By Michael Saunders.
In our ongoing research on the COVID-19 pandemic, supply chain strategy, and health system outcomes in Canada, we have heard frequently about the incredible increase in cost of personal protective equipment (PPE) during the first wave of the pandemic. We have heard as well about the cost-saving pressures that regularly shape health supply chain management and strategies; the discarding or destruction of pandemic supplies, for example, was often an outcome of these cost-saving pressures. A special aspect of the health supply chain, however, is that its end is not solely the movement or consumption of products. Instead, the unique end of the health supply chain is human life and care for this life. Accordingly, it is our contention that health supply chain strategies should not be organized by securing the lowest possible price or the cheapest possible products; instead, it should be motivated by the person, by this human life at the heart of health supply chain processes.
Masks, gloves, and gowns are worn by humans engaged in care. Gloved hands touch the flesh of a person in need of care. Ventilators sustain life; they return the breath. Heavy heads rest on pillows and linen. “[B]ehind the dehumanizing veil” of PPE, there is a person—not a machine—engaged in those most human of activities: caring, healing the sick, tending wounds.
There is a tendency, however, for the health supply chain to become an object of bioethical concern only in the wake of the breakdown or major destabilisation of its functioning—during, for example, shortages of critical supplies. For this reason, the ethics of the health supply chain is almost inevitably restricted to the ethics of rationing and triage. And yet, if the functioning of the health supply chain bears on human life and care for this life, then it is always already implicated in bioethical issues and concerns. For this reason, a more expansive bioethical grammar may be necessary to express the significant moral import of the health supply chain. Put otherwise, we need a non- or pre-triagic ethics of the health supply chain, in which the health supply chain is always already a locus of bioethical concern; it is our contention that such an ethics would encourage person-centred supply chain strategies.
Person-centred strategies for health supply chain resilience would always consider and be informed by the moral import of the health supply chain; and health supply chain processes would be organized not by economic exigencies but by the person at their heart. What supply chain capacity is necessary to safeguard the life of this person? What sourcing, procurement, and supply management strategies are best suited to enable this protection, to support the caregiver in their care work or the patient in their healing? Such questions may force a reconsideration of the current configuration of the health supply chain. Counter-intuitively, perhaps, the best principles for supply chain management may not be leanness and efficiency, but redundancy and sustainability. A “slower,” sustainable, and local health supply chain may be better suited for and more aligned with the human needs and humane activities of healthcare workers.
In turn, we may need to develop a more human and humane grammar to help bring to expression the moral significance of the health supply chain. A corporate idiom often imports an “inhuman” and technocratic grammar into considerations of the health supply chain and the activities of health supply chain management, emphasizing considerations of cost and obscuring the special continuity of the health supply chain with the health system; a bioethical and moral idiom, a human and humane grammar of care, would perhaps be better suited to the task of bringing to expression the continuity of the health supply chain with the health system and the activities of care work—as well as its integration into the moral community of the health system.
A world in which health supply chain team members are also bioethicists may seem far-fetched; and yet, nurses are daily asked to confront and navigate bioethical issues—to be both care workers and bioethicists. The obfuscation of the person at the heart of health supply chain processes distances health supply chain teams from this person, from the patient or care worker, and thus from bioethical considerations. Significantly, then, a bioethical approach to health supply chain management would help to bring together or integrate health supply chain teams and the frontline healthcare workforce; it would stress the continuity between the health supply chain and the healthcare system. Differently put, health supply chain teams should be integrated into the moral community of the health system; and the modifier “health” should always be emphasized in considerations of the health supply chain and health supply chain management. In this way, perhaps, we could consider health supply chain teams to be care workers: peers to their frontline companions that are engaged in the same “mission,” or working towards the same moral horizon; and a care ethos, not a corporate ethos, would motivate these health supply chain teams.
Contextualized in this way, health supply chain activities, motivated by an ethos of care, would be forms of compassionate assistance in continuity with and supporting the moral community of the health system. A person-centred approach to health supply chain strategies would be undergirded by a bioethical ethos of care. In their paper, “Navigating Towards a Moral Horizon: A Multisite Qualitative Study of Ethical Practice in Nursing,” Patricia Rodney et al. call for renewed attention to the “moral foundations of health policy.” We would like to suggest here that similar attention should be paid to the cultivation of a moral foundation for health supply chain policy, to policy that would recognize and emphasize the moral import of the health supply chain and its necessary integration into the moral community of the health system.
If critical products such as PPE are life-saving products, then it is this life—and not the abstractions of cost—that should motivate and organize the health supply chain: the life of the patient who is resting on linens, the life of the care worker whose gloved hands move to comfort them.
Acknowledgements: My sincere thanks to Dr. Anne Snowdon, Alexandra Wright, Dr. Melissa St. Pierre, and Carol Kolga for reading and commenting on this essay.
Author: Michael Saunders
Affiliations: SCAN Health – University of Windsor
Competing interests: None declared