and procurement, transport of people and goods, usage of materials, pharmaceuticals including anesthetic gases and energy consumption in the outpatient practice and also in disposal, recycling, and sterilization. High-quality publications do not describe a lack of knowledge on alternatives but on a lack of implementation in clinical practice. Therefore, the identified issues were classified in the 5‑R scheme (reduce, reuse, recycle, rethink, research) to present recommendations for action, which are synergetic in terms of cost reduction, patient and staff satisfaction. Furthermore, changes in regulatory frameworks are discussed.

Conclusion

Outpatient surgery comes with relevant consumption of resources and carbon emissions. There are numerous opportunities for action that combine environmental protection with cost reduction as well as patient and staff satisfaction. Incentives, guidelines, and legal framework conditions are needed for comprehensive environmental protection in the private sector.

[Sustainability in private surgical practice-A narrative review]

BACKGROUND

Surgery is contributing to the climate crisis, not least in the outpatient sector. The present publication aims to identify the challenges this poses, and to provide clear, preferably evidence-based recommendations on environmental protection while simultaneously reducing costs.

METHOD

Narrative review with a non-systematic search and selection in PubMed/MEDLINE and grey area literature as well as expert interviews.

RESULTS

Numerous primary articles, evidence syntheses, practical recommendations for action and checklists were identified and two experts were interviewed. Environmental issues were identified in the production and procurement, transport of people and goods, usage of materials, pharmaceuticals including anesthetic gases and energy consumption in the outpatient practice and also in disposal, recycling, and sterilization. High-quality publications do not describe a lack of knowledge on alternatives but on a lack of implementation in clinical practice. Therefore, the identified issues were classified in the 5‑R scheme (reduce, reuse, recycle, rethink, research) to present recommendations for action, which are synergetic in terms of cost reduction, patient and staff satisfaction. Furthermore, changes in regulatory frameworks are discussed.

CONCLUSION

Outpatient surgery comes with relevant consumption of resources and carbon emissions. There are numerous opportunities for action that combine environmental protection with cost reduction as well as patient and staff satisfaction. Incentives, guidelines, and legal framework conditions are needed for comprehensive environmental protection in the private sector.

[Health and investment: How are the 237 billion euro of the German professional pension funds invested?]

BACKGROUND

Exceeding ecological limits through climate crisis, loss of biodiversity, altered biogeochemical cycles and novel substances is dangerous and leads to increased morbidity. Hence, financial assets should be divested from hazardous industries and re-allocated to support the transformation to an economy that keeps activities within ecological limits. The present study investigates how sustainability criteria are applied to the assets of German pension funds.

METHODS

A survey containing 26 items on 1) business practice, 2) implementation of sustainability strategies, 3) application of ESG criteria to investment decisions, and 4) projects and goals was sent to each and every of 93 German professional pension funds. Furthermore, their annual business reports and publications were analyzed for information on sustainability efforts.

RESULTS

37 of 93 pension funds responded to our survey, 8 of them returned the query. All agreed that ESG criteria are part of their business culture. Predominantly, they adhere to common standards for sustainable investments (UNPRI [United Nations Principles for Responsible Investment], 75% approval); yet, they do not exclude the production of goods that are potentially harmful to health (e.g., tobacco and alcohol).

DISCUSSION

A minority of the participating pension funds agrees that ESG criteria are part of their business culture. However, only few of them provide information about their actual application. Nevertheless, there are pension funds that do not respect sustainability criteria in an appropriate way, and thus take unnecessary financial risks and invest in harmful industries.

[Climate protection in practices - current status, motivation and challenges in outpatient care]

INTRODUCTION

The impact of climate change on health and the necessity to reduce emissions in the health sector is becoming an increasingly discussed topic. Little is known about medical doctors' (MDs) attitude towards climate protection measures in outpatient practices.

METHODS

Between October 2020 and February 2021, a survey was conducted among MDs in German practices. 1,683 participants answered 39 questions on energy use, transportation, disposable materials, budget and patient counselling. Data were collected on status, motivation, obstacles and needs regarding climate protection in practices.

RESULTS

83% considered climate change an urgent problem requiring immediate action. A majority reported climate effects on their patients' health. Most MDs felt responsible for climate protection in their practices, showing a high degree of willingness to implement climate-friendly measures. Obstacles reported include lack of information and institutional support as well as the expected financial burden. A majority of MDs called on professional associations and politics to develop climate-friendly strategies.

CONCLUSION

In view of national climate targets and the willingness of outpatient MDs to contribute to climate protection, support from medical associations is required, e. g. through practical recommendations and financial help, in order to transform the health sector in accordance with the idea of Planetary Health. Accompanying studies should provide further evidence on effective measures to reduce greenhouse gas emissions in practices.

Do private German health insurers invest their capital reserves of €353 billion according to environmental, social and governance criteria?

BACKGROUND

To prevent the planet from catastrophic global warming a reduction of greenhouse gas emissions to net zero is required. Thus, divestment from fossil fuels must be a strategic interest for health insurers. The aim of this study was to analyse the implementation of environmental, social and governance (ESG) criteria in German private health insurers' investments.

METHODS

In 2019 a survey about ESG strategies was sent to German private health insurance companies. The survey evaluated investment strategies and thresholds for the exclusion of sectors and business practices, as well as company strategies for sustainable business development.

FINDINGS

Given their business reports, German private health insurers manage assets of more than €350 billion. 11 of 40 insurance companies provided quantitative data, 10 refused to answer. According to quantitative data, €66 billion of assets is managed according to any ESG criteria; this equals an average of 76% of each company's bonds. None of these insurers excluded the production and sale of fossil fuels. All excluded coal mining but only at high thresholds. For €226 billion, no data were provided.

INTERPRETATION

The findings are in contrast to the expected intrinsic economic interest of the insurers to stop global warming and improve public health. The majority of assets are managed in a highly problematic manner, especially the absence of capital allocated in fields contrary to medical ethics (eg, firearms, armour) cannot be presumed. Lack of transparency is a major problem that limits clients in choosing the insurer who has the most advanced ESG criteria.