2018-08-30
The prospect of increasing spread of antibiotic resistant bacteria in hospitals and other health care facilities has made taking measures to prevent spread of infection even more important. The ethical implications of such measures are however all too often not taken into consideration.
In a previous article, ReAct has described some ethical issues related to antibiotic resistance in broad strokes, here we dig deeper into the implications for infection prevention control for both patients and health care workers.
Four groups of individuals can be identified that are affected by infection control measures:
(i) patients with an infection caused by multi-drug resistant bacteria,
(ii) patients who carry multi-drug resistant bacteria in their microbiome, but do not have an infection caused by them (carriers),
(iii) health care workers who are carriers and
(iv) health care workers who are not carriers.
In a paper in Emerging Infectious Diseases, Dutch researchers identified and analyzed some of the issues related to carriage.
Four complexities of managing carriage of multi-drug resistant bacteria
The authors identified four main complexities of managing carriage of multi-drug resistant bacteria:
- Carriage is a state of being, i.e. once identified as a carrier, the label persists and even stigmatizes carriers. This might dissuade carriers to seek healthcare and non-carriers to get diagnosed.
- Carriage has limited relevance for the health of the carrier as they may never become ill due to the multi-drug resistant bacterium. Any restrictions imposed due to carriage may seem unfair.
- Carriage probably has little relevance outside health care settings.
- The contribution that individual carriers have on antibiotic resistance might be limited.
Three Example Situations
Access to healthcare
How should healthcare facilities manage patients that are carriers? While it is a legitimate concern that the carrier-patient may cause transmission of the bacterium within a hospital ward or a nursing home, the patient still needs and is entitled to health care. Infection prevention could cause significant delays in access to treatment due to eradication therapy before admission to the hospital, lack of single rooms or even by staff prioritizing non-carriers.
Restrictions within facilities
Once admitted to for example a hospital ward, restrictions that carrier-patients are commonly subjected to may affect their mental health and wellbeing. A common infection control measure for instance is isolation – providing a single room to the patient which the patient is not allowed to leave during the course of hospital stay. While a single room may be a privilege for many patients on the short term, the denial of social interaction with other than the nurses and physicians during a longer hospital stay is often devastating for many patients.
Consequences for carriers who are health care workers
How to deal with healthcare workers who become or are identified as carriers during their studies or career? In the interest of prevention of spread of the bacterium, healthcare workers could be banned from their elected profession or be placed on purely administrative duties. When someone has invested years of their lifetime and efforts into studies and building a career, such requirements of non-carriage among health care workers would be devastating, sometimes implying a need for starting a new career from scratch with accompanying impact on the workers livelihood.
Ethical Dilemmas
Imposing restrictions towards carriers such as the examples above, will inevitably cause ethical dilemmas. Are such restrictions justified in the interest of the public health concern of reducing transmission of multi-drug resistant bacteria? A risk assessment may be warranted in these cases: weighing the risk of spread of spread of resistance versus the potential efficacy of the restrictions to reduce that risk and the cost of the restriction for both society and the individuals. Such assessments are notoriously difficult, albeit not impossible, to perform. An alternative pathway would be to determine which ethical rules are applicable and how they should be prioritized.
There is no easy way to manage the ethical problems associated with the management of antibiotic resistance, whether in infection prevention and control or in conservation of antibiotic efficacy. Whichever route one chooses, dilemmas will present themselves and it is important to make conscious decisions, being aware of the implications of the choices made.
Further reading:
Prior ReAct article: The ethics of antibiotic resistance