Discussion
Antibiotic resistance: An ethical challenge

https://doi.org/10.1016/j.ijantimicag.2015.06.010Get rights and content

Highlights

  • Antibiotic resistance raises complex ethical challenges for policy-makers.

  • These problems are frequently not addressed in policy documents and their discussion.

  • We outline four areas in which these problems are of particular relevance.

  • Ethical standards for the restriction of access to drugs must urgently be developed.

Abstract

In this paper, we argue that antibiotic resistance (ABR) raises a number of ethical problems that have not yet been sufficiently addressed. We outline four areas in which ethical issues that arise in relation to ABR are particularly pressing. First, the emergence of multidrug-resistant and extensively drug-resistant infections exacerbates traditional ethical challenges of infectious disease control, such as the restriction of individual liberty for the protection of the public's health. Second, ABR raises issues of global distributive justice, both with regard to the overuse and lack of access to antibiotics. Third, the use of antibiotics in veterinary medicine raises serious concerns for animal welfare and sustainable farming practices. Finally, the diminishing effectiveness of antibiotics leads to questions about intergenerational justice and our responsibility for the wellbeing of future generations. We suggest that current policy discussions should take ethical conflicts into account and engage openly with the challenges that we outline in this paper.

Introduction

Antibiotic resistance (ABR) is now widely recognised as a grave threat to global health in the 21st century [1]. Increasing levels of ABR in many countries have sparked fears of a future ‘post-antibiotic age’ in which bacterial infections are no longer treatable [2], [3]. At the same time, unequal access to healthcare resources has meant that many low-income settings never fully entered this antibiotic age to begin with.

The consequences of ABR are difficult to forecast, but a recent report for the UK government estimates the cost of drug resistance to be as high as US$100 trillion worldwide by 2050, with a death toll of up to 10 million per year [4]. Whilst these figures also include the predicted consequences of resistance to other antimicrobial agents, they give an indication of the magnitude of the challenge that the world is currently facing.

Many of the consequences of increasingly drug-resistant bacterial infections are already affecting patients around the world; infections are becoming increasingly difficult to treat, have higher rates of complications and take much longer to cure [1]. Of special concern is the rapid global spread of bacteria with multiple resistances to antibiotics. The European Centre for Disease Prevention and Control (ECDC) estimates that, today, ABR is already responsible for ca. 25 000 deaths and €1.5 billion in health expenditures per year in Europe alone [5]. Given the limitations of available data, the true cost of ABR is likely much higher.

The challenge of ABR is increasingly recognised by policy-makers. The World Health Assembly recently adopted a new global action plan, and a number of national and international projects are underway to incentivise the development of new antibiotics [6], [7].

In addition, there is an increasingly vocal initiative for the development of a global treaty to combat ABR [8].

These on-going policy efforts seek, on the one hand, to revive and encourage the development of new antibiotics. On the other hand, they also include measures to improve surveillance and diagnostic tools for bacterial infections, to promote antibiotic stewardship and, crucially, to minimise the global uncontrolled sales of antibiotics. In countries with developed health and regulatory systems, a restrictive antibiotic prescribing policy is needed that limits the use of antibiotics for human and animal use to instances where their use is clearly indicated and offers a measurable therapeutic benefit. Similar policies need also to be implemented in low- and middle-income countries to the extent possible without reducing access to essential antibiotics [9].

As commendable as many of the current policy efforts to curb drug resistance are, they have so far failed to address sufficiently the ethical challenges that arise as a consequence of ABR. In this paper, we will describe these ethical challenges and outline their relevance for patients, physicians and policy-makers.

Section snippets

The ethical dimensions of antibiotic resistance

Given the complexity and dimension of ABR, as well as the many ways in which it affects people, there are numerous ethical problems that arise in its wake. At the most fundamental level, these can be distinguished into four different sets of problems.

  • (i)

    Ethical challenges in infectious disease control

These well-known challenges are exacerbated by ABR. For example, whether social distancing measures or mandatory reporting of patients with contagious bacterial infections is ethically acceptable has

Antibiotics: a class of drugs with inbuilt expiry?

Even careful use of antibiotics leads to the emergence of ABR, and thus eventually to the diminishing effectiveness of antibiotics [11]. Whilst this is broadly accepted among experts, it also implies that the use of antibiotics is inherently unsustainable. To be sure, the effectiveness of available drugs can be exhausted at varying rates and can temporarily be countered by the development of new drug classes. However, despite ongoing policy efforts to encourage their future development, the

Antibiotic resistance as a collective action problem

ABR has previously been described as a collective action problem. The individual's personal interests in using antibiotics may be misaligned with public interests, that is it can be rational for a self-interested individual to use antibiotics to an extent that is not compatible with rational-use criteria [14]. For the individual patient, the argument goes, the use of antibiotics is rational if the individual benefits of such a treatment outweigh the costs. In economic terms, this occurs when

From collective action to individual prescribing

If individual and societal preferences for the use of a resource are not aligned, economic theory prescribes a price adjustment through taxation, which accounts for the externalities of the resource and incorporates the societal costs of such a good [14]. For some externalities-producing goods this appears to be a sound approach. However, in ABR this comes with ethical issues: in most high-income countries the cost of medication is borne by the already strained healthcare systems, and higher

Conclusion

The complexity of ABR as a policy challenge is reflected in the multitude of practical and ethical problems. However, more often than not, ethical issues of ABR are not explicitly addressed in policy development and discussion, even though they are becoming increasingly relevant for prescribing physicians, patients, pharmacists and policy-makers. This paper has highlighted a number of pressing ethical challenges that effective and credible future policy should address. In particular, if and

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