What High-Income States Should Do to Address Industrial Antibiotic Pollution

Antimicrobial Resistance, One Health Interventions and the Least Restrictive Alternative Principle

Antimicrobial resistance (AMR) is increasingly recognised as a threat to human, animal and environmental health. In an effort to counter this threat, several intervention plans have been proposed and implemented by states and organisations such as the WHO. A One Health policy approach, which targets multiple domains (healthcare, animal husbandry and the environment), has been identified as useful for curbing AMR. Johnson and Matlock have recently argued that One Health policies in the AMR context require special ethical justification because of the so-called least restrictive alternative principle. This article analyses and rejects two assumptions that this argument relies on. The first assumption is that One Health policies are generally more restrictive than their alternatives because they target more domains and impact more people. The second assumption is that the least restrictive alternative principle has a special normative importance in that it establishes a systematic presumption in favour of the least restrictive policy options. Once these assumptions are rejected, the use of One Health policies on AMR can be justified more easily than Johnson and Matlock argue.

Pharmaceutical Pollution from Human Use and the Polluter Pays Principle

Human consumption of pharmaceuticals often leads to environmental release of residues via urine and faeces, creating environmental and public health risks. Policy responses must consider the normative question how responsibilities for managing such risks, and costs and burdens associated with that management, should be distributed between actors. Recently, the Polluter Pays Principle (PPP) has been advanced as rationale for such distribution. While recognizing some advantages of PPP, we highlight important ethical and practical limitations with applying it in this context: PPP gives ambiguous and arbitrary guidance due to difficulties in identifying the salient polluter. Moreover, when PPP does identify responsible actors, these may be unable to avoid or mitigate their contribution to the pollution, only able to avoid/mitigate it at excessive cost to themselves or others, or excusably ignorant of contributing. These limitations motivate a hybrid framework where PPP, which emphasizes holding those causing large-scale problems accountable, is balanced by the Ability to Pay Principle (APP), which emphasizes efficiently managing such problems. In this framework, improving wastewater treatment and distributing associated financial costs across water consumers or taxpayers stand out as promising responses to pharmaceutical pollution from human use. However, sound policy depends on empirical considerations requiring further study.

Justifying the More Restrictive Alternative: Ethical Justifications for One Health AMR Policies Rely on Empirical Evidence

Global consumption of antibiotics has accelerated the evolution of bacterial antimicrobial resistance. Yet, the risks from increasing bacterial antimicrobial resistance are not restricted to human populations: transmission of antimicrobial resistant bacteria occurs between humans, farms, the environment and other reservoirs. Policies that take a 'One Health' approach deal with this cross-reservoir spread, but are often more restrictive concerning human actions than policies that focus on a single reservoir. As such, the burden of justification lies with these more restrictive policies. We argue that an ethical justification for preferring One Health policies over less restrictive alternatives relies on empirical evidence as well as theory. The ethical justification for these policies is based on two arguments: (i) comparatively greater effectiveness, and (ii) comparatively better tracking of moral responsibility. Yet the empirical assumptions on which these claims rest are limited by existing empirical knowledge. Using livestock farming as an example, we suggest that scientific research into characterising antimicrobial resistance and linking practices to outcomes ought to be guided (at least in part) by the imperative to supply the context-specific data needed to ethically justify preferring a One Health policy over less restrictive alternatives.

Socio-cultural determinants of antibiotic resistance: a qualitative study of Greeks' attitudes, perceptions and values

Background

Antibiotic resistance is a complex phenomenon heavily influenced by social, cultural, behavioural, and economic factors that lead to the misuse, overuse and abuse of antibiotics. Recent research has highlighted the role that norms and values can play for behaviours that contribute to resistance development, and for addressing such behaviours. Despite comparatively high antibiotic consumption in Greece, both at the community and healthcare level, Greeks have been shown to be relatively aware of the connection between antibiotic overuse and antibiotic resistance. This suggests that Greeks’ non-judicious use cannot simply be explained by lack of awareness but may relate to other factors specific to Greek society. The present study aimed to explore attitudes, perceived norms, and values in relation to antibiotics, in order to improve understanding of socio-cultural determinants of antibiotic resistance in Greece.

Methods

Data were collected through online focus group discussions in 2021. Twenty Greeks were recruited through purposive sampling, aiming for as heterogeneous groups as possible regarding gender (12 women, 8 men), age (range 21–55, mean 33), and education level. Interview transcripts were analysed inductively using thematic content analysis.

Results

Participants considered antibiotic overconsumption as a consolidated habit influenced by ease of access, social expectations and, more generally, cultural practices. While critical of such norms and practices, participants opposed stewardship measures that would prioritize the societal interest in maintaining antibiotic effectiveness over individual needs. Participants considered responsibility for antibiotic resistance to be shared by the whole society, but the role of government actors and health professionals as well as of food producers was emphasized. Notably, scepticism about the prospect of effectively managing antibiotic resistance in Greece was commonly expressed.

Conclusions

The study makes explicit attitudes, perceived norms and values that, besides limited awareness, may contribute to non-judicious antibiotic use in Greece. These socio-cultural determinants of antibiotic resistance warrant further research and should be considered when designing measures aimed to mitigate this problem.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13855-w.

Sustainability principle for the ethics of healthcare resource allocation

We propose a principle of sustainability to complement established principles used for justifying healthcare resource allocation. We argue that the application of established principles of equal treatment, need, prognosis and cost-effectiveness gives rise to what we call negative dynamics: a gradual depletion of the value possible to generate through healthcare. These principles should therefore be complemented by a sustainability principle, making the prospect of negative dynamics a further factor to consider, and possibly outweigh considerations highlighted by the other principles. We demonstrate how this principle may take different forms, and show that a commitment to sustainability is supported by considerations internal to the ethical principles already guiding healthcare resource allocation. We also consider two objections. The first of these, we argue, is either based on implausible assumptions or begs the question, whereas the second can be adequately accommodated by the principle we propose.