In both the public sector and the private sector, the concept of the “triple bottom line” has become well established in recent years (Elkington, 1998; Esty and Winston, 2006; Savitz and Weber, 2006; Willard, 2002). This concept, sometimes summarized as “people, planet, and profit,” holds that the best performance for a firm, agency, or institution is one that optimizes social, environmental, and economic outcomes. For healthcare institutions, the social dimension includes health impacts. Thus a hospital with a successful triple bottom line would boast positive impacts on the health and well-being of its patients, staff, and visitors; efficient use of energy and natural resources, with minimal waste and pollution generated; and healthy financial performance. Many private firms recognize that this approach not only advances their goals but also positions them well on the market, enhancing their image and earning customer loyalty. These rationales apply directly to green health care.

There are also ethical reasons for pursuing green health care. Biomedical ethics are usually based on four principles: autonomy, beneficence, nonmaleficence, and justice (Beauchamp, 2001; Engelhardt, 1995). The provision of green health care is especially consistent with beneficence, as it provides benefits to patients and staff (and, in a larger sense, to communities near and far and to unborn generations), and with nonmaleficence, as it avoids harms (including distant downstream harms) that could result from certain conventional practices. Public health ethics have been linked to three traditions—utilitarianism, liberalism, and communitarianism (Roberts and Reich, 2002)—and these also offer a compelling rationale for green health care. Utilitarians would point out that the net sum of human well-being—considering patients, staff, visitors, community members, and others—is likely to increase if healthcare institutions are green. Liberal analysts, following Kant, would argue that the right to a healthy environment is infringed by policies and practices that permit dangerous exposures. And communitarians would argue that the necessary conditions for “good society” are enhanced by green health care. The Principles of the Ethical Practice of Public Health begins with a statement that, prima facie, supports green health care: “Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes.” (Thomas et al., 2002). Thus, green health care falls squarely in the traditions of both biomedical and public health ethics.


What one does in health care—the medications administered, the surgical procedures performed, the health behaviors that are recommended to the public, the systems that are fashioned to deliver services—ought to be safe and effective, and these attributes ought to be established by evidence. In the case of therapies,

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