Defensive endoscopy practices do not defend the planet

Aims Defensive medicine, including the over-prescription of diagnostic procedures due to legal concerns, is a significant issue. A previous study reported that gastroenterologists in Lombardy frequently prescribe esophagogastroduodenoscopies (EGDs) and colonoscopies defensively, placing an additional burden on healthcare resources. However, evidence on the environmental impact of these unnecessary procedures remains limited. Our study aims to address this gap by quantifying the carbon footprint associated with defensively prescribed EGDs and colonoscopies across Italy, providing a foundation for future efforts to reduce the environmental impact of healthcare practices driven by defensive medicine.

Methods A questionnaire assessing defensive medicine practices among gastroenterologists has been proposed to specialists in Lombardy. To extrapolate these findings to the national level, we used the total number of practicing gastroenterologists in Italy, as estimated by the Italian Association of Hospital Gastroenterologists (AIGO). To calculate the environmental impact in terms of CO₂ emissions, we relied on recent metrics on the carbon footprint of gastrointestinal endoscopy procedures from studies, including Lacroute J. et al. This approach allowed us to quantify the annual CO₂ emissions associated with defensively prescribed EGDs and colonoscopies nationwide.

Results Our analysis revealed that defensive endoscopic procedures contribute significantly to Italy’s healthcare-related carbon footprint. Specifically, we estimated an annual carbon footprint of 1,181,282.025 kg CO₂ for endoscopies prescribed for defensive reasons, with an approximately equal split between EGDs and colonoscopies (590,080.024 and 591,202.001, respectively). This total CO₂ output is equivalent to the emissions from 281 gasoline-powered passenger vehicles driven for one year and 154 homes' energy use for one year, according to the Greenhouse Gas Equivalencies Calculator (US-EPA). These findings underscore the environmental consequences of defensive medical practices in gastroenterology.

Conclusions Defensive medicine not only affects healthcare costs and patient care but also has a measurable environmental impact, as evidenced by the considerable carbon footprint of endoscopic procedures performed for legal rather than clinical reasons. Our findings suggest that addressing the underlying causes of defensive medicine could reduce not only unnecessary and inappropriate procedures and their economic cost but also their environmental impact. Efforts to raise awareness of the ecological cost of such practices, alongside policy initiatives to mitigate legal pressures on healthcare providers, could help reduce the carbon footprint of the Italian healthcare system [1] [2] [3].

Publication History

Article published online:
27 March 2025

• References

• 1 Elli L, Tenca A, Soncini M, Spinzi G, Buscarini E, Conte D.. Defensive medicine practices among gastroenterologists in Lombardy: between lawsuits and the economic crisis. Dig Liver Dis. 2013; 45(6) 469-73 doi:10.1016/j.dld.2013.01.004 Epub 2013 Feb 9 23402738.
• 2 https://www.epa.gov/energy/greenhouse-gas-equivalencies-calculator#results
• 3 Lacroute J, Marcantoni J, Petitot S, Weber J, Levy P, Dirrenberger B, Tchoumak I, Baron M, Gibert S, Marguerite S, Huppertz J, Gronier O, Derlon A.. The carbon footprint of ambulatory gastrointestinal endoscopy Endoscopy. 2023; 55 (10) 918-926 doi:10.1055/a-2088-4062 Epub 2023 May 837156511PMC10533215.