Michael Millar

There are substantial inequalities associated with antibiotics and the determinants of their effectiveness, including the risk of exposure to antibiotic‐resistant microbes, access to relevant treatment advice, diagnostic facilities, risk of life‐threatening infectious disease, and access to antibiotics. Current arrangements (social, political, economic) allow inequalities in the distribution of antibiotic benefits and burdens. This article focuses on the justification of relevant inequalities from a contractualist perspective.

Antibiotic resistance threatens the capacity to treat life-threatening infections. If it is accepted that it will be many years until the production of new antibiotics overcomes current concerns with antibiotic resistance then ways to conserve the effectiveness of current antibiotics will have to be found. For many bacterial agents of infection levels of antibiotic resistance are directly dependent on the quantity of antibiotic prescribed. Antibiotics are currently underutilised in many parts of the world. If a just distribution of access to antibiotics requires equal access for individuals with equal need irrespective of wealth then responding to this requirement of justice has the potential to shorten the effective life of currently available antibiotics. Increasing the range and numbers of individuals treated with antibiotics would seem to threaten sustainability and also potentially undermine the access of future generations to cost-effective treatments for bacterial infection. The control of antibiotic resistance requires that the determinants of infectious disease transmission are addressed, such as poor housing, education and nutrition as well as the provision of antibiotics. The apparent tension between intragenerational justice and sustainability diminishes when the account of distributive justice extends beyond access to antibiotics and includes plural entitlements. Controlling antibiotic resistance requires more than the redistribution or reduction of antibiotics.

Individuals are at risk of acquiring untreatable agents of infection when they travel to countries where antibiotic-resistant agents of infection are prevalent, and particularly when they travel for healthcare. Uncertainty with respect to the overall political and economic consequences seems to underlie the reluctance of public health authorities to issue relevant travel advisories. The conditions of choice, the act of choice and the consequences of choice can each be a primary focus of ethical appraisal of public health policy. The ‘value of choice’ account provided by Scanlon draws attention to the value of the choices that individuals are given, and the potential for reasonable rejection of policies that do not give adequate emphasis to the conditions of individual choice. There is both instrumental and symbolic value in informing people of the risk of acquisition of antibiotic-resistant microbes associated with health tourism. We cannot reasonably reject a principle of actively informing unless there are insurmountable countervailing reasons. These reasons should be explicit and subject to review. If health tourism is a concern then we might also consider how best to facilitate alternative choices

‘Zero tolerance’ of avoidable infection events is explicit in UK and international policy documents describing strategies for the control of healthcare-associated infection. I consider what principles governing avoidable infections acquired in healthcare institutions might be reasonably rejected from the contractualist perspective of Thomas Scanlon. Many hospital infections can be cost-effectively avoided. There would seem to be additional reasons to take the prevention of avoidable infection acquired in hospitals seriously in addition to optimizing the cost-effectiveness of healthcare. These include the irretrievable nature of the harm of some of the infections; the reasonable rejection of avoidable harm when the patient could not rationally consent to the risk of harm and the social consequences such as loss of trust in healthcare providers. Despite these reasons, a principle of ‘zero tolerance’ has implausible implications, promotes unrealistic patient expectations and can be reasonably rejected from the perspective of those who will suffer unacceptable opportunity costs. However, the contractualist perspective would also seem to reject a principle of tolerance of harm when there is a feasible reconfiguration of institutional arrangements that reduces the risk of harm without a redistribution of a proportionate or greater burden to others

Healthcare workers carry a substantial risk of harm from infectious disease, particularly, but not exclusively, during outbreaks. More can be done by healthcare institutions to identify risks, quantify the current burden of preventable infectious disease amongst HCWs and identify opportunities for prevention. We suggest that institutional obligations should be clarified with respect to the mitigation of infectious disease risks to staff, and question the duty of HCWs to care while healthcare institutions persist with a reactive rather than proactive attitude to infectious disease threats.

Decisions to use antibiotics require that patient interests are balanced against the public good, that is, control of antibiotic resistance. Patients carry the risks of suboptimal antibiotic treatment and many physicians are reluctant to impose even small avoidable risks on patients. At the same time, antibiotics are overused and antibiotic-resistant microbes are contributing an increasing burden of adverse patient outcomes. It is the criteria that we can use to reject the use of antibiotics that is the focus of this paper. Scanlon's contractualism explains why antibiotics should not be used to gain small benefits, even when the direct costs of antibiotics are low. We know that some individuals now (and probably more in the future will) carry a burden of irretrievable harm as a consequence of treatment- (antibiotic-) resistant infection. If we accept that the dominant justification for use of antibiotics is to prevent irretrievable harm to an individual or contact, then the use of antibiotics for self-limiting conditions, or for the treatment of individuals with conditions for which antibiotics do not substantially impact on outcomes (eg, in the latter stages of terminal illness), or for access based on preference or willingness to pay (internet or over-the-counter access), or the use of antibiotics as animal growth promoters can be rejected. Scanlon's approach also suggests that, with few new antibiotics in the pipeline and an increasing burden of disease attributable to resistant microbes, control of the spread of antibiotic-resistant microbes should be given increasing priority

Attribution of responsibility to individuals for outbreaks of infectious disease is challenging even with the most sophisticated microbial typing techniques. Typing methods can help to elucidate potential transmission pathways but there are additional conditions required before responsibility for the spread of infection can be attributed to individuals. These conditions include the knowledge and opportunity to undertake alternative actions. Governmental and institutional obligations arise from the requirement for concerted collective action(s) which, by contrast with individuals, have the knowledge and resources to investigate outbreaks, and design and implement control measures. Individuals should not be the presumptive targets for the ascription of responsibility for outbreaks of infection. Indeed, our focus ought to be on the institutional obligations that fall upon public health providers as the primary agents with responsibility for assuring the concerted actions required to protect the public’s health