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Antibiotics: Which Lives Matter?

By Angus Dawson

Resistance to antibiotics is growing. Are you prepared to go without them to save the lives of future generations?

Antibiotics are used to relieve the symptoms of disease and save human lives every day. They are one of the wonders of modern medicine and a key component of clinical care since the 1940s. However, there is growing consensus that we need to change the way we use them, and urgently. Why?

Antibiotics are increasingly ineffective for a number of reasons.

First, this is because of the nature of bacteria. When initially confronted by antibiotics, bacteria are killed. However, it is inescapable that those bacteria will develop resistance over time to the drugs designed to kill them. Bacteria reproduce and adapt quickly, and the strains that are resistant to a drug will be the ones that survive. Some projections into the future are terrifying: one suggestion is that 10 million lives per year could be lost by 2050 as a result of growing antibiotic resistance. We can develop new drugs, of course, but that cannot be the answer alone. New drugs will inevitably also encounter resistance.

Second, antibiotics are losing effectiveness due to human behaviour. Their power to reduce the burden of disease has resulted in overuse by humans. Antibiotics only work against bacteria, not viruses. Too often they have been prescribed even when doctors know they are unlikely to be beneficial. There is now, arguably, a culture of expectation from the public that they will receive a prescription for antibiotics after a visit to the doctor. Too many doctors are complicit in this, and find it hard to push back against inappropriate prescriptions.

Third, antibiotics are increasingly used in different fields, not just medicine, but also dentistry, veterinary medicine and agriculture. They have a role not only in treatment but also for preventing infection. They are used in meat production not just to prevent infection but also as a means to speed up the growth of animals and birds, thereby providing a quicker profit.

How should we think of the ethical issues in relation to antibiotic resistance? There are, perhaps, two main tasks. The first is to establish how to strike the balance between the potential harms and benefits of the different ways we use antibiotics. The second is ensuring a fair distribution of what will become an increasingly scarce resource.

How exactly different possible harms and benefits are to be set out and weighed against each other will always be contentious. However, we might argue that it is reasonable to think that saving human lives is a greater priority than reducing the cost of beef by a few cents per kilogram. A further line of reasoning is that saving a life in a country with poor health care infrastructure is more important than seeking to prevent the remote possibility of a minor infection in a patient who lives in a higher income setting. An additional factor is that we know that antibiotics themselves can cause harm by, for example, disrupting bacteria in the digestive system. We must begin to think more critically about how we can get the best out of our antibiotics.

The issue of harms and benefits links, inevitably, to ideas about the concept of justice. What is the fairest way of distributing antibiotics? We have a finite but valuable resource that we know will run out. How should we use them? We have to think of the distribution across the world between low- and high-income countries, between sectors such as health and agriculture, and also between using them today or in the future. Such decision-making needs good health policy at local, national and international levels.

Significant action needs to be taken now to ensure that antibiotics are only used when they are really needed. This is especially difficult because it is a global problem that individuals or even individual countries cannot solve alone.

Clearly, there should be greater investment in preventive interventions such as vaccines and diagnostic technologies to help secure appropriate use. However, we also need to think about effective ways to change professional practice and patient expectations. Restricted access may well play a role in achieving the aim of preserving antibiotics for when they are needed most.

Are you willing to go without unnecessary drugs today, so that your great-grandchild’s life might be saved in the future?

Angus Dawson is Professor of Bioethics and Director of Sydney Health Ethics, The University of Sydney.