Editor's Note: A version of this paper was presented at CHA's Theology and Ethics Colloquium March 11-13, 2020, in St. Louis.

In the creation story, God mandated that humans should be caretakers of the earth (Genesis 1:28) and gave ample provisions to meet the physical needs of all creatures (Genesis 1:29-30).

However, humans have failed to satisfy their duty to care and have threatened the survival of God's creation through environmental exploitation, unjust allocation of resources, and rampant consumption. While all people of good will have a responsibility to care for our planet, Christians have a transcendental obligation to preserve the earth. This obligation extends to all Christians in every vocation.

Health care has its own unique purpose, often envisioned in terms of Christ's healing ministry. Yet, health, healing, and environmental conservation are often thought of as discrete responsibilities. In order to connect these frequently compartmentalized aspects of Christian mission, this article will provide an overview of climate change and its effects, summarize Catholic Social Teaching on environmental responsibility, and offer two ways Catholic health care can continue to take ethical responsibility for the environment. The conclusion highlights the unique opportunity for Catholic health care to practice creation care and medical care in a way consistent with Catholic Social Teaching on the environment.

CLIMATE CHANGE
Climate change is largely a result of human activities that emit greenhouse gas emissions, such as carbon dioxide (CO₂). Climate change causes a number of social problems, including loss of biodiversity, food insecurity, and habitat disruption. Climate change also results in health hazards that increase burdens on health care, dramatically impact the poor, and exacerbate environmental racism.

CLIMATE CHANGE-RELATED HEALTH HAZARDS
According to the World Health Organization (WHO), climate change is estimated to cause approximately 250,000 deaths per year "due to thermal extremes and weather disasters, vector-borne diseases, a higher incidence of food-related and waterborne infections, photochemical air pollutants and conflict over depleted natural resources."¹ Temperature extremes cause higher morbidity and mortality as heat waves become more frequent, intense, and longer, while urbanization creates a "heat island" effect. Rising sea levels contribute to an increase in flooding and coastal erosion, storm surges, and damage to infrastructure. Some islands that are habitats for humans will completely disappear.² While people are fleeing tsunamis and flooding, injuries occur.

Flooding and drought impact food production through reduced crop yields, increased crop losses, and decreased nutritional content in food that is salvageable. Air quality is compromised through pollution and changes in the levels of pollutants. Altered pollutant dispersal translates to previously immune communities now facing respiratory problems like asthma and lung cancer. The WHO states "air pollution, which is linked to 7 million premature deaths annually, is the world's largest single environmental health risk."³ Climate change-related health hazards also include wildfires, tornadoes, and hurricanes. Survivors of these and other natural disasters show symptoms of post-traumatic stress disorders, anxiety, and depression.⁴ Loss of access to basic elements of life, like clean water and food, cause war and conflict, forced migration, and population displacement. These health hazards disproportionately impact people and communities who are economically and socially insecure.

POOR PERSONS AND CLIMATE CHANGE
As with much ecological degradation, the poor are absorbing the brunt of the problem.⁵ For instance, "Socioeconomic factors associated with heat related mortality… include inadequate housing conditions, lack of access to air conditioning, social isolation, chronic illness, as well as psychological and behavioral factors. Many of these factors are found disproportionately in urban areas, particularly among elderly, poor, and non-white individuals."⁶ Climate change health hazards are a result of carbon emissions, which do not stay within national borders.

Pope Francis reminds us that "pollution (is) produced by companies which operate in less developed countries in ways they could never do at home."⁷ While the rich benefit from the economic gain often associated with this resource use, poor persons are subjected to the noxious externalities of a compromised ecosystem. The compounded pollution and its health effects create an unjust system that exacerbates existing ecological and medical problems.

After a climate event, those without financial means face additional health complications and life disruption because they lack resources to move and are confined to dilapidated, moldy, or uninhabitable neighborhoods. The United States Conference of Catholic Bishops (USCCB) note in their statement, Climate Change: A Plea for Dialogue Prudence and the Common Good, that "projected sea level rises could impact low-lying coastal areas in densely populated nations of the developing world. Storms are most likely to strain the fragile housing infrastructure of the poorest nations"⁸ as well as the poorest people within nations. Climate change health hazards can be considered a form of environmental racism because of the effects on ethnic minorities and developing countries.

ENVIRONMENTAL RACISM
While "the economically well-off can choose to live amid acres of green … poor people are housed near factories, refineries, or waste-processing plants that heavily pollute the environment."⁹ Environmental racism is present whenever people are forced to subsist in poverty; when the poor feel the effects — but infrequently the benefits — of an economic system that emits massive amounts of carbon. Environmental racism has been a theological concern since the mid-1980s when "North American churches began turning their attention to environmental racism."¹⁰

At that time, the United Church of Christ's (UCC) Commission for Racial Justice issued its landmark publication, Toxic Wastes and Race in the United States: A National Report on the Racial and Socio-Economic Characteristics of Communities with Hazardous Waste Sites.¹¹ The document found that environmental threats such as toxic waste sites, municipal dumping grounds, and hazardous waste facilities were clustered in low-income areas where racial and ethnic minorities dwell. Impoverished locations were deliberately chosen since poor people generally lack the political resources to mobilize a constituency to lobby against policies that negatively affect their health. Furthermore, as former World Bank economist Lawrence Summer stated, toxic waste was put in places where poor people live because they "don't live long enough to feel the effects."¹²

A follow-up investigation to the Commission for Racial Justice's Toxic Wastes Report made twenty years later found that little had changed.¹³ Linked with a history of colonialism and slavery, environmental racism in the United States is no less than, as Womanist theologian Emilie Townes describes, a "contemporary version of lynching a whole people."¹⁴ Victims of environmental racism are subjected to an insidious and obfuscated form of social injustice, which denigrates human dignity.

Environmental exploitation impacts all people, countries, and health care organizations that care for those affected by climate change health hazards. Given that health is intimately tied to the natural environment — as well as other social factors like race, sex, and income — health care has a responsibility for carbon reduction to minimize climate change and climate change health hazards.

CATHOLIC SOCIAL TEACHING ON ENVIRONMENTAL RESPONSIBILITY
Reduction of carbon emissions is an ethical imperative in all areas of life, from transportation, to food consumption, to family lifestyle, to health care. The ecological writings of Catholic Social Teaching (CST) provide the theological rationale to reduce carbon.¹⁵ In the last 30 years, CST has demonstrated the continuity, coherence, and, at the same time, diversity of approaches to theological ecology, which is instructive for Catholic health care.¹⁶ Several documents have received a significant amount of attention and analysis, including John Paul II's World Day of Peace Message: Peace with God, the Creator, Peace with All of Creation (1990); the United States Conference of Catholic Bishops' Climate Change: A Plea for Dialogue Prudence and the Common Good (2001); Benedict XVI's World Day of Peace Message: If You Want to Cultivate Peace, Protect Creation (2010); and Pope Francis' Laudato Si': On Care for Our Common Home (2015). The themes of integral ecology, the common good, and the preferential option for the poor, which are leitmotifs in the aforementioned writings, also emerge powerfully in Pope Francis' 2020 Post-Synodal Apostolic Exhortation "Querida Amazonia."

Demonstrating a cohesive approach to environmental problems of the day, Pope Francis recognized that "a true ecological approach always becomes a social approach; it must integrate questions of justice in debates on the environment, so as to hear both the cry of the earth and the cry of the poor."¹⁷ Social ethics, justice and environmental ethics can be synthesized with the foundational commitments of Catholic health care.

ENVIRONMENTAL ETHICS AND SOCIAL ETHICS
First, Pope Francis believes that an ecological approach to sustainability is a social approach. Obviously, ecology is not separate from society — our ecosystem sustains our life and shapes the way we interact with our world. While the natural environment is circumscribed by natural law, humans, who are endowed with freedom, may act in ways that conform to, or rebel from, natural law. Francis reflectively writes, "alongside the ecology of nature, there exists what can be called a 'human' ecology which in turn demands a 'social' ecology. Humanity…must be increasingly conscious of the links between natural ecology, or respect for nature, and human ecology."¹⁸ Humans must yield to natural law in ecology and society.

To be sure, appealing to natural law as a moral standard for ecological and social activities does not need to lead to a naturalistic fallacy. Natural law upholds the rationality of humans and creative processes thereof. Intelligence, engineering, technological developments, and modern medicine are channels for humans to fulfill our unique imperative to protect and enrich the world. However, rationality is lost when a frantic drive towards progress results in irreparable damage. Thus, an ecological approach has to be a social approach, recognizing that "the care of people and the care of ecosystems are inseparable."¹⁹

Likewise, care for people's bodies and care for their souls are interconnected with care for the environment. Environmental destruction has negative repercussions on human health. Exploitation of nature reduces access to fresh water, nutritious and abundant food, the biodiversity of medicinal herbs, and a dynamic landscape. Moreover, the manner in which environmental destruction occurs often comes at a human cost. For instance, people who work in slaughterhouses have higher than average rates of domestic abuse because of the instrumentalization of sentient beings.²⁰ In Querida Amazonia, Francis recognizes that the elimination of the Amazon forests is "purchased with a thousand deaths."²¹ This should not only be viewed as a physical death, thus falling into a Cartesian dualism. Rather, there is a spiritual death when one's home is razed; even more so when it is destroyed by one's own hands. Social ecology recognizes this.

ENVIRONMENTAL ETHICS AND JUSTICE
In Querida Amazonia Pope Francis also implores, for an integration of "justice in debates on the environment, so as to hear both the cry of the earth and the cry of the poor."²² Earth justice and social justice are mutually reinforcing, not exclusionary. A healthy society will not only acknowledge the value of nature and seek to preserve wild spaces and wild animals, it will also facilitate the mechanisms to do so.

Pope Francis observes that "the culture of waste is already deeply rooted. A sound and sustainable ecology, one capable of bringing about change, will not develop unless people are changed, unless they are encouraged to opt for another style of life, one less greedy and more serene, more respectful and less anxious, more fraternal."²³ Greed is not only found in malls and restaurants, it is also in luxury medical procedures, hotel hospitals, clinical spas, and lifestyle pharmaceuticals.

The line between greed and progress is thin. Particularly in the hard sciences and in medicine, the never-ending pursuit of "progress" drives the industry. With this mindset, "it becomes almost impossible to accept the limits imposed by reality."²⁴ One can always look younger, upgrade their body parts, enhance their cognition, and defy mortality for yet another day. Yet, medical greed comes at a cost to patients through redundant treatments that do not meet the goals of medicine, to staff who experience moral distress at futile health care measures, to the poor who suffer in medical deserts, and to our sisters and brothers around the world impacted by the carbon emissions of the medical industry, justified by patient "autonomy."

CATHOLIC HEALTH CARE'S ETHICAL RESPONSIBILITY TO THE ENVIRONMENT
Throughout Catholic Social Thought, the responsibility for creation care and care for the poor are imperatives, not suggestions. Fulfilling these obligations requires a conversion of thought and action where we live, work, and worship. In health care, the responsibility for eco-justice and social justice extends to practices and policies that heal the earth and heal the sick. Fortunately, there are multiple, non-exclusive tactics to discharge the responsibility to respond to climate change, climate change health hazards, and participate in the healing ministry of Christ. With growing consensus that environmental sustainability is an urgent priority that deserves attention and action, and with green hospital practices already proliferating in Catholic health care facilities, environmental bioethics and Green Bioethics offer two ways to pursue responsibility to the environment in health care.

ENVIRONMENTAL BIOETHICS
Environmental bioethics is a subdiscipline within environmental ethics and biomedical ethics. Environmental bioethics developed with two foci: the effects of climate on human health and the effects of health care on the environment.²⁵ While the former concern is situated within public health, health care organizations, hospitals, and clinics have taken up the latter.

The Catholic Health Association (CHA) has helped make hospital facilities more sustainable and has educated employees about environmental ethics.²⁶ The CHA continues to innovate and update strategies for sustainable health care, addressing the most pressing environmental issues with a rigorous dedication to the Catholic social tradition.²⁷ This courage and leadership are laudable. However, environmental bioethics is ultimately limited in its ability to reduce carbon emissions of the medical industry because it only focuses on the structural aspects of health care — buildings, energy, and transportation — rather than the resources used in health care itself.

Health care facilities do produce a significant amount of carbon dioxide.²⁸ However, a detailed analysis of carbon emission by sector reveals that hospital care and physician and clinical services are the largest emitters in the U.S. medical industry, with structures, equipment and pharmaceuticals at third and fourth, respectively.²⁹ The environmental impact of health care has been under considered, in part, because of the belief that all treatments are medically necessary and, therefore, carbon emissions are morally irrelevant. Yet, this paradigm circumvents environmental responsibility at the level of the patient-physician relationship and fails to engage the largest stakeholders in medical care — the people giving and receiving treatment. In recognition of this, Green Bioethics was developed.³⁰

GREEN BIOETHICS
Green Bioethics proposes four principles for determining the sustainability of the medical developments, techniques, and procedures that doctors offer and patients use. The four principles of Green Bioethics are: distributive justice, resource conservation, simplicity, and ethical economics.³¹

The first principle of Green Bioethics—distributive justice: allocate basic medical resources before special-interest access — begins where Tom Beauchamp and James Childress' principles of biomedical ethics conclude.³² This continuity provides an avenue for bioethicists to engage with environmental ethics in familiar terms. In particular, distributive justice downplays the biomedical principle of respect for autonomy, while highlighting the value of solidarity.

The second principle — resource conservation: provide human needs before human wants — recognizes that resources must be used, but that they should be used in a way that all people can access them. Resource conservation is firmly entrenched in ecological ethics.

The third principle — simplicity: reduce dependence on medical interventions — is closely identified with the environmental movement. However, physicians practice the principle of simplicity when they act with therapeutic parsimony or diagnostic elegance. Moreover, simplicity connects to the principle of non-maleficence since unnecessary medical treatments can harm patients.

The fourth principle — ethical economics: humanistic health care instead of financial profit — reinforces the principle of beneficence, since it acknowledges that basic health care should be given to all people regardless of ability to pay. Here, natural resources are directed at greatest clinical benefit, while luxury medical goods are curtailed.

Green Bioethics requires a participatory approach to effectively support environmentally responsible health care. Indeed, a 2012 document published by the Catholic Health Association observes that "health care professionals can lead by example by reducing their personal carbon footprints and embracing sustainable lifestyles and considering the environmental costs at work."³³ Doctors and health care professionals are responsible for their prescribing practices and treatment plans. However, patients must also be cognizant of the environmental impact of their medical care. Both must be supported by sustainable health care organizations and insurance plans.

CONCLUSION
In 2018, the United States Conference of Catholic Bishops (USCCB) reiterated that "throughout the centuries … a body of moral principles has emerged that expresses the Church's teaching on medical and moral matters … has proven to be pertinent and applicable to the ever-changing circumstances of health care and its delivery."³⁴ Through dedication to sustainable health care, health organizations that are members of the Catholic Health Association can simultaneously maintain the immense worth of individual human life through medical care and the responsibility of environmental stewardship.

Cristina Richie, Ph.D.
Assistant Professor
Bioethics and Interdisciplinary Studies Department
Brody School of Medicine
East Carolina University
Greenville, N.C.
[email protected]

ENDNOTES

1. World Health Organization. Global Health Risks: Mortality and Burden of Diseases Attributable to Selected Major Risks. Geneva: WHO Press, 2009, p. 24.
2. DiPrete Brown, Lori. Foundations for Global Health Practice. John Wiley & Sons, 2018.
3. World Health Organization. "7 Million Premature Deaths Annually Linked to Air Pollution." 25 Mar. 2014. Available at: http://www.who.int/mediacentre/news/releases/2014/air-pollution/en.
4. Brown, Foundations for Global Health Practice.
5. McNeill, Charleen C., Cristina Richie, and Danita Alfred. "Individual Emergency Preparedness Efforts: A Social Justice Perspective." Nursing Ethics 27, no. 1 2020 pp. 184-193.
6. Fuhrmann, Christopher M., Margaret M. Sugg, Charles E. Konrad, and Anna Waller, "Impact of Extreme Heat Events on Emergency Department Visits In North Carolina 2007 – 2011." Journal of Community Health 41, no. 1 2016: 146-156, at p. 148.
7. Pope Francis. Laudato Si': On Care for Our Common Home Rome: Vatican Press, 24 May 2014, 51.
8. United States Conference of Catholic Bishops. Climate Change: A Plea for Dialogue Prudence and the Common Good. 2001. Available at: http://www.usccb.org/issues-and-action/human-life-and-dignity/environment/global-climate-change-a-plea-for-dialogue-prudence-and-the-common-good.cfm.
9. Johnson, Elizabeth. Quest for the Living God: Mapping Frontiers in the Theology of God. New York: Continuum, 2007, p. 187.
10. Jenkins, Willis. Ecologies of Grace: Environmental Ethics and Christian Theology. Oxford: Oxford University Press, 2008, p. 63.
11. United Church of Christ Commission on Racial Justice. Toxic Wastes and Race in the United States: A National Report on the Racial and Socio-Economic Characteristics of Communities with Hazardous Waste Sites. United Church of Christ Commission on Racial Justice: Public Data Access, 1987.
12. Sobrino, Jon. The Principle of Mercy: Taking the Crucified People from the Cross. Maryknoll, NY: Orbis Books, 1994, p. 192 note 7.
13. Bullard, Robert D. Paul Mohai, Robin Saha, and Beverly Wright. Toxic Wastes and Race at Twenty: Grassroots Struggle to Dismantle Environmental Racism in the United States. Cleveland, OH: Justice and Witness Ministries, United Church of Christ, 2007.
14. Townes, Emilie. In a Blaze of Glory: Womanist Spirituality as Social Witness. Nashville: Abington Press, 1995, p. 55.
15. Richie, Cristina. "Carbon Reduction as Care for Our Common Home: Laudato Si', Catholic Social Teaching, and the Common Good." Asian Horizons- Dharmaram Journal of Theology, 9, no. 4 2015: pp. 695-708.
16. For documents on the environment as early as 1989 see John Paul II. The Ecological Crisis: A Common Responsibility. 1989; John Paul II. 1990 World Day of Peace Message: Peace with God, the Creator, Peace with All of Creation. 1990; Pontifical Council for Justice & Peace. "Chapter 10: Safeguarding the Environment." In Compendium of the Social Doctrine of the Church. 2005: Pontifical Council for Justice and Peace. "Contribution of the Holy See to the Fourth World Water Forum." March 16-22, 2006.
17. Pope Francis. "Querida Amazonia", Esortazione Apostolica post-sinodale. 12 Feb. 2020, no. 8, Available at: https://press.vatican.va/content/salastampa/it/bollettino/pubblico/2020/02/12/0091/00189.html#ing
18. Ibid., no. 41.
19. Ibid., no. 42.
20. Fitzgerald, Amy J., Linda Kalof, and Thomas Dietz. "Slaughterhouses and increased crime rates: An empirical analysis of the spillover from 'The Jungle' into the surrounding community." Organization & Environment 22, no. 2 2009: pp. 158-184.
21. Francis. "Querida Amazonia." no. 9.
22. Ibid., no. 8.
23. Ibid., no. 58.
24. Ibid., no. 59.
25. Richie, Cristina. "A Brief History of Environmental Bioethics." AMA Journal of Ethics 16, no. 9 2014: pp. 749-752.
26. See Risse, Guenter B. Mending Bodies, Saving Souls: A History of Hospitals. Oxford: Oxford University Press, 1999, pp. 522-524.
27. Catholic Health Association, Catholic Healthcare Ministry. "Environmental Responsibility." Available at: https://www.chausa.org/docs/default-source/general-files/catholic-healthcare-ministry-environmental-responsibility.pdf?sfvrsn=6.
28. Pichler, Peter-Paul, et al. "International Comparison of Health Care Carbon Footprints." Environmental Research Letters. 14 2019: 064004.
29. Eckelman, M.J. and J. Sherman. "Environmental Impacts of the U.S. Health Care System and Effects on Public Health." PLoS ONE 1, no. 6 2016: e0157014.
30. Richie, Cristina. "Building a Framework for Green Bioethics: Integrating Ecology into the Medical Industry." Health Care Ethics USA 21, no. 4 2013: pp. 7-21.
31. Richie, Cristina. Principles of Green Bioethics: Sustainability in Healthcare. Michigan State University Press, 2019.
32. Beauchamp, Tom and James Childress. Principles of Biomedical Ethics, 1st ed. New York: Oxford University Press, 1979.
33. Anderko, Laura, Stephanie Chalupka, Brenda M. Afzal. Climate Change and Health: Is there a Role for the Health Care Sector?. St. Louis: Catholic Health Association of the United States, 2012, pp. 12.
34. United States Conference of Catholic Bishops. Ethical and Religious Directives for Catholic Health Care Services, 6th ed. Washington, DC: United States Conference of Catholic Bishops, 2018, p. 4.

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