Critical Decisions

The ins and outs of our medical decisions

Gorillacillin and the Tragedy of the Commons

Best for the patient; worst for everyone else.

Russell Carey had suffered from a nasty cough for the better part (OK, maybe the worst part!) of two weeks.  A healthy young man, he had never had this problem before.  But sometimes even healthy young people get bad cases of bacterial bronchitis that require a dose of antibiotics.  

So I prescribe a round of bactrim for Carey.  Bactrim is a generic antibiotic that works for problems like this the vast majority of the time.  Carey didn’t care one way or another that the medication was generic.  He had a premium insurance package that covered almost all his medication costs.  So he took the pills and was feeling better within forty-eight hours. 

In retrospect, it’s easy to say I made the right decision that day.  But in prescribing him these pills, you should know that I failed to prescribe an alternative antibiotic which would have had an even greater chance of curing his bronchitis.  This alternative, I will call it Gorillacillin (because it is more powerful than an enraged gorilla), would have been powerful enough to kill 99% of the bugs likely to be invading his bronchus.  Bactrim on the other hand—my best guess is that it would have worked maybe 95 or 96% of the time.  

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Was I right to prescribe an inferior medication to my patient?  

There are several things we need to consider in answering this question.  First, Gorillacillin is more expensive than bactrim.  But Carey wasn’t worried about such financial costs, as I described above. 

Second, Gorillacillin might be powerful and this might cause Carey to experience more side effects.  Wipe out too many bacteria, for example, and patients are likely to experience diarrhea from the destruction of the bacteria normally residing in their colons.  But let’s put that concern aside for now, too, because there is another reason I prescribed bactrim for Carey that day. 

I prescribed bactrim because I didn’t want to ruin the long-term effectiveness of Gorillacillin, by increasing the chance that bacteria would become resistant to its, umm, charms. 

Right now, antibiotic resistance has become a major public health problem.  Tuberculosis for example has been a terrifying disease for centuries, but now it is becoming even more terrifying thanks to the rise of tuberculosis bugs that are resistant to even the most powerful antibiotics.  News sources are full of stories of healthy patients now threatened by “MRSA”—Methicillin-resistant Staphylococcus aureus.  These formerly mild infections now threaten to destroy people’s health, because they are no longer killed by common antibiotics.  Patients’ lives are also being threatened by vancomycin resistant enterococci, too.  The list goes on. 

All this antibiotic resistance has resulted from basic evolutionary forces.  Expose enough bacteria to an antibiotic, and some of them will survive and live to spread their resistant genes.  That’s why the best way to maintain the killing power of broad spectrum antibiotics is to limit their use.

Physicians like me have long balanced the needs of our individual patients—the treatment of their current infections, for example—with the needs of society—to have powerful antibiotics available for more serious infections. 

Do you see where I am going with this argument?  In my previous post, I asked whether doctors should balance their own patient’s best interests with broader societal interests.  Now I have shown you that doctors have long performed this balancing act.  As bad of a problem as antibiotic resistance has become, it would have become an even worse problem if doctors like me hadn’t been withholding powerful new antibiotics from our individual patients, to reduce the spread of antibiotic resistance.  We trade off small benefits to our current patients in order to generate bigger benefits to society at large.

Established then is the following: physicians recognize that, in their job, they need to balance the interests of their own patients with the broader interests of society.

Now for the next question, which I will discuss in my next post: should these broader societal interests include society’s financial interests? 

Peter Ubel, M.D., author of Critical Decisions and Free Market Madness, is a physician, behavioral scientist, and Professor of Business and Public Policy at Duke University.

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