The public sector should pick up the bill to meet European Union (EU) demands for the efficient removal of pharmaceuticals from the bloc’s wastewater.
So says an analysis carried out by researchers at the Centre for Antibiotic Research (CARe) at the University of Gothenburg, Sweden.
The work, published in a recent issue of Public Health Ethics, seemingly flies in the face of the “polluter pays principle” (PPP) that underpins much of EU policymaking related to pharmaceutical pollution.
However, the authors, including senior lecturer in practical philosophy Erik Malmqvist and professor of environmental pharmacology Joakim Larsson, highlight both ethical and practical challenges to its application to pharmaceutical pollution from human use.
The problem, they say, is pharmaceuticals differ from most other goods in that supranational systems approve them, states subsidize them, and regional councils and doctors decide on prescriptions before individuals can use them. Both society and individual consumers demand pharmaceuticals and thus contribute to emissions in different ways.
So, as the use of medication increases, the problem of pollution and associated environmental impact grows as well. Pharmaceutical residues in urine and feces are increasingly released into the environment via municipal wastewaters, posing risks to both public health and ecosystems.
Therefore, the authors argue, the justification for placing the burden of potential sewage purification solely on the manufacturer of a medicine can be questioned.
Four specific challenges to the application of PPP to pharmaceutical pollution from human use are highlighted. First, since it is unclear who the most salient polluters are, PPP fails to unambiguously assign responsibility. Second, insofar as PPP does identify responsible actors, these may be unable to avoid or mitigate their contribution or, third, only able to do so at excessive cost to themselves or others. Fourth, PPP is susceptible to assigning burdens to actors who cannot fairly be held responsible due to excusable ignorance.
“All four challenges apply to the use of PPP as a guide to selecting management options, whereas the use of PPP as justification for allocating economic costs is mainly vulnerable to the first one. This suggests that European water operators’ appeal to PPP requires significant modification, especially as a justification for prioritizing source-directed and use-orientated measures but also as rationale for allocating costs of end-of-pipe action to upstream actors,” the authors note.
More fundamentally, they argue, these challenges arise because PPP assigns responsibility exclusively on retrospective grounds, by asking who caused or is causing a problem. This provides reason to include prospective considerations when assigning responsibility in this area, asking who is best placed to solve or mitigate the problem.
Hence, the authors challenge the suitability of PPP as the sole rationale for allocating responsibility in this area. They propose combining PPP with the “ability to pay principle” (APP) and explore the practical implications of such a shift.
APP, they say, is the expression of a more fundamental capacity principle, according to which the responsibility to address a problem should be allocated to the actor(s) who are able to address it (most) efficiently.
An actor’s capacity to pay has two dimensions: effectiveness, the likelihood of having an impact and the magnitude of that impact; and cost, the burden the actor incurs or imposes on others by addressing the problem.
“Thus, the ‘pay’ in APP should be understood as including not only direct and indirect financial costs but also other burdens to the actor and other parties, whereas ‘ability’ includes both the ability to shoulder these burdens and the ability to accomplish effective management,” they write.
The hybrid PPP/APP framework proposed balances PPP’s emphasis on holding those causing large-scale problems to account, with APP’s focus on efficient management of such problems.
They conclude that while sound policy here depends on empirical issues that need further study, the authors believe the framework tentatively supports managing pharmaceutical pollution from human use by improving wastewater treatment: “The allocation of associated costs remains to some extent an open question, but the importance of preserving access to clinically important medicines supports distributing these across water consumers or taxpayers.”
Of note, if pharmaceutical companies are compelled to bear the costs of advanced sewage treatment, there is a substantial risk that, for purely economic reasons, they would refrain from selling medications in a given region. It’s often challenging to replace a specific medication with a more environmentally friendly one without jeopardizing patient benefit.
“The consequences of sales halts would, in many cases, be devastating for national healthcare. On average, it takes more than a decade for a new medicine to reach the market, and it often costs more than one billion euros. Developing 'green' pharmaceuticals is thus not a viable solution, except perhaps in the very long term," noted Larsson, who is also a center director at CARe.
