AMA Journal of Ethics

This brief suggests a few ethical reasons to interrogate our bioproduct supply chains as we have begun interrogating our food chains.

There has been little attention given to roles played by human trafficking in health care organizations' supply chains. Hand sanitizers and gloves, for example, might be produced by forced labor, which tends to increase in prevalence during pandemics, mass violence, migration, or other global crises. This article considers the nature and scope of health care organizations' corporate and social responsibilities to procure products and personnel justly, offers recommendations to minimize possibilities that supplies are produced by forced labor, and advocates for a public health approach to limiting human trafficking in organizations' supply chains...

Reliable, adequate supply of essential items, including quality-assured medicines, is hard to maintain in refugee camps in low- and middle-income countries. Disruption of medicine supply chains delays treatment for displaced persons and drives procurement of poor-quality products, often from unauthorized or unlicensed sellers. This article explains how current strategies and policies disrupt reliable flow of safe medicines to refugee camps and calls on stakeholders to rigorously map medicine supply chains to refugee camps, which would help identify strategies to improve displaced persons' access to quality-assured medicines...

When any drug is in short supply, it must be rationed. Recent increases in the frequency of shortages require more rationing by clinicians. Most health systems have policies on managing drug shortages, but transparency of criteria according to which specific scarce medications should be rationed-and by whom-are rare. The COVID-19 pandemic offered several examples of clinical and ethical need to develop and implement clear, fair strategies for distributing medications in short supply. Lessons from the pandemic should inform strategies for managing drug shortages now and in the future...

This article argues that drug shortages should be addressed as crises that exacerbate already compromised US health care infrastructure. Clinicians, especially pharmacists, can help limit threats that shortages pose to patients. For example, pharmacists can canvass procurement options, consolidate inventory, and prepare medications to prevent need for some clinical interventions. This article describes how pharmacists' preparation and training equip them to help clinical teams navigate shortages by equitably rationing limited medicines, suggesting appropriate therapeutic alternatives, modifying drug administration routes, or delaying interventions...

The COVID-19 pandemic exposed vulnerabilities of the United States' routine and emergency supply chains of medicines and critical equipment. These vulnerabilities underscore an urgent need to prevent routine and emergency shortages by making drug manufacturing more transparent and by tracking how key supplies get to end users. Near real-time surveillance systems must be developed to monitor fluctuations in supplies of medicines and equipment. Implementation of such systems will require getting key stakeholders (clinicians, administrators, community members, manufacturers, and policy makers) to collaborate...

The Strategic National Stockpile (SNS) is a national system maintained by the US federal government to deliver medical supplies during emergencies. In the past, the SNS has been used to mitigate public health consequences of tragedies, such as Hurricane Katrina and Ebola outbreaks. However, challenges in maintaining and utilizing the SNS for patient safety are prevalent. This article canvasses ways in which the SNS is accessed and suggests needed changes in the wake of the COVID-19 pandemic.

Drug shortages are a persistent and serious problem in the United States, affecting patient care and health care costs. This article canvasses factors that contribute to drug shortages, such as manufacturing complexity, price, and quality inspection records. This article further proposes an early warning system and payment, contracting, and pricing innovations to mitigate drug shortages and offers data-driven recommendations to stakeholders looking to protect the supply of quality medicines.

Drug importation raises several ethical and safety concerns relevant to prescribers and policy makers considering costs and benefits of international medicine importation. This article suggests key points to consider, especially from a policy perspective, when weighing imported medicines' perceived affordability and accessibility against additional resource expenditure needed to assure sufficient regulatory oversight and equitable distribution and to mitigate potential risks of harm to patients.

This commentary responds to a case about diethylene glycol-contaminated glycerin in cough syrup. Glycerin is a commonly used excipient in medicines to improve texture and taste. Excipients are typically pharmacologically inactive ingredients contained in prescription and over-the-counter drugs that play a critical role in the delivery, effectiveness, and stability of active drug substances. The commentary first canvasses how contaminants enter the excipient supply chains. One way is by misleading labeling or intentional adulteration by manufacturers or suppliers...

The World Health Organization (WHO) published its first Essential Medicines List (EML) in 1977, and it is updated biennially. One might reasonably think drugs on the EML are there because they are critical to effective, evidence-based patient care and intervention. One might not reasonably guess, however, that a particular drug's supply chain vulnerabilities that make it a shortage risk would contribute to a drug's listing on the EML. This commentary on a case first describes why the WHO makes the EML and suggests reasons why it might be important to consider a drug's shortage risk when revising and updating it...

No abstract text is available yet for this article.

This article draws on architectural analogies and popular culture to consider ethically and clinically important characterizations of causation and nonarbitrariness. This investigation also suggests similarities between intention and design.

This series of digital drawings considers how design influences patients' experiences.

Since the Joint Commission shifted its focus to suicide mitigation strategy implementation in behavioral health units in 2007, examining modern design trends in historical context is more clinically and ethically important than ever. This article considers architectural evolutions in how health care organizations have used structure and space designs to balance safety and healing when housing patients who are suicidal.

Inpatient psychiatric units should be therapeutic environments that support dignity and recovery. When adverse outcomes (eg, self-harm, violence) happen in these settings, clinicians and administrators can face litigation and other pressures to prioritize risk management over supporting patients' access to personal belongings, exercise equipment, and private spaces. This article describes these downward pressures toward sparser, controlling environments in inpatient psychiatric settings as a safety funnel and suggests strategies for balancing safety, humanity, and recovery in these contexts...

This article canvasses extant literature about values, evidence, and standards for inpatient psychiatry units' design. It then analyzes apparent trade-offs between quality of care and access to care using empirical and ethical lenses. From this analysis, the authors conclude that standards for the built environment of inpatient psychiatric care should align with patient-centeredness, even if a downstream consequence of implementing new patient-centered designs is a reduction in beds, although this secondary outcome is unlikely...

Inpatient psychiatric units are heavily regulated physical environments designed around the twin aims of treatment and containment. Less formally regulated but no less important are emotional norms and tones that also contribute significantly to psychiatric care environments. Inpatient psychiatric units are co-created by patients and clinicians, but clinicians have authority that patients do not. This means that clinicians' management of their own transference and reactions is clinically and ethically important...

What clinicians document about patients can have important consequences for those patients. Paternalistic language in patients' health records is of specific ethical concern because it emphasizes clinicians' power and patients' vulnerabilities and can be demeaning and traumatizing. This article considers the importance of person-centered, trauma-informed language in clinical documentation and suggests strategies for teaching students and trainees documentation practices that express clinical neutrality and respect...

Patients often report experiencing boredom during inpatient psychiatry stays. Because patients' vulnerabilities and conditions can be exacerbated when they feel bored, this article considers ethical dimensions of inpatient units' designs that limit patients' autonomy or access to activities or interactions with others. This commentary on a case also considers whether and how boredom should be considered an iatrogenic harm and influence discharge planning.