The Working Groups reached the following general conclusions:

            1. The environmental costs of health care pose ethical problems.

Awareness is growing that the environmental impact of health care services is significant and that promoting health and saving lives within the health care system should be balanced against harm to the environment. Health professionals and institutions, like any other activity with material implications, have a responsibility to balance and consider the environmental harm we do in meeting our primary responsibilities for patient care.

            Many of the ethical aspects of environmentally responsible health care are outlined in the August 1999 consensus statement; The “Ethical Principles and Purpose” of the Working Group of the Green Health Center Project included on this web site.

            2. Health care institutions incur four main kinds of environmental costs.

            a) Downstream Costs: The most obvious to consider and minimize are the “downstream” wastes of health care systems. Such wastes need to be reduced partly because of their volume, and partly because infectious, toxic, and radioactive materials are involved. By and large, dangerous forms of medical waste are closely watched and highly regulated. However, not all such forms of waste are either well understood or well controlled. Environmental activists concerned with health care raise questions about persistent organic pollutants, pharmaceuticals in the water supply, toxic metals, and other hazards. Clinicians have an ethical responsibility to cooperate in the control of these substances and of overall waste volume.

            b) Upstream Costs: It is equally important to consider the life cycle cost of health care, including the upstream costs. This is partly in order to reduce downstream problems before they reach clinical areas. This is also partly because the greatest volume of environmental costs from health care occur in the upstream areas. In order to manufacture and purify pharmaceuticals, for example, it is necessary to use solvents and intermediate compounds that may be harmful. Production of radioactive materials may produce more dangerous radioactive materials on the side. Transportation of potentially hazardous products is also an environmental issue.  Shipping, handling, controlling, and packaging materials all involve environmental costs. Because of climate change, it is becoming increasingly important to use energy efficiently. Many manufacturers have moved rapidly ahead in recent years to pay attention to and to begin to cope with such problems. Although clinical and purchasing personnel may not have a direct impact in these areas, they are in a position to know about and to pay attention to them. Health care professionals can use their purchasing power to support manufacturers in their decisions to protect the environment.

            c) Public Consumption: Patients also have responsibilities with regard to environmental costs. Patients who lead high consumption life-styles tend to need health care more often. By leading more healthy lives, patients can help to reduce the environmental costs of health care. Especially where the public engages in hazardous forms of overconsumption—such as tobacco use, alcohol and drug abuse, over-eating, use of guns, and excessive use of automobiles—it adds to the disease burdens of health care. Overconsumption has a cyclical consequence on the environment.  Overconsumption thus poses a doubled environmental problem by incurring costs at the point of consumption, and then again in the greater need for health care. The higher the demand for health care services and products, the more harm imposed on local ecosystems. If First World countries are to come to grips with this problem, we will need a change in economics and culture. Current bioethical opinion tends to support wide discretion by citizens in this arena and to resist limits, but as environmental pressures increase over the years, this judgment may come to seem too liberal.

            d) Footprint: First World health care, and especially U.S. health care, has an “ecological footprint” problem. The ecological footprint is a rough per capita estimate of the ecological impact of economic activity—the amount of water, forest, agricultural land, natural restorative capacity, and so on—needed to keep humans at their current level of consumption. Because the global human economy currently overshoots the productive capacity of the natural world, the condition of earth’s biosphere is declining, with increasing long-term costs to human and ecological health. For more details, see the web site Redefining Progress.

            The U.S. health care system has a disproportionately large ecological footprint. Although there is no exact measure of the footprint, financial measures offer a rough surrogate: The U.S. health care system is the most expensive in the world. Besides consuming roughly 14% of the U.S. Gross Domestic Product, it uses over 40% of all the world's dollars spent in health care (World Bank, World Development Report, 1993). Despite these costs, neither does the U.S. have particularly good public health figures, nor does it provide universal access to basic health care.

            This means that if the U.S. is to reduce its environmental impact to a sustainable level, it must also substantially reduce the scale of its health care system. Such reductions will probably have to be so extensive that limitations on available services will need to be considered. Thus, environmental concerns raise many of the same ethical issues of justice and limits raised in prior years by cost control discussions. One advantage of considering environmental costs, is that they are more concrete and of firmer ethical significance as compared with financial costs. One drawback is that environmental considerations are more complex and coping with environmental costs may actually increase the costs of services. If so, this will make reductions in the scale of services even more important and challenging at the same time.

            3. There are resources available to address these problems.

There are resources and activities in health care available for increasing attention to the environmental aspects of health care and for generating conversations and debates that may help to balance environmental costs with the benefits of health care services. For instance, architects are designing greener health care buildings and striving to apply the LEED criteria of the U.S. Green Building Council to new health care structures. Hospital-based purchasers and group purchasing organizations are increasingly considering environmental costs in their purchasing decisions. Manufacturers are considering alternative materials and processes. The new field of green chemistry is beginning to reach the pharmaceutical manufacturing processes. Safer plastics and cleaning materials are being identified and developed. Activist networks, such as Health Care Without Harm, are studying problems and suggesting alternatives.

• eliminating mercury waste as completely as possible by 2005;

• reducing the waste volume of health care by 50% by 2010.
  These partners are health care facilities that have pledged to eliminate mercury and reduce waste consistent with the overall goals of H2E;

• identifying and reducing the output of toxic substances;

• creating a health care culture more respectful of environmental concerns.

            There is enough activity in these realms to allow clinicians concerned with the environmental impact of their care to begin to reduce the environmental impact of their practices and materials. Clinicians can help to ensure that these new ideas are welcomed by patients and other health care providers.

            4. It is possible to envision a thoroughly “green” health center.

            The working groups envisioned what a Green Health Center might be like and what principles it might adhere to. The main principles of such a center are summarized at “Ethical Principles and Purpose”. For more details and discussion, see the fifth chapter of the book, Ethics of Environmentally Responsible Health Care.

            5. More unity is needed between environmental and clinical ethics.

           Clinical ethics and environmental ethics need to speak more with one voice. Right now, a dedicated environmentalist may only be able to obtain health care in an environmentally costly institution. And, a clinician striving to save lives may do so at an unacceptably high environmental price, one that may in the long run cost more lives to future generations than lives saved by health care.

            This means that principles of ethics need to recognize a new integration of principles and values. These include a deeper recognition of the global interconnection of all human activities with the earth’s ecosystem, and of the strong demands of ecological sustainability on our daily decisions. In order to live at a high level of health, liberty, community, and creativity, only modest amounts of materials and energy are required. This means that ethics needs to speak to material modesty and to resist cultural pressures in the U.S. toward unrestrained growth. Meanwhile, the great needs of people in impoverished areas of the world require increased cooperation from the First World in restoring their environment and establishing adequate economies. Some of the basic principles of one approach to this reconceptualization can be found in a statement on “ecological medicine” from the Science & Environmental Health Network.

            6. Many ethical dilemmas remain.

            Although the projects identified environmental aspects of health care as important areas to consider, they did not resolve potential issues in balancing environmental costs with immediate patient needs. There are a number of ways to look at these issues. A list of key topics is available at this web site.