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Published in the journal Public Health Ethics, the research introduces an ethical framework for assessing the use of coercive antimicrobial stewardship policies to address the ‘silent pandemic’ of antimicrobial resistance.

Pile of medicine blister packs© Image by Freepik


Antimicrobial resistance (AMR) has been declared a top ten global public health threat by the World Health Organization, with potential to cause 10 million deaths each year by 2050 if no action is taken. 

Often termed a ‘silent pandemic’ or a ‘hidden threat’, there is low public awareness of the problem.

To address AMR, health policymakers may implement antimicrobial stewardship measures, which support appropriate use of existing antibiotic stocks. Of these, coercive stewardship measures can include bans or taxes on antibiotic use in some sectors, capping doctors’ prescriptions, or eliminating over-the-counter antibiotic sales. 

These policies, like all in public health, require ethical justification. But what does a strong ethical justification look like? In a new paper, PSI, Ethox Centre and Nuffield Department of Population Health researcher Dr Tess Johnson addresses a significant gap in the debate. 

The research brings together ethical arguments for coercive antimicrobial stewardship into an ethical framework and, importantly, considers the limitations of those arguments.

The paper also explores some of the challenges related to developing an ethical evaluation framework, including how such a framework should be adapted for different contexts, and how ethical justifications should feature alongside other health priorities.

Dr Tess Johnson said: “Antimicrobial resistance is a hidden threat facing health policymakers throughout the world.

“As we work toward global coordination in addressing antimicrobial resistance, policymakers must consider how to ethically justify the actions they take, particularly for coercive antimicrobial stewardship measures such as bans on antibiotic use or caps on prescriptions.

“It’s very important that we both offer ethical concepts that might justify coercive measures and keep strongly in mind how different national contexts affect whether an ethical concept can be used in a justification for a coercive measure.

“In this paper I offer the beginnings of a framework that could help policymakers understand ethical justifications for coercive antimicrobial stewardship policies, as well as the limits of those justifications.”

Further development of ethical guidance will allow policymakers to better communicate their reasoning to the public, and will allow the public to better hold policymakers to account for implementing context-appropriate, ethically acceptable coercive antimicrobial stewardship policies.

Read the paper in Public Health Ethics