The global surgical triple goal: Surgery must improve health, be equitable, and environmentally sustainable

If carbon emissions are not substantially reduced, human health will suffer irreparably. At the same time, global healthcare suffers from inequitable distribution which also leads to avoidable suffering. Health practitioners have always assessed treatment through the lens of potential benefits versus potential risks and harms. This lens must be widened to include global equity and carbon emissions if the triple goal of improving health, equitable delivery and environmental sustainability is to be achieved. This perspective looks at the surgery-specific challenges to sustainability through an equity lens, especially the tension between surgery being one of the most carbon-intensive forms of healthcare, and in many cases also being lifesaving or life-altering and hence essential. Carbon footprints should be made more visible, and sustainability should drive surgical innovation and be part of accreditation processes. Environmental impact should be built into research proposals, and the evidence arising from research used to make hard decisions about low value care. Carbon offsets may be a temporary measure. The surgery of the future must have a lower carbon footprint and consist of procedures that have been proven to be essential and/or of great benefit. Additionally, the burdens of achieving sustainable surgery must not exacerbate existing current or future healthcare inequity globally.