Sleep Stewardship

In 1943, Abraham Maslow proposed his Hierarchy of Needs,¹ a pyramidal depiction of how our lower-level needs (eg, physiological requirements for food, clean water, clean air, shelter, hygiene, and sleep) must be met before we can pursue or promote our higher-level interests. Many of us take our basic requirements for granted, but one requirement will get clinical, ethical, and population-level attention in this issue of the AMA Journal of Ethics: sleep. Of course, everyone with a sleep disorder deserves equitable, timely clinical attention and intervention. This issue’s focus is broader than sleep pathologies, however, and looks to investigate how sleep is perhaps best conceived as a communal natural resource, a basic physiological need.

The idea of sleep as a natural resource—because we must all be stewards of the conditions of sleep for one another—that deserves individual and communal protection has gained traction in the scientific and public health literatures. For disadvantaged populations, access to darkness, quiet, and even calmness can be limited due to structural, socioeconomic, and psychological factors. An extreme example is homeless shelters. While shelters and warming houses can provide a reprieve from the outdoors, there is often a lack of resources to provide the quiet and darkness necessary for restful sleep. This theme issue focuses on populations that can be disproportionately affected by inadequate communal sleep resources and how we can begin to address these social determinants of health as health care professionals.

In particular, this issue of the AMA Journal of Ethics examines key structural factors that underlie our modern sleep disturbances. A biological framework of sleep, for example, includes circadian rhythms that play an important part in adequate sleep hygiene. When one’s rhythms are interrupted with artificial light, demanding work schedules, and social expectations, one’s internal clock shifts. Increasingly, this pathological shift has been shown to play roles in physical and mental health. In fact, inequalities exist that have shaped entire groups’ rhythms. This theme issue will discuss ethical questions about circadian rhythm maintenance. One factor that affects circadian rhythms, artificial light, will be discussed in greater detail by a physician member of DarkSky International.²

Some populations are at higher risk for more severe health outcomes from sleep disturbances. In the light of current events, one article in our theme issue will examine sleep in detained immigrant children and adults. It focuses on ambiguous policies surrounding torture, especially in the context of sleep deprivation. This theme issue will also provide a framework for effectively addressing poor sleep quality of children of all backgrounds in time-limited clinic visits, with attention to contributing social and environmental factors.

Finally, how do we address these issues in health professions education? The amount of sleep a medical student receives,³ for example, does not align what that student is now formally taught about sleep’s importance to health. A pathway to better sleep care for patients begins with education, and an article in this issue will discuss the prior and next steps that must be taken to properly educate health professionals about the importance of sleep and how to treat patients with sleep trouble. With that knowledge, this theme issue will also discuss how to care for patients with sleep trouble in practice, along with some currently available therapeutic options. Finally, a trio of experts with extensive backgrounds in socioeconomic factors affecting sleep health discuss public health policies relevant to sleep duration and sleep quality.