The counterintuitive role of efficiency: implications for the ecological impact of health care

摘要

Health systems must decarbonise and, in rich nations, degrow their overall ecological impact if they are to operate within ecological limits.1Sherman JD Thiel C MacNeill A et al.The green print: advancement of environmental sustainability in healthcare.Resour Conserv Recycling. 2020; 161: 104882Crossref Scopus (53) Google Scholar, 2Hickel J O'Neill DW Fanning AL Zoomkawala H National responsibility for ecological breakdown: a fair-shares assessment of resource use, 1970–2017.Lancet Planet Health. 2022; 6: e342-e349Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar This imperative has inspired a range of policies and practices for sustainable health care, including those focused on efficiency, defined here as measures that seek to deliver an equivalent service using fewer inputs.1Sherman JD Thiel C MacNeill A et al.The green print: advancement of environmental sustainability in healthcare.Resour Conserv Recycling. 2020; 161: 104882Crossref Scopus (53) Google Scholar In health care, as in other sectors, efficiency measures are attractive for several reasons: they appear to avoid tradeoffs between the interests of patients, the environment, and health system funders; their benefits can be quantified in formats familiar to decision makers; an they are premised on providing the same care that people have come to expect.3Shove E What is wrong with energy efficiency?.Build Res Inform. 2018; 46: 779-789Crossref Scopus (152) Google Scholar In short, efficiency is seemingly objective and apolitical.4Berman E Thinking like an economist: how efficiency replaced equality in U.S. public policy. Princeton University Press, Princeton, NJ2022Google Scholar However, as critics note, efficiency measures alone cannot produce sustainable health systems. Other efforts are necessary, including those to eliminate care that is inappropriate or of little benefit to patients and to shift approaches from curative to preventive.1Sherman JD Thiel C MacNeill A et al.The green print: advancement of environmental sustainability in healthcare.Resour Conserv Recycling. 2020; 161: 104882Crossref Scopus (53) Google Scholar In this Comment, we expand on these criticisms, arguing that efficiency measures can directly, but unintentionally, contribute to growing ecological harms by entrenching what are ultimately unsustainable practices.3Shove E What is wrong with energy efficiency?.Build Res Inform. 2018; 46: 779-789Crossref Scopus (152) Google Scholar A first observation is that increasing efficiency generally depends on delivering the same service with fewer inputs.3Shove E What is wrong with energy efficiency?.Build Res Inform. 2018; 46: 779-789Crossref Scopus (152) Google Scholar For example, one manufacturer of robotic surgery technology reports that efficiency measures saved 996·37 metric tons of greenhouse gases in 2021.5IntuitiveSustainability report 2021. January, 2022.https://www.intuitive.com/en-us/-/media/ISI/Intuitive/Pdf/2021-intuitive-sustainability-report.pdfGoogle Scholar This efficiency claim takes the current scale of robotic surgery as given and compares a world with efficiency measures against a counterfactual without them. But how can we understand such avoided emissions in the context of evidence that, for some procedures, a robotic approach incurs a 5-times increase in embodied energy and a 2·5-times increase in emissions compared with non-robotic approaches?3Shove E What is wrong with energy efficiency?.Build Res Inform. 2018; 46: 779-789Crossref Scopus (152) Google Scholar, 6Thiel CL Eckelman M Guido R et al.Environmental impacts of surgical procedures: life cycle assessment of hysterectomy in the United States.Environ Sci Technol. 2015; 49: 1779-1786Crossref PubMed Scopus (133) Google Scholar Our intent is not to point out so-called greenwashing; indeed, any efficiency calculation must necessarily draw boundaries around the system in question. The problem is that these analytical boundaries, which are deliberately chosen yet