Resolved: The Use Of Antibiotics Should Be Restricted

Thanks to That1User for inviting me to debate this.

Aside perhaps only from vaccines, antibiotics have been hailed as one of the most important medical advances in history, resulting in “enormous gains… in public health through the prevention and treatment of infectious disease.” In combination with vaccines, they have led to the near eradication of diseases that plagued the world for millennia.[1] This has only been accomplished because medical professionals could distribute antibiotics freely, providing the means to address diseases like diptheria and whooping cough.

 

So, what’s the harm in making them more difficult for doctors to use? I’ll spend this round breaking the potential damage down by focusing on what it does to both physicians and their patients.

I) Physicians:

1) The Bottom Line

Any restriction put in place requires either incentives or penalties be used as a mechanism for enforcement. Doctors need these consequences to alter their decision-making, as they face numerous ethical concerns through more limited action. They also face financial concerns, including those affected directly by patient satisfaction ratings,[2] and by the incidence of costly malpractice lawsuits [3]. Thus, damaging patient relations can lead physicians to financial ruin, forcing them to close their practices. While this may be a just outcome for doctors whose interpretations and reactions yield poor outcomes for their patients, Pro is altering that dynamic: now, it is the government that will make these decisions, and doctors who will suffer the social and financial consequences, regardless of the choices they would otherwise make for their patients. This violates the capacities of these doctors to run their businesses, placing their success entirely at the mercy of a government that cares more about the big picture than their livelihoods and the communities they serve.

However, it is possible that some doctors will choose not to follow these restrictions. Many may see a higher risk in limited response; survey data shows that physicians are far more motivated by the desire to treat their patients than they are by incidence of antibiotic resistance [4, 5]. This further destabilizes access to care, resulting in some doctors who freely prescribe antibiotics, while others abide by the law, resulting in different treatments driven by adherence to or disdain for societal restrictions. In a just society, health care should be an equal access system with patients expecting to receive the same standard of care from every doctor. That justice is lost in Pro's system.

2) Beneficence and Nonmaleficence

Taken together, these terms represent the essential balance of benefits versus risks of treatment, essential pieces of any discussion of health care. This balance is best struck using the principle of double effect, in that doctors and society should prefer an intended and otherwise unattainable good effect to an unintended yet foreseen adverse event. We cannot replace the known benefit, but we can respond to the known harm by limiting its likelihood, reducing its spread, and using multiple antibiotics, ergo we should prefer the benefit.

 

Allowing doctors to prescribe antibiotics without restriction follows this principle by weighing the far more tangible harm of allowing bacterial infections to gain and retain a foothold in their hosts without substantial response against the vaguer, more nebulous, intangible harms of antibiotic resistance. Pro’s case allows for more instances of sepsis and abscesses, where taking time to determine whether a bacterial infection is present could kill or cause permanent damage to the patient.[6] This also effectively demonizes doctors that put their patients first, placing principle before the patient, essentially putting the Hippocratic Oath itself on trial by denying doctors the necessary means to help their patients.

II) Patients:

1) Increased Disease Burden

Any restriction of antibiotics from those in need is going to hurt people. Doctors will have to deny their patients access to care or restrict the amounts they can take, preventing some treatments from being effective. They will do this often in the face of uncertainty – doctors often won’t make specific diagnoses separating viral and bacterial diseases, instead relying on hallmarks of diseases that could be either viral or bacterial but present a great enough threat that they will start antibiotic regimens before the diagnosis has been confirmed. Such is the case with infectious pneumonia [7]. Failing to address cases like this could easily result in loss of life simply because they are unable to diagnose a clear-cut bacterial diagnosis rapidly enough to address the problem. Patients will have to get by without access to antibiotics in the face of that uncertainty. Remember, antibiotics are the sole readily available means of treating an active bacterial infection. Pro’s case subjects more patients to prolonged bacterial infections that can have lasting consequences to patients’ health.

2) Backlash

Pro is sacrificing some people in hopes of saving others. Her case will result in injury to patients, and her efforts to build future success on that harm is blatantly unethical. This harm is best explained by Kant's categorical imperative, which states that we must treat human beings as ends and not solely as means to a better end for others, as otherwise we degrade their humanity by stripping away their desires and making them tools for societal benefit.[8]

This might be more palatable if we knew that Pro had a good chance of saving future lives. I’ll address the solvency of her case in my rebuttals, but ignoring case specifics, there are no studies of any countries or communities having implemented the measures Pro is suggesting. Any broad effect from such a principle being exercised could only be theorized, and many of the consequences may be unexpected. So, Pro using human beings the world over as an experiment, a case study to analyze the effects of denying them treatment on the grounds that the prevalence of antibiotic resistance will decrease with their sacrifice. That’s not enough of a reason to put patients through this, especially when many doctors may be unable to monitor their conditions carefully enough to respond quickly if their infections worsen. That’s why doctors advocate the need for a careful monitoring system even when antibiotic prescriptions are changed, let alone when they are entirely eliminated [7].

 

This effort will have lasting psychological consequences on patients, many of whom would see the denial of their and others’ autonomy and self-determination regarding their medical care, their incapacity to provide inform consent, as a denial of their right to live and thrive. In a world where patients are taking more control over their health and even clinical decision-making, actively seeking to thoroughly inform themselves so that they can consent to procedures they otherwise wouldn't understand, denying them access to a simple and effective treatment is a bastardization of their efforts. It removes an integral piece of their medical autonomy and undermines the basic trust that patients need to have in their doctors to willingly pursue health care. Knowing that your doctor will not provide you the best-known means to respond to an infection can only sow distrust,[9] which may lead many patients to shun the medical establishment and even self-medicate, further harming societal health.

Back to Pro!

1. https://www.pfizer.com/news/featured_stories/featured_stories_detail/the_value_of_antibiotics_in_treating_infectious_diseases

2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3979780/

3. https://www.malpracticeteam.com/blog/2016/february/a-doctors-refusal-to-treat-a-patient-may-lead-to/

4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495012/

5. http://www.ncbi.nlm.nih.gov/pubmed/12458980

6. https://www.aafp.org/afp/2013/0701/p44.html

7. https://theconversation.com/yes-we-must-prescribe-fewer-antibiotics-but-were-ignoring-the-consequences-89266

8. https://www.qcc.cuny.edu/SocialSciences/ppecorino/MEDICAL_ETHICS_TEXT/Chapter_2_Ethical_Traditions/Categorical_Imperative.htm

9. http://onlinelibrary.wiley.com/doi/10.1111/j.1469-0691.2006.01526.x/pdf

If we are to treat each individual as an end, then patient use and response to antibiotics must be accounted for, in order to maintain antibiotic effectiveness in treatment and prevent antibiotic ineffectiveness via antibiotic resistance.

To achieve this systematically,  “the optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance.” {1} must be pursued. This is the definition of antimicrobial stewardship, having three goals.

This systematic approach takes into account the patient's health at a wide level,  documenting antimicrobial dose, duration, and indication, tracking patient antimicrobial response to see how they react to antimicrobials and what is optimal to prescribe.  {2} This approach ensures antimicrobial effectiveness by maintaining optimal treatment and the best responses to medication

Pro’s case is predicated on two assumptions:

 

-        That continuing to use antibiotics as we do will lead to antibiotic nullification

-        That restricting use of antibiotics as she suggests will prevent antibiotic nullification.

 

Before I get into the problems with those assumptions, I feel I must define antibiotic nullification, as the term has not been defined so far. Yes, I have to give you a science lecture.

 

When she says nullification, she means the development of total or near-total resistance to antibiotics. This is something that has already occurred, particularly with the organism Mycobacterium tuberculosis.[10]The designation for these organisms is extensively drug resistant, or XDR. Bacteria generate this resistance using circular pieces of DNA called plasmids. These plasmids are usually exogenous, i.e. they are commonly expressed outside the genome. This makes them easy to transfer in a process called conjugation.[11]

 

With this in mind, there are a few reasons why Pro’s assumptions do not hold up.

 

First, these resistant strains exist now. Pro gives no reason why these bacteria would lose their resistance genes. There are still antibiotics being used in Pro’s world; the challenge that results in the development of antibiotic resistance is still there. Regardless of amountsused, the antibiotic resistance that exists now will continue to “be selected and propagated. The reverse situation, loss of resistance gene(s), is not selectable. Moreover, when the new gene inserts into the chromosome or plasmid, it may cause changes which prevent it from coming out by the same way it went in.”[12] The natural mechanisms used to transfer these pieces of DNA compound these problems by spreading resistance without the need to develop new mechanisms.

 

Second, antibiotic resistance is an inevitable consequence of using any antibiotics. “No antibiotic has been developed without resistance appearing soon after.”[13] Bacteria evolve to resist antibiotics faster than we can generate new ones. For example, vancomycin, an antibiotic that was heavily restricted in its use and employed solely as a last resort, nonetheless generated resistance shortly after it was introduced to the market.[14] Pro can’t solve for this unless she stops all antibiotic usage. And Pro worsens this problem by constricting the market, which “stifles innovation and investment; fewer antibiotics are developed, leaving us more dependent upon existing agents that may no longer be maximally effective. An increased dependency on a reduced number of antibiotics may also accelerate the development and spread of resistance to these agents.”[15] As such, her case leads to fewer new vaccines, slowing down human progress in the already losing evolutionary arms race. “Antibiotics...are unique among drugs in that their use precipitates their obsolescence. Paradoxically, these cures select for organisms that can evade them, fueling an arms race between microbes, clinicians and drug discoverers.”[13]

 

Third, antibiotic resistance will get worse under Pro’s plan. The second plank of her plan, which would reduce the size of prescriptions given to patients, will facilitate the generation of new resistances. Doctors prescribe longer-term, larger doses for antibiotics because the priority is ending the infection. Reducing those doses or cutting them off early is likely to propagate antibiotic resistance, as has been the case with patient non-adherence to dose regimens.[16]

 

And all of this plays out in the data. There is no established “causal relationship between antibiotic use policies and changes in rates of resistance,” and many antibiotic usage restriction studies show no significant reduction in rates of antibiotic resistance.[17, 18]

 

On a practical level, Pro’s case doesn’t address the fact that developing and developed countries have very different factors that contribute to their respective incidences of antibiotic resistance. There is no one-size-fits-all solution, and though she appears to suggest a systematic approach this round (which differs from her initial case), the means to implement that kind of “antimicrobial stewardship” aren’t equally present in all countries, nor can it be feasibly implemented uniformly across all countries.

 

And this supposed benefit, despite what Pro says, comes at the cost of the individual and treats them as a means to this “greater good” of reducing antibiotic resistance. So much of Pro’s case supposes a utopia where we can get quick and consistently clear knowledge of patient diseases, when in reality, diagnoses are a slow and laborious process that can cost lives if decisive actions aren’t taken early.

 

Back over to Pro.

 

10. https://www.news-medical.net/health/What-are-Extensively-Drug-Resistant-(XDR)-Bacteria.aspx

11. https://www.onlinebiologynotes.com/bacterial-conjugation/

12. http://www.tufts.edu/med/apua/practitioners/faqs.shtml

13. http://www.theguardian.com/commentisfree/2014/jul/21/back-to-the-future-with-antibiotic-resistance

14. https://academic.oup.com/cid/article/42/Supplement_1/S5/275962

15. http://onlinelibrary.wiley.com/doi/10.1111/j.1469-0691.2006.01528.x/pdf

16. http://njlm.net/article_fulltext.asp?issn=0973-709x&year=2014&month=March&volume=3&issue=1&page=11&id=2003

17. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1853255/

18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6380099/