Morten Fibieger Byskov is a postdoctoral researcher with the department of Communication, Philosophy, and Technology at Wageningen University & Research, the Netherlands, and our current Caroline Miles visiting scholar.
Multi-drug resistant organisms (MDROs), or antimicrobial resistance (AMR), pose a dire threat to individual and public health. Not only is AMR a danger to vulnerable individuals who require antibiotic treatment, but the over- and misuse of antibiotics also threatens the effectiveness of antibiotics for future generations. As such, AMR presents a unique problem for public health ethics and healthcare ethics that should ideally address ethical issues at both the public and individual level.
At the public level, there are two trends that have contributed to accelerate the evolution of AMR (WHO 2016). The overuse of antimicrobials means that microbials are more exposed to antimicrobial drugs than is necessary through a process called evolutionary pressure. In effect, the overuse of antimicrobials, as intended, kills off those microbials that are not resistant but leaves those that have evolved resistant genes. Thus, ironically, the effectiveness of antimicrobials means that the reproductive success of resistant microbials is reduced while, importantly, the chance that resistant genes will be reproduced in future generations is enhanced. The overuse of antimicrobial drugs is especially driven by the lack of regulation of the sale of drugs in some (especially low and middle-income) countries where antibiotics, for example, are sometimes accessible over the counter.
The occurrence of AMR is further exacerbated by the misuse of antimicrobials. The misuse of antimicrobials may be due to errors on behalf of either or both the practitioner and the patient. In the first case, the practitioner may prescribe the wrong kind of antimicrobial, for example antibiotics for a viral infection. In the second case, the patient may be to blame, for example if he or she does not complete the full course of antimicrobial treatment, leaving some microbials alive to further evolve and possibly develop resistance to the drug.
Dealing with AMR at the public level, then, is primarily an issue of global distributive justice (Krom 2014; Littmann 2014; Littmann, Buyx, and Cars 2015, 360): how can we distribute antimicrobials in a way that, on the one hand, adequately protects public health by ensuring that everyone has access to antibiotics and vaccines while, on the other hand, ensuring that antibiotics and vaccines do not become useless? Is it justified, for example, to limit access to antibiotics in places where there is little control with drug prescriptions? Other ethical issues that arise at the public level concern, for example, the social and institutional determinants of AMR and who is responsible for addressing the threat of AMR (Littmann and Viens 2015).
At the individual level, meanwhile, individuals who require antibiotic treatment are vulnerable to contracting MDROs as it risks rendering such treatment ineffective. This makes AMR a particular threat within healthcare settings, such as hospitals, nursing homes, day-care centers, and rehabilitation centers, where MDROs are (more) likely to reach vulnerable individuals. As a result, many countries, such as in the Netherlands and in Scandinavia, have implemented zero-tolerance policies within healthcare institutions in order to prevent the spread of MDROs. These policies include far-reaching control measures to detect and contain MDROs, ranging from mandatory screenings, such as nose swabs and blood tests, and strict hygiene regimes for healthcare personnel, including donning gowns and masks in interactions with infected patients, to the isolation of infected patients, quarantining of family members, the abandonment of infected pets, and (repeated) mandatory eradication therapy.
Many of these measures threaten to seriously affect the lives of individual carriers, however, and as important as such prevention is, it may have burdensome implications for infected patients and healthy persons in whom a resistant pathogen has been colonized: they may feel stigmatized, face restrictions in their work or private life, or might be refused access to certain institutions (Byskov, Rump, and Verweij forthcoming). In some cases it is almost impossible to eradicate an AMR pathogen in a carrier and then it may be impossible for the person to return to what used to be his/her normal life. Consider, for example, the case of a medical student who was repeatedly diagnosed as carrier of Methicillin-Resistant Staphylococcus Aureus (MRSA) (Rump 2011; Rump et al. 2016). In line with the guidelines, the student was not allowed to be involved in patient-care, which is an implicit part of completing the internships necessary to graduate. Because of this, the student had to eventually discontinue his studies. Whether this outcome was indeed necessary or not remains unclear, though, since the risk of further contamination could have been minimized through proper hygiene and guidance.
Or consider the case of a four-year-old girl who goes to a day-care center where she routinely comes into contact with other children, including another child who suffers from cystic fibrosis. Cystic fibrosis is a genetic disease that makes the patient especially vulnerable to contracting lung infections and antibiotic resistance may prove lethal to cystic fibrosis patients. Hence, it is paramount that cystic fibrosis patients only come into contact with healthy individuals. The problem is that the girl’s father works as a pig farmer who regularly comes into contact with livestock associated MRSA and has repeatedly been tested positive for resistant pathogens. Often the solution to these kinds of cases is to have the vulnerable child stay home until the threat has passed. However, this raises ethical issues, such as whether it is permissible to potentially harm the social and cognitive development of someone who bears little responsibility for her condition.
Additional ethical issues that arise at the individual level concern what it means for AMR control measures to be ‘proportionate’ to the impact that they have on individual carriers; to what extent it can be justified to relax AMR zero-tolerance policies; who should be involved in making decisions about these issues and how; how a trade-off between different kinds of risk can be made; whether all carriers should be treated as posing the same risk and, if not, how we can decide what measures to take and in which contexts; and to what extent harmful interventions can and should be compensated for.
An important feature of these issues and dilemmas is that they involve conflicts between well-accepted ethical principles within clinical care and the experience of AMR carriership, on the one hand, and values pertaining to public health, on the other. The ideal of clinical care is that it is patient-centered, which implies seeing the individual patient’s quality of life as a central aim, and giving him or her a clear if not decisive voice in important health care decisions. From a public health perspective, however, collective considerations are central, such as the prevention of emerging antimicrobial resistance, and the prevention of further spread of highly resistant pathogens, to protect other individuals at risk, and also to sustain antibiotic effectiveness for current and future generations. How can these conflicting values be balanced in a responsible way?
At the individual level, then, the practical dilemmas show the need for solid ethical justification of responsible care towards people with AMR in which integration and compromise is sought between what is good patient-centered care and which ways of dealing with AMR are necessary and justified from a public health ethics perspective. This points to a normative question that is in need of further analysis, clarification, and justification, namely: what is ethically responsible care for patients or otherwise healthy persons colonized with an antimicrobial resistant pathogen? How can we treat carriers in a way that minimizes the risk that they contaminate other individuals while at the same time respect the rights, well-being, and freedom of individual carriers?
While it is possible to address each of these ethical foci separately, a comprehensive approach to antimicrobial resistance should ideally take into consideration the ethical issues that arise at both the public and the individual level. In particular, while the literature on the ethics of AMR has so far been primarily focused on addressing AMR public and population health perspective, this focus risks ignoring important ethical issues and dilemmas that consequently arise at the individual level and related to the (potential) carriership of AMR.
Byskov, Morten Fibieger, Babette Rump, and Marcel Verweij. forthcoming. “Conceptualizing the Impact of AMR Control Measures: A Capability Approach.” In Ethics and Antimicrobial Resistance. Springer Nature.
Krom, André. 2014. “Not to Be Sneezed At. On the Possibility of Justifying Infectious Disease Control by Appealing to a Mid-Level Harm Principle.” Utrecht University. http://dspace.library.uu.nl/handle/1874/288514.
Littmann, Jasper. 2014. “Antimicrobial Resistance and Distributive Justice.” Doctoral, UCL (University College London). http://discovery.ucl.ac.uk/1427440/.
Littmann, Jasper, Alena Buyx, and Otto Cars. 2015. “Antibiotic Resistance: An Ethical Challenge.” International Journal of Antimicrobial Agents 46 (4):359–61.
Littmann, Jasper, and A. M. Viens. 2015. “The Ethical Significance of Antimicrobial Resistance.” Public Health Ethics, September, phv025.
Rump, Babette. 2011. “Stoppen Met de Studie Geneeskunde Omwille van MRSA-Dragerschap?” Ethiek in de Infectieziektebestrijding, 19.
Rump, Babette, Carla Kessler, Ewout Fanoy, Marjan Wassenberg, André Krom, Marcel Verweij, and Jim Van Steenbergen. 2016. “Case 2: Exceptions to National MRSA Prevention Policy for a Medical Resident with Untreatable MRSA Colonization.” In Public Health Ethics: Cases Spanning the Globe, edited by Drue H. Barrett, Leonard W. Ortmann, Angus Dawson, Carla Saenz, Andreas Reis, and Gail Bolan, 191–94. Springer.
WHO. 2016. “WHO | Antimicrobial Resistance.” WHO. 2016. http://www.who.int/mediacentre/factsheets/fs194/en/.
Morten is currently working on a project investigating the ethical issues of antimicrobial resistance carriership together with Prof. Marcel Verweij and Babette Rump, M.D. Originally from Denmark, he has previously received his doctorate degree from Utrecht University, the Netherlands, and is active in the Human Development and Capability Association and the International Development Ethics Association.