Good Morning,
I am writing today to let you know about an Australian Senate enquiry that may consider the future of healthcare in Australia. The enquiry is examining the likelihood that the era of cheap and plentiful crude oil is drawing to an end, and what that may mean for our society.

I am a GP in Newcastle NSW, and a member of the local Hunter Urban Division of General Practice. I am concerned that medicine in particular (as well as society in general) will be ill-prepared for peak oil, especially as it is predicted to occur as early as 2010.

In collaboration with a Victorian anaesthetist (Dr James Barson), I recently co-authored an in-depth submission on the healthcare aspects of peak oil to the Senate enquiry. We submitted it on behalf of the Australian chapter of the Association for the Study of Peak Oil and Gas (ASPO-Australia), and it is available on their website: http://www.aspo-australia.org.au/

In brief, our submission covered:

• Ways that modern medicine is oil-dependent
• How Australian general practice is susceptible to peak oil, and how that might be changed.
• Why hospital medicine is vulnerable to peak oil, and how it might be remodelled.
• Ethical challenges of healthcare and peak oil
• Introduction to the methodology of oil vulnerability analysis
• Demonstration of the vulnerability of the health care system to fuel supply disruption
• Techniques of relocalised healthcare

I refer you to the Senate website for more information on peak oil: http://www.aph.gov.au/senate/committee/rrat_ctte/oil_supply/int_report/index.htm. Note that our submission was made after the release of the interim Senate report, but we hope that it will be considered for the final report.

Additionally, I have started a website called Peak Oil Medicine (www.peakoilmedicine.com) where I discuss these issues at depth.

Peak Oil Theory Background
The peak oil theory was formulated in the 1950?s by American geologist M King Hubbert. His theory states that sooner or later, oil production from any given field will reach a maximum (or peak) before turning downwards and declining.

He based his theory on what he observed occurring in US oil fields at that time, and accurately predicted the peak in Lower-48 US oil production in the early 1970?s.

His method has been validated by production patterns in other countries, and by extension has been applied to global oil production.

His theory shows that a peak in oil PRODUCTION typically follows the peak in oil DISCOVERY by about 30 years.

It also predicts that we will find progressively fewer new oil fields, and that they will be smaller, more technically challenging, cost more, and be located in more environmentally sensitive, climatically hostile, or geopolitically unstable areas.

In this context, the new US oil discovery in the Gulf of Mexico (called ?Jack-2?) is completely congruous with his theory (deeper water than ever before, much more expensive, in a ?hurricane zone?, and only has enough reserves to supply world requirements for six months).

According to his theory, world oil production will eventually peak and then enter a permanent decline. Back in the 1950?s world oil discoveries were around 30 billion barrels per year, while annual consumption was 4 billion barrels. Currently, these figures are roughly reversed: we now burn 7 or 8 barrels of oil for each one that we discover.

When global peak oil occurs, there will not be enough crude oil to satisfy progressively increasing world demand (especially from countries like China and India). Prices must then increase (due to supply and demand), and may reach relatively astronomical levels (US$200 a barrel has been suggested).

Such price increases will have a profound impact on our society, and are thought likely to trigger global recession or depression (akin to the 1930?s). Unfortunately, there are no ready oil-substitutes on the scale required: one US study (called the Hirsch Report) suggests that it will take 20 years of urgent and massive mitigation action to avoid significant economic impacts.

Summary
From the perspective of peak oil, modern medicine is clearly unsustainable. While there are many reasons for this assertion, I would draw your attention to two:

1. Many modern pharmaceuticals are based on crude-oil feedstocks.
2. Plastics are derived from oil, and modern medicine is pervasively dependent on them.

The implications of peak oil are such that even if one remains unconvinced about if and when it might occur, the consequences may be so devastating that not to consider how our system might respond to such a crisis would be foolhardy.




Yours faithfully,

Paul Roth

Open Letter to Australian GPs
Image Credits: Taken from Robert Hirsch?s peak oil report and subsequent work.

An ethical conflict occurs whenever the rights of two or more people, or groups of people, come into conflict. Put another way, it occurs when everyone can?t get what they want, and tough decisions need to be made about the allocation of scarce resources.

It is particularly likely that ethical dilemmas will arise during the redesign of the healthcare system as a response to peak oil. This is because there will be a conflict between what is best for society as a whole, versus what is best for the individual.

It is also likely that the quality of life, safety and material abundance that we currently enjoy will decline once oil becomes scarce and expensive. It is probable that the next few decades will be characterized by the scarcity of many things, necessitating the need for rationing of healthcare and other important services.

Why ethics?
Ethics are important because:

• Reasoned and ethical action is a sign of a civilised society.
• Ethics includes the ideas of fairness, equality and compassion. I believe that we must strive to remain as ethical as possible, so that the best qualities of humans and their society may survive for the benefit of future generations.
• Ethical societies value and care for their young, old and infirm.
• A more ethical approach to the environment is needed for its survival, and our own.
• Medical practice has always been informed and guided by ethics.
• Doctors have an ethical duty to patients that should be absolute, regardless of the society in which they practice, or the conditions in which they find themselves.

A physician has three main ethical duties to patients:

• Beneficence ? ?do good?
• Non-maleficence ? ?do no harm”
• Respect for autonomy ? ?a patient?s rights and preferences are important?

These ethical duties are inviolate, and should form the foundation upon which all further activity (including considerations of rationing) is built. Ethics must be considered in our response to peak oil if we are to remain a just and compassionate society.

Healthcare rationing
Rationing presents peculiar ethical challenges, because the conflict between community and individual rights is brought into stark relief. And while health care systems already have some rationing (in the form of the Pharmaceutical Benefits Scheme and public hospital waiting lists in Australia, for example), it is likely that much tougher decisions will need to be made in the future. These decisions are likely to involve issues of life and death, such as who may have access to potentially life-saving treatment, and who may not.

The case of renal dialysis
Consider the example of renal dialysis (as it has been discussed extensively in the bioethical literature). It is a complex and expensive undertaking, and is already being rationed in New Zealand. They have introduced a strict and explicit system of rationing to determine who may have access to dialysis, and essentially who may die fairly quickly of end-stage renal failure. Their system relies on a set of clinical guidelines that were developed by a consensus process in the early 1990s, and considers age and the presence of significant co-morbidities. The intent was originally that no-one over the age of 75 years would be dialysed. The system has generated a large amount of controversy and public discussion, and has been tested in the courts at least twice.

Rationing inevitable regardless of peak oil
Even if oil peaking wasn?t imminent, it is likely that the ethical dilemma of rationing would become increasingly important anyway. There are two reasons for this statement:

1. Ageing populations in Western socities will need much more care as the get older, especially as the baby-boomers enter their seventies.
2. As medical technology continues to produce technological breakthroughs, the cost to access these treatments goes up. This is because ?designer drugs? and ?magic bullets? are becoming more common but have very high development costs. As these sorts of treatments (termed pharmacogenomics) tend to be targeted at uncommon or rare conditions, the cost per patient is high so that research and development costs can be recovered. They also tend to be targeted at age-related diseases like cancer, so demand will increase significantly in the coming years.

It is clear then that sooner or later, countries like Australia will need to make tough decisions about health care rationing, which will result in serious illness or death for those that miss out. There is no way to dodge the magic bullets! The rights of the individual will always collide with the good of society, thereby producing ethical dilemmas.

Developing ethical decision-making frameworks
Coming resource scarcity, whatever the cause, is adequate motivation to develop an ethically-based framework that can guide fair and just decisions about resource allocation. Such a framework ensures that the decision-making process is transparent, and that it satisfies the ethical duties of honesty and disclosure. It also ensures that the concept of justice (in this case distributive justice) is incorporated by including a process of public consultation. An honestly conducted public enquiry satisfies the ethical duty of fairness, and should reduce conflict down the track by seeking consensus up-front.

Having explicit guidelines for clinical decision making is one of the two ways that healthcare rationing can be achieved. Explicit guidelines are prescriptive and relatively inflexible. The New Zealand experience shows that they may be open to legal challenge, or trigger widespread debate and dissent in a population. Even though the idea of such guidelines is attractive, there are several potential problems in addition to legality and public opinion:

1. Fails to acknowledge that medicine is both art and science.
2. Difficult to incorporate new information or clinical developments once treatment has started.
3. Doesn?t acknowledge clinically-relevant differences between patients.
4. Relatively inflexible.
5. Susceptible to outside influence (such as political or media pressure).

The other way of rationing scarce healthcare resources is through an implicit process. Such a system relies on the making of discretionary decisions within a fixed healthcare budget. Strategies include:

1. Queuing (eg public hospital elective surgery waiting lists).
2. Decreased service intensity (eg monthly therapy sessions instead of weekly ones).
3. Substitution of less expensive services for more costly ones (eg generic medications).
4. Excluding some treatments from the public system completely (eg weight loss medications and the PBS).

So while at first explicit guidelines seem more attractive, implicit rationing (within a given budget) seems better able to respond to the complex, diverse and rapidly-changing environment likely to occur after peak oil. It will also be more likely to have the speed and flexibility required to cope with shortages, natural disasters, accidents and civil unrest, and allows physicians to make exceptions to rules that seem unfair or unwise in specific instances.

Distributive justice
It is a moral imperative that rationing be fair and just. It is also a practical one both politically and socially (to maximise the chances of re-election, and reduce the risk of revolt, respectively). Inequality in the distribution of goods is evident when favouritism or discrimination occurs: the process is then said to be unfair or unjust.

According to Kjellstrand (1996), there are three theories of justice that are frequently applied to medical decision-making:

1. Egalitarianism ? All people have intrinsic worth. Equal access to health care is a right. Need for services is the primary criterion to make decisions.
2. Utilitarianism ? Values the good of the community over the good of the individual. Equality subordinated to overall outcome.
3. Libertarianism ? Primacy of personal autonomy. No automatic right to healthcare. Healthcare is just another service for those who want and can afford it.

These three different views of the one ethical principle explain how conflict in resource allocation occurs. We need to recognise the difficulty, complexity and challenge of making decisions after oil peaking. We should favour processes that are as fair and honest as possible, but which retain their flexibility and are able to react to changing conditions quickly.

Values after peak oil
In the interests of stability and safety after peak oil (themselves utilitarian values), it is likely that the order of priority for the three theories listed above will be (1) utilitarianism; (2) egalitarianism; (3) libertarianism. This is because the good of the community will be of primary importance as our society adapts to changed and unstable conditions, and resource scarcity means that limited medical services must be allocated to maximise the greater good, and promote security and safety. For instance it is likely that workers and those with useful skills will receive treatment first, as the survival of the group will depend on the survival of the able-bodied and skilled. Although the order of the other two approaches will depend on local factors, one would hope that compassion and charity might remain important.

A new land ethic
Different ethical viewpoints make distinctions between those entities that count in a moral consideration, and those that don?t. At one extreme is the belief that only living humans with the capacity to think are worthy of moral consideration. This viewpoint excludes the foetus, unborn future generations, and the natural world from consideration.

At the other extreme is the viewpoint of deep ecology, whereby all things are seen as being equal, morally important, as having intrinsic net worth, and as deserving of being treated in an ethical manner. This includes nature. The current state of our environment serves as evidence that our globalised industrial society doesn?t extend basic moral protection to the natural world, thereby allowing phenomena such as the clear-felling of old-growth forests, strip-mining and global warming.

In contrast, many indigenous peoples held their environment in high regard, often to the point of sacredness. This reverence for the natural world is one of the factors that allowed some indigenous cultures to develop sustainable societies.

In a scarce oil future, it is envisaged that many of us will live in much closer approximation to nature, spend a significant part of our time working the land using low-tech methods, and depend on the health of local ecosystems for our own health and survival.

Although this article is about medical ethics and rationing, it is worthwhile considering the type of ethical approach to nature that will be required to achieve long-term sustainability in a relocalised future. The ?land ethic? of Aldo Leopold and the ethics of the permaculture system demand a respect for and partnership with nature that will be crucial to our survival. Both approaches acknowledge that natural things have intrinsic worth and moral standing. It logically follows then that they deserve to have the same ethics applied to them as we use for ourselves.

Once the place of nature in an ethical framework has been clarified, the preceding discussion on rationing can be used to determine the way that other goods (such as water, food, clothing, shelter and energy) are shared and distributed. Indigenous people used an oral tradition of stories, rules and taboos to disseminate and enforce their systems of land stewardship (for example a prohibition on hunting female animals during breeding season, or the way that water holes were to be managed during a drought). Hopefully we can formulate a similar system of ethics that includes all of nature as a moral being worthy of ethical consideration. Only in that way can we effectively deal with peak oil and energy descent.

The Australian Senate released their interim report into peak oil earlier this month. Unfortunately I could see no mention of healthcare at first glance, even though ASPO-Australia put in a submission (Jim Barson and I have subsequently sent in an in-depth supplement to the original submission which we hope might be considered for the final report). It does look like they considered that peak oil is a reality, as they referenced the Hirsch report extensively.

I have included a few excerpts from the impacts section of the report below. You can see the full Senate pdf here.

3. Economic and social impact of high fuel prices

3.1 Recent sharp rises in the price of oil have served to demonstrate that there are significant sectors within Australian society who have limited capacity to cope with sustained high oil prices.

3.2 Submissions and evidence to this inquiry on the effects of high fuel prices were mostly qualitative and anecdotal. There appears to have been little hard research on the effects to date or the likely longer term effects.

3.6 A recent report for the US Department of Energy, the Hirsch report, notes that end use sectors that are able to switch to other fuels such as natural gas, coal and nuclear will do so but that in the transport sector there are no alternative sources that are able to compete economically.

3.8 ……Farm costs are projected to rise 4.2% faster than farm gate prices in 2005/06 with farmers continuing to be price takers rather than price dictators…They have little capacity to pass on increased fuel charges. Net farm incomes have been falling with fuel being the fastest growing cost input. Fuel costs in 2006 are double what they were eight years ago, while farm revenues have risen by just a quarter.

3.10 A number of submissions raised concerns over expected impacts if the world is not prepared for peak oil. ASPO-Australia also claim that the economic and social impacts will be very serious unless we take the necessary precautions very soon.

3.11?..Oil price increases transfer income from oil importing to oil exporting countries, and the net impact on world economic growth is negative.

3.16 The Murdoch University Institute for Sustainability and Technology Policy expects global trade to continue in a post peak oil world, although the character of global trade is expected to change once the costs of this trade become expensive. Trade in future is likely to become more localised.

3.17 Treasury in the 2006-07 budget papers noted that given the low level of spare capacity for oil production, there remained a risk of further supply side disruptions. In particular it was concerned about the potential for instability in key oil producing countries to have a more pronounced impact than the demand driven rises experienced to date. Treasury noted that oil demand is unresponsive to price in the short run, and modest disruptions in world supply could raise oil prices very substantially, and for some time.

3.18?..ASPO-Australia argues that many adaptations are justifiable even without peak oil concerns. Certainly, preparing well in advance for Peak Oil is a very prudent strategy. Many of the possibilities are so-called no regrets options (those that are already justified on social, environmental, health or economic grounds).

3.20 The Committee notes that there are credible concerns that markets will not respond in time to provide a smooth transition to a post peak oil world without government action. Given the uncertainty about much of the information on world oil supplies and the geopolitical instability of the oil bearing regions, there may be a risk that markets will under invest in oil and energy technologies, resulting in economic and social hardship as supply falls below demand.

3.21 The information required to make a clear determination on whether peak oil will occur before the market can provide mitigating action is not available. The following chapters discuss possible mitigation actions that can be applied that would allow a prudent approach to managing the possibility that peak oil will result in substantially higher oil prices and a constraint on liquid fuel availability.

Most peak oil studies to date have focussed on trying to predict when peaking might occur. There is one notable exception, however. In 2004 the US Department of Energy?s National Energy Technology Laboratory released their landmark Peaking of World Oil Production: Impacts, Mitigation and Risk Management.

Background
Unlike the others, this study (informally called The Hirsch Report after the lead author ? who coincidentally appeared on the recent ABC-TV Four Corners episode on peak oil) made no attempt to predict when a peak might occur.

After identifying that peak oil would cause a liquid fuels crisis, it looked at how long it would take to replace oil as a transport fuel. The authors calculated that it would take 20 years of ?crash? programs to produce enough facilities to significantly replace oil with artificial fuels. In contrast, if the US waited until peaking was obvious, there would be 20 years of significant economic hardship (similar to, or worse than, the Great Depression).

Medical Hirsch Report
I contend that a study with a similar purpose would be a useful tool for the each country?s health care system. It would provide useful information for planning and implementing mitigation programs, allowing us to manage the significant expected impacts of oil scarcity and energy descent.

Hirsch Report Methodology
The authors purposely kept the analysis simple. They did this so that their results would be transparent. They acknowledged that no study could infallibly predict the impacts, and used a semi-qualitative approach, rather than a rigidly quantitative one. In simple terms the approach was:

1. Describe the current situation and identify the scope of the problem.
2. Consider any examples or analogous situations that might shed light on the analysis (they used the peaking of US domestic natural gas supply).
3. Only consider commercial or near-commercial processes (to maintain realism).
4. Calculate the timeframes and capacities of the necessary number of fuel-production plants.
5. Repeat the process for each technology (eg coal-to-liquids; vehicle energy efficiency).

Applying Hirsch to health care
In order to think about how this process might be applied to the health care system, I chose the hypothetical example of plastic syringes (with a proposal to replace them with glass ones):

• How many single-use plastic syringes are used each year? What sizes? Where are they used (eg hospital versus community)? What are they used for? Who makes them? Which countries do they come from?

• What happened in Cuba when their oil supplies were cut off? How about Zimbabwe (a country that has been called the ?first casualty? of peak oil)? How do NGO aid-agencies like MSF currently handle this issue in third-world countries? The idea is to try to distil some generalized lessons. For example: What alternatives are there? If glass syringes will be used, how can they be made, packaged and shipped safely? How might they be cleaned, sterilized and reused? What are the infection control issues? And so on.

• What viable processes currently exist to manufacture precision glass instruments in our country? Who might do it (eg consider scientific instrument makers but also manufacturers of glass bottles and jars)? What is their current capacity? Do they have the technology or would it need to be bought from overseas and adapted here?

• Educated guesses about how long it would take to build and tool up enough factories to make them (in the format of ?Complete X factories per year, each producing Y syringes per year, Z years lead time until the first one is operational then 1 per year thereafter?).

• Repeat this process for each important oil-based component of the current health-care system ( I would suggest that there are at least several hundred such “critical” areas if we are to maintain a resonable semblance of the current system). Such a study would be much harder to do than the original one, because Hirsch et al only considered one output; we need to consider many.

One would also need to try and predict the increased sterilizing load (both in staff and equipment terms), infection control issues, financial costs and benefits, patterns of use, etc.

Outcomes
The possible outcomes of such a study include:

• A reasonable idea of the enormity of the problem and the scale of mitigation required.
• An estimate of the number of years needed to significantly reduce our current dependence on oil-based materials, allowing timeframes for implementation to be developed.
• Identification of the critical areas of the current healthcare system that need urgent attention.
• The realisation that perhaps a stockpiling strategy might be favoured over developing domestic manufacturing capacity.
• A complete redesign of the current system (really a paradigm shift) to new ways of delivering satisfactory health care - now there’s an area to discuss!

Summary
Unfortunately I quite scared myself as I thought about this and the enormity of the problem. Please tell me what you think.