Is It Ethical to Ration Medication?

The other day, I overheard a conversation on the bus. Two middle-aged ladies were chatting about a mutual friend:

"Yeah, Debbie's got it bad. She's missed yoga two weeks in a row now! We've been texting and she says it must be the flu. Fever, headaches, bad throat...the works!"

"Two weeks? That does sound bad. She should ask her doctor for some of the hard stuff. Some strong antibiotics!"

When was the last time you took antibiotics, and what did you take them for? Antibiotics are a type of drugs that does not act against viral infections such as the flu. Hence, no matter the severity of Debbie's symptoms, taking antibiotics would be futile. Only bacterial infections such as pneumonia or urinary tract infections are treatable with antibiotics. But even in those cases, the use of antibiotics comes at a cost.

When was the last time you have taken antibiotics?

Source: qimono/Pixabay

The Cost of Antibiotics

Every time we take antibiotics, we increase antibiotic resistance in existing bacteria. Antibiotic resistance happens naturally, when some bacteria manage to withstand antibiotic drug action and subsequently pass on their stronger genes to other bacteria. As those genetically resistant bugs continue to multiply, antibiotic drugs lose their effectiveness and become less useful for treating bacterial infections in the future.

The development of antibiotic resistance is a gradual process, but scientists have estimated that antibiotic drugs could completely stop working for us within the next decades. It goes without saying that such antibiotic drug depletion would be extremely dangerous for mankind. Political leaders have described such a development as a return to the “medical dark ages” and some have compared it to the existential threat associated with climate change. Indeed, without effective antibiotics, humans would start dying again from simple wound infections and common infectious diseases. Additionally, most elective surgery would become too dangerous to carry out, and many immunosuppressive treatments (i.e. aggressive treatments that weaken our natural immune systems) such as chemotherapy would no longer be possible.

Controversial Questions

To protect future generations from the dangerous consequences of antibiotic resistance, it is essential that we reduce current overuse of antibiotics. One way of achieving this would be to restrict drug prescriptions, but this is highly controversial, and rightly so.

It seems obvious that Debbie from the anecdote above shouldn't receive antibiotics. But what about patients with actual bacterial infections? Is it ethical to ration what could be considered a basic medical treatment and therefore a human right? How far can we take antibiotic rationing? Can we put current patients at risk in order to save future generations?

Justice Between Generations

A common problem when considering future generations is that we can’t identify the people who are yet to be born. Future generations therefore have no opportunity to speak out for themselves or defend their interests. Nevertheless, philosopher John Rawls made a strong case for our moral obligation to protect future people’s lives. He proposed a concept termed “justice between generations," stating that existing populations and future offspring are morally equal and should therefore have the same rights to common resources such as effective antibiotic drugs. Rawls’ principle thus implies the need to preserve antibiotics and thereby guarantee their future availability. But could this mean denying current patients a treatment they need?

Veil of Ignorance

In most healthcare systems across the world, a doctor’s prescription is necessary for obtaining antibiotics. The reason is that antibiotics need to be administered with medical knowledge to ensure correct use and minimal side effects to patients. However, medical knowledge doesn't guarantee making the right choice. Decisions can be tricky in cases of medical uncertainty, when a patient’s best treatment options are unclear even to doctors. Uncertainty presents unique challenges for decision making. If a patient suffers from confusing symptoms, the immediate use of antibiotics can seem like a "safe option" to provide protection against all eventualities. Doctors want to minimise risks to their current patients, and this drive is often strengthened by a personal concern or attachment to the patient. Quick prescribing of antibiotics can therefore become appealing.

When trying to establish which patient really needs antibiotics, another philosophical concept comes into play. The so-called “veil of ignorance” is a useful framework which encourages greater impartiality when making morally difficult choices. The concept requires decision makers to imagine being placed behind a "veil of ignorance" and to treat any choice situation like an abstract situation without personal involvement. The consequent judgment should be a general one that isn't tied to specific patient identities and therefore free from complicating factors such as emotions and personal attachments. This way, doctors’ decisions about the use of antibiotics should become more objective and appropriate.

Rule of Rescue

Importantly, however, making an impartial choice about antibiotics use should never mean withholding life-saving treatment to a dying patient. Rawls proposed a “Rule of Rescue," according to which exceptional cases of extreme severity and urgency should be treated as morally different from less urgent situations. An example in the context of antibiotic prescribing may be a patient with unclear symptoms, who is acutely unwell and at risk of dying. In such a situation, the mere severity would justify immediate prescribing of antibiotics as opposed to a more restrictive approach.

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What can patients do?

Fair rationing of antibiotics is an extremely challenging quest, which, like climate change, requires everyone’s support. To protect effective antibiotics for future generations, it may be ethically justifiable to restrict antibiotics use in certain non-emergency situations. Currently, the decisions about antibiotic use typically lie with medical professionals. To help them manage such a complex dilemma, they need support from patients and the general public.

If you’d like to assist the collective effort to tackle antibiotic resistance, why not become an antibiotic guardian? It’s quick and easy, and everyone from health professionals to lay people can participate, as I have.