Antibiotics and antibiotic resistance

278 Pages·2014·1.18 MB·English

by  Michael Millar

ANTIBIOTICS AND ANTIBIOTIC RESISTANCE:
WHAT DO WE OWE TO EACH OTHER?

By

MICHAEL MILLAR

A thesis submitted to the University of Birmingham
for the Degree of DOCTOR OF PHILOSOPHY

School of Health & Population Sciences
University of Birmingham
Submitted April 2013
Revised and resubmitted October 2013
University of Birmingham Research Archive

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ABSTRACT

There is a tension between the need to use antibiotics to prevent adverse outcomes from
infection, and a consequence of their use, which is antibiotic (treatment) resistant infection.
Actions taken to control the spread of antibiotic resistant microbes, and constraints on the use
of antibiotics both give rise to ethical tensions.

I consider the evaluative framework and the principles that might be used to decide a just
distribution of burdens and benefits associated with the use of antibiotics.

Nussbaum specifies a list of capabilities. A minimum sufficiency of each capability is
required for a life of human dignity. Nussbaum’s approach provides a richer framework for
the evaluation of the distribution of burdens and benefits associated with the use of antibiotics
than prevailing health economic, or prevalence of disease measures.

There are contexts in which we cannot assure a sufficiency of capabilities. I consider the
potential for Scanlon’s contractualism to provide principles for deciding the distribution of
burdens and benefits associated with the use of antibiotics under differing levels of resource
constraint.

Finally I consider the influence of metaphor and analogy in the context of the human
relationship with microbes.
ACKNOWLEDGEMENTS

I owe particular gratitude to my wife and family for the patience that they have shown while I
have worked on this thesis.

I am also grateful for the support that I have received from members of the staff at the
University of Keele both while studying for the MA and subsequently for the Professional
Doctorate. The experience at Keele provided much of the impetus to start this work, in
addition to laying a foundation for the thesis.

Finally I am particularly grateful to my supervisors Angus Dawson and David Hunter for their
continuing support.
CONTENTS

PAGE

OVERVIEW OF THESIS 1

CHAPTER 1

ANTIBIOTICS AND ANTIBIOTIC RESISTANCE:
WHAT DO WE OWE TO EACH OTHER?

Summary 10

1.1 Introduction 11

1.2 Sustaining the effectiveness of antibiotics 13

1.3 Antibiotics continue to be ‘over-prescribed’ 14

1.4 What is appropriate use of antibiotics? 16

1.5 Risk mitigation 18

1.6 Risk perception 19

1.7 Public Health ethics 21

1.7.1 Public Health ethics and antibiotic resistance 25

1.7.2 The Harm principle 27

1.7.3 Antibiotic resistance and a precautionary approach 29

1.7.4 Minimisation of impositions on individuals 33

1.8 The opportunity costs of controlling antibiotic resistance 34

1.9 Dimensions beyond health 35

1.10 Conceptualising antibiotic resistance and the use of metaphor 37

1.11 Research questions 39
CHAPTER 2

THE EVALUATION OF BURDENS AND BENEFITS

Summary 42

2.1 Introduction 43

2.2 Strengths and weaknesses of current health economic frameworks 44

2.2.1 Valuation of health states 46

2.2.2 Valuing ‘Public Goods’ 49

2.2.3 Valuing choices, which include uncertainties 51

2.2.4 Can we cost all of the dimensions of the patient experience? 52

2.2.5 Should we include societal costs/benefits? 54

2.2.6 Are all relevant ‘goods’ commensurable? 58

2.2.7 Level of aggregation of costs, risks and benefits 59

2.2.8 Achievable benefits depend on life expectancy 60

2.3 Capability theory 62

2.3.1 Capability approaches 63

2.3.2 Capabilities or human rights 70

2.3.3 Human rights and infectious disease 72

2.3.4 Why capabilities when we have rights? 74

2.3.5 Positive attributes of a capabilities approach 79

2.4 Conclusion 82
CHAPTER 3

APPLYING CAPABILITY THEORY

Summary 84

3.1 Introduction 85

3.2 Capabilities as an evaluative framework 86

3.2.1 The burden of antibiotic resistance 87

3.2.2 The prevalence of infection 88

3.3 An evaluative framework 89

3.3.1 Antibiotics, antibiotic resistance, and assuring capabilities 89

3.3.2 Evaluating individual experience 91

3.3.3 Evaluating the justice of institutional arrangements 93

3.4 Can we assure the capabilities of all? 97

3.4.1 Inevitability of capabilities trade-offs 100

3.5 A contractualist approach to capability trade-offs 105

3.5.1 Contractualism 107

3.5.2 The redundancy objection 112

3.6 Conclusion 114

CHAPTER 4

‘ZERO TOLERANCE’ OF AVOIDABLE
HOSPITAL INFECTIONS?

Summary 116

4.1 Introduction 117

4.2 What is an avoidable harm? 124

4.3 Institutional obligations for the prevention of ‘avoidable infection’ 125
4.3.1 Prevention of avoidable harm and providing benefit: moral differences 129

4.3.2 Negative Rights 133

4.3.3 Compensation for harm from avoidable infection 137

4.3.4 Damage to Trust 139

4.3.5 Autonomy and Consent 142

4.3.6 When priority to prevention constrains treatment opportunities 146

4.4 A contractualist approach to infection prevention 148

4.4.1 Differentiating risk imposition and precaution 152

4.5 Conclusion 154

CHAPTER 5

THE USE OF ANTIBIOTICS: REASONABLE REJECTION

Summary 156

5.1 Introduction 157

5.2 Antibiotic treatment guidelines can be controversial 159

5.3 Costs and benefits 160

5.4 Duties of a doctor 163

5.5 The sufficiency of professional guidelines 165

5.6 Criteria for the use of antibiotics 168

5.7 A contractualist approach to the use of antibiotics 169

5.7.1 Putting to one side the role of intention 172

5.7.2 An effectiveness razor 173

5.7.3 How much risk justifies the use of antibiotics? 175

5.7.4 When antibiotic resistance is not a consideration 179
5.8 Practical implications 180

5.8.1 An incentive for innovation 181

5.8.2 Does the principle of use (P6) challenge existing guidelines? 182

5.8.3 Does the principle P6 support current patterns of use of antimicrobials? 185

5.8.4 Implications for the non-rational 189

5.8.5 The moral status of animals 184

5.8.6 The use of antibiotics in animals 194

5.8.7 The moral status of infants and children 195

5.8.8 Use of antibiotics in infancy 197

5.8.9 A contractualist approach to use of antibiotics in early life 199

5.9 Conclusion 200

CHAPTER 6

CONSTRAINING THE USE OF ANTIBIOTICS:
BROADER IMPLICATIONS FOR GLOBAL JUSTICE

Summary 201

6.1 Sustainability and justice 202

6.2 Sustainability 203

6.3 The epidemiology of antibiotic resistance 204

6.4 Inequity in access to antibiotics 206

6.5 Sustainability while improving access: incompatible objectives? 208

6.6 International standards? 209

6.7 Risks and burdens 212

6.8 Intra and intergenerational justice 213
6.8.1 Intergenerational justice 213

6.8.2 Justifying the principle P6 to future generations 214

6.8.3 The tension between ‘just’ use of antibiotics and sustainability 216

6.9 The insufficiency of antibiotic prescribing principles 218

6.10 Precautions 220

6.11 Priority to antibiotics, or Public Health? 222

6.12 Conclusion 223

CHAPTER 7

CONCLUDING CHAPTER

Summary 225

7.1 Sustaining the effectiveness of antibiotics: two approaches 226

7.2 Does practice need principles? 230

7.3 Precaution when the future of antibiotics is uncertain 232

7.4 The detrimental impact of the ‘War’ metaphor 234

7.5 Argument from analogy 238

7.6 Microbes are ‘us’! 243

7.7 Conclusion 246

REFERENCES 247

PUBLICATIONS COMING FROM THIS WORK 267