Physicians, as well as other healthcare professionals, are active in various roles. They can be involved in the physician–patient relationship, but they can also act as consultants, as public health experts, or as experts in political institutions or public discussions. The most important medical role is the one towards a patient. In this relationship, a physician is to a large extent relieved of further social responsibilities and should act primarily in a way that is in the patient’s best interest. The same is true for other healthcare professionals, but interestingly also for priests and lawyers, when they are in professional contact with individual believers or defendants. They also must focus on the individual may it be a patient, believer, or client. If conflicts were to arise with other roles of the physician, the role towards a patient mostly has precedence.
The Declaration of Geneva (DoG) of the World Medical Association confirms this, with the statement: “The health and well-being of my patient will always be my first consideration.” (World Medical Association 2017).
This is underlined by the individual orientation of the whole document. The DoG is written entirely in the singular and always speaks in terms of “the patient” and “the physician.” It primarily addresses the duties in an individual physician–patient relationship. The World Medical Association strongly believes that this is the primary responsibility of a physician. First and foremost, a physician is obligated to an individual patient and his or her health.
In this respect, it is surprising that the Planetary Health Pledge (PHP) does not refer to a patient in the singular, but rather always refers to “people,” “persons,” or “patients” in the plural form. Why should the individualistic orientation of the medical profession change? Why does the accompanying text to the PHP not address this alteration? Historical experiences, where physicians were primarily obligated to a group (be that race, class, or nationality) should have cautioned the authors of the PHP. To put it clearly, the authors of the PHP should not be accused of having similar intentions as totalitarian regimes; their intention is convincing and worthy of support. But there is a parallel: In both cases, the individual responsibility in the doctor-patient relationship is extended by a collective one. But in his or her central role it is not the first task of a physician to improve the health of a group. Rather a physician should do what is best for the individual patient in the physician–patient relationship—which might as a result improve the health of a group. Conflicts can arise between an individual orientation in the physician–patient relationship and political guidelines, even in environmental protection.
According to a study by "Health Care without Harm", the health sector contributes 4.4% to global emissions (Health Care without Harm). In terms of climate protection these emissions must be reduced, also for the sake of health. But should physicians in the physician–patient relationship therefore refrain from taking helpful measures? Environmental protection and medical care can lead to conflicting goals. Changing a medical procedure to protect the environment may result in the patient being better off in case of unnecessary treatment or the medical outcome being just as good. These two cases are unproblematic, the first case is even desirable for two reasons. However, if the best intervention is not chosen for environmental reasons and the patient is not treated optimally and worse off, then there is a serious conflict. This is exactly what the PHP ignores. How should a physician act when a medically required procedure for a patient imposes a significant environmental burden? Should the physician withhold the treatment because it produces copious amounts of CO2? What should be done when adequate individual medicine conflicts with the requirements of environmental protection? How much harm towards patients is justifiable for the good of the environment? And for the integrity of the profession, the central question arises: who should decide this? Should a physician weigh at the bedside a concrete suffering of a patient against the protection of the environment? Who gives him the authority to do this and where does he get the concrete benchmarks?
Especially the responsibilities in environmental protection are difficult to define. The polluters are often not confronted with the consequences and the results of the environmental changes show up only in later generations. It is difficult to determine exactly how much an individual action contributes to environmental harm (see e.g. Wardrope 2020). In view of this complexity, it is even more important to establish the clear responsibility in the different roles of a doctor. As long as physicians have two equally helpful measures, they can be expected to choose the less environmentally harmful measure. But should physicians have to decide personally in the physician–patient relationship whether to help a patient or reduce greenhouse gas emissions? No, physicians must be relieved of such decisions in the physician–patient relationship, otherwise trust in the medical profession will be lost. These are decisions that need to be clarified at the societal level. The PHP fails to address this conflict and to describe different responsibilities. It leaves doctors alone when they are confronted with conflicting goals in the physician–patient-relationship.