Sustainability has become an important notion in healthcare and bioethics. It is not a new concept. It was advanced in global discourse in 1987, when the World Commission on Environment and Development famously defined it as meeting “the needs of the present without compromising the ability of future generations to meet their own needs” (World Commission on Environment and Development 1987, 16). The report of the Commission identifies three pillars of sustainability: environmental protection, economic development, and social equity. More recently, it has been argued that culture is a fourth pillar (Weaver 2016). The concept of sustainability is related to other concepts such as conservation and resilience. Environmental sustainability for example indicates protection and preservation of natural resources. It also includes resilience as the capacity to endure stress while maintaining functioning and to adapt to changing circumstances. Sustainability is furthermore related to the concept of stewardship.
The Commission’s report initiated numerous global initiatives, culminating in the adoption of the Sustainable Development Goals by the United Nations in 2015. The term sustainability is used in very different contexts. In healthcare it refers to the capacity to sustain programs to provide care and treatment. That implies that healthcare is provided without substantial environmental damage (for example reducing waste and energy). Nowadays, it is evident that environmental degradation has negative repercussions for health (Pierce and Jameton 2004; Ten Have 2019). At the same time, it is recognized that healthcare can have an impact on environmental degradation. The healthcare sector itself significantly contributes to environmental degradation. In 2007, for example, it contributed 8% of the total greenhouse gas emissions in the U.S. (Chung and Meltzer 2009). Potter pointed out that better medical care leads to population growth, which produces habitat destruction and pollution, which leads to environmental degradation (Potter 1971). The impact argument can also be specific and local. All medical centers produce toxic waste. Current practices of healthcare, especially in more developed countries, are not using scarce resources in the most efficient way. The notion of sustainability should therefore be applied to healthcare. The idea of ‘sustainable medicine’ has particularly been promoted by Daniel Callahan (1999). Recognition that the environment is a crucial global condition for the pursuit of health has advanced the awareness that bioethics should transform into ‘green bioethics:’ a broader ethical perspective that takes into account that human beings and nature are connected and that sustainability is a fundamental value (Richie 2019).
The notion of sustainability as introduced by the World Commission is in fact a compromise between social equity, economy and ecology. However, the balance between these pillars can be very different. Western countries have seen enormous development and economic growth, but at the expense of environmental degradation. Developing countries argue that in order to grow and develop, they should not be bound to environmental limits. The issue of global inequality should be addressed with a differential approach, requesting more environmental sacrifices from the most developed countries. That means that a good balance between the three pillars is not difficult and in many cases will be unfair to developing countries. The approach of the Commission (and the United Nations) operates with a weak notion of sustainability, assuming that the socio-political, economic and ecological spheres are separate, having their own logic and values, but nonetheless the expectation is that they can be integrated. In reality, economic growth and social development often have priority. The Commission’s notion of sustainability is also strongly anthropocentric; human beings and their needs are the point of departure. Everything in nature has instrumental value and contributes to achieving human purposes. Others argue that this will not do. A stronger notion of sustainability will be necessary that requires a drastic change in patterns of production and consumption, and that respects the intrinsic value of nature, regardless of any benefits for humans. It assumes that the socio-political and economic spheres are not separate from the ecological one but embedded in it (Hattingh 2006).
The debate on the notion of sustainability is an important one. It defines not only environmental responsibilities and obligations, but also what we (in policies and everyday practices) should try to achieve. Sustainability, as underlined in the Johannesburg Declaration on Sustainable Development, implies a commitment “to build a humane, equitable and caring global society cognizant of the need for human dignity for all.” (World Summit on Sustainable Development 2002, 2). In this issue Min-Jui Yeh (2020) examines the normative values that are embedded in the notion of sustainability. He distinguishes three basic values: equity, stability, and solidarity. He also analyzes three historical periods in which the concept of sustainability was defined and expanded. Because sustainability is broadly endorsed in the literature it is helpful that its underlying values are clarified so that we better know what are the commitments and implications when this notion is used.
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ten Have, H., Gordijn, B. Sustainability. Med Health Care and Philos 23, 153–154 (2020). https://doi.org/10.1007/s11019-020-09946-3