What Could (Or Should) Be the Regulatory Response to the Wicked Problem of Climate Change?

Overwhelming scientific consensus points to causal links between industrial processes such as the burning of fossil fuels and deforestation and climate change, which has also been referred to as global warming or climate breakdown and is amongst the most important issue of our time.^1,2,3 

The provision of healthcare contributes significantly to climate breakdown.⁴  It is estimated that over 70% of the climate footprint of healthcare is a result of greenhouse gas emissions (GHGs).^4,5  Emissions are primarily a result of the medication and medical equipment supply chain, including the production, distribution, storage, and disposal of medicines, devices, or equipment.⁵ 

A vicious (or wicked) cycle results: healthcare work fuels health-related harm which then creates a need for more polluting healthcare work. This trend was noted in a special 2018 report in The Lancet which highlighted the realities of significant climate breakdown on global health, referencing the Intergovern-mental Panel on Climate Change (IPCC) and its objectives.⁶  It is estimated that healthcare work alone contributes close to 5% of all global GHG emissions, and if health care professionals were their own country, they would be the 4^th or 5^th largest global polluter in the world.⁷ 

An inevitable increase in rates of climate change will further perpetuate this cycle. Further climate breakdown will result in increased risks of heat-related illnesses, respiratory and inflammatory conditions, contaminated water and food, zoonotic illnesses and infectious diseases becoming even more prevalent and difficult to manage. At the same time extreme weather events such as wildfires, floods, and hurricanes disrupt local and global supply chains and health service provision.⁶  All of this will require increased levels of healthcare which, itself, being a significant contributor to climate change, creates a violent and self-augmenting positive feedback loop. As climate breakdown leads to more severe and unpredictable weather events (including wildfires, heat emergencies, and hurricanes), the risks of interruptions to the medical and pharmaceutical supply and distribution chain will also worsen—precisely at a the time when health systems are most reliant on the products of this supply chain.^6,7  Already, recent extreme weather events have led to global medication shortages as production facilities are unable to cope, and supply chains at the best of times have become increasingly fragile.⁷ 

Sociologists have coined the term “wicked problem” to describe social and cultural situations that are impossible to solve.⁸  Characterizing climate change as a wicked problem explains why—despite decades of rhetoric, pronouncements, and promises—progress is fleeting, and demonstrable change has been disappointing.

Wicked problems are not solvable in the traditional sense. They lack a definite formula or clear solution pathway due to the inherent complexity and interconnectedness of the issue itself.^8,9  Climate change fits this paradigm because the economic burdens associated with climate mitigation are simply unbearable by most of humanity. Like most wicked problems, climate change has triggered fierce political polarization. Militant and sometimes violent protests on both sides of the issue trigger decisional paralysis at the governmental and regulatory level.

Wicked problems are distinguished by the notion that there is no simple “stopping rule” for determining when a satisfactory solution or acceptable outcome has been achieved. In the context of climate change, a consistent argument on both sides of the issue is that the goalposts for climate action are constantly changing. This is in part due to the constantly evolving scientific understanding and consensus.⁹ 

Wicked problems naturally involve a lag time between implementation of proposals and solutions and actual outcomes or results. Hypotheses therefore can almost never be tested in a scientific or traditionally accepted manner and outsized faith must be placed in expertise, models, and theories that suggest positive outcomes may occur decades in the future while sacrifices must occur today.

As with any wicked problem, to manage the fallout from climate change, regulators must appreciate as a starting point that there is no “right” answer possible to the problem of climate change. Instead, we are forced to select from an unenviable menu of “least worst” alternatives. Naturally, this includes the alternative of doing nothing; indeed, this may be the easiest solution given the overwhelming nature of the wicked problem of climate change.

The realities of climate breakdown on the life of citizens around the world is becoming more prevalent. Those who argue that regulators should more forcefully respond to planetary health (including authors of the Lancet publication), come to this wicked problem with an understanding that regulators of health professionals are, first and foremost, citizens and members of a community.⁶ 

The enormity of this wicked problem demands every person use every point of leverage available to them to mitigate the effects of climate change (eg, by supporting the attainment of IPCC Climate Goals) as a moral requirement.

Regulators of health professionals have an additional moral imperative, especially given the critical role healthcare will play as the effects of climate change are exacerbated, and the resulting self-propagating nature of climate impacts within healthcare work itself. Healthcare work itself is causing climate harm. This is a violation of the Hippocratic Oath and any number of codes of ethics promulgated by regulatory bodies themselves.

Every single member of a profession is, by definition, governed by a regulatory body. This gives health professional regulators unprecedented scope to influence, direct, and potentially change behaviour of large, and invariably influential and powerful, swathes of society: the professionals they regulate. Owing to their special perch within a profession, regulators not only influence their registrants directly, but also have an important steering effect on other large, impactful agents within that profession, including employers, educators, professional associations, researchers, and unions. The power of a regulatory body to convene and steer coalitions of different stakeholders within a profession focused on specific issues that transcend the specific profession has not been adequately explored nor discussed. It is understood that it has scarcely, if ever, been leveraged by regulators to evoke positive change.

In this sense, the power of regulation can go well beyond simple moral suasion or vapid cheerleading. Within their quasi-legislative and quasi-judicial toolkits, regulators can leverage rules and sanctions (“sticks”) to motivate individuals to change behaviour; they are not simply relegated to using positive reinforcement or “carrots” as are most other non-governmental entities. While the leveraging of regulation to change behaviour is always a matter of nuanced and careful consideration, it has thus far been an approach that most (virtually all) regulators have been hesitant to discuss or explore.

Regulators could be adopting a more muscular approach to addressing climate change issues within their professions. This is not only because they—and only the—have the legal and social took kit to do so. Regulators also have a moral and civic responsibility to do so. This goes hand in hand with regulators’ duty to safeguard the public from which they obtain their legal legitimacy and social power. Regulators must operate in the public trust; this is the very foundation on which they are created.

Inaction by regulators is antithetical to this mandate. A regulators’ failure to act on invariably critical issues such as climate change, breeds both public contempt and disrespect, stripping regulators of their power and legitimacy. How can regulators claim to act to ensure “safe” practice of a profession, and to “serve and protect the public” and pretend that climate change is not happening or that health care work is not directly contributing to it? Doing so means a regulator is allowing a profession to operate in a manner which is not only negligent of public safety, but also actively detrimental to it.

Inaction on climate change by regulatory bodies does not equate to climate change denial or skepticism. Rather, inaction might be viewed as a deliberate and prudent choice, maintaining the narrow scope and ambit of a regulator.

Regulatory scope creep is a constant issue that must be monitored closely, and which threatens the well-calibrated balance between public interests, professional autonomy, and proportionate regulation. While climate change is clearly far more important than a “flavor of the day” issue, its wickedness as a problem may be precisely the reason regulators should not be leading or initiating sweeping action.

The complex amalgam of knock-on problems that arise from well-intentioned but simplistic solutions to climate change are what make climate change a wicked problem. These knock-on problems are the reason climate change evades effective and simplistic regulation. Instead, climate change requires professions and professionals themselves—not regulators—to actually lead change. The kinds of behavioural changes required to meaningfully influence climate outcomes in health care are complex and include (for example) climate conscious prescribing and de-prescribing, and office management related to climate-conscious workplace standards.

These variables are important in contributing to meaningfully tempering climate change, but they are not within the scope of regulators to directly—or sometimes even indirectly—influence. At best, regulators might introduce continuing competence requirements to build awareness and knowledge of climate mitigation and adaptation strategies in health care or could assess readiness for climate conscious practice at entry-to-practice. However, these knowledge-and competence- focused activities do not necessarily translate into behavioural changes. Consequently, the value and impact of these approaches might be marginal at best, and merely a form of virtue-signalling, at worst.

The nature of regulation is complex. Regulators’ mandate and are not necessarily focused on professional evolution or innovation per se; they only further such objectives within their scope: safeguarding the public. As creatures of statute, the “regulatory tools” available to regulators are always at the discretion of government and legal structures and legislation to which regulators are subject. This significantly delimits what regulators can do to address climate change in a practical manner. More importantly, regulators are unable to race ahead of the governments that oversee them, and the legal systems within which they must operate, in attempting to effect change. This means that regulators efforts to combat climate change in any meaningful way must necessarily be commensurate with, and flow from, the legislative mandate and efforts of the operative government to achieve the same goal.

Regulation, in this sense, is not education or professional development; it is more properly a legal instrument focused on public safety. According to this narrow view of the regulator’s function, well-intentioned attempts by regulators to expand their ambit to include unsolvable, wicked problems such as climate change threatens credibility and effectiveness of regulatory bodies themselves.

The pro and con arguments for regulatory action with respect to climate change can, and often do, lead to decisional paralysis, though not in such explicit terms. The resulting state of indecision and institutional inertia in turn support the argument that regulators should not be directly involved in this issue, as this is the status quo which should not be disrupted.

Rather than opting for this path of least resistance, a principles-based approach to regulatory decision making may be considered instead.

• Regulatory intentionality: In most regulatory bodies, the decision to become involved (or not) in climate change work is rarely done intentionally. Instead, informal discussions, institutional platitudes with little or no concrete action, or overwhelming workload trigger action or inaction without any specific discussion of the problem to be solved or the specific action to be taken.

  In managing wicked problems, an intentional, deliberate approach grounded in preliminary discussions, strategic planning, and prioritization of action is essential. Such an intentionally deliberate and strategic approach may indeed lead to the conclusion that “not now” is the appropriate regulatory response to calls for engagement in climate related issues. However, discussion, documentation, and evidence of regulatory intentionality in planning and subsequently acting are essential elements of a principles-based approach to guide regulatory involvement in engaging with the wicked problem of climate change.

  As a starting point, regulators could publicly declare their alignment with profession-focused climate change initiatives, to signpost their awareness of and interest in this issue. Simply agreeing and confirming that climate breakdown is in fact a scientifically confirmed and accepted reality might seem like a minor advancement, but it sends important messages across the community and for the general public. While some may say that such rhetoric or agreement without action is meaningless, a public declaration by regulators of the reality and negative impacts of climate change—and a public acknowledgement of health care’s role in worsening the problem—is an important first step in situating regulators on the side of scientific evidence.

• Coalition building: The scale of this wicked problem is immense. Regulators acting alone will not be effective in tackling this issue. Instead, a central principle guiding regulatory decision making should focus on the unique opportunities and capacities regulatory bodies have in generating and potentially leading profession-specific and interprofessional coalitions including educators, employers, professional associations, patient advocacy groups, and insurers.

  As the focal point of a profession, regulators can assist in aligning efforts across all arms of the profession; this objective should be viewed as a priority principle for regulatory involvement. Conversely, if regulatory capacity precludes actual leadership or coalition building, regulators’ support for other institutions or entities in leading or building such coalitions could also be considered to procure professional buy-in for that solution. Examples could include regulatory sponsorship/financial support of profession-specific climate change-related research through scientific groups through targeted grant competitions, highlighting the work of climate conscious practitioners through regulators’ publications and outreach to registrants, and being co-signatories to the growing number of profession specific charters and declarations related to the climate emergency. While such techniques require investment of time and resources, these could provide important moral and financial support for groups involved in this work when regulators themselves are unable to lead.

  Critically, in the context of this wicked problem, regulators are not the natural adversaries to professional associations or unions as they may sometimes appear to be in other contexts. Rather, the nature of the problem often means that their interests are commensurate; this alignment is essential to allow for successful collaboration.

• Finding the right lane: The actors within all successful institutional coalitions have complementary skills and interests; this is what makes them successful. A significant challenge in managing coalitions is ensuring separate groups can leverage their strengths in a manner that is aligned with the work of the overall coalition to develop synergies to benefit the coalition. This applies to regulators; both as leaders and within their involvement in such coalitions. In the context of climate change, what might be the “right lane” for regulators to occupy?

  In part, this will be dictated by the specific activities that are the unique purview of regulatory bodies. For example, the annual registration/licensure renewal process that all practitioners must undertake has historically been a bureaucratic form-filling exercise. Using this pre-existing procedural construct as an opportunity to support awareness building or professional development may be an opportunity for regulators to select the “lane” they wish to occupy in contending with climate change. In some professions, annual registration renewal is contingent upon completion of a prescribed educational program (eg: a 30–60-minute online education module). The module itself is neither onerous nor detailed but focuses on raising awareness of various issues which are apposite for the profession, and providing concrete, general strategies to address those issues. In the same way that employers mandate online learning for work-place safety, such requirements may present an avenue for regulators to use their unique authority and position in the profession to mandate low-impact but helpful educational interventions, and thereby gradually build awareness in the profession of climate-related issues. Of course, this must be done in a way that is not perceived by registrants as burdensome or bureaucratic, or that potentially builds resentment and negativity towards climate-conscious practice. The value of compulsory continuing education in changing practitioners’ behaviour has been questioned for decades, and education does not automatically equate to practice change. Still, as a service provided to registrants, educational programming focused on climate conscious practice may provide opportunities to reflect upon professional practice and generate collegial dialogue and discussion that could support environmentally positive outcomes.

  Such an approach not only gradually shifts the attitude of a profession as a whole (see the next point) but might also serve the larger function of promoting wider partnerships across the profession (eg: with employers or educational institutions). If active and overt partnerships are not feasible, signposting available resources from coalition partners may also be considered. In this context, finding the right lane means collaborating with coalition partners to develop synergies—n this example, with respect to the development of educational tool—using the gentle “sticks” that are singularly and exclusively within the regulator’s “tool kit.”

• Incepting awareness across a profession: By virtue of their role and powers within the lives of the professionals they regulate, regulators have unique opportunities to reach every single member of a profession. This creates an opportunity for regulators to establish and reinforce certain messages, attitudes, and learnings. Through regular communication with registrants, it may be raising awareness and incept ideas within the professional community related to climate conscious practice. The objective is not to force or badger individuals but simply to develop a particular perspective, reminding individuals of the urgency of climate-related issues, and practical ways that each individual professional can reflect upon their practice and to create an impetus for professionals to consider taking reasoned action based on evidence, rather than relying on dubious claims to which professionals might be exposed, for example on social media.

  For example, coalitions with climate-conscious health care researchers, and communications related to aspects of clinical practice which may impact the environment and climate enable practitioners to learn more about certain aspects of climate conscious practice (for example, shifting to therapeutically equivalent but environmentally safer inhaler options for patients with asthma/COPD, or supporting growing initiatives related to selection of less polluting medical gases for anaesthetic procedures).¹⁰  Growing interest in the interprofessional field of “de-prescribing” also has important patient-specific benefits (in terms of reducing risks of adverse drug reactions and reducing cost and time burdens) while supporting smaller carbon footprints in health care. Armed with this perspective and evidence on how to take simple, concrete actions that can have positive climate impacts, professionals can adapt their practice in an evidence-based manner to effect real change.

  In this manner, educational information on climate change emanating from a regulatory body may have a powerful influence on professionals, both in terms of effecting attitudes and catalyzing real, practical change.

• Staying connected to the issue: The scope of wicked problems means they are not something that can be solved in a fiscal year or a 3-year strategic planning cycle.¹¹  While there is currently tremendous interest in and awareness of climate-related health care harm, it is also realistic to expect that over time this interest may fade.

  Given their constant and necessary communication with professionals, regulators have important opportunities to ensure that messaging continues to evolve and remain prominent, even as other socio-cultural issues emerge. A one-year focus on climate change, or a special edition of a newsletter focused on the topic will not be sufficient. In addition to being ineffective, regulator flitting from one cause de jour to another might result in a regulator appearing to go beyond its legislative mandate of public protection and engaging in an (improper) role of social advocacy. This could result in a regulator’s messaging losing its influence over members of a profession and, ultimately, a regulator losing its legitimacy in the eyes of the public.

  It is therefore essential that regulators remain focused on their mandate to protect the public in remaining connected to the issue of combating climate change, and with respect to any other wicked problem a regulator might consider attacking. Regulators must therefore continuously refine and evolve their messaging and supportive materials to keep the issue of climate change both relevant for registrants and consistent with the overarching objective of public protection. Such efforts can be considered part of strategic planning within regulatory organizations. One particularly interesting opportunity may exist in the evolution of codes of ethics governing professionals’ practice. Traditional ethical principles (eg: beneficence, non-maleficence) are well aligned with planetary health objectives, but implicitly or explicitly connecting existing codes of ethics to climate conscious practice has not been undertaken. Considering the way regulatory tools such as standards of practice and codes of ethics could be interpreted or adapted to emphasize climate objectives falls within the remit of regulatory bodies and could be a valuable and powerful tool for shifting thinking and practice.

These principles provide a useful starting point for considering practical issues associated with regulatory action toward climate change and extended, other wicked problems. We stress, however, that they are not a roadmap nor a treatment algorithm, but instead provide a framework for regulators to consider strategies and opportunities for greater engagement with registrants, coalition partners, and the broader community to address this massive, wicked problem.

Despite abundant scientific evidence and consensus, the issue of climate change has become a bitterly and politically polarizing issue, leading many regulators to become paralyzed, avoiding any involvement or engagement. However, the unique role and reach of regulatory bodies provide untapped potential for regulators to address climate change—and other wicked problems—in an active and collaborative manner.

Regulators addressing climate change in this manner is particularly important in the context of health care, where the actual work of health care itself contributes so significantly climate impact, that in turn cause sickness and a need for more health care, creating a vicious cycle perpetuating climate change. As public awareness and interest in this issue has grown, so too has pressure for health system evolution grown. For example, employers and individual practices have increasingly adopted organization-wide recycling mandates, or embraced renewable energy sources, and pharmaceutical manufactures have responded to public pressured by enhancing transparency of supply chain carbon footprints and reverted to “near-sourcing” rather than “off-shoring” production processes.⁶  These innovations are critical developments that can occur without formal regulatory involvement. While regulatory bodies vary significantly in their ability and capacity to consider or enact ideas presented here, they still have opportunities within their professions and communities to help mitigate the effects of climate change. However, doing so is not simple. The complexity of this wicked problem defies simple or unilateral solutions: processes and principles to help regulators better understand how, when, where, and why to engage and become involved will be essential.