Journal of Business Ethics (2009) 85:445–462
DOI 10.1007/s10551-008-9740-1
Purchasing and Marketing of Social
and Environmental Sustainability
for High-Tech Medical Equipment
ABSTRACT. As the functional capabilities of high-tech
medical products converge, supplying organizations seek
new opportunities to differentiate their offerings.
Embracing product sustainability-related differentiators
provides just such an opportunity. This study examines
the challenge organizations face when attempting to
understand how customers perceive environmental and
social dimensions of sustainability by exploring and
defining both dimensions on the basis of a review of
extant literature and focus group research with a leading
supplier of magnetic resonance imaging (MRI) scanning
equipment. The study encompasses seven hospitals and
one private imaging center in the Netherlands and
identifies five social aspects that cover 11 indicators. The
authors conduct 22 customer perception interviews with
key decision-making stakeholders involved in purchasing
MRI scanning equipment. Respondents find environ-
mental and social sustainability dimensions personally
relevant but professionally secondary to cost, perfor-
mance, and ability to use the equipment in their orga-
nizations’ physical infrastructure. Finally, incorporating a
product’s environmental and social credentials within the
marketing of MRI scanning equipment enhances
the perception of the product offering in decision-
making stakeholders’ minds and provides a means of
differentiation.
KEY WORDS: high-tech medical equipment, pur-
chasing process, decision making stakeholders, environ-
mental sustainability, social sustainability
Introduction
This article examines a given product’s (high-tech
medical equipment) social and environmental sus-
tainability and its potential to support a product
purchasing process. Sustainability describes how
Springer 2008
Adam Lindgreen
Michael Antioco
David Harness
Remi van der Sloot
an organization integrates social, environmental, and
economic activities in the pursuit of outcomes other
than profit (Amaral and La Rovere, 2003; Cowell
et al., 1999). Historically, companies have focused
on the economic dimension and employed
resources to maximize the company’s profit (e.g.,
Friedman,
1970; Gauthier, 2005; Walker, 2002), but in re-
sponse to the view that ‘‘companies do not only
serve shareholders, but are embedded in their eco-
nomic, ecological and social environment, which
they must take into consideration when doing
business’’ (Seuring et al., 2003, p. 204), they have
begun pursuing other aspects of sustainability, bal-
ancing economic prosperity with environmental
protection and social equity, to meet the principles
of sustainable development (Isaksson and Garvare,
2003; Keeble et al., 2003). Customers’ perceptions
of a product’s social and environmental sustainability
in turn influences their purchase choice as they seek
offerings compatible with their views of sustainable
development (Isaksson and Garvare, 2003). Al-
though this influence has been identified, its nature
has yet to be defined, making the use of environ-
mental and social sustainability in support of product
purchasing and marketing efforts problematic. For
example, few offerings highlight social sustainability
credentials (Isaksson and Garvare, 2003), though
such credentials may provide marketing opportuni-
ties if perceived as relevant by customers. Further-
more, though the economic and environmental
dimensions of sustainability are well understood, its
social dimensions remain novel and unexplored
(e.g., Amaral and La Rovere, 2003; Keeble et al.,
2003).
An example of the increasing importance of social
sustainability emerges in the high-tech medical
 Purchasing and Marketing of Social and Environmental Sustainability
equipment industry. Philips Medical Systems
introduced magnetic resonance imaging (MRI)
scanning equipment in 1983 and currently com-
mands 25% of the worldwide market, which rep-
resents 24.8% of the company’s total sales. With
annual growth levels of greater than 6%, the Euro-
pean market for high-tech medical equipment is
both attractive and strategically important for Philips
and its competitors, such as GE Healthcare and
Siemens Medical Solutions. As the technological
capabilities of MRI scanners converge, companies
increasingly turn to social and environmental
responsibility standards to influence customers’
purchasing decision-making. Within the Nether-
lands, four types of institutions purchase MRI
scanning equipment: academic, teaching, and com-
munity hospitals, and private imaging centers. The
purchasing decision-making process in each is gen-
erally similar and influenced by three types of
stakeholders: clinicians, operators, and business
managers (Heesch, 2006). The influence of each
stakeholder during the different purchasing stages for
MRI scanning equipment already has been sum-
marized into a customer-purchasing framework
(Figure 1).
This study has three additional objectives. First,
we provide clearer insights about what constitutes a
product’s environmental and social sustainability.
Second, we identify whether, and how, social and
environmental sustainability may influence the
Figure 1. Stages and key decision-making stakeholders in the purchasing process.
1
purchasing processes associated with high-tech
medical equipment. Third, we consider how social
and environmental sustainability can enhance the
marketing of such products. In order to address these
objectives, the remainder of this article is structured
as follows: First, a literature review explores the
environmental and social dimensions of sustainability
to conceptualize a theoretical framework. Second,
we report the findings of an empirical study that
qualitatively explores the influence of social and
environmental sustainability during the purchase of
MRI scanning equipment. Third, we present an
analysis and discussion of these empirical findings.
Fourth and finally, the conclusion identifies this
study’s theoretical and managerial contributions,
addresses some limitations, and suggests avenues for
further research.
Theoretical background
Dimensions of environmental and social sustain-
ability pertain to impacts on society’s future needs
(e.g., Cowell et al., 1999; Fiksel et al., 1998; Se-
uring et al., 2003; Veleva and Ellenbecker, 2001),
which requires satisfying present needs without
compromising the needs of future generations (e.g.,
Cowell et al., 1999; Ottman, 1997). A sustainable
company thus is one ‘‘whose characteristics and
actions are designed to lead to a ‘desirable future
state’ for all stakeholders’’ (Funk, 2003, p. 65), and
stakeholders are ‘‘those groups who can affect or
are affected by a firm’s objective’’ (Seuring et al.,
2003, p. 205). These definitions provide a context
from which to consider social and environmental
sustainability.
Environmental sustainability refers to a com-
pany’s use of natural resources and its consequent
ecological impact (Isaksson and Garvare, 2003;
Veleva et al., 2000). Although environmental sus-
tainability is reasonably well understood in existing
literature, social sustainability research fails to make
the nature of social matters clear (Littig and Gri-
essler, 2005). Since social sustainability is intangible
and qualitative in nature, a consensus about its
dimensions is difficult to reach, though it clearly
relates to how a company influences individuals’ or
society’s well-being (Geibler et al., 2006). As
depicted in the framework in Appendix 1, how-
ever, by adapting a concept specification model to
display the different aspects and their subelements
(i.e., indicators) of social sustainability, some clari-
1
fication has been achieved (Geibler et al., 2006).
This study in turn explores the nature of sustain-
ability indicators, then considers how they might be
summarized into sustainability aspects that can
provide insights into a product’s social and envi-
ronmental sustainability, and finally examines how
social and environmental sustainability can enhance
product marketing.
Sustainability indicators
Sustainability indicators are specific, measurable
product attributes that characterize contributions to
social and environmental sustainability (Fiksel et al.,
1998). Such indicators should be relevant, under-
standable, robust, and limited in number; they
should be easy to use, collect, and reproduce; they
should complement existing legal follow-up pro-
grams and be financially feasible; and finally, they
should be useful as a management tool and able to
protect company data, as well as remain adaptable
to future developments (Amaral and La Rovere,
2003; Isaksson and Garvare, 2003). Indicators thus
must take into account a product’s resource con-
sumption and value creation throughout its entire
life cycle (Fiksel et al., 1998; Gauthier, 2005;
Seuring et al., 2003), which in this context refers to
the extraction of raw materials for and manufacture,
packaging, storage, distribution, recycle, and
destruction of the product (Gauthier, 2005).
Therefore, companies’ social and environmental
indicators must relate to both internal and external
stakeholder needs throughout the stages of product
production, consumption, and disposal (Amaral and
La Rovere, 2003; Funk, 2003; Global Reporting
Initiative, 2006; Seuring et al., 2003). The broad
nature of sustainability (Fiksel et al., 1998) in turn
suggests that companies may risk generating too
many indicators, which could obscure those most
relevant to the product (Isaksson and Garvare,
2003).
Environmental aspects
With a firm understanding of environmental sus-
tainability, Philips Medical Systems defines its envi-
ronmental credentials according to five aspects:
reducing products’ energy consumption, packaging
materials, hazardous substances, and weight, and
increasing levels of recycling and safeguards during
disposal of products (Philips Sustainability Report,
2006). Governments, companies, and other organi-
zations adopt sustainable development initiatives to
address concerns about climate change and the
depletion of natural resources, reinforced by con-
sumers and activists who push large companies to
develop such practices (Cowell et al., 1999; Keeble
et al., 2003). Companies failing in this effort often
become the target of activist pressures (Gauthier,
2005).
Social aspects
Social sustainability is less well understood; accord-
ing to the Brundtland Commission’s (WCED, 1987)
view of social sustainability, this term relates to how
companies contribute to the well-being and quality
of life of society and individuals in current and future
generations (Steurer et al., 2005). Product-related
social aspects therefore refer to how their produc-
tion, use, and disposal satisfy such conditions. Social
aspects conceptualized and derived predominantly
from studies linked to the chemical industry appear
in the literature, and the cited aspects differ in their complete understanding of the social sustainability
level of focus. For example, some discuss ‘‘taking dimensions – aspects and indicators – that stake-
employees into consideration’’ to summarize how an holders of MRI scanning equipment view as
organization supports employees (e.g., Gauthier, important.
2005), whereas others separate this aspect into
‘‘working conditions,’’ ‘‘education and training,’’
and ‘‘equity’’ (Geibler et al., 2006; Tanzil and Bel-
Methodology
off, 2006). The differentiation in the level of focus
suggests that the nature of production, product
Qualitative methods are appropriate when studying
characteristics, and product use influence the level of
complex phenomena and when there is a need to
focus.
take into account numerous variables to study the
Various social aspect themes also emerge. For
issue(s) at hand (Eisenhardt, 1989; Matthyssens and
example, one theme relates to health and safety
Vandenbempt, 2003; Yin, 1994). In order to en-
(Gauthier, 2005; Geibler et al., 2006), also known as
able a focus on social sustainability, this exploratory
safety and well-being (Tanzil and Beloff, 2006) or
study adapts Geibler et al.’s (2006) concept speci-
accident and injury reduction (Fiksel et al., 1998).
fication model on the basis of the social sustain-
Regardless of the terminology, this theme is based
ability aspects and indicators identified in literature,
on the premise that the supplying company should
as well as customer perception interviews with key
minimize the potential for a product to harm an
decision-making stakeholders involved in purchas-
individual during its product’s lifecycle.
ing of MRI scanning equipment, interviews with
Another theme pertains to product usage within
marketing and other functional managers in Philips
the product’s operating context. The quality of the
Medical Systems, and secondary research about the
working environment, including issues of noise
company.
level and room temperature, impinges on how
In order to identify how decision-making stake-
people perform their jobs (Gauthier, 2005; Geibler
holders (both purchasers and users) perceive sus-
et al., 2006; Tanzil and Beloff, 2006). Such issues
tainability indicators, we undertake two stages. The
often get related to how they might create user
first stage involves a focus group comprising a range
‘‘peace of mind’’ (Fiksel et al., 1998). A product
of marketing and other functional managers from
further must answer stakeholders’ needs (Gauthier,
Philips Medical Systems who evaluate potential
2005; Seuring et al., 2003); for example, MRI
sustainability aspects and indicators. The second
scanning equipment must provide quality images
stage employs customer perception interviews, sup-
of the internal workings of a body. The product
ported by a short questionnaire, to build, test, and
also generates employment or wealth in different
validate a new theory (Newman and Benz, 1998;
social environments (Steurer et al., 2005). Ethical
Onwuegbuzie and Leech, 2005).
production requires treating employees and those
within the supply chain fairly (Gauthier, 2005;
Geibler et al., 2006; Seuring et al., 2003) by
ensuring that the production process protects Selection of case company
individuals and does not violate human rights or
require the use of child labor (Fiksel et al., 1998; Philips Medical Systems provides an excellent
Gauthier, 2005; Steurer et al., 2005; Tanzil and vehicle to explore the idea of sustainability, and
Beloff, 2006). Social sustainability thus represents a social sustainability in particular, because the com-
force for good that encompasses equity transfer, pany generally has a good reputation for under-
such that profit is more evenly distributed be- taking sustainability projects, such as replacing the
tween those involved in the manufacture within traditional lamp bulb (environmental sustainability)
the organization and those within the supply chain and minimizing purchasing and exploitation costs
(Seuring et al., 2003). For Philips Medical Sys- (economic sustainability). It is less clear, however,
tems, the greater use of social sustainability in the which social sustainability aspects Philips Medical
marketing of products would require a more Systems appreciates with regard to its product
offerings. In addition to its sustainability reputation,
the simplicity of the company’s competitive sce-
nario and strategic response relative to larger and
more complex manufacturers of high-tech medical
equipment makes Philips Medical Systems attractive
as a study subject. Finally, the company’s MRI
scanning equipment likely has multiple identifiable
social sustainability indicators that customers might
perceive.
The selection of a case study as a research
methodology and the associated techniques of this
method comply with Yin’s (1994) principles. First,
a comprehensive understanding of Philips Medical
Systems’ contextual setting is important, because
the developed analytical criteria pertain to the
company’s industry sector, in this instance, the
high-tech medical equipment sector. Second, one
of the authors works within the company, offering
a unique opportunity to access otherwise unob-
tainable data.
Secondary data and multiple interviews provide
rich insights, as well as a basis for greater transfer-
ability of the study’s findings to other contextual
settings (Eisenhardt, 1989). We undertake a stake-
holder assessment (e.g., Seuring et al., 2003) to
clarify hospitals’ and imaging scanning centers’ view
of social sustainability aspects and indicators by
interviewing the key decision-making stakeholders
and a customer context employee from each hos-
pital or imaging center. The inclusion of a variety
of stakeholders with different points of view en-
hances the overall validity of our model develop-
ment stage.
A literature review establishes some social sus-
tainability indicators and identifies some potential
aspects identified. By combining these results with
company-specific data and information gained from
marketing and other functional managers, we de-
velop a framework with which to assess the per-
ception of key decision-making stakeholders
involved in the purchase and use of MRI scanning
equipment. This approach offers an in-depth
understanding of what the social sustainability as-
pects and related indicators are, as well as a clear
identification of how they can support the marketing
of MRI scanning equipment (see Appendix 2 for
the conceptualized social aspects and potential
indicators).
Data collection and analysis
In order to build the case, we collect data using
several methods. First, to increase our familiarity
with the issues at hand, we obtain from Philips
Medical Systems a variety of written documentation,
including annual reports, research and development
reports, promotional materials, benchmark studies,
and business customer records, as well as financial
and other data relating to study subjects. In addition,
we undertake a widespread search for industry and
consulting reports and academic papers and obtain
more than 90 documents for the study. These data
are comprehensive, particularly in outlining the
company’s social sustainability values and how they
translate into activities, such as the ethical treatment
of suppliers and the sustainability criteria used for
sourcing inputs into the business.
Focus group research provides a more complete
understanding of Philips Medical Systems’s view of
sustainable aspects and indicators. We interview 24
representatives from marketing, sales, the medical
systems customer visitor center, X-ray total quality
management, the corporate sustainability office,
and eco-facilitators from different functional areas
within the company in these focus groups. Other
representatives include persons responsible for
managing customers’ purchasing, which enables us
to identify the types of social sustainability indi-
cators used in the production and marketing of
MRI scanning equipment. Discussion points in the
focus group research center on social sustainability
aspects and indicators of MRI scanning equipment,
as well as how they are communicated to institu-
tions (purchasers and users). Finally, we identify
the hospitals and imaging centers suitable for
interviewing during this stage.
Customer perception interviews indicate how
different key decision-making stakeholders value
environmental and social sustainability indicators. We
conduct this study in the Netherlands at two aca-
demic hospitals, three teaching hospitals, two com-
munity hospitals, and one imaging center. At each
institution, the interviews feature key stakeholders
involved with MRI scanning equipment; their
responsibilities can be summarized as clinicians,
operators, and business managers. In total, we con-
duct 22 interviews with these stakeholders, as well as
a focus group with the institutions; the length of the
interviews and focus group was between 60 and
90 minutes. The use of multiple data collection
methods adds to the robustness of this study’s find-
ings, compensates for any weaknesses of a specific data
collection method, improves the final interpretation
quality, and helps ensure triangulation (Jick, 1979;
Strauss and Corbin, 1998; Yin, 1994). The unit of
analysis is the case company or each of institution and
its decision-making unit. Finally, we combine the
information from each set of interviews and the
sec- ondary sources into a final case manuscript.
At the formulation stage, we analyze the data
gathered from Philips Medical Systems to confirm
the research problem. Together with data gathered
from the literature review, we assess these data to
identify any areas in addition to Geibler et al.’s
(2006) social sustainability dimensions model. In the
confirmatory phase, data reduction relies largely on
within-case analysis, supported by data from the
customer perception tool. This approach allows in-
sight into how different decision-making stake-
holders view social sustainability aspects and
indicators within their job role for subsequent use in
the data displays. We also compare the data to the
adapted social sustainability model as the frame of
reference (Yin, 1994), then compare the hospital
cases to analyze any similarities and differences and
gain greater understanding of the phenomena. Open
and axial coding procedures expand the theoretical
categories (Strauss and Corbin, 1998). Throughout
the analysis, we tack back and forth between the
literature on sustainability and the data, which leads
us to develop several theoretical categories and
subcategories (Spiggle, 1994). Such practices are
consistent with case studies in general, as well as
with studies on corporate social responsibility (e.g.,
Beverland and Lindgreen, 2006; Maon et al., 2008;
Wood, 1996).
Throughout the study, we adopted several
methods to improve the quality of the research.
Industry experts helped select the case company and
institutional customers; four researchers provided
independent interpretations of the findings; and after
the multiple interviews, interviewees could provide
feedback on initial findings. These tactics reinforce
reliability. Finally, all interviews are conducted by
the same interviewer, which reduces bias (Lincoln
and Guba, 1985; Strauss and Corbin, 1998).
Findings
Customer perception analysis
The customer perception questionnaire contains 11
social and 5 environmental sustainability indicators
derived from literature and interviews with Philips
Medical Systems’s personnel. The interviewees
responded to the following question: ‘‘When pur-
chasing MRI scanning equipment, do you think ‘X’
is important, and why?’’ by indicating ‘‘1’’ if
important and ‘‘0’’ if unimportant. Their answers,
where relevant, receive support from quotes from
interviewees who elaborated on their answers
(Table I).
None of Philips Medical Systems’s five ‘‘green
focal areas’’ indicators are universally considered
important as influences on the purchasing decisions
of interviewees. A significant percentage, 63%, of
interviewees stated that ‘‘hazardous substances’’
should be minimized. The business managers be-
lieved this effort represented a duty of care toward
employees and patients, whereas operators’ concerns
were for their personal welfare. Information mini-
mizing the ‘‘harm’’ to individuals also appears to
outweigh the need for information on environ-
mental impact. Weight emerges as the second most
important indicator, such that interviewees’ con-
cerns about moving and installing heavy equipment
ranks above the environmental factors associated
with raw material consumption. Half of the inter-
viewees who mentioned weight attempted to
determine the location within a hospital that scan-
ning equipment could be sited and transported
safely:
Weight places restrictions on the room an MRI
scanner can be put in. On the one hand, it concerns
floor pressure per square meter; on the other hand, it’s
whether there is a transport route through the hospital
(Operator, teaching hospital).
Almost half (45%) of interviewees consider
environmental damage caused by inappropriate
recycling and disposal important, though increasing
government legislation and taxation likely will
make this concern more relevant. Packaging does
not emerge as important, because the benefits of
using the scanner far outweigh the environmental
concerns about the packaging used. Finally, 27% of
 TABLE I
Summary of social and environmental sustainability indicators (N = 22)

Customer type Customer Responsibility type Energy Weight Packaging Hazardous Recyling Proactive Health Health
use substances and safety complaints complaints Pur
Disposal regulation operators patients cha
sin
Academic Hospital AZM Business responsible 0 1 0 1 0 1 1 1 g
Academic Hospital AZM Operational responsible 0 1 0 1 1 1 1 1 an
Academic Hospital LUMC Business responsible 0 1 0 1 0 1 1 1 d
Academic Hospital LUMC Clinical responsible 0 0 0 1 0 1 1 1 Ma
Academic Hospital LUMC Operational responsible 1 1 0 1 1 1 1 1 rket
Teaching Hospital CWZ Clinical responsible 0 0 0 0 0 1 1 1 ing
Teaching Hospital CWZ Operational responsible 1 0 0 1 1 1 1 1 of
Teaching Hospital JBZ Business responsible 0 1 0 0 1 1 1 0 Soc
Teaching Hospital JBZ Clinical responsible 1 1 0 0 0 1 1 1 ial
Teaching Hospital JBZ Operational responsible 0 0 0 0 0 1 1 1 an
Teaching Hospital Kennemer Gasthuis Business responsible 0 1 0 1 0 1 1 1 d
Teaching Hospital Kennemer Gasthuis Clinical responsible 1 0 0 0 0 1 1 1 En
Teaching Hospital Kennemer Gasthuis Operational responsible 0 0 0 0 1 1 1 1 vir
Community Hospital Gelderse Vallei Business responsible 0 0 0 1 1 1 1 1 on
Community Hospital Gelderse Vallei Clinical responsible 0 1 1 1 1 1 1 1 me
Community Hospital Gelderse Vallei Operational responsible 0 0 0 1 0 1 1 1 ntal
Community Hospital St. Anna Business responsible 0 1 0 1 1 1 1 1 Sus
Community Hospital St. Anna Clinical responsible 0 0 0 0 0 1 1 1 tain
Community Hospital St. Anna Operational responsible 0 1 0 1 0 1 1 1 abil
Imaging Centre DiaSana Business responsible 1 1 0 1 1 1 1 1 ity
Imaging Centre DiaSana Clinical responsible 1 0 0 0 1 1 1 1
Imaging Centre DiaSana Operational responsible 0 0 0 1 0 1 1 1
Total 6 11 1 14 10 22 22 21
% 27.3 50 4.55 63.6 45.5 100 100 95.5

45
1
 45
2

TABLE I
continued

Customer type Customer Responsibility type Availability Accessibility Ethical Ethical Operator Patient Contribution Increase
in different different production production comfort comfort to science level of
markets patient types producer suppliers living

Academic Hospital AZM Business responsible 0 1 1 1 1 1 1 0

Academic Hospital AZM Operational responsible 0 1 1 1 1 1 1 0
Academic Hospital LUMC Business responsible 0 1 0 0 1 1 1 0
Academic Hospital LUMC Clinical responsible 0 1 1 1 1 1 1 0
Academic Hospital LUMC Operational responsible 0 1 1 1 1 1 1 0
Teaching Hospital CWZ Clinical responsible 0 1 1 1 1 1 1 0
Teaching Hospital CWZ Operational responsible 0 1 1 1 1 1 1 0 Ad
Teaching Hospital JBZ Business responsible 0 1 0 0 1 1 1 0 am
Teaching Hospital JBZ Clinical responsible 1 1 1 1 1 1 1 0 Lin
Teaching Hospital JBZ Operational responsible 0 1 0 0 1 1 1 0
dgr
een
Teaching Hospital Kennemer Gasthuis Business responsible 0 1 0 0 1 1 0 0
et
Teaching Hospital Kennemer Gasthuis Clinical responsible 0 1 1 1 1 1 1 0
al.
Teaching Hospital Kennemer Gasthuis Operational responsible 0 1 1 1 1 1 1 0
Community Hospital Gelderse Vallei Business responsible 0 1 1 1 1 1 1 0
Community Hospital Gelderse Vallei Clinical responsible 0 1 1 1 1 1 0 0
Community Hospital Gelderse Vallei Operational responsible 0 1 1 1 1 1 1 0
Community Hospital St. Anna Business responsible 0 1 0 0 1 1 1 0
Community Hospital St. Anna Clinical responsible 0 1 1 1 1 1 1 0
Community Hospital St. Anna Operational responsible 0 1 0 0 1 1 1 0
Imaging Centre DiaSana Business responsible 0 1 1 1 1 1 1 0
Imaging Centre DiaSana Clinical responsible 0 1 0 0 1 1 1 0
Imaging Centre DiaSana Operational responsible 0 1 1 1 1 1 1 0
Total 1 22 15 15 22 22 20 0
% 4.55 100 68.2 68.2 100 100 90.9 0
 Purchasing and Marketing of Social and Environmental Sustainability 1

the sample considers energy important, though
unexpectedly, this percentage includes only one
business manager. That is, energy usage seems less
relevant than scan quality, perceived as a minor cost
compared with the purchasing and running costs
and because it gets subsumed into the hospitals’
overall electricity costs. The business manager’s
view was moderated by the desire to apportion
actual energy cost per patient.
Social sustainability aspects
Five social aspects can be derived from literature and
company-based focus groups, combined with the
production and usage attributes of MRI scanning
equipment: customer health and safety, customer
comfort, ethical production, product accessibility,
and contribution to society (see Figure 2).
Customer health and safety
‘‘Health and safety’’ refers to how product usage
might harm individuals and the producer initiatives
to minimize such harm. All interviewees identified
this aspect as an important influence. Philips
Medical Systems was perceived to engage proac-
tively in enhancing safety during usage and
equipment maintenance, based on the assumption
of duty of care rather than tangible evidence. The
complexity of MRI scanning equipment meant
users must rely on the company’s expertise to
guarantee safeness:

Figure 2. MRI scanning equipment: social aspects and indicators.

 I assume the producer pays attention to that so that it
will be OK, I hardly can know if a system is safe or
not; we don’t have that level of knowledge (Clinician,
academic hospital).
In a similar vein, the indicators related to ‘‘health
complaints operators’’ and ‘‘health complaints pa-
tients’’ influence purchase in three ways. First, in
terms of safety of use:
You cannot allow it to do something medical which
gets the patient hurt…. I cannot imagine that a client
would get a health complaint and not get a lawyer
(Operator, imaging center).
Second, continued exposure to the scanning
equipment should not cause health problems; the
interviewees mention their worries that the long-
term impact on operators from continual use of
scanning equipment remains unknown:
Field strength health complaints, we still assume that it
has no short-term consequences, but the real long-
term consequences are still a little unknown (Clinician,
teaching hospital).
Third, scanning equipment must be maintained
by hospital employees, which means any injury
could result in a loss of working days that would
affect the institution’s ability to treat patients and
potentially result in claims for compensation for
industrial injury:
I find this very important; several repair positions are
not nice. The coils are not good from an ergonomic
point of view, and are often too big and heavy to
easily move – more attention should be paid to this
(Oper- ator, academic hospital).
Customer comfort
‘‘Customer comfort’’ involves the physical interac-
tion among the scanning equipment, patients, and
operators during usage and its ability to create peace
of mind. Both ‘‘operator comfort’’ and ‘‘patient
comfort’’ universally are perceived as important, but
their influence differs because of the involvement
timescale. That is, operators spend their entire
working day scanning, whereas patients spend just
a fraction of that time but must be comfortable
to ensure scan quality. Business managers’ and
clini- cians’ view of operator comfort was tempered
by the
belief that its lack would result in diminished work
performance:
Of course, this aspect is important. Not as important as
operator comfort because these patients are only in the
scanner for half an hour to 45 minutes (Clinician,
academic hospital).
It is very important because if operators don’t work
very hard or well then the quality of the scans will
decrease (Clinician, teaching hospital).
The influence of operator comfort on the deci-
sion-making process remains secondary to quality
and safety though. Factors that created operator
discomfort also had a bearing on the patent, such as
noise, the ergonomics of the scanning equipment,
and the operating environment. Pragmatically,
patient comfort was considered in relation to the
scan quality:
I find this important, but it still has to be practical.
Patients don’t come for a beauty session. Issues like
less noise and a more comfortable table are very
important, but we have to remain realistic (Operator,
community hospital).
These different views indicate the range of
information required to address the concerns of
stakeholders, including information about mainte-
nance tasks, the level of noise created during the
operation, and the impact on the operator after
multiple hours of usage. This diversity suggests that
comfort indicators should be included in the man-
ufacturer’s promotional material to create a differ-
ential advantage.
Ethical production
‘‘Ethical production’’ is relevant because an MRI
scanner’s production consumes raw materials
sourced from global markets and requires the
application of human capital. The interviewees
consider both ‘‘ethical production’’ and ‘‘ethical
production at the producer’s suppliers’’ synony-
mous, but even though unethical production has
high media impact, only 68% of interviewees
consider this indicator professionally important,
though the majority consider it personally so.
Interviewees believe Philips Medical Systems is an
ethical producer and uses ethical suppliers, elimi-
nating the need for them to seek out information.
If the company were to produce unethically, it
would become an issue:
We never really think about this aspect and assume
that it is ok. But I think that if I found out and it’s in
the media, for example, child labor or forced labor,
then I would not want to work with the scanner of
that supplier (Operator, imaging center).
The finding that 32% of interviewees do not
perceive ethical production as important may be
explained best by the difference between personal
and professional views. Professionally, the first pri-
ority was that the scanner had superior performance:
As a person of course I would totally disagree, even in
my function this matters to me. But it is difficult, even
if I knew, I don’t know if it changes my perception of
the scanner, because I know how good the system is
(Operator, imaging center).
Currently, the ethical standing of Philips Medical
Systems and similar suppliers negates the need for
such information. However, its inclusion during the
purchase process could provide a base for compari-
sons among competitors.
Product accessibility
‘‘Product accessibility’’ requires answering the needs
of different stakeholders and providing availability in
different markets. Only one interviewee thought this
indicator professionally important. The majority
found the issue too distant to influence them; their
concerns lie closer to home:
This is far beyond the scope of our organization, so
from a functional perspective this is unimportant.
Personally, I find this not important because in these
markets other things, for example immunization pro-
grams and health education, are more important and
have a much higher priority (Clinician, teaching
hospital).
Although it did not have a direct influence on the
purchase decisions, all interviewees, due to their
sense of conscience and job orientation, saw this
issue as personally important. Indirect communica-
tion of how Philips Medical Systems improves
developing countries’ health care therefore may
enhance the company’s reputation with health care
professionals, which would provide a subliminal
differentiation between its products and those of
competitors.
The notion of distance also may explain why all
interviewees identify ‘‘accessibility for different types
of patients’’ as important; that is, it directly affects
their ability to treat patients. Stakeholders wanted to
identify the scanners’ dimensions and ability to cope
with different types of patients, such as those who
are claustrophobic or extremely overweight, during
the prepurchase stage:
The people scanned here all have a certain physical
problem; otherwise they would not be here … if these
people that have a disability, walk with difficulty or are
overweight, so that they cannot be scanned, then that’s
a problem. The gantry for each scanner differs. This
can make a difference too if a patient can be scanned
or not, even if it is only about a few centimeters
(Business manager, teaching hospital).
Contribution to society
‘‘Contribution to society’’ describes the scanners’
benefit to society through improved diagnosis
techniques, illness reduction, knowledge develop-
ment, and enhanced employment. In turn, 90% of
the interviewees believe the ‘‘contribute to science’’
indicator is important, because they perceive it to
mean that the scanner advances the science of
diagnosis. However, hospital type influences how
interviewees interpret this dimension, such that
academic and teaching hospitals want information to
help them understand the potential for research,
whereas community hospitals and the imaging cen-
ter desire reassurance that innovation and a contri-
bution to science represent inherent qualities of the
scanner. Finally, the ‘‘increase level of living’’ indi-
cator seems irrelevant to the respondents.
Discussion
This study identifies that sufficient numbers of
stakeholders view social and environmental sustain-
ability aspects as influences on their perceptions of
MRI scanning equipment. In addition, it reveals
considerable similarity between the customer insti-
tution and the three stakeholder groups in terms of
the information sought and product requirements.
That is, companies that supply high-tech medical
equipment should incorporate social and environ-
mental sustainability into their marketing efforts.
Although this finding derives from a study con-
ducted within a clearly defined and narrow context,
the principle offers insights and possibilities for other
businesses and product types.
In response to the lack of a robust definition of
social sustainability within existing literature, this
study builds on work by Geibler et al. (2006) and
confirms that the majority of social sustainability
indicators actually are known and understood and
can influence purchasing decisions. Thus, it be-
comes possible to suggest a tentative definition of
social sustainability: A product or system that meets
the performance requirements and expectations of cus-
tomer stakeholders without causing harm to the well-
being of society and its members across different time
periods. In addition, the identified indicators add to
our understanding of what social sustainability is
not only through a link to actual product func-
tions (e.g., the scanner’s ability to produce quality
images) but also by noting that customers’ views
of social and environmental dimensions and indi-
cators are personal but still inform how they think
professionally about social sustainability. We also
demonstrate that society involves impacts on both
individuals and groups connected to the produc-
tion, use, and disposal of MRI scanners. Finally,
and directly related to a technology that contains
hazardous substances and emits radiation, stake-
holders are concerned about the long-term po-
tential for harm, which suggests applicability
beyond the production of high-tech medical
equipment.
By using the concept specification model to
conceptualize the social sustainability aspects and
their linked indicators, we validate the five social
sustainability aspects, which now can be considered
relevant to high-tech medical equipment. We also
validate most of the social sustainability indicators,
providing a basis for measuring both the extent to
which customers see these aspects as important and
their awareness of the product’s relationship with
these aspects. The aspects and indicators also comply
with the success criteria suggested in literature
(Amaral and La Rovere, 2003; Fiksel et al., 1998;
Isaksson and Garvare, 2003), in that they are rele-
vant, understandable to users, limited in number,
and adaptable to future developments.
The findings highlight that not all indicators can
measure performance. First, because interviewees
cannot differentiate between the ethical production
of the company and that of its suppliers, measuring
beyond the ‘‘headline’’ title may not provide
meaningful results, though ethical production re-
mains important for the customers’ overall percep-
tion of the company and can influence brand
attitude at a holistic level. Second, the ‘‘packaging,’’
‘‘accessibility in different markets,’’ and ‘‘increase in
living’’ indicators do not appear important in the
context of purchasing MRI scanning equipment,
which challenges both these indicators’ inclusion
within the model and their value as inputs for
measuring performance. The framework suggested
by Geibler et al. (2006) thus provides a useful means
to conceptualize both sustainability aspects and
linked indicators and has applicability beyond its
current focus.
The hierarchy of the influence of the social
aspects and indicators cannot rank actual indicators
but can classify them into three levels. The cost
and performance of the scanning equipment con-
stitute the first level and provide the business
context, on which all other levels depend. This
finding is not surprising; the actual cost of scanning
equipment is likely to represent a major element of
the capital expenditure for a hospital or imaging
center. Performance pertains to the scanner’s ability
to fulfill its core function; the higher the quality of
the scan, the greater its use as a diagnosis tool. The
second level consists of indicators that appear
professionally relevant because they have a direct
or potentially direct impact on users of the scan-
ning equipment, such as hazardous substances,
health complaints of operators, and patient com-
fort. Finally, the third level comprises factors that
matter personally but have little direct influence on
the purchasing decision, including packaging,
accessibility to different markets, and increase in
level of living. By identifying these different levels
of the perceived importance of social and envi-
ronmental sustainability dimensions, companies can
focus their efforts on dimensions valued more by
their customers. This suggestion also mirrors the
view that too many indicators become hard to
measure, and organizations need to be selective
when choosing social and environmental dimen-
sions (Isaksson and Garvare, 2003).
 TABLE II
Summary of social and environmental sustainability-related marketing opportunities

To whom When How Pur

Business Clinical Operational Periodically During the Customer Purchase Brochures White Sales cha
responsibles responsibles responsibles in time purchase magazines meetings papers conversations
sin
g
process
an
d
Energy use
Weight
Ma
rket
Packaging
ing
Hazardous substances
of
Recycling and disposal
Soc
Environmental aspects ial
Proactive safety regulation an
Health complaints operators d
Health complaints patients En
Availability in different markets vir
Accessibility different patient types on
Ethical performance producer me
Ethical performance suppliers ntal
Operator comfort Sus
Patient comfort tain
Contribution to science abil
Increase level of living ity
Social aspects
Sustainability aspects

45
7
 Purchasing and Marketing of Social and Environmental Sustainability
Managerial implications
Marketing guidelines for each of the 11 social and 5
environmental sustainability indicators can be de-
rived from answers to three key questions: (1)
Which stakeholder should be targeted? (2) When
during the purchasing process should marketing
communication occur? and (3) How should it be
communicated? In answering these questions, we
note the importance attached to each aspect by the
interviewees, as well as the communication tools
used by Philips Medical Systems (Table II).
The similarity in the purchasing processes de-
scribed by the institutions and their stakeholder
groups provides some common ground for mar-
keting effort. The stakeholders should have a
general awareness of the products’ social and
environmental sustainability credentials for all
indicators, with the exception of packaging,
availability in different markets, and increase level
of living, which are not considered important or
professionally relevant to interviewees and there-
fore do not influence the purchasing process. In
order to ensure that stakeholders gain an appro-
priate and complete understanding of the MRI
scanning equipment’s sustainability credentials,
marketing should focus on a more generic view of
environmentalism.
The interviewees’ own ethical standpoints
regarding social and environmental sustainability
tend to be greater than their employers’ view,
though for the indicators related to the potential to
do harm (socially or environmentally), their views
about its importance are approximately equal.
Therefore, the marketing of social and environ-
mental indicators should focus on how the supplier
minimizes the potential for harm and provide reas-
surance that scanning equipment is already safe, so
adequate precautions are in place. However, the
price of the scanning equipment and image quality
remains more influential in the purchasing decision
than either social or environmental sustainability
indicators. Thus, stakeholders might use the com-
pany’s reputation in these two areas to differentiate
between products and suppliers.
Ensuring that stakeholders know the social and
environmental sustainability credentials of the MRI
scanning equipment requires a range of approaches
1
and careful media selection. The selection of
appropriate media should be based on the prox-
imity to the purchasing decision and target specific
‘‘concerned’’ stakeholders. For Philips Medical
Systems, this selection represents a function of its
brand positioning, which it could use to reinforce
at a holistic level that the company is concerned
with sustainability. Opportunities to reinforce the
company’s general adoption of sustainability efforts
into its business practices also could be communi-
cated through trade literature used by the stake-
holders to keep abreast of developments in the field
or during meetings with customer stakeholders
related to the ongoing development and use of
scanning equipment. The specific social and envi-
ronmental sustainability indicators also should be
communicated to support the sales process. Product
brochures could address the key concerns related to
the product’s potential to harm and how the
company minimizes this risk; such information also
should be incorporated into briefing sessions from
the company.
Although the concept of companies ‘‘doing the
right thing’’ underpins corporate social responsi-
bility, in which context the environmental
dimension is integral, its use to support marketing
activities also has two commercial advantages. First,
it increases the sustainability of the company by
supporting the sales of its products. Second, it
embeds the policies into the company, which helps
create a virtuous circle of improvement that further
strengthens the company’s reputation and generates
a positive halo for its product offerings. Overall,
this study provides an embryonic overview of
how social and environmental indicators of sus-
tainability can be used to strengthen the marketing
of high-tech medical products and establish
differentiation within the minds of key customer
stakeholders.
Limitations and further research directions
As in most research, this study contains certain
limitations that affect our interpretation of the results
while also suggesting directions for further research.
First, we employ a single-case approach. Although
the sample of customer institutions can be considered
representative of Dutch hospitals that purchase MRI Note
scanning equipment, a study that considers other
1
European or North American customers, whose The term ‘‘aspect’’ might be changed to ‘‘focal area’’
regulations and institutional operating environments to reflect its use as a summary label of indicators (Geibler
differ, would provide additional insights. Second, we et al., 2006), in line with Philips Medical Systems’s incor-
focus on the purchasing stage, though the findings poration of environmental sustainability in its marketing
of high-tech medical equipment, which the company
indicate that stakeholders form personal opinions
refers to as ‘‘green focal areas’’ (Philips Sustainability
about social and environmental sustainability factors Report, 2006). In this article, however, we continue to
prior to their purchase. This process therefore re- use the term aspect.
quires better clarification to enable firms to influence
their development and thus support the purchase
process stage. Third, patients as customer stake-
holders do not appear in the study, which limits Appendix
understanding of how their views about indicators
such as safety and comfort might influence the APPENDIX 1
opinions of the decision makers and thus prevents a Concept specification model to highlight social sustain-
recommendation about the desirability and practi- ability aspects and indicators (cf Geibler et al., 2006).
cability of targeting marketing effort to them.
Fourth, the medical systems context may limit the
transferability of our findings. Further studies in
other business contexts would broaden our under-
standing of the role played by social and environ-
mental sustainability in influencing corporate
purchasing decisions. Fifth, this study relies on
historical information and interviewees’ recall; real-
time data collection could identify transitory influ-
ences on stakeholder’s views, and longitudinal
research might distinguish how these influences have
affected company policy.
These limitations thus must be kept in mind when
considering our results. However, despite the limi-
tations, we believe that this research represents a
substantial step toward understanding the social and
environmental responsibilities that purchasers of
high-tech medical equipment identify as important,
as well as developing guidelines that can aid manu-
facturers in marketing such equipment.
 APPENDIX 2
Conceptualized social aspects with potential social indicators

Social aspects Examples Potential social indicators

Customer health Health complaints of operators because of use Health and safetya,g
and safety of equipment Healthb
Health complaints of patients because of use of Quality, health, and safetyc
equipment Peace of mindd
Proactive anticipation of safety regulations Illness and disease reductiond
Accident and injury reductiond,h
Health and well-beingd
External social improvementse
Products and service labelingg,h
Customer comfort Operator comfort Quality of working conditionsa
Patient comfort Satisfaction of needsb
Peace of mindd
External social improvementse
Noise and pollutionh
Ethical production Ethical performance of the company Quality of working conditionsa,f
Ethical performance of the suppliers Education and traininga,b
Healthb
Equityb
Individual contentmentb
Taking employees into considerationc
Quality, health, and safety at workc
Quality of lifed
Illness and disease reductiond
Equity within organizatione
Internal social improvementse
Ethical productionh
Accidents or incidentsh
Supplier fairnessi
Product accessibility Product accessibility for patients with physical Equityb
or mental disadvantages Quality of lifed
Product availability at emerging markets and International equitye
base of pyramid External social Improvementse
Accessibility to key servicesh
More equitable accessibilityi
Contribution to Contribution to science (e.g., new health Employmenta,i
society solutions) Innovation potentiala
Increase level of living Product acceptance and societal benefitsa
International equitye
Social impact of operationsf
Quality of life in communityf
Community developmenth
Regeneration and rebuilding
of communitiesh
Intellectual assetsi
a
Geibler et al. (2006).
b
Seuring et al. (2003).
c
Gauthier (2005).
d
Fiksel et al. (1998).
e
Steurer et al. (2005).
f
Tanzil and Beloff (2006).
g
Global Reporting Initiative (2006).
h
Sigma (2007).
i
Sherwin (2004).
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