View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by UCL Discovery ANTIMICROBIAL RESISTANCE AND DISTRIBUTIVE JUSTICE JASPER LITTMANN University College London Thesis submitted for the degree of Doctor of Philosophy February 2014 Thesis Declaration I, Jasper Littmann, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. 2 Abstract The rapid emergence of Antimicrobial Resistance (AMR) over the past decades together with a lack of research into new drugs presents health care systems with serious challenges and threatens their ability to effectively treat serious bacterial infections. As a result, it is realistic to expect that effective treatment options for some infections will run out in the future. The thesis begins by outlining the mechanisms and consequences of AMR and argues that AMR differs from other distributive problems, due to the specific characteristics of antibiotics. It is suggested that for considerations of distributive justice, antibiotic effectiveness should be treated as a resource, which can be depleted and which must be fairly distributed between people and generations. The thesis then goes on to examine the distinctive moral challenge posed by AMR. It begins by considering a consequentialist account, which suggests that AMR is a moral problem due to the bad health outcomes it entails. However, this approach is subsequently dismissed because it struggles to account for some of the particular features of AMR. An alternative is to consider AMR as a morally wrongful harm to individuals, which requires not only that AMR has adverse effects, but also violates the victim’s rights. It is shown that the harm caused by AMR is morally wrongful and that people have a right to be protected from adverse health outcomes, which AMR violates. However, it is difficult to specify correlative duties that result from such a rights claim. As an alternative, the thesis suggests and defends a form of Scanlonian contractualism, which offers the best model to represent and address issues of distributive justice in the case of AMR. It is shown that a principle of antibiotic use, which rules out the use of antibiotics for infections that do not pose a serious risk of irreversible harm, offers a convincing contractualist argument. The thesis examines the concerns for intergenerational justice that arise as a consequence of AMR and shows that contractualism is capable of addressing them. The thesis concludes by suggesting a new way of framing AMR as a specific type of policy challenge, which better captures its complexity and advocates a reduction of future dependency on antibiotics. 3 FOR MY PARENTS 4 Acknowledgements I would like to thank my supervisors James Wilson and Anthony Kessel for their help and continued support. Their willingness to engage with my ideas and to challenge and encourage me along the way was a great help. I would also like to express my gratitude for the generous financial support I received from both, the Arts and Humanities Research Council and Public Health England. I am indebted to the numerous friends and colleagues, with whom I discussed this project over the past years. In particular, I would like to thank Frej Klem Thomsen and Giovanni de Grandis for their feedback on earlier drafts and Adrian Viens for countless discussions about the ideas contained in this thesis. While writing this thesis, I was lucky enough to be invited to spend time as a guest researcher at a number of institutions. Chikwe Ihekweazu, Verina Wild, Jesper Ryberg and Sune Lægaard made these visits possible and I thank them for their generosity. I could not have wished for a more supportive family over the last years. My parents and my brother encouraged and motivated me and helped more than they could ever know. This thesis is dedicated to them. Finally, I would like to thank Cecilie, who has made it all worthwhile. 5 Table of Contents Abstract ........................................................................................................................ 3 Acknowledgements ...................................................................................................... 5 Table of Contents ......................................................................................................... 6 Abbreviations ............................................................................................................... 9 Chapter 1: Introduction and overview of the thesis ................................................... 10 1.1 Introduction ............................................................................................................ 10 1.2 Aims of the thesis and the question it tries to answer ............................................ 13 1.3 The scope of discussion and the questions I do not try to answer ......................... 16 1.4 Why the questions addressed in this thesis are important ...................................... 17 1.5 Research approach and interdisciplinary work ...................................................... 18 1.6 Research methods .................................................................................................. 20 1.7 Main conclusions of the thesis and its contribution to the field ............................. 22 Chapter 2: Antibiotics, their use, and the emergence of drug resistance ................... 23 2.1 Bacteria - a brief microbiological overview and taxonomy ................................... 23 2.2 Antibiotics .............................................................................................................. 25 2.3 Discovery and initial use of antibiotics ................................................................. 26 2.4 Emergence and mechanisms of AMR .................................................................... 28 2.5 Causes of AMR ..................................................................................................... 31 2.5.1 Overprescription ............................................................................................ 31 2.5.2 Lack of research into new drugs .................................................................... 33 2.5.3 Antibiotic use in agriculture .......................................................................... 35 2.5.4 Other factors .................................................................................................. 36 2.6 Current responses to AMR ..................................................................................... 37 2.6.1 The prudent use of antibiotics ........................................................................ 38 2.6.2 Infection control to reduce transmission........................................................ 40 2.6.3 Research and development of new antibiotics ............................................... 41 2.7 Antibiotic Prescribing and consumption ................................................................ 43 2.7.1 Antibiotic prescribing in primary care and general practice ........................ 44 2.7.2 Antibiotic Prescribing in secondary care settings ......................................... 48 2.7.3 Antibiotic Consumption - the role of the patient ............................................ 50 2.8 Summary ................................................................................................................ 52 Chapter 3: Antimicrobial resistance and analogical reasoning ................................. 53 3.1 Introduction ............................................................................................................ 53 3.2 AMR and the distribution of which commodity? .................................................. 53 3.3 Analogical reasoning ............................................................................................. 55 3.4 Analogical reasoning and AMR ............................................................................. 57 3.5 Antibiotic overconsumption - a tragedy of the commons? .................................... 58 3.6 Antibiotic effectiveness as a renewable resource - the analogy of overfishing ..... 61 3.7 Is AMR analogous to greenhouse gas emissions? ................................................. 64 3.8 Antibiotic effectiveness as a non-renewable resource ........................................... 66 3.9 Economics and AMR - taking stock ...................................................................... 68 3.10 Characteristics of antibiotics as a commodity ........................................................ 68 3.11 Summary ................................................................................................................ 71 6 Chapter 4: What makes AMR a moral problem? A consequentialist approach ........ 72 4.1 Consequentialism as the obvious answer? ............................................................. 72 4.2 A case for more sophisticated versions of consequentialism? ............................... 75 4.2.1 Compatibility with current practice of policy-making ................................... 76 4.2.2 The ability to trade off benefits between groups of people ............................ 76 4.2.3 Accounting for the interests of future persons ............................................... 78 4.3 The problems that remain: the case against consequentialism ............................... 78 4.3.1 The first remaining problem: measuring health