To the Editor:
Using life cycle assessments, McGain et al. account for the carbon footprint of general, regional, and combined anesthesia techniques for total joint replacements in Australia. With the accounting of carbon emissions, we applaud the authors for demonstrating that the environmental impact of our clinical endeavors extends far beyond the four walls of the operating room. We would like to expand the focus to include an assessment of the impacts to local water systems and to shine the spotlight on ecologic economics. In contrast to life cycle assessments, ecologic economics views human systems as a subsystem of Earth’s larger ecosystem. By emphasizing the preservation of natural capital, ecologic economics is very different from life cycle assessments, and most life cycle assessments are merely a mainstream economic analysis of the environment. McGain et al. glance upon ecological economics when they point to the water needs when sterilizing and reusing equipment even though their system boundaries did not accommodate the long-term impact of the operating room on water ecology. Using ecologic economics, one begins to appreciate the extant and extent of healthcare delivery. Tradeoffs between reusable and disposable equipment are not just an issue of the carbon footprint. The sterilization of medical equipment requires a water supply to clean the equipment. Therefore, any ecologic analysis should include the specific geographic location of water sources and an appreciation that these sources are renewable. Water systems are intricate and complex, and water is recycled and reused.3 It is time that we more fully understood the ecologic impact of healthcare delivery. Thankfully, McGain et al. have shown us a way.