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. 2019 Sep;33(7):756-765.
doi: 10.1111/bioe.12604. Epub 2019 Jul 2.

The international dimensions of antimicrobial resistance: Contextual factors shape distinct ethical challenges in South Africa, Sri Lanka and the United Kingdom

Eva M Krockow  1 , Carolyn Tarrant  1
Affiliations

The international dimensions of antimicrobial resistance: Contextual factors shape distinct ethical challenges in South Africa, Sri Lanka and the United Kingdom

Eva M Krockow et al. Bioethics. 2019 Sep.

Erratum in

  • Corrigendum.
    [No authors listed] [No authors listed] Bioethics. 2020 May;34(4):444. doi: 10.1111/bioe.12735. Bioethics. 2020. PMID: 32333686 Free PMC article. No abstract available.

Abstract

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.

Keywords: Rule of Rescue; antibiotic stewardship; antibiotics; antimicrobial resistance; conflict of interests; hospitals; veil of ignorance.

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Conflict of interest statement

Contexts in which doctors retain full decision autonomy over antibiotic prescribing, but where significant conflicts of interest exist that incentivize antibiotic prescribing, can become problematic. A particular example appears to be Sri Lanka's private healthcare sector. The incentive structure for hospitals in the private sector, and for the doctors who work within them, results in a privileging of current individual patient outcomes, both clinical and experience‐based, over the interests of generations to follow. The sector is characterized by high levels of competition between hospitals to attract patients, a strong business orientation, and significant investment in marketing. In Sri Lanka's private hospitals, most doctors are employees of the public sector hospitals but also work in private hospitals to augment their relatively low public sector salaries. Doctors are dependent on their extra private practice income, which in turn depends on a continuous influx of patients. As such, doctors typically aim to please their private patients. Widespread patient beliefs about antibiotics as strong and powerful drugs, and as having an almost mythical status, mean that patients often demand and expect to receive antibiotics. Even if private consultants believe in the necessity to preserve antibiotic efficacy, they are aware that patients can choose to ‘shop around’ for other doctors until obtaining their preferred prescriptions. This practice, which has also been observed in other South Asian countries, results in doctors being disempowered to act to protect the collective interest. Furthermore, in the hospitals we visited, the insurance reimbursement schemes left doctors with discretion to prescribe excessively to meet patient demand without scrutiny. With no incentive or pressure to rationalize antibiotic prescribing, doctors rarely curb or refine their treatment strategy.

Doctors working in private healthcare in South Africa face the same pressures to satisfy patient demand as those apparent in Sri Lanka, but, in contrast, we observed healthcare insurance reimbursement schemes in private hospitals that required detailed reporting of resource use, and that limited payments for antibiotic use. This incentive scheme resulted in tighter organizational monitoring and control of prescribing decisions, balancing out incentives to respond to patient demand. This is an example of a shift towards the interests of society driven by financial incentives as opposed to the moral reasoning of individual doctors; however, the same in the two cases.

As identified above, the use of collectively agreed guidelines provides a means of supporting doctors to make ethical decisions about restricting the use of antibiotics without patient consent—although whether or not doctors adhere to these guidelines is another matter, particularly where there are conflicts of interest. Insurance reimbursement schemes can act to support or undermine implementation of such guidelines by reinforcing or discouraging an individual prescriber's inclination to choose their treatment without consideration of collective interests.

The authors declare no conflict of interest.

References

    1. Bioethics. 2019 Sep;33(7):756-765 - PubMed

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