The problem of antimicrobial resistance is so dire that people are predicting that the era of antibiotics may be coming to an end, ushering in a ‘post-antibiotic’ era. A comprehensive policy response is therefore urgently needed. A part of this response will require framing the problem in such a way that adequately reflects its nature as well as encompassing an approach that has the best prospect of success. This paper considers framing the problem as a slowly emerging disaster, (...) including its potential benefits and difficulties, from a conceptual and policy perspective. (shrink)

Governments can practically and efficiently address zoonoses and AMR –– within the text of the new pandemic instrument. We map the overlaps between the efforts needed to address both pandemic threats, including (a) equitable access to medical countermeasures, (b) globally integrated One Health surveillance and monitoring systems, (c) increased technical and laboratory capacity in low- and middle-income countries, and (d) a regulatory framework governing the stewardship of antimicrobials. By outlining potential dual-purpose provisions that could be included in a pandemic instrument, (...) we argue that addressing AMR in the pandemic instrument is practicable, the most effective use of limited time and resources, and provides the best opportunity for future global pandemic readiness. (shrink)

Antimicrobial resistance kills people. According to a recent estimate, ‘7 00 000 people die of resistant infections every year’, and ‘by 2050 10 million lives a year are at risk due to drug resistant infections, as are 100 trillion USD of economic output’.1 Today, ‘bacteria are resistant to nearly all antibiotics that were earlier active against them’.2 For all these reasons, antimicrobial resistance is considered a ‘slowly emerging disaster’3 and a ‘global health security issue’.4 The prospect (...) we are facing is that of a ‘post antibiotic era’,5 in which we risk losing the availability of effective antibiotics and, with them, of medical interventions that require effective antibiotics, such as chemotherapy, transplantation and major surgery. One of the causes of antimicrobial resistance is antimicrobial consumption. As put by the Centers for Disease Control and Prevention, ‘the use of antibiotics is the single most important factor leading to antibiotic resistance around the world: simply using antibiotics creates resistance’.6 According to the 2016 Review on Antimicrobial Resistance commissioned by the UK Government, ‘more consumption of antibiotics directly leads to more resistance’.1 This is because microbes that are not killed by antimicrobials are more likely to reproduce and proliferate and to pass their resistance genes on to other microbes. Thus, exactly like the consumption of many other finite resources, antibiotic and antimicrobial consumption gives rise to the collective action problem known as ‘tragedy of the commons’: consuming a certain resource, such as antimicrobials, is in an individual’s best short-term interest, but many instances of individual consumption erode the resource and therefore conflict with the collective interest in preserving the good. How to solve a tragedy of the commons? As is the case with the consumption of other finite resources, the answer is quite simple: by rationing the resource. Simon Oczkowski’s article …. (shrink)

As we combat the COVID-19 pandemic, both the prescription of antimicrobials and the use of biocidal agents have increased in many countries. Although these measures can be expected to benefit existing people by, to some extent, mitigating the pandemic's effects, they may threaten long-term well-being of existing and future people, where they contribute to the problem of antimicrobial resistance (AMR). A trade-off dilemma thus presents itself: combat COVID-19 using these measures, or stop using them in order to protect (...) against AMR. Currently, I argue, we are choosing to continue with these measures, and thus to prioritize combatting COVID-19, without adequate ethical reflection on the AMR-associated costs of these measures. I discuss the magnitude of the possible costs and benefits involved in making the trade-off in favour of COVID-19, and their distribution. I highlight two salient aspects of distribution that can help determine whether combatting COVID-19 whilst exacerbating AMR produces justly distributed costs and benefits: distribution between current and future populations, and distribution between existing geographical populations. Adopting this account, I argue that based on the magnitude and distribution of costs and benefits of combatting COVID-19, we have good reason to rethink this trade-off, and instead consider prioritizing protecting current and future people against AMR, but jettisoning measures against COVID-19 that also exacerbate AMR. (shrink)

As we combat the COVID-19 pandemic, both the prescription of antimicrobials and the use of biocidal agents have increased in many countries. Although these measures can be expected to benefit existing people by, to some extent, mitigating the pandemic's effects, they may threaten long-term well-being of existing and future people, where they contribute to the problem of antimicrobial resistance (AMR). A trade-off dilemma thus presents itself: combat COVID-19 using these measures, or stop using them in order to protect (...) against AMR. Currently, I argue, we are choosing to continue with these measures, and thus to prioritize combatting COVID-19, without adequate ethical reflection on the AMR-associated costs of these measures. I discuss the magnitude of the possible costs and benefits involved in making the trade-off in favour of COVID-19, and their distribution. I highlight two salient aspects of distribution that can help determine whether combatting COVID-19 whilst exacerbating AMR produces justly distributed costs and benefits: distribution between current and future populations, and distribution between existing geographical populations. Adopting this account, I argue that based on the magnitude and distribution of costs and benefits of combatting COVID-19, we have good reason to rethink this trade-off, and instead consider prioritizing protecting current and future people against AMR, but jettisoning measures against COVID-19 that also exacerbate AMR. (shrink)

Antimicrobial resistance is a growing public health concern and is associated with the over - or inappropriate use of antimicrobials in both humans and agriculture. While there has been recognition of this problem on the part of agricultural and public health authorities, there has nonetheless been significant difficulty in translating policy recommendations into practical guidelines. In this paper, we examine the process of public health policy development in Quebec agriculture, with a focus on the case of pork production (...) and the role of food animal veterinarians in policy making. We argue that a tendency to employ strictly techno- scientific risk analyses of antimicro- bial use ignores the fundamental social, economic and political realities of key stakeholders and so limits the applicability of policy recommendations developed by government advisory groups. In particular, we suggest that veterinarians’ personal and professional interests, and their ethical norms of practice, are key factors to both the problem of and the solution to the current over -reliance on antimicrobials in food production. (shrink)

Antimicrobial resistance is a growing public health concern and is associated with the over- or inappropriate use of antimicrobials in both humans and agriculture. While there has been reco- gnition of this problem on the part of agricultural and public health authorities, there has none- theless been significant difficulty in translating policy recommendations into practical guidelines. In this paper, we examine the process of public health policy development in Quebec agriculture, with a focus on the case of pork (...) production and the role of food animal veterinarians in policy making. We argue that a tendency to employ strictly techno-scientific risk analyses of antimicro- bial use ignores the fundamental social, economic and political realities of key stakeholders and so limits the applicability of policy recommendations developed by government advisory groups. In particular, we suggest that veterinarians’ personal and professional interests, and their ethi- cal norms of practice, are key factors to both the problem of and the solution to the current over-reliance on antimicrobials in food production. (shrink)

Antimicrobial resistance (AMR) has become one of the defining challenges of the twenty-first century. Food production and farming are a key if troubling component of that challenge. Livestock production accounts for well over half of annual global consumption of antimicrobials, though the contribution of the sector to drug resistance is less clear. As a result, there is an injunction to act in advance of incontrovertible evidence for change. In this paper we engage with the role of market (...) actors in the precautionary regulation of farming practices and AMR threats. The paper takes the UK poultry sector as exemplary of an audit-led process that has, in recent years, achieved impressive reductions in antimicrobial use. Using qualitative interview data with farmers and veterinarians we chart the changing practices that have accompanied this reduction in treatments. We use this analysis to raise some cautions around audit-led systems of regulation. Audits can lock farms and animals into particular versions of farming and animal health; they can elevate harmful compensatory practices (including disinfectant uses); and they can reproduce an actuarial approach to an issue that does not fit the conventions of risk management. The paper presents the considerable successes that have been achieved over a short period of time in a livestock sector, while generating notes of caution concerning the audit-led management of livestock-related AMR threats. (shrink)

Antimicrobial resistance (AMR) describes the evolution of treatment‐resistant pathogens, with potentially catastrophic consequences for human medicine. AMR is driven by the over‐prescription of antibiotics, and could be reduced through consideration of the ethical dimensions of the dilemma faced by doctors. This dilemma involves balancing apparently opposed interests of current and future patients, and unique contextual factors in different countries, which may modify the core dilemma. We describe three example countries with different economic backgrounds and cultures—South Africa, Sri Lanka (...) and the United Kingdom. Then we discuss how country‐specific factors impact on the prominence of various ethical dimensions of the dilemma (visibility and moral equality of future generations; Rule of Rescue; prescribing autonomy and conflicts of interest; consensus on collective action). We conclude that a nuanced understanding of national prescribing dilemmas is critical to inform the design of effective stewardship approaches. (shrink)

Antimicrobial resistance (AMR) in bacterial infections is a growing threat to humanity and a challenge to healthcare systems worldwide. Healthcare professionals have an important role in preventing AMR and the spreading of infections. This article focuses on trade union financed journals for nurses in Scandinavia studying how the journals articulate AMR to its readership. A systematic literature search over an eleven‐year period was conducted, using web‐based national trade union financed journals, searching for ‘bacteria’ and ‘resistance’. A thematic (...) analysis, inspired by Foucault's concepts of power and governmentality, was made of 131 texts to understand, which kind of practices, strategies and policies the journals frame regarding AMR. The time period studied resulted in the recognition of four separate themes: the horror scenario, the ‘dangerous’ other, healthcare professionals as a source of resistance development and AMR as a field of research and producer of research qualifications. The study concludes that the journals tend: to present AMR in apocalyptic terms with more research and pharmaceutical industries needed for avoidance; to point out problems in other countries, populations, and sometimes nurses’ working conditions, but primarily with other professionals’ behaviour; and lastly, to present the nurse as a good fairy and disciplinator of doctors. (shrink)

In this paper, we provide a state-of-the-art overview of the ethical challenges that arise in the context of antimicrobial resistance, which includes an introduction to the contributions to the symposium in this issue. We begin by discussing why AMR is a distinct ethical issue, and should not be viewed purely as a technical or medical problem. In the second section, we expand on some of these arguments and argue that AMR presents us with a broad range of ethical (...) problems that must be addressed as part of a successful policy response to emerging drug resistance. In the third section, we discuss how some of these ethical challenges should be addressed, and we argue that this requires contributions from citizens, ethicists, policy makers, practitioners and industry. We conclude with an overview of steps that should be taken in moving forward and addressing the ethical problems of AMR. (shrink)

The issue of regularly feeding low levels of antibiotics to farm animals in order to increase productivity is often portrayed as a dilemma. On the one hand, such antibiotic use is depicted as a necessary condition for producing cheap and plentiful food, such that were such use to stop, food prices would rise significantly and our ability to feed people in developing nations would decrease. On the other hand, such antibiotic use seems to breed antibiotic resistance into pathogens affecting (...) human health. Resolving this dilemma, it is alleged, will require great amounts of research into risk/benefit assessment. Contrary to this claim, we will argue that society has all the data it needs to make a reasonable ethical decision, which would be curtailing such use. Such curtailment will not harm consumers significantly, will not harm developing nations'' evolving agriculture, and could produce hitherto unnoticed benefits, namely restoring the possibility of a more husbandry-based, sustainable agriculture to replace the high-tech agriculture that has hurt animals, the environment, small farms, and sustainability. (shrink)

ArgumentThis article examines how antimicrobial resistance (AMR) came to be constituted as a matter of public concern in Sweden in conjunction with the development of an inter-professional organization called Strama, founded to promote rational prescription of antibiotics. An outbreak of penicillin-resistant pneumococci in the mid-1990s was crucial for this development, because it brought attention to AMR as an urgent public threat. This outbreak fuelled the constitution of AMR as caused by consumption of antibiotics and as a matter of (...) disease control. As a consequence, Strama was able to mobilize the Swedish health officers responsible for disease control. The outbreak is conceptualized as a “transformative event” – an event that makes an issue and its associated risks concrete and urgent. Transformative events play the crucial role of expediting the transformation of issues into matters of public concern. (shrink)

Existing ethical frameworks for public health provide insufficient guidance on how to evaluate the risks of public health programs that compromise the best clinical interests of present patients for the benefit of others. Given the relevant similarity of such programs to clinical research, we suggest that insights from the long‐standing debate about acceptable risk in clinical research can helpfully inform and guide the evaluation of risks posed by public health programs that compromise patients’ best clinical interests. We discuss how lessons (...) learned regarding the ethics of risk in one context can be fruitfully transferred to the other, using the example of a so‐called ‘rational antibiotic use’ guideline that limits antimicrobial prescribing in order to curb antimicrobial resistance. (shrink)

Despite being acknowledged as a major global health challenge, growing levels of antimicrobial resistance (AMR) in pathogenic and commensal organisms have proven an awkward fit for international health frameworks. This article surveys the history of attempts to coordinate international responses to AMR alongside the origins and evolution of the current international health regulations (IHR). It argues that AMR, which encompasses a vast range of microbial properties and ecological reservoirs, is an awkward fit for the ‘organismal’ philosophies that centre (...) on the rapid control of individual pathogens that have characterised international policy-making since the 19th century. (shrink)

Antimicrobial resistance is a major and increasing problem globally. Economics has engaged with this issue increasingly over the last 20 years. Much of this concerns assessments of the cost of various forms of resistance, but it also includes economic analyses of interventions and policies designed to contain resistance. Analysis has, however, thus far largely neglected possible distributional issues associated with such interventions and analysis. The article explores three normative bases for the conduct of economic analysis: welfarism; (...) extra-welfarism focused on health gain; and extra-welfarism focused on capability assessment. It then considers issues intrinsic to antimicrobial resistance in terms of the distributional implications and how these might be handled within economic analyses from each of the normative perspectives, before considering the actual focus of empirical studies on these distributional issues. The article concludes that the different normative starting points for economic analysis will affect how distributional issues are incorporated into analysis, but suggests that all analyses could benefit from greater discussion of these issues. (shrink)

Antimicrobial resistance is a global collective action problem with dire consequences for human health. This article considers how domestic and international legal mechanisms can be used to address antimicrobial resistance and overcome the governance and political economy challenges that accelerate it.

Humans, animals, and the environment face a universal crisis: antimicrobial resistance. Addressing AR and its multi-disciplinary causes across many sectors including in human and veterinary medicine remains underdeveloped. One barrier to AR efforts is an inconsistent process to incorporate the plenitude of stakeholders about what AR is and how to stifle its development and spread—especially stakeholders from the animal agriculture sector, one of the largest purchasers of antimicrobial drugs. In 2019, The Wellcome Trust released Reframing Resistance: (...) How to communicate about antimicrobial resistance effectively, which proposed the need to establish a consistent and harmonized messaging effort that describes the AR crisis and its global implications for health and wellbeing across all stakeholders. Yet, Reframing Resistance does not specifically engage the animal agriculture community. This study investigates the gap between two principles recommended by Reframing Resistance and animal agriculture stakeholders. For this analysis, the research group conducted 31 semi-structured interviews with a diverse group of United States animal agriculture stakeholders. Participants reported attitudes, beliefs, and practices about a variety of issues, including how they defined AR and what entities the AR crisis impacts most. Exploration of Reframing Resistance’s Principle 2, “explain the fundamentals succinctly” and Principle 3, “emphasis that this is universal issue; it can affect anyone, including you” reveals disagreement in both the fundamentals of AR and consensus of “who” the AR crisis impacts. Principle 2 may do better to acknowledge that animal agriculture stakeholders espouse a complex array of perspectives that cannot be summed up in a single perspective or principle. As a primary tool to combat AR, behavior change must be accomplished first through outreach to stakeholder groups and understanding their perspectives. (shrink)

Rather than ‘superbugs’ signifying recalcitrant forms of life that withstand biomedical treatment, drug resistant infections emerge within and are intricate with the exercise of social and medical power. The distinction is important, as it provides a means to understand and critique current methods employed to confront the threat of widespread antimicrobial resistance. A global health regime that seeks to extend social and medical power, through technical and market integration, risks reproducing a form of triumphalism and exceptionalism that (...) class='Hi'>resistance itself should have us pause to question. An alternative approach, based on a postcolonial as well as a ‘post-colony’ approach to health and microbes, provides impetus to challenge the assumptions and norms of global health. It highlights the potential contribution that vernacular approaches to human and animal health can play in altering the milieu of resistance. (shrink)

Antimicrobial resistance (AMR) is one of the defining global health threats of our time, but no international legal instrument currently offers the framework and mechanisms needed to address it. Fortunately, the actions needed to address AMR have considerable overlap with the actions needed to confront other pandemic threats.

To combat the OneHealth threat of antimicrobial resistance (AMR), the use of antibiotics in agriculture is subject to significant governance-led initiatives to change food system behaviours, including promoting more responsible use of antibiotics on farms through market-level interventions. To combat knowledge gaps about how consumers perceive risks associated with antibiotic use and AMR in farming, the current study carried out an in-depth qualitative focus group study incorporating a risk information exposure exercise with food consumers on the island of (...) Ireland (_n_ = 36). Using a theoretical lens of social representation theory, a thematic analysis of the collected data identified how participants made sense of, often new, information on agricultural antibiotic use and AMR. Participants displayed high awareness and concern for AMR but low understanding and misconceptions around AMR transmission from the agri-food sector. Social representations about antibiotics and food and farming systems shaped preferences for a movement away from antibiotics in farming, and in particular, prophylactic use. However, participants acknowledged the role of antibiotics to protect animal health and the integrity of the food supply chain. They debated the lack of a simple fix to antibiotics in the agri-food system and revealed preferences for preventive actions at farm level and supporting actions at market level. The study highlights the need to first tackle low levels of public understanding through effective risk communication including strategies such as targeted message framing and proactive, cross-sector OneHealth awareness campaigns, followed by the introduction of a trusted antibiotic use food labelling system. (shrink)

Control measures directed at carriers of multidrug-resistant organisms are traditionally approached as a trade-off between public interests on the one hand and individual autonomy on the other. We propose to reframe the ethical issue and consider control measures directed at carriers an issue of solidarity. Rather than asking “whether it is justified to impose strict measures”, we propose asking “how to best care for a person’s carriership and well-being in ways that do not imply an unacceptable risk for others?”. A (...) solidarity approach could include elevating baseline levels of precaution measures and accepting certain risks in cases where there is exceptionally much at stake. A generous national compensation policy that also covers for costs related to dedicated care is essential in a solidarity approach. An additional benefit of reframing the questions is that it helps to better acknowledge that being subjected to control measures is a highly personal matter. (shrink)

This chapter explores the question of whether or not individual agents are under a moral obligation to reduce their ‘antimicrobial footprint’. An agent’s antimicrobial footprint measures the extent to which her actions are causally linked to the use of antibiotics. As such, it is not necessarily a measure of her contribution to antimicrobial resistance. Talking about people’s antimicrobial footprint in a way we talk about our carbon footprint may be helpful for drawing attention to the (...) global effects of individual behaviour and for highlighting that our choices can collectively make a real difference. But can we be morally obligated to make a contribution to resolving a collective action problem when our individual contributions by themselves make no discernible difference? I will focus on two lines of argument in favour of such obligations: whether a failure to reduce one’s antimicrobial footprint is unfair and whether it constitutes wrongdoing because it is harmful. I conclude by suggesting that the argument from collective harm is ultimately more successful. (shrink)

Many countries have implemented infection control measures directed at carriers of multidrug-resistant organisms. To explore the ethical implications of these measures, we analyzed 227 consultations about multidrug resistance and compared them with the literature on communicable disease in general. We found that control measures aimed at carriers have a range of negative implications. Although moral dilemmas seem similar to those encountered while implementing control measures for other infectious diseases, 4 distinct features stand out for carriage of multidrug-resistant organisms: carriage (...) presents itself as a state of being; carriage has limited relevance for the health of the carrier; carriage has little relevance outside healthcare settings; and antimicrobial resistance is a slowly evolving threat on which individual carriers have limited effect. These features are of ethical relevance because they influence the way we traditionally think about infectious disease control and urge us to pay more attention to the personal experience of the individual carrier. (shrink)

Antimicrobial therapy is a cornerstone of therapy in critically ill patients; however, the wide use of antibiotics has resulted in increased antimicrobial resistance and outbreaks of resistant disease. To counter this, many hospitals have instituted antimicrobial stewardship programmes as a way to reduce the inappropriate use of antibiotics. However, uptake of antimicrobial stewardship programmes has been variable, as many clinicians fear that they may put individual patients at risk of treatment failure. In this paper, I (...) argue that antimicrobial stewardship programmes are indeed a form of bedside rationing, and explore the risks and benefits of such programmes for individual patients in the intensive care unit, and the critically ill population in general. Using Norman Daniels’ Accountability for Reasonableness as a framework for evaluating resource allocation policies, I conclude that antimicrobial stewardship programmes are an ethically sound form of bedside rationing. (shrink)

Antimicrobial resistance is one of the greatest public health crises of our time. The natural biological process that causes microbes to become resistant to antimicrobial drugs presents a complex social challenge requiring more effective and sustainable management of the global antimicrobial commons—the common pool of effective antimicrobials. This special issue of Health Care Analysis explores the potential of two legal approaches—one long-term and one short-term—for managing the antimicrobial commons. The first article explores the lessons for (...) antimicrobial resistance that can be learned from recent climate change agreements, and the second article explores how existing international laws can be adapted to better support global action in the short-term. (shrink)

The inclusion of antimicrobial resistance (AMR) and increased research and development (R&D) capabilities in the most recent outline of the World Health Organization’s (WHO’s) international pandemic instrument signals an opportunity to reshape pharmaceutical R&D system in favour of antimicrobial product development. This article explains why the current innovation ecosystem has disadvantaged the creation of antimicrobial products for human use. It also highlights how the COVID-19 pandemic experience can inform and stimulate international cooperation to implement innovative R&D (...) incentives to bring new, life-saving antimicrobial products to the market. (shrink)

The European Commission’s proposal to address antimicrobial resistance using transferable exclusivity vouchers (TEVs) is fundamentally flawed. European policymakers and regulators should consider alternatives, such as better funding for basic and clinical research, use of advance market commitments funded by a pay-or-play tax, or enacting an EU Fund for Antibiotic Development.

Antimicrobial resistance (AMR) is an urgent threat to global public health and development. Mitigating this threat requires substantial short-term action on key AMR priorities. While international legal agreements are the strongest mechanism for ensuring collaboration among countries, negotiating new international agreements can be a slow process. In the second article in this special issue, we consider whether harnessing existing international legal agreements offers an opportunity to increase collective action on AMR goals in the short-term. We highlight ten AMR (...) priorities and several strategies for achieving these goals using existing “legal hooks” that draw on elements of international environmental, trade and health laws governing related matters that could be used as they exist or revised to include AMR. We also consider the institutional mandates of international authorities to highlight areas where additional steps could be taken on AMR without constitutional changes. Overall, we identify 37 possible mechanisms to strengthen AMR governance using the International Health Regulations, the Agreement on the Application of Sanitary and Phytosanitary Measures, the Agreement on Trade-Related Aspects of Intellectual Property Rights, the Agreement on Technical Barriers to Trade, the International Convention on the Harmonized Commodity Description and Coding System, and the Basel, Rotterdam, and Stockholm conventions. Although we identify many shorter-term opportunities for addressing AMR using existing legal hooks, none of these options are capable of comprehensively addressing all global governance challenges related to AMR, such that they should be pursued simultaneously with longer-term approaches including a dedicated international legal agreement on AMR. (shrink)

To the extent that antibiotic resistance (ABR) is accelerated by antibiotic consumption and that it represents a serious public health emergency, it is imperative to drastically reduce antibiotic consumption, particularly in high‐income countries. I present the problem of ABR as an instance of the collective action problem known as ‘tragedy of the commons’. I propose that there is a strong ethical justification for taxing certain uses of antibiotics, namely when antibiotics are required to treat minor and self‐limiting infections, such (...) as respiratory tract infections, in otherwise healthy individuals. Taxation would allow a reduction in consumption (given certain behavioural economics assumptions) and/or ensure that individuals internalize or compensate for their contribution to the erosion of the common good of antibiotic effectiveness. I suggest that revenue from the tax could be used to fund conservation and innovation strategies. Taxation might be a coercive policy, especially for certain individuals, but the ethical case for coercive policies is very strong when the good to be preserved is important enough and when they force individuals to do something they have a moral obligation to do anyway. I argue that, in the case of mild and self‐limiting infections, individuals have a moral duty of easy rescue and a moral duty of fairness to make their contribution to the preservation of the common good of antibiotic effectiveness by foregoing antibiotics. I also suggest that taxing antibiotics in such cases is an all things considered ethically justified policy even if it would introduce inequalities in access to healthcare. (shrink)

The majority of antimicrobials that are produced are administered to animals, particularly food animals. While the overall impact of antimicrobial use in animals on antimicrobial resistance in humans and the environment is unclear, it undeniably has a role. Yet, some degree of antimicrobial use in animals is necessary for animal health and welfare purposes. Balancing the benefits and risks of antimicrobial use in animals is challenging because of the complexity of the problem and limitations in (...) available data. However, a range of measures can be implemented to reduce, refine and optimize antimicrobial use in animals, with a goal of minimizing the impact on human and environmental health while maintaining necessary therapeutic use in animals. A pandemic instrument can provide the necessary foundation for the whole-of-society and whole-of government One Health approach that is required to strengthen surveillance, communication, collaboration, and action. (shrink)

To address the complex challenge of global antimicrobial resistance (AMR), a pandemic treaty should include mechanisms that 1) equitably address the access gap for antimicrobials, diagnostic technologies, and alternative therapies; 2) equitably conserve antimicrobials to sustain effectiveness and access across time and space; 3) equitably finance the investment, discovery, development, and distribution of new technologies; and 4) equitably finance and establish greater upstream and midstream infection prevention measures globally. Biodiversity, climate, and nuclear governance offer lessons for addressing these (...) challenges. (shrink)

Antimicrobial resistance is an emerging global health problem. Antimicrobial stewardship interventions attempt at regulating the prescription and use of antimicrobials so that the emergence of resistance is reduced. But antimicrobial stewardship interventions have several ethical issues such as inequity in access to antimicrobials among the poor who need them more, and limitation of the autonomy of prescribers and patients. Several upstream social determinants influence susceptibility to infections, antimicrobial prescription practices, and emergence of antimicrobial (...) resistance. Some of these social determinants impose ethical burdens on the antimicrobial stewardship interventions. Addressing these social determinants with a public health approach will help reduce antimicrobial resistance. This article argues that the social determinants approach helps reduce the ethical burdens of antimicrobial stewardship. (shrink)

An international legal agreement governing the global antimicrobial commons would represent the strongest commitment mechanism for achieving collective action on antimicrobial resistance (AMR). Since AMR has important similarities to climate change—both are common pool resource challenges that require massive, long-term political commitments—the first article in this special issue draws lessons from various climate agreements that could be applicable for developing a grand bargain on AMR. We consider the similarities and differences between the Paris Climate Agreement and current (...) governance structures for AMR, and identify the merits and challenges associated with different international forums for developing a long-term international agreement on AMR. To be effective, fair, and feasible, an enduring legal agreement on AMR will require a combination of universal, differentiated, and individualized requirements, nationally determined contributions that are regularly reviewed and ratcheted up in level of ambition, a regular independent scientific stocktake to support evidence informed policymaking, and a concrete global goal to rally support. (shrink)

Non‐genetic forms of antimicrobial (drug) resistance can result from cell‐to‐cell variability that is not encoded in the genetic material. Data from recent studies also suggest that non‐genetic mechanisms can facilitate the development of genetic drug resistance. We speculate on how the interplay between non‐genetic and genetic mechanisms may affect microbial adaptation and evolution during drug treatment. We argue that cellular heterogeneity arising from fluctuations in gene expression, epigenetic modifications, as well as genetic changes contribute to drug (...) class='Hi'>resistance at different timescales, and that the interplay between these mechanisms enhance pathogen resistance. Accordingly, developing a better understanding of the role of non‐genetic mechanisms in drug resistance and how they interact with genetic mechanisms will enhance our ability to combat antimicrobial resistance. Also see the video abstract here: https://youtu.be/aefGpdh-bgU. (shrink)

Antibiotic resistance presents a classic example of the “tragedy of the commons.” In this eponymous tragedy, the commons — shared, public access lands — are overgrazed because farmers can send their livestock onto the land at a zero price. The “tragedy” occurs because overgrazing destroys the land and reduces its ability to provide fodder. The application to antibiotics is obvious: the use of antibiotics creates selection pressure leading to increased proportions of resistant bacteria in the patient and the environment. (...) The increase in frequency of resistant organisms diminishes the effectiveness of antibiotics in treating future infections; thus, the long-term value of the antimicrobial resource is reduced. (shrink)

Drug‐resistant bacterial infections constitute a major threat to global public health. Several key bacteria that are becoming increasingly resistant are among those that are ubiquitously carried by human beings and usually cause no symptoms (i.e. individuals are asymptomatic carriers) until and/or unless a precipitating event leads to symptomatic infection (and thus disease). Carriers of drug‐resistant bacteria can also transmit resistant pathogens to others, thus putting the latter at risk of resistant infections. Accumulating evidence suggests that such transmission occurs not only (...) in hospital settings but also in the general community, although considerably more data are needed to assess the extent of this problem. Asymptomatic carriage of drug‐resistant bacteria raises important ethical questions regarding the appropriate public health response, including the degree to which it would be justified to impose burdens on asymptomatic carriers (and others) in order to prevent transmission. In this paper, we (i) summarize current evidence regarding the carriage of key drug‐resistant bacteria, noting important knowledge gaps; and (ii) explore the particular implications of existing public health ethics frameworks for policy‐making regarding asymptomatic carriers. Inter alia, we argue that the relative burdens imposed by public health measures on healthy carriers (as opposed to sick individuals) warrant careful consideration and should be proportionate to the expected public health benefits in terms of risks averted. We conclude that more surveillance and research regarding community transmission will be needed in order to clarify relevant risks and design proportionate policies, although extensive community surveillance itself would also require careful ethical consideration. (shrink)

Multidrug resistant organisms are a public health threat that have reduced the effectiveness of many available antibiotics. Antimicrobial stewardship programs have been tasked with reducing antibiotic use and therefore the emergence of MDROs. While fecal microbiota transplant has been proposed as therapy to reduce patient colonization of MDROs, this will require additional evidence to support an expansion of the current clinical indication for FMT. This article discusses the evidence and ethics of the expanded utilization of FMT by ASPs for (...) reasons other than severe recurrent or refractory Clostridioides difficile infection. (shrink)

For decades, myxobacteria have been spotlighted as exemplars of social “wolf‐pack” predation, communally secreting antimicrobial substances into the shared public milieu. This behavior has been described as cooperative, becoming more efficient if performed by more cells. However, laboratory evidence for cooperativity is limited and of little relevance to predation in a natural setting. In contrast, there is accumulating evidence for predatory mechanisms promoting “selfish” behavior during predation, which together with conflicting definitions of cooperativity, casts doubt on whether microbial “wolf‐pack” (...) predation really is cooperative. Here, it is hypothesized that public‐goods‐mediated predation is not cooperative, and it is argued that a holistic model of microbial predation is needed, accounting for predator and prey relatedness, social phenotypes, spatial organization, activity/specificity/transport of secreted toxins, and prey resistance mechanisms. Filling such gaps in our knowledge is vital if the evolutionary benefits of potentially costly microbial behaviors mediated by public goods are to be properly understood. (shrink)

There is currently great controversy over the contribution antimicrobial use in animal agriculture has made to antimicrobial resistance in pathogenic bacteria with negative consequences for human health. In light of this, the approval process for antimicrobials used in US animal agriculture, known as New Animal Drug Application or NADA, is currently being revised by the federal government. We explore the public deliberations over the development of these new policies focusing our attention on the interaction between pharmaceutical companies (...) and the U.S. Food and Drug Administration. What appears to be an antagonistic public discourse is examined in terms of its ability to simultaneously legitimate the roles of the Food and Drug Administration as the official arbiter of policy on antimicrobial use in animal agriculture and as a protector of the public welfare, as well as the role of pharmaceutical companies as the producers of safe and effective products necessary for the protection of public well-being. (shrink)

This Open Access volume provides in-depth analysis of the wide range of ethical issues associated with drug-resistant infectious diseases. Antimicrobial resistance is widely recognized to be one of the greatest threats to global public health in coming decades; and it has thus become a major topic of discussion among leading bioethicists and scholars from related disciplines including economics, epidemiology, law, and political theory. Topics covered in this volume include responsible use of antimicrobials; control of multi-resistant hospital-acquired infections; privacy (...) and data collection; antibiotic use in childhood and at the end of life; agricultural and veterinary sources of resistance; resistant HIV, tuberculosis, and malaria; mandatory treatment; and trade-offs between current and future generations. As the first book focused on ethical issues associated with drug resistance, it makes a timely contribution to debates regarding practice and policy that are of crucial importance to global public health in the 21st century. (shrink)

Resistance to the drugs used in the treatment of many infectious diseases is increasing, while microbial infections are being found to be responsible for more life‐threatening diseases than previously thought. Despite a large investment in the invention and application of high‐throughput screening techniques involving miniaturization and automation, and a diverse array of strategies for designing and constructing various chemical libraries, relatively few new drugs have resulted. Natural products, however, have been a major source of drugs for centuries. Since some (...) of them are produced by organisms as a result of selection in favour of improved defense against competing deleterious microorganisms, in principle they would be less likely to incur resistance. Furthermore, the production of those defensive secondary metabolites is inducible because their original function is a response to environmental challenges. Moreover, symbioses, co‐habitation associations between two or more different species of organisms, are universal in nature, and the production of secondary metabolites by symbiotic microbes may be an important adaptation allowing microbes to affect their hosts. Therefore, co‐culture strategies, using combinations of plant cell–pathogenic microbes, plant cell–endophytes (or symbionts), and symbiont–pathogenic microbes, based on the principles of chemical defense and the known mechanisms of organism interactions, may be an efficient general approach in the search for new anti‐microbial drugs. BioEssays 26:808–813, 2004. © 2004 Wiley Periodicals, Inc. (shrink)

This article assesses which policies for addressing antibiotic resistance as part of a multi-pronged approach would benefit from legalization through an international legal agreement. Ten candidate policies were identified based on a review of existing literature, especially The Lancet Series on Antimicrobial Resistance, The Lancet Infectious Diseases Commission on AMR, and the World Health Organization Global Action Plan for AMR. These policies were then grouped under the headings of access, conservation, and innovation.Each of the ten policies were (...) assessed using four criteria developed by Hoffman, Røttingen, and Frenk to help consider why their legalization may be helpful, necessary and/or justified. These criteria are: the problem has a significant transnational dimension; the goal justifies the coercive nature of law; the outcome is likely to be beneficial; and legalization represents the best commitment mechanism among competing alternatives. (shrink)

The right to health is enshrined in the constitution of the World Health Organization and numerous other international agreements. Yet today, an estimated 5.7 million people die each year from treatable infectious diseases, most of which are susceptible to existing antimicrobials if they were accessible. These deaths occur predominantly among populations living in poverty in low- and middle-income countries, and they greatly exceed the estimated 700,000 annual deaths worldwide currently attributed to antimicrobial resistance. Ensuring universal appropriate access to (...) antimicrobials is not only a critical part of realizing the right to health, it is necessary for mobilizing effective collective action against the development and spread of AMR. (shrink)

Antimicrobial resistance (AMR) is a global public health disaster driven largely by antibiotic use in human health care. Doctors considering whether to prescribe antibiotics face an ethical conflict between upholding individual patient health and advancing public health aims. Existing literature mainly examines whether patients awaiting consultations desire or expect to receive antibiotic prescriptions, but does not report views of the wider public regarding conditions under which doctors should prescribe antibiotics. It also does not explore the ethical significance of (...) public views or their sensitivity to awareness of AMR risks or the standpoint (self-interested or impartial) taken by participants. Methods: An online survey was conducted with a sample of the U.S. public (n = 158). Participants were asked to indicate what relative priority should be given to individual patients and society-at-large from various standpoints and in various contexts, including antibiotic prescription. Results: Of the participants, 50.3% thought that doctors should generally prioritize individual patients over society, whereas 32.0% prioritized society over individual patients. When asked in the context of AMR, 39.2% prioritized individuals whereas 45.5% prioritized society. Participants were significantly less willing to prioritize society over individuals when they themselves were the patient, both in general (p = .001) and in relation to AMR specifically (p = .006). Conclusions: Participants’ attitudes were more oriented to society and sensitive to collective responsibility when informed about the social costs of antibiotic use and when considered from a third-person rather than first-person perspective. That is, as participants came closer to taking the perspective of an informed and impartial “ideal observer,” their support for prioritizing society increased. Our findings suggest that, insofar as antibiotic policies and practices should be informed by attitudes that are impartial and well-informed, there is significant support for prioritizing society. (shrink)

Global antimicrobial resistance (AMR) is currently governed by a decentralized regime complex composed of multiple institutions with overlapping and sometimes conflicting principles, norms, rules, and procedures. Such a decentralized regime complex provides certain advantages and disadvantages when compared to a centralized regime. A pandemic instrument can optimize the regime complex for AMR by leveraging the strengths of both centralization and decentralization. Existing climate treaties under the UNFCCC offer lessons for achieving this hybrid approach.