Does the principle (P6) support current patterns of use of antimicrobials?

The contractualist approach of Scanlon requires that we take account of those who will suffer adversely from infection with antibiotic resistant microbes however unpredictable their numbers may be and in so doing makes it clear why we should not use antibiotics for small gains (even when cost-effective to do so), or to treat patients with otherwise retrievable, or inevitable outcomes. There is no requirement that we cost the consequences of infection with

antibiotic resistant bacteria it is sufficient to know that some will suffer irretrievable adverse consequences.

Antibiotic prescribing decisions require that we decide when antibiotics should be prescribed, for how long, and the antibiotic resistance thresholds (degrees of ineffectiveness) that we are prepared to tolerate.I am suggesting that the contractualist approach outlined provides a principle for decision-making that requires that we should use antibiotics when use will ameliorate some substantial risk of irretrievable harm and that we can reasonably reject use for many other reasons. This may seem an obvious and trivial conclusion but acceptance of this principle requires that we move some way from the patterns of antibiotic access and use that we currently tolerate. All potentially benefit from the adoption of this principle and the rejection of alternatives (P2-5) when account is taken of the interactions with infectious diseases over the course of each of our lives.

Although broadly consistent with some guidelines the contractualist position outlined above does seem to oppose the tolerance of some current antibiotic usage scenarios (P2-5 above). Many drugs including antibiotics are available over the counter and in countries where antibiotics are more heavily regulated are still accessible for self-administration through the internet (Mainous et al. 2009). Unregulated access to antibiotics may be an important factor in the selection and dissemination of bacterial strains resistant to our remaining effective

antibiotics (carbapenems) (Kumarasamy 2010).In China (according to Hvistendahl 2012) the healthcare system encouraged doctors to churn out antibiotic prescriptions. There was

intensive marketing by pharmaceutical companies, and heavy use of antibiotics in animal husbandry and fisheries. The Chinese government had linked doctors’ pay to the sales of

drugs, so that doctors were financially motivated to prescribe antibiotics. Recognising the disastrous rise in antibiotic resistant forms of infection the Chinese authorities broke the link between doctor’s pay and the use of antibiotics in 2010. Unregulated use of antibiotics motivated by advertising, profit, preference or ignorance can be reasonably rejected.

Patients may request an antibiotic prescription and may be willing to pay to satisfy that preference. The GMC (September 2008) specifically draw attention to the importance of eliciting patient preferences. An individual patient and/or doctor may believe that an antibiotic prescription will be of benefit and argue that individuals should have choices when it comes to antibiotic prescribing. There is tension between patient choice and public good when it comes to antibiotics. Sandel (1997)has argued that it is immoral to buy (or be entitled to buy) the right to pollute, because it allows the wealthy to evade obligations; it turns pollutants in to commodities (removing the moral stigma); and it undermines a sense of shared responsibility. These arguments can equally be applied to antibiotics. The patient may be prepared to pay extra to obtain a real or perceived short-term benefit from use of an antibiotic. A principle allowing individuals to pay a premium to allow access to antibiotics could reasonably be rejected if we take account of those who will suffer an irretrievable loss associated with the selection of antibiotic resistance. Willingness to pay should not be a criterion because those without access to the resources required to pay may still need antibiotics and it is in all of our interests that effective treatment is not withheld when there is sufficient need. Our interests include the benefit of controlling the burden of infectious disease in a world that we

increasingly share (Selgelid 2007; Millar 2010). Equally over our lives we will all be exposed to the risk of treatment resistant infection and all will potentially benefit from constraints on

over-prescribing and the consequences of over-prescribing (unless we can each find our own island to live on).

Preferences (P4) of relatives and healthcare workers may also sometimes drive treatment decisions to use antibiotics (Marcus 2001) even when patient benefits are marginal or non- existent. A large proportion of patients in the terminal stages of dementia are treated with antibiotics (D’Agata & Mitchell 2008) in many cases without much evidence of patient benefit (P5) (Givens et al. 2010). Schwaber & Carmeli (2008) in an editorial recognised the tension between antibiotic use and resistance state that - “The solution is not to categorically deny antibiotics to the severely demented elderly, or even to impose limits on their use

…Such decisions, in addition to being ethically untenable, would run counter to the expressed wishes of patients and their families”. Unfortunately the ethical justification for this statement is unclear. A contractualist might insist that the interests of those who carry the consequences of infection with treatment resistant infection should also be considered. Patients dying in Intensive Care Units frequently receive antibiotics right up to the time of death even when treatment is futile (Stiel et al. 2011)(P3). ‘Withdrawal of treatment’ orders may reduce the risk that patients will harbour (and potentially provide a reservoir for) antibiotic resistant bacteria (such as MRSA) at the end of their lives (Levin et al. 2010). I am suggesting that a contractualist approach would reasonably reject unregulated access to antibiotics, use in response to the preferences of relatives or healthcare workers, or the ‘routine’ use of

antibiotics for terminally ill patients – “Physicians may feel more comfortable in continuing to try to correct a theoretically reversible condition by use of antibiotics even in the face of an irreversible dying process” (Marcus et al. 2001, p1698). Instead a contractualist could insist

on reasons for believing that use of antibiotics would ameliorate some substantial risk of irretrievable harm to the patient as justification in each case.