In hospital resource allocation conflicts between health goods and environmental goods, a relational, co‐benefits frame, rather than a dualistic, competing goods frame, is key

ABSTRACT

Health systems contribute to the environmental crisis. Yet, addressing this problem seems to generate a resource allocation dilemma for hospitals: investing in healthcare delivery seems to mean sacrificing environmental goods, and vice versa. We question this zero‐sum thinking. After presenting the benefits of investing in the two seemingly competing goods—environmental goods and health goods—we propose that the apparent dilemma arises due to a tendency to think in dualisms. Consequently, health and environmental goods seem, respectively, to correspond to opposing sides of four dualisms: human/nature, local/global, present/future and therapy/prevention. We argue, instead, that a relational frame that considers the human person in their relational context should be used to approach the problem. A relational understanding of the human person as a meaning‐making subject in relationship to all that is shows us that choosing between either health goods or environmental goods is frequently a false dichotomy: both can serve the well‐being of human beings adequately understood. Such an approach, then, widens our conception of health and healthcare to include environmental goods. This wider conception of health and healthcare means that hospitals should (1) look for co‐benefits in the first instance when allocating resources, thereby often resolving zero‐sum thinking that gives rise to the competing goods dilemma, and (2) in the remaining cases where co‐benefits are not achievable, use classic resource allocation principles, such as proportionality of benefits and burdens, to reach allocation decisions about a now wider range of goods (i.e., health and environmental, rather than merely health goods).

1. INTRODUCTION

We are in the midst of an environmental crisis that will only get worse unless significant changes are rapidly made. We are now exceeding six of the nine planetary boundaries, including climate change, loss of biodiversity, chemical pollution and land‐system change.¹ Once these thresholds are crossed, it could generate unacceptable environmental change, often with deleterious or even disastrous consequences for human and nonhuman well‐being.²

There is increasing awareness and evidence that health systems are contributing to the environmental crisis. Their built environment, delivery of healthcare, procurement and patient and staff travel generate greenhouse gas emissions, hazardous and nonhazardous waste and other pollutant emissions, including ammonia, carbon monoxide, methanol, nitrogen oxides and sulphur dioxide.³ Globally, health systems are, on average, responsible for 4.6% of worldwide carbon emissions.⁴ They further negatively affect aspects of circularity and biodiversity via their material extraction, blue water consumption and land use practices.⁵

By harming the environment, the health sector is paradoxically contributing to worsening human health and to health inequity. It thus obstructs its own primary mission of healing and advancing human well‐being.⁶ To avoid such an outcome going forward, the health sector is seeking ways to minimise its environmental impacts while providing the best quality care and promoting healthy living.⁷ The sector's environmental footprint can be reduced by implementing the following core components:

• −low‐emissions models of care;
• −procurement of low‐emissions goods and services;
• −reduce, recycle and reuse waste;
• −low‐emissions transport; and
• −low‐emissions healthcare buildings and spaces that also minimise their impact on biodiversity, habitats and animal migration.⁸

At COP26, 50 countries pledged to transition to climate resilient and low‐carbon health systems, with 14 countries setting a target date of reaching net zero emissions by 2050.⁹ The United Kingdom, for example, has made significant progress at a national level. There is also increasing prioritisation of such policies at the state and territory level.¹⁰ State health departments, local health departments and individual healthcare organisations are also working to make the healthcare that they deliver less harmful to the natural environment.¹¹

Nonetheless, the pursuit of these strategies to reduce harms to the environment are likely to generate ethical dilemmas for health systems. The changes required to protect or restore environmental goods can come into tension with the health sector's primary mission—the good of human health. For example, not damaging the planet may mean restricting what healthcare we prescribe to patients and what medicines we procure. It could require limiting service delivery to treatments that provide sufficient health benefit to be worth their environmental impacts.¹²

In this article, we focus upon a particular resource allocation problem that minimising harm to the environment creates for hospitals: How should hospitals make decisions about allocating resources to the equitable delivery of healthcare versus to minimising that healthcare's negative environmental impacts? The problem arises because allocating resources to measures to minimise environmental impacts seems to compete with a hospital's core mission of saving lives. As an example, although long‐term cost savings can be an incentive to make hospital buildings more environmentally friendly, doing so requires high upfront capital costs. This means less money in the short term to spend on current patients who need care. A 2015 Health Facilities Management Sustainable Operations Survey found that about half of the 276 facilities surveyed had yet to create a formal sustainability programme or even put together a committee to get things moving. Competing investments/spending priorities (61%) topped the list of roadblocks, followed by employee time limits (52%) and lack of adequate staff (50%).¹³ A decade later, cost continues to be seen as a key barrier.¹⁴ Drawing from our experience working with hospitals, in relation to minimising environmental impacts, it is said that things not essential for patient care or keeping people alive can be seen as overkill. The money could be better spent on another operating theatre, more beds, better equipment, better care and so on.¹⁵

Within healthcare systems, there are many levels at which such resource allocation dilemmas can arise in decision‐making: health policy at the macro‐level, hospital administration at the meso‐level and clinical decisions about individual patients at the micro‐level. At the meso/hospital level, decisions are made about whether or not to implement various changes/interventions to reduce the environmental impacts of clinical care, procurement, built environment and staff and patient travel. Such decisions generate resource allocation dilemmas because making changes often costs more than not making them. In relation to clinical care, the changes can be general or service‐specific. Greener waste management, for example, comprises a general change that has potential to add costs.¹⁶ Reducing nitrous oxide leakage comprises a service‐specific change that has potential to add upfront costs.¹⁷ Nitrous oxide is a common anaesthetic and is widely used in birthing suites, paediatric and adult operating theatres and emergency departments.¹⁸ In relation to procurement, purchasing greener equipment and supplies can come at a higher cost, for example, green concrete can cost 5%–20% upfront compared to traditional concrete.¹⁹ In relation to travel, shifting to electric or hybrid vehicles for home care fleets, for instance, often means purchasing more expensive vehicles. Finally, in relation to built environment, deciding whether or not to pursue green building accreditation when building or retrofitting hospitals also comes at an added upfront cost.²⁰ Thus, allocating resources to minimise environmental impacts creates an apparent competing goods dilemma: health vs the environment. ‘The conflict arises because, in a world of finite resources, it is impossible to maximize for each of the competing goals. Society, therefore, is put to the choice among incommensurables’.²¹ Investment in one is seen as a loss of investment in the other: investing in reducing environmental harm seems to come at a loss of investment in status quo healthcare.

In this article, we ask whether it is correct to always view this resource allocation problem as a competing goods dilemma, in which there must be a ‘winner’ and a ‘loser’ in a zero‐sum game. We first argue that dualistic thinking leads to the competing goods frame. Western cultures and philosophy often think in dualisms.²² A dualism is the idea that, for some domain, there are two essential kinds or categories of things or principles such that one can distinguish clearly one thing from another thing. For example, in classical philosophy, the essential feature that distinguishes the human animal from other kinds of animals is its rational capacity.²³ So, there is a dualism set up between animals (not rational) and humans (rational). This kind of dualistic thought compels us to think in categories of ‘either…or’ rather than ‘both…and’: something is either human or nonhuman, hot or cold, good or bad and so on.

To demonstrate that the competing goods frame is a symptom of dualistic thinking, in Section 2, we assess the benefits associated with the two seemingly competing goods (i.e., environmental goods and health goods). In Section 3, we then show that the benefits of investing in health goods or environmental goods seem to correspond to four dualisms that are common in Western cultures and thinking, which perhaps explains both why the decision seems like a zero‐sum game and hospitals’ hesitation to substantially invest in reducing their environmental footprint. Here, the relevant dualisms are human/nature; present/future; local/global; and therapy/prevention.

Yet, dualistic thinking entails seeing humans and nature as distinct, rather than interrelated. Humans, however, are a part of, not separate from, nature. Nonhuman and human health and well‐being are interconnected and interdependent, as is acknowledged in philosophical theory²⁴ as well as in existing approaches like One Health and Planetary Health.²⁵ As such, in Section 4, we argue that dualistic thinking is not the correct approach and that we should rather frame the goals of healthcare based on a relational conception of the human person. The result is a broader conception of health and healthcare that includes environmental goods. In such a conception, the problem of competing goods is frequently (but not always) dissolved because resource allocation in healthcare is no longer a zero‐sum, ‘either…or’, win/lose game between health and the environment. Relational thinking empowers hospital decision‐makers to look, in the first instance, for co‐benefits, by approaching resource allocation in a way that seeks out and prioritises interventions that generate positive environmental outcomes in the pursuit of high‐quality healthcare.²⁶ The result is often not ‘either…or’ but co‐benefits of both environmental and healthcare goods. We acknowledge that even with a relational approach, sometimes, co‐benefits will not be possible²⁷ and decisions will still have to be made that favour one good over another. Nonetheless, in such situations, what relational thinking and broader conception of health and healthcare do is allow the application of classical resource allocation decision methods, such as considerations of proportionality and burden, to a wider set of health‐related goods, which now include both environmental and health goods. In Section 5, we provide examples of how relational thinking can empower decision‐makers to look for co‐benefits and of how relational thinking and its broader conception of health can help decision‐makers in their use of classical resource allocation methods when co‐benefits are not possible.

2. COMPETING GOODS

This section compares the benefits associated with the two seemingly competing goods: environmental goods and health goods. More space is given to the benefits of investing resources in environmental goods in healthcare, not because they are more important, but because their impact is less well explored in the existing literature. Green Star and LEED are the green building certification programmes in Australia and the United States, respectively.

2.1. Benefits of Allocating Resources to Environmental Goods in Healthcare

Hospital investment in reducing the environmental impact of healthcare can generate benefits for both humans (present and future generations) and nature, including health co‐benefits, cost savings, disease prevention, reduced global health inequity, reduced biocultural homogenisation and reduced disruption of the webs of relationships that are key to the stability of ecosystems and their resilience.

Investing in the reduction of environmental impacts by hospitals can generate health co‐benefits for current patients and staff members. Comparing a new, LEED‐certified hospital relative to its previous, traditional counterpart, it was found that the number of direct care hours, or the amount of time spent directly with patients, increased 10% in the new, green facility and marked improvements in mortality rates occurred.²⁸ The health co‐benefits of a green hospital also extend to staff well‐being. Green hospitals create an environment that reduces stress and measurably improves performance and the delivery of patient care. They also contribute to increased employee retention, which correlates with reduced turnover, cost savings and smoother overall operations. Thiel et al. found a 25% reduction in general employee turnover.²⁹ In the 2 years that LEED‐Platinum‐certified Dell Children's Medical Center has been open, it has had a nurse turnover rate of 2.4% compared with a national average of 12% to 15%.³⁰

Investing in environmental goods can thus generate medium‐ and long‐term cost savings, which can then be allocated elsewhere by the hospital. In the United States, it can cost up to USD70,000 to recruit and train new nurses.³¹ Energy‐efficient and environmentally friendly buildings may further yield operational cost savings.³² Over a decade ago, it was found that savings could exceed 5.4 billion USD over 5 years and 15 billion USD over 10 years for hospitals with programmes to reduce energy use and waste and achieve operating room supply efficiencies.³³ In Australia, Green‐Star‐certified buildings use, on average, 66% less electricity than average Australian buildings and 51% less potable water than if they had been built to meet minimum industry requirements.³⁴ The Fable Hospital analysis showed that a one‐time construction cost increase of 29 million USD on a 350 USD million hospital (8.3%) would be recovered through reduced operating costs within 3 years.³⁵ Other studies have, in contrast, found that LEED‐certified buildings in the United States would not achieve source/primary energy savings relative to other buildings or did not achieve anticipated (site) energy savings once they were operational.³⁶ Even so, where savings occur, they can then be reallocated to patient care. For instance, the University of Arkansas for Medical Sciences saved enough through efficiency efforts from one project that it was able to create 60 new beds, remodel five operating suites, build out a floor of a cancer institute and buy seven acres of land.³⁷ Beyond the built environment, shifting from single‐use to reusable equipment has been shown to generate cost savings.³⁸

Investing in environmental goods can help prevent illness and reduced well‐being in present and future generations. For example, one study found that US national emissions for hysterectomy could be reduced annually by 72 kilotons of CO² using the ideal, green intervention for laparoscopic cases—equivalent to removing 15,200 passenger vehicles from the road annually.³⁹ An analysis of Green‐Star‐certified healthcare facilities showed that facilities certified in 2017 and 2018 produce 57% fewer greenhouse gas emissions than average healthcare buildings.⁴⁰ Reduced carbon emissions help mitigate climate change, which means lessening the effects of global warming on human health and well‐being, such as chronic undernutrition, water scarcity, respiratory impacts, widening seasonality of vector‐borne disease and increased heat stroke and death.⁴¹

Mitigating climate change also helps reduce global health inequities. Climate change impacts the worst‐off most, primarily in low‐ and middle‐income countries, and is thus widening global health disparities. The global poor are the most burdened by the impacts of climate change due to the geographical and climatic conditions in low‐ and middle‐income countries, the economic importance of climate‐sensitive sectors (e.g., agriculture and fisheries) for their livelihoods and their lack of institutional and financial capacity to adapt to climate change. More intense storms and floods, more frequent heatwaves and the spread of infectious disease threaten to undermine years of health and well‐being gains for those experiencing marginalisation and disadvantage.⁴²

Beyond human health, investment in environmental goods promotes harmony between past, present and future generations. Present generations achieve harmony with past and future generations through reciprocal relations of care with them. The latter demands leaving the Earth in at least as good a condition as she was received in.⁴³ The relations of care are reciprocal because past generations did this for the current generation and that generation must now do so for future generations and to repay their ancestors.⁴⁴ By minimising their environmental impact, hospitals, thus, help maintain relations of care between generations.

Investment in reducing environmental impacts of healthcare also promotes harmony because it is less disruptive to webs of relationships within nature and between nature and humans. When new healthcare facilities are constructed, altered land use patterns can disrupt natural relationships (and destroy habitats) and traditional custodians of the land could be displaced. Prominent green building accreditation programmes take many of these environmental impacts into consideration.⁴⁵

Investment in reducing environmental impact helps reduce biocultural homogenisation: the interwoven losses of native biological and cultural diversity.⁴⁶ Climate change and environmental degradation put place‐based cultures under threat. Their traditions and practices; land or water‐based economic practices (e.g., ricing); and structures of political self‐determination require a particular range of ecological processes and access to large territories of land and water ecosystems. Without them, individuals and communities cannot develop, experience and express their cultural identity and heritage.⁴⁷

Investment in reducing healthcare's environmental impact can help reduce biodiversity loss. Biodiversity loss happens as an effect of rising greenhouse emissions,⁴⁸ but can also occur due to healthcare facility construction where land is cleared and/or native biota are replaced with cosmopolitan species in the green spaces that are part of the new facility. The building of habitats in a similar fashion around the world is causing a massive disappearance and replacement of native biota with cosmopolitan trees and flowering shrubs and herbs.⁴⁹

Finally, reducing healthcare's environmental impact helps reduce harms to nature's wellbeing or, in other words, the natural environment's capacity to thrive or flourish. Health systems push nature below an adequate level of well‐being or functioning through their production of toxic waste and chemicals, greenhouse gas emissions and air pollutants,⁵⁰ and hospitals are one of the most significant emitters and polluters within the health system.⁵¹

2.2. Benefits of Not Allocating Resources to Reducing Healthcare's Environmental Impact

Current hospital investment in equitable healthcare delivery generates benefits primarily for humans in the present generation corresponding to five aims: improving population health, enhancing the care experience, reducing costs, improving the work life of healthcare workers and advancing health equity.⁵²

Consequently, status quo hospital investments primarily generate benefits in terms of reducing morbidity and mortality of humans in the present generation. They also promote greater efficiency, quality of care, staff well‐being, and local equity (i.e., a reduction in health inequities within their catchments, not internationally) in terms of better access both to healthcare and to the social determinants of health. With respect to the latter, examples of how hospitals are assuming a role in “community health and equity” are growing.⁵³ Hospitals can be “community partners” that support access to the social determinants of health by, for example, making investments in safe and affordable housing and expanding access to fresh, healthy foods.⁵⁴

3. DUALISTIC THINKING

The above analysis presents the benefits associated with the two goods of minimising environmental impacts and equitable healthcare delivery. In the aforementioned resource allocation dilemma, they are seemingly mutually exclusive outcomes (a zero‐sum game): either one invests in environmental goods and obtains those benefits or one invests in healthcare goods and obtains those benefits. We propose that this apparent competition between goods and their benefits, is symptomatic of dualistic thought.

In analysing the benefits of environmental goods versus health goods above, we identify four dualisms that each correspond to four broader dimensions of our reality, namely, community, time, place and intervention (Table 1). Minimising environmental impacts and delivering equitable healthcare respectively correspond to opposing sides of each dualism below, which makes them seem to be competing goods. Environmental goods are not seen as benefiting human health because humans and nature are viewed as separate, rather than interrelated.

Table 1.

Dualisms in thinking about resource allocation and reduction of environmental impact.

Dimension	Dualism
Resource allocation	Healthcare goods	Environmental goods
Community	Human	Nature
Time	Present	Future
Place	Local	Global
Intervention	Therapy	Prevention

Healthcare delivery is primarily seen to be about addressing health of the present generation of humans, who are local to the hospital in question, through therapy for acute and chronic health conditions. Environmental goods, by contrast, are seen as ‘someone else's problem’ or ‘not my job as a healthcare provider’ because they concern caring for the natural environment for the good of near and distant future generations by solving global problems like climate change and its associated disasters through their prevention and mitigation. From this perspective, hospital administrators and staff may well sympathise or even actively pursue environmental goods in their personal capacity, but, in their role as healthcare providers, their core business is conceived primarily along the lines of the ‘Healthcare’ poles—human, present, local, therapy—of the dualisms (Table 1).

One explanation for why people may emphasise the ‘Healthcare’ pole may be that as human beings, we seem to have a natural tendency to focus on what is immediate to us rather than distant, both in terms of time and space. It is well known, for example, that young children struggle to resist the temptation of an immediate reward despite the promise of a future reward. In the case of healthcare, both providers and patients (and politicians and voters) will, therefore, tend to favour the immediate benefit to the patient in the hospital than the more distant and intangible benefit of health to unknown others somewhere in the world or in the future or of well‐being for nonhuman creatures and the functioning of natural systems. Table 2 expands on the dualisms to include the benefits highlighted in the previous section. Seeing it like this demonstrates what is seemingly at stake by choosing either health goods or environmental goods.

Table 2.

Benefits of health goods versus environmental goods.

Dimension	Dualism
Resource allocation	Health goods	Environmental goods
Community	Human Reduce human morbidity and avoidable death Improved care experience Reduce financial burden Ensure equitable access	Nature Harmony in environmental webs (which include humans) Promote biodiversity Nature's wellbeing
Time	Present Present cost savings Present therapy Present generation Provision of best evidenced‐based treatment	Future Future cost savings Prevention of future illness and reduced wellbeing Intergenerational harmony Reduced biocultural homogenisation
Place	Local Treat actual local needs	Global Reduce global health inequities
Intervention	Therapy Effective treatment of acute and chronic conditions	Prevention Health co‐benefits to patients and staff Prevention of Illness and reduced wellbeing

Is such a competing goods framing appropriate in this situation? The tension in this instance seems to arise because of the way in which healthcare and its goals have been dualistically defined. Healthcare is ‘this’ and not ‘that’ based on certain features that have been selected as ‘essential’ to distinguish it from other goods. Environmental goods are one such other good and they do not seem to overlap with the poles of human, local, present and therapy, so they are thus not healthcare goods. However, stepping back from these essential features may reveal that it need not be an ‘either…or’, zero‐sum scenario when goods correspond to alternate sides of dualisms. Rather, health goods could be seen to include or at least substantially overlap with environmental goods such that the benefits of environmental goods are also integral to quality healthcare. The next section reframes the resource allocation problem by challenging the assumptions about the goals of healthcare based on a comprehensive relational anthropology.

4. APPROACHING THE RESOURCE ALLOCATION PROBLEM FROM A RELATIONAL PERSPECTIVE

In contrast to the dualistic thinking described above, this section proposes that relational thinking should be preferred to dualistic thinking because it allows us to expand our conception of health and healthcare and, in effect, see resource allocation through a co‐benefits frame. Healthcare is reconceived more holistically, based on a relational personalist anthropology. It then includes in its goals not only the poles of human, present, local and therapy but also the poles of nature, future, global and prevention (Table 1). The upshot of such an approach is that resource allocation problems can then be reconceived as opportunities for solutions that improve both health and the environment rather than as win/lose conflicts. Where win/win solutions are not possible and difficult choices still need to be made, they now include the environmental goods within the resource allocation considerations as part of the goods of healthcare, rather than as automatically and easily opposed to them.

Who or what does healthcare serve? The answer, at its core, is human beings. How one defines human beings, one's anthropology, will therefore affect how one conceives of healthcare and its goals. Excessively anthropocentric and individualistic views will tend to see human beings as isolated individuals competing for limited material resources (to which the natural world is reduced). Personalism, by contrast, is characterised by ‘a strong commitment to defend the concrete human person against the arrogance of systems, bureaucracies and ideologies, while at the same time avoiding the pitfalls of individualism’.⁵⁵

We maintain, therefore, following a Personalist account, that human beings are embodied subjects who are always in relation to all that is and who work out their flourishing (which includes a sense of self‐worth and meaning in life) through moral behaviour in these relationships.⁵⁶ Such a holistic anthropology or ontology is not unique to Personalism, and is found also among feminist, African and Indigenous writers.⁵⁷ According to Janssens, human beings, because they exist as particular physical bodies, find themselves always already situated in relationship to the natural world, to others, to human institutions, to time and history and to transcendent ideas (God, Love, Truth, Freedom and so on).⁵⁸ As subjects, capable of reason and free choice, all human beings want to feel good about themselves (self‐worth) and feel like their lives have meaning and purpose. In other words, they want to ‘flourish’.⁵⁹ They realise their flourishing through their moral behaviours (i.e., freely chosen actions in pursuit of objective goods) in response to their experiences of being in relationship.⁶⁰ Because each person can be described this way, each person is unique (since each is uniquely situated in a set of relationships over time) and yet fundamentally equal in moral status to all others.⁶¹

This view is still anthropocentric, but not excessively so, because the human person is seen as a fundamentally relational being necessarily constituted by and therefore dependent upon relationships with the natural world and other human beings. At times, these relationships may be competitive, but personal flourishing can never be separated entirely from the flourishing of the natural world and other human beings.

Who or what does investment in reducing negative environmental impacts serve? Clearly, it serves the good of ‘the environment’, but, as is evident from the relational anthropology above, it also serves human beings, since human beings are integral to the environment. The idea of the ‘human’ vs ‘natural’ world is in this case a false dichotomy. It is a true dichotomy in that the natural world is not created or manufactured by humans, but it is a false dichotomy to think that either is entirely independent of the other. Human beings and all that they manufacture are part of the natural world, which exists with its laws of physics and biology and so on logically before humans and their inventions and is the precondition for their existence. Moreover, human beings influence the natural world, with human‐caused climate change being a prime example. This embeddedness of human beings in the environment means, therefore, that both health goods and environmental goods are ‘good’ for human beings. It also means that any understanding of healthcare that ignores this embeddedness is inadequate.

The conceptions of healthcare and its aims outlined in Section 2.2 are inadequate because they do not take into account this embeddedness and interrelatedness. Human health, even if thinly conceived as reduced morbidity and mortality, cannot be separated from the environment. Therefore, even on this thin account of health, healthcare must include care for the environment as both a precondition for health and a possible cause (either naturally or because of human activity) of ill‐health.

This broader conception of healthcare resolves the first of the dualities in Table 1, namely, Human/Nature. It also goes some way towards conceptually resolving the other dualities, because every human being is part of both the local and the global, the present and the future (even if one died today, the fact of one's existence has an impact on the world and future outcomes). And every human being benefits from both therapy and prevention.

This leaves the problem of the human tendency to prefer the immediate concrete good over the distant abstract one, which needs to be addressed to adequately solve the problem presented by the dualisms of place, time and intervention. Human beings are not reducible to self‐interested consumers of resources (like the child who cannot resist the treat in front of them). Rather, as embodied subjects in relationship to all that is who pursue flourishing, they are capable of working towards longer term goods, both concrete and abstract (e.g., transcendent ideas of freedom, love, democracy, salvation), even at some cost to themselves in the shorter term. Human beings want to be healthy, not merely to be ‘free of disease and avoid death', but because they want to live their lives in a meaningful way (usually for as long as possible).⁶²

Conceiving of health and healthcare on the basis of such a vision of the human being offers a twofold resolution of the dualisms of place, time and intervention. First, once I realise that my flourishing is bound up with the good of an environment (the place aspect), I want healthcare institutions, like other institutions, to take the problem of damage to the environment seriously. The barriers of cost and lack of political will become more porous as more still healthy people (i.e., those not currently in need of acute or chronic care) advocate for and support the cause of protecting and restoring environmental goods (the time aspect), even if in their minds this is effectively only for their own benefit (the prevention aspect). Second, this conception of the human being and of their health as flourishing in an interconnected world reframes the roles of healthcare workers, hospital administrators and policymakers. Their roles are not simply to treat acute and chronic health needs, but rather to both treat these and find ways to promote and support the broader conception of health presented here (which now includes global, future and preventative goods) by finding less environmentally damaging ways to deliver equitable healthcare. This is the right thing to do because it supports the health of the environment and, therefore, the flourishing of human beings in that environment. Moreover, since, as explained in the anthropology above, a person realises their flourishing through engaging in moral behaviour in their relationships, hospital workers, administrators and policymakers realise their own flourishing by working for the good of health, now more broadly conceived, in others’ lives.

What relational thinking does is move us to a position where we are justified to, and indeed obliged to, look for co‐benefits in the first instance, and then use classical resource allocation methods of proportionality and burden where no co‐benefits can be achieved. Our approach does not mean that hospitals will never have to make choices about allocating limited resources to different goods. Rather, it means that the problem is no longer framed solely and always as a competing goods dilemma, because both environmental and health goods are under the purview of the aims of healthcare. This means that classical resource allocation decision‐making methods can be applied to achieve the best outcomes for healthcare with the resources available. This includes considerations of proportional benefits and disproportionate burdens, which are effective in clinical contexts and provide a degree of moral certainty about difficult clinical decisions, such as the withholding or withdrawing of treatment or the allocation of scare resources.⁶³

The difference between this use of resource allocation principles and the dualistic mode is that, now, environmental goods are integral to the conception of health, and so become part of the goods considered in the classical resource allocation methods applied to achieve healthcare. It is thus not a decision about ‘either health or the environment’ but rather a moral decision about how best to choose between both health goods and environmental goods or between certain environmental goods and other environmental goods in the overarching pursuit of this broader conception of healthcare.

We acknowledge that there are multiple ways in which consideration of the environment could be made substantive in classical resource allocation methods: (1) by reinterpreting existing resource allocation principles to account for the environment⁶⁴; (2) by functioning as a side‐constraint, ruling out excessively unsustainable actions with lexical priority over other principles; and (3) by gradual weight, being entered into moral deliberations alongside, and potentially in competition with, other ethical principles.⁶⁵ A relational frame endorses the former of these three options. Since environmental goods are no longer alternative goods that conflict with healthcare goods, they should be incorporated into the goods considered using classical resource allocation principles. They need not sit in conflict to healthcare goods via consideration using a separate principle or as a side constraint.

5. THREE EXAMPLES TO ILLUSTRATE HOW A RELATIONAL FRAME CAN PROMOTE CO‐BENEFITS AND IMPROVE RESOURCE ALLOCATION DECISIONS IN HEALTHCARE

In this section, we present three examples of how the claim made at the end of the last section could work in practice. First, we present an example of how co‐benefits can be prioritised. Second, we present an example that demonstrates how proportionality and the personalist criterion enable looking for co‐benefits first and then using proportionality when there are no co‐benefits. Finally, we present an example of resource allocation between two environmental goods when there are no co‐benefits.

It is important to recognise that we do not claim that our approach constitutes a kind of rational calculus that provides to every problem a solution that one can claim to have reached with absolute or mathematical certainty. They remain moral problems, about which moral, not empirical, decisions must be made by human beings with a degree of moral, not empirical certainty.⁶⁶ Recall the anthropology set out in Section 3. The human being seeks to realise a sense of self‐worth and meaning in life precisely through their moral choices and actions in their relationships. They become virtuous through their orientation to achieving the good. Their moral character is reflected in the goods that they deem worth pursuing and how they set out to achieve them. This does not mean that they make every decision perfectly, but rather that they make every decision with sincere commitment to achieve the good in the circumstances in which they find themselves. To expect more than this changes the nature of these decisions and puts unrealistic expectations on human subjects in solving difficult moral problems. It is for this reason that, when co‐benefits are not possible, recourse should be made to classical resource allocation methods that use considerations of proportional benefits and burdens as shown below. First, however, we shall consider how the relation frame can remove apparent dilemmas caused by dualistic thought by obliging us to look for co‐benefits.

5.1. Example 1. Khoo Teck Puat (KTP) hospital: Co‐benefits and the end of the zero‐sum game

Because our approach means that working for environmental goods or health goods need no longer be viewed as a zero‐sum game, hospital leaders and staff should think creatively (beyond their functional roles) to seek co‐benefits. This is exemplified by the Khoo Teck Puat (KTP) Hospital in Singapore.

This 550‐bed general and acute facility is described as a biophilic hospital. The hospital walls are covered with living plants, green balconies and multilevel gardens (including ponds containing 92 fish species; 32 species of butterflies and 24 species of birds have been recorded). Every bed and office has healing views. The hospital has a community garden on the roof that has 140 fruit trees, vegetables and spices, is managed by the local community and the produce is sold in the hospital canteen to cover costs. ‘The energy consumption of the KTP is 30% less than comparable new hospitals, saving S$1 million a year’.⁶⁷ Studies show that the KTP has lower per bed costs and shorter patient stays than comparable hospitals.⁶⁸

This example demonstrates how thinking of healthcare as including environmental goods (rather than competing) should lead to wise investment in environmental goods as part of the planning and development of new healthcare facilities resulting in financial, health and environmental benefits. The health benefits include not only benefits for patients but also benefits for their visitors, healthcare workers and the surrounding community. Such thinking can move beyond mere reduction of harm to the environment to planning healthcare facilities that actually are restorative in their own right. Such facilities are not merely addressing the causes of disease but promoting the causes of health.⁶⁹

5.2. Example 2: Pharmaceuticals: Starting with co‐benefits and using proportionality to decide between health and environmental goods

Pharmaceuticals are significant contributors to carbon emissions.⁷⁰ An overly simplistic reading of our proposal may conclude that we should therefore stop prescribing most medicines, and, because environmental goods are now conceived of as a good that is part of healthcare, we could still claim that this is achieving healthcare. However, this would not meet the test of proportionality in classical resource allocation. The burden of such an approach on the health of individual humans would be disproportionate to any good that it achieved for the environment.

Personalist ethics requires that healthcare (now broadly conceived) still be at the service of concrete human beings. So, to address the problem of environmental damage by pharmaceuticals: first, taking a co‐benefits approach, hospital administrators should find ways to encourage more accurate (i.e., proportional because it is the lowest effective dose) prescription of medicines because this can have significant environmental benefits and reduce the disproportionate burden on hospitals caused by inaccurate prescription; second, still taking a co‐benefits approach, more environmentally sustainable but equally effective medications should be preferred where possible because it would be disproportionate to cause unnecessary harm to environment; and third, if an environmentally ‘unfriendly’ medication is the only effective, proportionate and available treatment for a particular person (i.e. there are now no co‐benefits), this should be prescribed. Because this approach intentionally minimises harmful effects to the environment as part of its goal of achieving effective healthcare, the resulting burden to the environment is not likely to be judged as disproportionate in most cases. It would have to be an extremely toxic medicine with potentially catastrophic consequences for the environment (and therefore also for the health of other people now and in the future) to meet this bar. If done properly, therefore, both environmental and immediate health outcomes are improved and no one in need of treatment should be worse off.

5.3. Example 3: Reusable ICU equipment: Using classical resource allocation criteria to decide about competing environmental goods

Disposable equipment is often used in ICU settings to reduce the risk of infection. This has negative environmental effects: instead of manufacturing one item that can be used 300 times, disposable equipment must be manufactured 300 times and disposed of 300 times. However, recent research has indicated that with proper sterilisation, the infection risk is sufficiently minimised.⁷¹ With infection risk being the same, the question becomes: which is environmentally better? In other words, the conflict here is not between a health good and an environmental good, because the clinical outcome is the same. The relational approach enables us to still consider these environmental problems within the scope of healthcare.

In classical clinical resource allocation methods, when choosing between who should have access to a limited resource, for example, a ventilator, clinicians make their decision based on consideration of which patient has the greatest need, the best prognosis (proportional benefit holistically considered) and for whom the treatment would be least burdensome.⁷² Whilst some patients will not get the treatment that might have helped them, those who most needed it and were most likely to benefit did. There can be no moral obligation to do more than what is possible. The overall aim of healthcare is achieved.

In the ICU equipment example, the limited resource is the money spent on ICU equipment. In Australia, where the energy supply is largely coal‐based, reusable equipment might contribute to higher greenhouse gas emissions than disposables. On the other hand, disposables result in more waste.⁷³ So, there are no co‐benefits here. Hospitals must choose between minimising waste or minimising emissions for the same clinical outcome. Just as each patient is considered holistically in classical clinical decision‐making, so the context of each hospital should be holistically considered in allocating resources. So, in this example, administrators would ask whether there is greater need to reduce waste or carbon emissions, which investment would have the greater proportional benefit on the problem it seeks to address (i.e., waste or carbon emissions) and which has the least burden on the environment (in terms of bad knock‐on effects) or the health system (not merely cost but also service efficiency and the like might be considered). On balance, a hospital in Australia might decide to stick to disposables because they think that reducing carbon emissions is more important. This would not be the case in Europe, where the energy mix includes more renewables,⁷⁴ swinging the consideration of need, benefit and burden in favour of reusable equipment.

6. CONCLUSION

In this article, we set out to answer the question, ‘How should hospitals make decisions about allocating resources to the equitable delivery of healthcare versus to minimising that healthcare's negative environmental impacts?’ The problem is often seen as a resource allocation dilemma of competing goods, that is, healthcare goods versus environmental goods, with the impression that an investment in one means the loss of the other. However, we argue that this framing of the question is based on a reductionist understanding of the human being, and consequently of health and the goals of healthcare. By reconsidering the human person as a flourishing‐seeking being always already embedded in the natural environment, investment in environmental goods is no longer a good that is in addition to the good of healthcare but is rather an integral part of healthcare. Thus, hospitals should not merely allocate resources either to healthcare goods or to environmental goods because investing in the environment is investing in healthcare.

Because hospitals must, in this view, consider and deliver on a broader range of goods, they are given a licence and a responsibility to look beyond the often narrow confines of their traditionally conceived functions, to see how they can contribute to human health and flourishing through seeking creative solutions to environmental problems that arise precisely because one recognises the interconnectedness of humans and the natural environment. They should approach resource allocation by looking for co‐benefits in the first instance, and then using classical resource allocation methods of proportionality and burden that factor in both health goods and environmental goods where no co‐benefits can be achieved.

CONFLICT OF INTEREST STATEMENT

Queensland Bioethics Centre receives funding from the Roman Catholic Archdiocese of Queensland, the Roman Catholic Bishops of Queensland, Mater Misericordiae Ltd., St Vincent's Health Australia and Southern Cross Care Queensland. Authors’ views are their own.

Kirchhoffer, D. G. , & Pratt, B. (2025). In hospital resource allocation conflicts between health goods and environmental goods, a relational, co‐benefits frame, rather than a dualistic, competing goods frame, is key. Bioethics, 39, 565–575. 10.1111/bioe.70002

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no data sets were generated or analysed during the current study.