1 Introduction

Transitioning to environmentally sustainable healthcare systems is globally recognized as imperative [1-3]. This acknowledgment of stakeholders, such as governments and healthcare professionals, is driven by the intricate relationship between healthcare delivery, environmental impact and health outcomes. It underscores the necessity for equitable and environmentally conscious healthcare practices to improve planetary health and wellbeing for all [4]. The rising focus on environmental sustainability in healthcare is reflected not only by the growing body of research on environmental impact of healthcare systems and potential mitigation strategies, but also through increasingly explicit policy ambitions [5-10].

Patients could be important stakeholders in achieving ambitious sustainability goals within healthcare. Ultimately, the consultation room, the heart of our health system, is where some environmental trade-offs might become tangible, shifting from policy ambitions to practical implementation that incorporates patient perspectives. Patients themselves are advocating for sustainability in healthcare practices. For example, a 2024 Dutch national survey among 9371 patients found that 69% of patients considered environmental sustainability an important aspect of healthcare delivery, and 73% expressed a willingness to incorporate sustainability factors into healthcare decisions [11]. A qualitative focus group study in the United States among patients and physicians found that patients encouraged climate and health counselling from physicians, especially when impacting their health [12]. Along these lines, multiple studies have suggested patient receptivity to ‘climate-sensitive health counselling’, defined as the communication of the health effects of environmental hazards and the health benefits of climate mitigation strategies within healthcare encounters [13-15].

Despite studies showing patient support of sustainable healthcare systems, uncertainties persist regarding the integration of environmental considerations into healthcare decisions that may affect individual patient care, particularly in terms of ethics and shared decision-making. Indeed, patients might show resistance regarding sustainable choices that could directly affect their treatment and would compromise clinical effectiveness, which was also highlighted in the Dutch national survey and a 2024 survey study among gynaecological patients of two outpatient clinics in the Netherlands [11, 16]. However, the ethical obligation to reduce greenhouse gas emissions suggests that all social sectors – including healthcare – ought to be more sustainable. This prompts an exploration of if and when environmental concerns should be integrated into clinical decision-making and whether patients believe that individual needs should take precedence over environmental considerations or if there are circumstances in which trade-offs may be ethical and clinically acceptable.

While economic considerations, such as healthcare costs, are increasingly studied in regard to shared decision-making processes, research on patient attitudes towards integrating environmental outcomes into healthcare decision-making remains scarce [13, 17-20]. Qualitative studies are needed to gain a more profound understanding of patient values, preferences and the acceptability of discussing environmental outcomes of healthcare practices within patient–provider consultations. Gaining insight into patient attitudes can shape how environmental information is incorporated into consultations, enabling meaningful patient involvement. This approach would not only make clinical practice more sustainable but also safeguard patient wellbeing amidst the ongoing ecological crisis, which increasingly impacts both health and access to care. This interview study serves as an in-depth follow-up of a survey study on patients' perspectives on environmental sustainability within healthcare settings [16]. Specifically, this study aims to elucidate patients' attitudes regarding the provision of environmental information in healthcare decision-making and to identify preferred approaches for integrating these considerations into patient–provider consultations. This focus on communication strategies within consultations ensures that patient perspectives directly inform the evolving approach to sustainability in healthcare decision-making while upholding principles of clinical ethics.

2 Methods

We performed qualitative research conducting semistructured interviews with patients of two outpatient clinics in the Netherlands. To elicit in-depth responses and the nuances of patients' experiences regarding environmental sustainability in healthcare settings, we decided to organize one-on-one interviews. The Ethics Review Board of Amsterdam University Medical Centre (Amsterdam UMC) concluded that the research did not fall within the scope of the Medical Research Act with People (METC application number 2024.0027, date of approval 31 January 2024). We adhered to the Standards for Reporting Qualitative Research (Table S1) [21].

3 Results

A total of 14 patients from 5 gynaecological subdepartments were interviewed. All participants completed the previously published questionnaire, which included questions on demographics and climate-friendly healthcare perspectives (Table 1) [16]. The median age was 41 years (range 31–68 years), and all participants identified as women. Most participants worried about the consequences of climate change and agreed that healthcare contributes to CO₂-emissions and thus to climate change.

The interviews averaged 49 min in duration (range 40–83 min) and were conducted between February and May 2024. None of the participants had previously received information on the environmental impact of healthcare within patient–provider interactions. Based on their own experiences as patients, most participants highlighted the substantial waste produced by the healthcare sector and the waste associated with leftover medication. Five main themes and two subthemes were identified as visualised in Figure 1. The first theme provided the foundation for the other themes. Themes two and three were associated with information provision, whereas themes four and five addressed decision-making within patient–provider interactions.

4 Discussion

Our study revealed that patients are open to receiving environmental information in healthcare settings, recognizing that both the healthcare sector and individuals have a shared responsibility in adopting sustainable practices. While patients acknowledged the need for environmental awareness, they expressed concerns about potential confrontations with others who might not be as receptive. Despite this, they emphasized the importance of personalized care and context-sensitive conversations on environmental impact. Patients prioritized individual health over environmental considerations, but some would accept environmentally friendly healthcare practices that involve reduced comfort or increased side effects, depending on the context.

These findings align with other studies that show patients' increasing interest in environmentally sustainable healthcare [11, 13, 16, 28, 29]. While concerns have been raised in the literature about the risk of potentially compromising the physician–patient relationship when mentioning environmental topics, our study highlights the potential benefits and positive impact these conversations could have when initiated under adequate conditions [13, 30]. In fact, one patient even perceived environmental conversations within the healthcare context as ‘heroic’, and another found it compelling if healthcare professionals would consider not only the patient in front of them, but also future generations and broader societal implications. These findings are consistent with a larger focus group study in the United States, that showed that both patients and physicians were interested in participating in climate and health conversations, and agreed that climate discussions in healthcare settings could increase awareness [12]. The latter study also found that physicians underestimated the interest and willingness of patients to engage in environmental conversations – a perception that aligns with our findings, showing that patients underestimated the interest of other patients. These studies add an important normative dimension to sustainable healthcare, defeating arguments that resource conservation is unimportant or irrelevant in clinical care.

A large study published in 2024 investigated this phenomenon known as the ‘perception gap’ between actual and perceived support for climate action among 130,000 people across 125 countries [31]. People significantly underestimated the willingness of their fellow citizens to contribute to climate action. These systematic gaps between perception and reality can form an obstacle to engage in climate action, thereby confirming the negative beliefs held by others. Our study showed a positive perception of patients with regard to receptiveness to environmental information. Therefore, the study should be considered an effort to correct any misperceptions by healthcare professionals and patients themselves regarding patients' positive attitudes towards transitioning to environmentally sustainable healthcare. Instead of echoing the concerns of a minority that opposes any form of environmental conversations, our study helps communicate that patients are worried about the consequences of climate change and would find it both acceptable and desirable to incorporate environmental considerations into healthcare decision-making in a patient-centred context. As such, clinical ethics would accept discussions on climate change and the environmental impact of care under the umbrella of informed consent, patient autonomy and patient preferences [32].

This support for sustainability considerations within healthcare does not come without caveats: patients outline clear conditions under which these types of conversations are appropriate and when these are not. For example, patients highlighted that discussing the environmental impact of healthcare does not have a place in emergency settings that require immediate clinical action, when there are time constraints, and when there is lowered patient decisional capacity in case of low health literacy or experienced anxiety, stress or pain. This is consistent with widely held views of information provision in patient–provider encounters, which truncate the quantity and kind information given [33]. On the other hand, patients reported that the healthcare sector should strive to implement sustainable practices whenever feasible (e.g., purchasing green energy and using as few disposables as possible) and present options to patients in situations of clinical uncertainty or preference-sensitive equipoise (e.g., when deciding which contraceptive to use). Patients highlighted that elective treatments for long-term non-life-threatening conditions are particularly suitable for discussing environmental impact, such as in the case of (surgical) treatment for heavy menstrual bleeding. Interestingly, these facilitators and barriers resemble those reported in the context of shared decision-making [34-36]. Some of the principles of shared decision-making could therefore usefully guide environmental communication within healthcare settings. The core of shared decision-making lies in the view that individuals should be aware of all relevant options and their characteristics, and that their personal perspectives and preferences are taken into consideration when determining choices [37]. Similarly, as demonstrated in our study on discussing environmental outcomes, the degree to which patients wish to be involved in decision-making, as well as their desire to become informed about relevant information, will vary. Our findings suggest that environmental sustainability should be normalized among other forms of health information provision in non-emergency settings. The sharing of this information, as well as involving patients in related decision-making, should always be tailored to the individual patient and the specific context. In the end, this will enable patients to consider how environmental impact, along with other factors, affects their treatment choices and will foster awareness beyond the consultation room. Moreover, patients reported that receiving information on environmental impact in an adequate manner could positively influence their perceptions of the care they receive, as it demonstrates healthcare's commitment to and concern for public health.

There are some important considerations regarding the inclusion of environmental impact within shared decision-making frameworks. First, patients generally reported that the impact of environmental outcomes on decision-making is expected to be minimal because individual health is prioritised over sustainability. Rather than emphasizing the need of healthcare decisions alone, the focus could be redirected toward facilitating patient discussions about environmental impact (e.g., using patient conversation aids instead of patient decision aids), which patients in our study identified as particularly valuable. Second, ethical challenges related to environmental conversations in healthcare settings should also be taken into account, a topic we have explored elsewhere [38]. In short, these discussions address balancing the inclusion of environmental impact information with the need to avoid moral coercion and to preserve patient autonomy [30, 38]. The findings of our current study, however, suggest that we should not assume these topics have no place in patient consultations. Our study underscores the importance of integrating sustainability into clinical practice, aligning with bioethical principles and the expectations and goals of patients. Similarly, increased ethical concerns about financial burden (so-called ‘financial toxicity’) within healthcare have translated into recommendations to include information about pricing and costs of healthcare in shared decision-making, increasing the frequency of cost conversations about treatment options [39-41]. While notable differences exist between personal healthcare expenses and environmental ‘costs’ such as negative public health effects, certain parallels are evident in the literature: studies have found that some patients may feel more comfortable than healthcare professionals when discussing these environmental and economic costs and may support the inclusion of such considerations, whether addressed by physicians or as part of their own decision-making responsibilities [12, 42]. Third, questions arise regarding whether we should consider environmental information within the same context as shared decision-making, given that it is a public health issue where wider societal interests may supersede individual preferences, similar to the case with vaccinations [35]. As we confront the environmental crisis, there is a need to establish new standards for quality of care. This necessitates centring medical expertise while also incorporating patient perspectives on a fundamental level through proactive co-design of services. For example, we could take patients' environmental considerations into account when designing medical products like specula rather than soliciting their opinions after implementation in clinical practice, which may leave patients feeling abandoned when making complex decisions [43]. Future research should examine the role of environmental sustainability within the context of shared decision-making, preferably in real-life situations that are applicable to the target population. Lastly, the provision of information on environmental impact should not exacerbate health inequities or evoke feelings of guilt. Clinicians should be aware that feelings of guilt might be higher in marginalized populations, particularly women, who are socialized to be self-sacrificial [44].

5 Conclusion

This study demonstrates that patients are open to receiving environmental information as part of patient-centred care, specifically in non-acute elective settings. Our findings suggest that with the right approach, healthcare professionals can help bridge the gap between patient attitudes and perceived support for sustainability initiatives. By integrating patient preferences into care and ensuring that environmental considerations are introduced in a personalized and context-appropriate manner, healthcare can foster greater support for sustainable practices, accelerating systemic changes in the sector.

Author Contributions

Eva S. Cohen: conceptualization, investigation, funding acquisition, writing–original draft, methodology, writing–review and editing, formal analysis, data curation, visualization, project administration, validation. Dionne S. Kringos: conceptualization, investigation, funding acquisition, writing–review and editing, methodology, data curation, supervision, validation, resources. Fleur Grandiek: investigation, writing–review and editing, data curation. Lisanne H. J. A. Kouwenberg: visualization, data curation, conceptualization, methodology, writing–review and editing. Nicolaas H. Sperna Weiland: conceptualization, funding acquisition, writing–review and editing, methodology. Cristina Richie: conceptualization, writing–review and editing. Wouter. J. K. Hehenkamp: supervision, conceptualization, investigation, funding acquisition, writing–review and editing, data curation, methodology, validation, resources. Johanna W. M. Aarts: conceptualization, funding acquisition, investigation, writing–review and editing, supervision, methodology, data curation, validation, resources.

Ethics Statement

The Ethics Review Board of Amsterdam University Medical Centre (Amsterdam UMC) concluded that the research did not fall within the scope of the Medical Research Act with People (METC application number 2024.0027, date of approval 31 January 2024).

Conflicts of Interest

The authors declare no conflicts of interest.