The projects studying the concept of the Green Health Center raise a number of broad philosophical and ethical concerns not easily resolved. We identify a few of these issues in the paragraphs below:

1.  Public Health & Overconsumption

Many of the increasing costs, of health care are related to patient inflow from poor health practices, many of which are types of overconsumption. For example, obesity, alcohol-related diseases, smoking-related diseases, and gunshot wounds are results in part of overconsumption of food, alcohol, tobacco, and guns. The problem of making health care sustainable would be much easier if the public’s consumption practices moderated. What would it be like to undertake a public health regime that effectively reduced consumption in these and related areas?

2.  Broadening the Scope of “Do No Harm”

Health Care without Harm is a network of activists, health professionals, and associations working to reduce the toxicity and waste level of health care. They fly under the banner of “Do No Harm” extended to apply to the environment, especially toxic exposure to the public by hospital incinerators and waste disposal practices. Yet, almost no one in health care ethics considers this plausible extension of the principle of “do no harm.” Is this extension of the principle valid? What are some of the obligations, limits, and nuances of this extension?

3.  Unintended Consequences of Genetic Innovation

Bioethics focuses intensely on the potential costs and benefits of potential genetically derived technologies on patients, their families, and the public. Unlike the debate over agricultural genetics, we have seen little in bioethics with regard to the environmental evaluation of the production and disposal of genetic medications. Nor have we seen anything about intentional misuse of genetic technologies (such as their use in war). Although there was early discussion of long-term germ-line effects, this discussion has dropped from the horizon. At this point, as best we can tell, no one has any idea of potential intended and unintended environmental effects of new genetic therapies, which could end up to be a cause of wide-ranging, uncontrollable, non-point-source public health problems.

4.  Reviving the Concept of Natural

We could recover the concept of “natural” as a range divider to express a balance, on one side, of such considerations as “sustainable”, “environmentally friendly,” and “effective”, as contrasted to their opposites on the other side. This is a matter of using a widely accepted (but vulnerable) concept to help conduct complex priority-setting discussions which are fundamentally utilitarian, but for which the full factual picture is too costly to obtain. But, is it a good idea to do use this complex and potentially misleading concept? NOTE: Our “sustainable” approach to health care could help to find a conceptually viable middle way through the public debate over allopathic and alternative practices.

5. Case Studies of Medications, Tools, Therapies, & Public Health Measures

What would an effective protocol for the full environmental evaluation (“life cycle analysis” or “cradle-to-grave” analysis) of medical tools, therapies, and medications look like? At what places in the hospital purchasing system might such analyses be conducted effectively? How should the considerations of economic cost, environmental cost, and patient benefit be balanced, and by whom? What would be some good case studies of hospital devices, materials, and the like. Similar questions could be asked about the environmental costs of public health measures. For example, energy consumption in sewage systems puts carbon into the air and aggravates climate change.

6.  The Hospital Unobserved

Bioethics could be refreshed by moving to environmental ethics issues in the larger and “invisible” hospital: In the last decades, bioethics has had an intensively clinical focus. And, insofar as bioethics discusses health care technologies, it tends to discuss a narrow range of technologies largely with regard to their effects on patients. The hospital is much bigger, more complex, and more interesting than this. Bioethics study of the “background” world of purchasing, environmental services, dining hall, cost management, distributive technologies, warehousing, architecture, energy services, and the like, can open a new and refreshing world to the study of bioethics. It can also help win support for bioethics by foregrounding and supporting the work of non-clinicians, who often feel that their work goes insufficiently recognized by the public.

7.  Environmental Costs of Public Health Measures

Are the environmental costs of maintaining public health in the First World too high? The U.S. agricultural system uses more fossil fuel energy than it produces in food. Midwest agriculture is killing off the Gulf of Mexico. Standard sewage processing techniques put four pounds of carbon into the atmosphere for every one pound taken out. Roughly half of public health work involves getting people into health care--the most environmentally costly form of public health. Much public health activity related to the environment focuses on reduction of toxics in the environment, but without addressing the problem of an over-scaled material economy that drives much of the pollution. In the long run, such approaches to public health are self-defeating. Can we address the contradictions of public health philosophically?

8.  The Fundamental Philosophical Project

How can justice and environmental sustainability be achieved for a world populated at six to eight billion people, while mitigating the ominous fraying of the global ecosystem? How can lives and health be improved for half the world’s population, while at the same time, consumption is moderated for the world’s consumer classes, without sacrificing the needs of future generations? How can population and consumption be balanced at levels adequate for a high level of public health? What sorts of ideals, values, and commitments do people need to strive for to achieve these difficult goals?