The ethics of prescribing antibiotics

Antibiotics are overprescribed. That is, they are given out in many cases where they will achieve little or nothing for the patient. On its own, this would merely be wasteful, but usage of antibiotics increases the development of antibiotic resistant organisms and this is bad for everyone. Today's Guardian has an article suggesting that antibiotic resistance could become a *very* big problem, with all major antibiotics becoming ineffective within a couple of generations (see also the original research in the Lancet). This leads to some very interesting questions concerning the ethics of prescribing antibiotics.

Losing antibiotics would be disastrous for humanity. It is estimated that antibiotics have saved over 80 million lives since the 1940s, so losing them (without having an adequate replacement) would lead to millions of deaths. It is thus of paramount importance that this is not allowed to happen, and one of the most important planks in any approach is to stop overprescribing them. However, this is easier said than done: health services have been trying to cut down on prescriptions for a long time, and it has become an international issue. The new antibiotic resistant strains appear to have arisen in India, but have spread around the world. Thus, fixing the problem in one country is not enough.

The case of antibiotics parallels many cases of pollution or environmental destruction, where individual action has diffuse negative effects on many others. For example, driving a car releases carbon dioxide which moves the whole world very slightly closer to global warming. In such situations, there is often a call for taxes so that the person gaining the benefit (of driving their car) pays costs equivalent to the damages they cause. As is mentioned in the Guardian article, a similar thing could be done for antibiotics. We are currently not paying the true cost of antibiotics and this encourages us to use them profligately. If instead there was a world-wide tax on antibiotics, we would stop using them on viral infections and depending on the size of the tax, might only use them on the most serious bacterial infections, increasing the length of time before anti-biotic resistance takes hold and thus increasing the benefits we get from these amazing drugs.

A perennial criticism of such 'Sin taxes' is that they may put an unfair burden on the poorest people (in this case, the world's poorest people). This is only true if the taxes are done in a simplistic manner. Like other sin taxes, they could instead be made 'revenue neutral', or even progressive so that the world's poorest people are the joint beneficiaries of the tax. If the antibiotics situation is as dire as these recent reports suggest, then such a tax would be well worth looking into before it becomes too late.

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8 Responses to The ethics of prescribing antibiotics

  • Antibiotic resistant bugs are indeed a pressing concern. However, it is not over-prescription that is the underlying cause, so far as I understand the issue. The underlying problem is that people who do get prescribed antibiotics do not follow their prescribed schedules. People do not use the antibiotics that they have in the appropriate manner, primarily by not finishing the treatment course assigned by their physician.

    Of course, I do not want to oversimply the issue. Undoubtedly there are multiple factors at play here but the dominant one, as I see it, is that people misuse antibiotics and not that they use too much. If we actually used antibiotics too much (“overdosing”) we would have a host of other problems to deal with, associated with killing of the micro-fauna that naturally occurs in our systems and giving niche space for new and harmful organisms.

  • Toby Ord says:

    Dmitri,

    You are right that misuse is also a large part of the problem, and a tax would not fix that part. There is a pretty good description of the different aspects of misuse and overprescription here:

    http://en.wikipedia.org/wiki/Antibiotic#Antibiotic_resistance

  • Akshat Rathi says:

    Your aim is good and your thought noble. The same can be said about Global Warming (with many factors remaining absolutely same. But we haven’t reached a global solution that problem. Nothing points to this happening in the case of antibiotics.

    I am not trying to be pessimistic here but realistic.

  • I’d be interested to read some details of the antibiotic tax suggested in the Guardian article. Who would be the bearer of this – the pharmaceutical companies, NHS trusts, individual GP surgeries, the patient, or is something else envisaged? Each of these seems problematic.

    If it is the pharmaceutical companies the cost would simply be passed on to whomever buys the antibiotics. If the NHS trusts then it is unlikely to make much difference since they already have to pay out for many drugs of differing costs. Levying the tax at a GP surgery, for example, might give an incentive for GP’s to make extra efforts to reduce prescribing. This, however, is not likely since the nub of the problem is not that the relevant doctors are not making relevant efforts. One problem for most GP’s is that the 10 minute time slot per patient is usually not enough to convince those intent on having antibiotics that they do not need them. A path of least resistance is, therefore, sometimes taken so that one consultation does not have a knock on effect for the entire morning’s/day’s surgery. I am unsure whether a tax is the solution to this problem.

    Then the final option of levying the tax on the end user might just make the whole issue worse. Firstly, because patients might not obtain and take antibiotics when actually warranted if there was a further cost involved. Secondly, taxes might have the opposite to the intended effect and actually make antibiotic resistance worse. This is because sometimes one course of antibiotics is not enough and the patient might need a second course. By then, however, the patient, feeling a little better, might not want to pay for further courses of antibiotics which might be needed once the first one runs out. This then makes the resistance problem worse rather than alleviating it.

  • Toby Ord says:

    Muireann,

    Very good points!

    You are right that if the tax were felt by individuals and these individuals had the option of buying too short a course of antibiotics, then that would be a problem. One possibility is to only provide prescriptions for the appropriate number of pills, but there might still be problems of black markets or hoarding. This might not be insurmountable, but it is a problem.

    My preferred approach would be for the cost to be felt by NHS trusts in a roughly revenue neutral manner. For example, each trust is paid a certain amount per patient such that at the current prescribing rates they would end up even. It might be true that the NHS is sufficiently dysfunctional that increases in price of medicines don’t lead to *any* decrease in ordering, but I doubt this. That said, the connection between the price and the demand is probably not as elastic as it should be, so it might be the type of situation where NICE would have to step in.

    Ultimately, I’m really not sure about the details, but I do think it is an idea worth exploring. Even if you do not think it has much chance of being made to work, the alternatives might be *very* bad.

  • Oelsen says:

    Erm, resistant bacteria, because some dude takes too little and aborts a prescription?

    What about agriculture, where we get this stuff out in TONS, not milligrams?! There is the lab creating those nasty monsters, at least in numbers.

    Because bacteria can “trade” genes with Pilii ( http://en.wikipedia.org/wiki/Pilus ), it is no wonder someone gets infected with it. Sure, there are hospital bugs, but the vast creation is in agriculture. Remember that we spray anti-biotics on trees too.

    Just a thought.

  • Peter Wicks says:

    I think Oelsen has raised an important point here. Assuming we trust wikipedia, drugs used in animals that are in turn used as human food can be a source of superbugs as well as affecting the safety of the food produced from those animals. While (again according to wikipedia) the EU has banned four antibiotics widely used to promote animal growth (interestingly this seems to have happened in spite of the relevant scientific panel’s recommendations, which raises a host of other interesting issues!) the US has yet to collect data on antibiotic use in animals.

    Of course the idea of tax could apply to this case as well as to over-prescription in humans, although in both cases I tend to share Akshat’s scepticism as to how likely it would be to make a significant impact.

  • Toby Ord says:

    Yes, the widespread use of antibiotics in agriculture is a good point. I really don’t know what proportion of antibiotic resistance comes from each type of use/misuse, but it would obviously be a key fact for any policy considerations. Bans or taxes in agricultural use sound like a very good idea. As far as I am aware, reduced use of antibiotics would have a positive longterm effect on animal welfare (as it means that the animals would be kept in less crowded conditions) but I am not sure about this, and any possible reduction in animal welfare would have to be considered when thinking about this.

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