Towards appropriate guidance for the ethical challenges of environmentally sustainable prescribing

The environmental impact of medicines poses a significant threat to planetary and public health, making it essential to integrate environmental sustainability into prescribing practices. While the most effective measures to reduce environmental impact, such as reducing unnecessary prescriptions and medication waste, are consistent with appropriate prescribing and relatively straightforward, incorporating environmental considerations into choices between alternative medicines can raise complex ethical questions. This article examines these challenges in light of the established biomedical ethical principles of beneficence, nonmaleficence, justice and respect for autonomy, while considering values at both individual and societal levels and integrating perspectives from current literature in this field. It discusses how environmental sustainability, along with its associated population benefits, can be aligned with direct patient benefits and considers the implications for distributive and intergenerational justice, as well as for shared decision-making and patient autonomy. It also explores the allocation of responsibilities among stakeholders and argues that environmentally sustainable prescribing should not be the sole responsibility of individuals. Ethical guidance should facilitate proportional, context-sensitive, environmentally sustainable decision-making, acknowledging that appropriate decisions also depend on factors such as disease severity and exact variations in treatment efficacy and safety. To this end, the article proposes three key steps: developing case-based ethical analyses of prescribing dilemmas, translating these analyses into stakeholder-informed value frameworks and embedding these frameworks in practical guidelines and decision aids. Together, these measures can support a responsible integration of environmental sustainability into prescribing practices, safeguarding high-quality patient care while promoting the health of all current and future populations.