Healthcare systems have an ethical duty to ensure equal access to high-quality healthcare as a matter of social justice. In their pursuit of that duty, they generate substantial environmental harms. For that reason, healthcare systems also have an ethical duty to minimise their environmental impacts as a matter of environmental justice and ecological justice. Many countries are already transitioning to less environmentally harmful healthcare. This study investigates whether the two duties come into tension when designing new green hospitals and how such tensions (if found to eventuate) are navigated in practice. We conducted case study research in collaboration with an Australian hospital network, with one of the network's new public hospital builds comprising our case of focus. We undertook semi-structured interviews between March and June 2023 with those responsible for making design decisions in relation to the new public hospital being built. We analysed interview data thematically and report three main themes: separating the clinical and the environmental; tensions; and addressing tensions. We conclude by providing analysis of what is at stake in identified tensions using theories of justice, offering lessons that can help other hospitals mitigate against such tensions arising, and considering whether and when the moral reasoning employed in the case-under-study should be used to navigate the tensions. This study provides those responsible for green hospital design with a better understanding of what tensions they are likely to encounter between health, social, and environmental goods and how to reduce those tensions' occurrence. That understanding will help them to identify and avoid such tensions in their practice, but further work is needed to develop ethical guidance on how they should navigate the tensions when they occur.
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