Training under planetary risk: planetary health ethics in clinical education and governance

BACKGROUND: Health-professional training in many low- and middle-income countries (LMICs) unfolds amid long-standing yet intensifying environmental, infrastructural, and health-system stressors, including extreme heat, unreliable power and water supplies, seasonal surges in vector-borne disease, and seismic risk. Yet undergraduate ethics teaching often remains encounter-centred, offering limited preparation for safe, fair, and role-bounded action when clinical systems are strained. This study examined how final-year medical and nursing students in Nepal understand these conditions and what they identify as practical entry points for planetary health ethics education. METHODS: We conducted a qualitative descriptive study at a tertiary public institution in Madhesh Province, Nepal. Twenty-one final-year students participated in semi-structured interviews: 10 Bachelor of Science in Nursing students and 11 Bachelor of Medicine, Bachelor of Surgery students. Data were analysed using the Framework Method, combining inductive coding with sensitising concepts from planetary health ethics. RESULTS: Three practice-proximal themes were identified. First, students described planetary disruptions as the "new clinical context": clinical learning occurred amid overlapping pressures, including climate-exacerbated heat, dengue-season surges, intermittent power and water supply, cold-chain and equipment vulnerability, and earthquake-readiness routines. Their accounts emphasised supervised safety work: noticing risks early, adjusting tasks within scope, documenting clearly, and escalating through established channels. Second, professional futures were shaped by safety, reciprocity, and conditional return. Speciality and migration narratives were grounded less in abstract planetary ethics than in occupational safety, remuneration, family responsibility, reliable training, usable expertise, functioning equipment, and institutional readiness. Third, students identified a curricular gap and proposed concrete solutions, including locally grounded cases, hazard thresholds, escalation routes, Objective Structured Clinical Examination (OSCE) stations that simulate system failures, interprofessional drills, and the inclusion of situated expertise from staff who manage the material conditions of care. CONCLUSIONS: Planetary health ethics becomes educationally meaningful when translated into teachable and assessable routines for clinical practice under constraint. Programmes should prepare students to recognise hazard thresholds, communicate transparently, document constrained decisions, escalate appropriately, and learn from the infrastructures and personnel that make safe care possible. High-hazard LMIC settings are not peripheral to planetary health ethics; they offer vital insight into educating health professionals for just, resilient, and context-responsive care.