News and Opinions  –  2017

The ethics of antibiotic resistance

2017-11-28

Bacterial resistance to antibiotics gives rise to new ethical problems. Much of medical ethics prior to antibiotics has been focused on whether a certain procedure is justified, for example with respect to safety, efficacy and costs. But as antibiotic resistance has a global impact that persists over time, new questions arise that cannot be solved only by more or better science.

Image: Pixabay.

Science sets out to describe the world as it is: laws of nature, molecular interactions and integrated systems. As such, science appears to be amoral – no consideration is made whether it is good or bad that gravity pulls a person jumping from a rooftop toward the ground or whether a predator is unethical while killing its prey. These kinds of value-based judgments are instead the domain of ethics. In contrast with science, which is descriptive, ethics is normative. Ethics deals with what we ought to do or ought not to do. It tries to distinguish right from wrong using an ethical framework such as the ones briefly described in the box below.

Ethical aspects of antibiotic resistance

While science doesn’t make statements on morality, scientific findings may have ethical implications. The mere fact that we might be able to clone a person in the future does not in any way help to answer if we ought to clone somebody. Antibiotic resistance gives rise to several ethical questions that need to be addressed:

  • Who should have access to antibiotics? Anyone who can afford buying them while respecting intellectual property?
  • In case access is restricted, who should receive the antibiotics? All who need it or a select few? In that case, who are the select?
  • When choosing which antibiotic to use, is the physician’s main (or only) moral duty towards the patient’s current need or toward potential future patients?
  • Should our current use of antibiotics be restricted out of consideration of future generations?
  • Do high-income countries have an obligation to help fund and implement surveillance or stewardship programs in low-income countries?

Framing an ethical problem: new antibiotic to be released to market

Consider a possible situation where a new antibiotic is about to be released to the market. A scientific case can be made that without conservation systems and effective stewardship policies in place, resistance to the drug will arise within a few years. This has been seen over the history of antibiotic use from penicillin through all classes of antibiotics. If stewardship measures are applied, the antibiotic may be useful for a longer period of time. As the development of resistance is expected to then become slower, the new antibiotic can cure more patients over time.

For the major part of human existence, moral obligations have been directed to relatively small groups. Our own next of kin, tribes or nations have been considered in ethical issues, but often little regard has been given to future generations. This is reflected in our moral intuitions, as we generally have difficulties seeing the moral implications beyond these smaller groups. But if we expand our thinking so that future generations – or even just our newborn children – have the same value in our ethical thinking as we current adults do, we can make a sustainability argument: In our strive to increase our wellbeing, we ought not to act in a manner that deprives future people of the means to do so as well.

This means that we are not morally permitted to deplete a limited resource for our own wellbeing, but should ensure that others will have access to clean air, cultivable land or fresh drinking water. Applied to the situation with the new antibiotic, this could be translated as an obligation to use the new antibiotic sustainably, i.e. only under the best stewardship practices. By applying stewardship, we fulfill the obligation to not deprive future people of the limited resource of antibiotic efficacy.

Some ethical views on access to antibiotics and excess use of antibiotics

Applying stewardship measures would in that perspective be the moral thing to do.  However, low and middle-income countries may not have the structural or financial capacity to apply such rigorous stewardship measures. What do we do then?

  • A deontological view, as well as a virtue based view, could be that we have a duty to do what we can to cure the sick people we encounter, even if the consequence is that antibiotic resistance will develop more rapidly. This would seem to imply that access to the new antibiotic should be granted to anyone who needs it, even in the face of excess use.
  • This is in stark contrast with the sustainability view and seems untenable. Such excess use appears to be a blatant violation of our duties toward future generations.
  • A teleological view on the other hand could be that we have an obligation to ensure that as many patients as possible benefit from the new antibiotic over time. This seems to imply that access to the antibiotic should be severely restricted for most low and middle-income countries. Such a restriction would affect millions of people, causing thousands of deaths, but if the long-term outcome would be that more people are cured due to the longer life span of the antibiotic, it would be the moral thing to do.
  • Most people would consider this position to be irreconcilable with the human right to life and health; that every human has the right to life and healthcare. As such the view is untenable.

A sustainable ethic for access and excess

There seems to be a contradiction between the sustainability argument, human rights and the implications of our ethical systems. Can that gap be bridged, or are we stuck with either unrestricted access and use, or restrictions, both of which come with harsh consequences? Luckily, there is a third option: that high-income countries and international financing institutes provide adequate financial and technical support to low and middle-income countries to build appropriate structures so that stewardship can be applied. This could ensure that our moral responsibility to provide access to these lifesaving drugs can be ensured while the prohibition of excess and unsustainable use is not violated.

Luckily, there is a third option: that high-income countries and international financing institutes provide adequate financial and technical support to low and middle-income countries to build appropriate structures so that stewardship can be applied.

Moral obligation to act

Without choosing a particular ethical system, ReAct believes that the right to health is a human right regardless of who you are or where you live. This means that it is our moral obligation to promote that antibiotics are distributed justly and sustainably. Antibiotic efficacy can be seen as a common good and a potentially non-renewable resource. As such, it is at risk to be another example of the tragedy of commons, where the self-interest of individual stakeholders collectively causes depletion of the resource. Therefore it is imperative that actions to counter antibiotic resistance are made concertedly on a global scale.

A framework for global action to handle antibiotics with care

Cornerstones for collective global action are:

  • Ensuring access to affordable, effective antibiotics for all, including low and middle-income countries. This also includes reliable distribution systems and redundancies in manufacture to minimize shortages.
  • Limitation of excess use by stewardship: developing and implementing local guidelines for antibiotic use and improving diagnostic capacity.
  • Prevention of infection, as every averted infection is potentially a course of antibiotics saved. Infection prevention and control requires actions on both systems and individual level.
  • Innovation in the fields of new antibiotics and options for antibiotics, diagnostic tools and methods to minimize excess use by guiding therapy, and efficient systems to prevent, control and track infections and epidemics.
  • Technical and financial support in these areas for countries with limited resources.

These cornerstones form a practical framework to fulfill our moral obligations within the field of antibiotic resistance and promote the development of a world free from fear of untreatable infections.

Some ethical systems

Deontological, based on duties or rules

Deontological ethics state that there are rules or principles that determine whether or not an act is moral or not. The perhaps most well known deontological rule in western culture is “Thou shalt not kill”. The ends do not justify the means, i.e. an act may be right but still lead to terrible consequences.

Teleological, based on consequences of actions

Teleological or consequentialist ethics focus on the consequences of an act, i.e. the act that has the most advantageous consequences is moral. For most consequentialists, the arbiter is human welfare.  Driven to its extreme, it can justify killing any one person if that leads to that four others, who would die otherwise, are saved.

Virtue-based

Virtue-based ethics state that whichever act is virtuous, is also moral. Virtues can be e.g. kindness, patience, justice and respect. Virtue ethics can be distilled in the golden rule: “Do to others as you would have them do to you”.  One needs to cultivate character and conscience.

Human rights

Human rights are not really a part of any ethical systems, but can be incorporated into the above. In deontological systems, human rights can be included as duties towards all humankind. In teleological ethics, particularly rule consequentialism, human rights may act as a boundary for how far one can push the acceptability of consequences. In virtue ethics, respecting human rights can be viewed as a virtue.