In early 2020, many of us around the world experienced the full force of coercive public health restrictions for the first time. In response to the Covid-19 pandemic, governments enforced lockdowns, quarantine and social distancing. Whilst some of us were growing sourdough starters, others lost businesses or were unable to say goodbye to loved ones on their deathbeds. The minority protested and refused to comply with any restriction, but the vast majority of us accepted some form of infringement of our rights to freedom of movement and association, as well as to private and family life. Our right to health care was also restricted, as hospital care for some conditions was deprioritised.
Coercion involves one person using a credible threat of a negative consequence to make another person decide (or decide not) to take a certain action. We are used to coercion in our everyday lives, whether through taxation, seat-belt mandates or threats from partners if we fail to take out the bin (again). Yet, these more mundane forms dim in comparison to infringements we might see in the public health space. We accepted coercive restrictions when facing Covid-19, because it was seen to be a global emergency. But the definition of an emergency isn’t always clear-cut.
Antimicrobial resistance is one health crisis that is relatively slow-moving, complex and varied in how it presents. When microbes including bacteria, fungi and parasites develop resistance to the drugs designed to kill them, they can cause a serious health threat. Antibiotics are designed to kill bacteria that cause disease, but as certain hospital-acquired infections become resistant, the risks of even minor surgeries and hospital visits may increase drastically.
Diseases as varied as tuberculosis, gonorrhoea, malaria and sepsis all have “superbug” variants. There is evidence to suggest that deaths associated with antimicrobial resistance could reach 10 million per year by 2050 if no action is taken. Already those deaths associated with resistance hit 4.95 million in 2019. Bangladesh’s Prime Minister Sheikh Hasina warned in 2021 that antimicrobial resistance could grow to pose a bigger public health emergency than Covid-19, and she is not the only one ringing the alarm bell.
Some measures are already being taken. Many countries, including the UK, have adopted clinical guidelines to help ensure that doctors are not prescribing unnecessary antibiotics. There are plenty of public awareness campaigns on the risks of overuse. Yet, despite clinical evidence that shorter courses of antibiotics are as good as longer ones, doctors here in the UK continue to prescribe courses longer than what is recommended in clinical guidelines up to 80 per cent of the time for common respiratory infections. There is a fear of under-prescribing, which could also result in legal liability.
The EU Council recently implemented prohibitions on the use of some antibiotics in livestock farming, given that it risks transmitting drug-resistant bacteria to humans. But here in the UK we rely on voluntary measures. Much more needs to be done. The government could make prescription guideline adherence mandatory through penalties for over-prescribing doctors. Pharmaceutical facilities could be discouraged from releasing antimicrobial-like chemicals into waterways, through water testing and fines. Farmers could be banned from giving certain drugs earmarked for human use to their livestock – except where they have a prescription from the vet.
However, there seems to be little public appetite for such measures. We don’t seem to want to be bullied by government into action. The problem is that such measures ask us to weigh our need for antimicrobials against others’ future needs. We all want to be given antibiotics by our doctor when we feel we need them, and we don’t want to pay more for food that has been less intensively produced, even if we do recognise the future health threat that antimicrobial resistance poses.
When is coercion justified?
The problem is also complex. Because of the wide variety of bugs developing resistance, preventing human deaths from antimicrobial resistance likely won’t be a matter of stopping the spread of a single drug-resistant bug that starts a pandemic. Instead, it will be about making sure that these variants don’t spread locally, particularly in hospitals, as secondary infections that people catch when being treated for other conditions. Without effective antimicrobials, a trip to the hospital to have your appendix removed or to get a C-section could be life-threatening.
Microbe adaptation to drugs is inevitable, so we can’t stop antimicrobial resistance completely, but we need to get a grip on the current situation before we run into real trouble. In the UK, data released by the Health Security Agency shows that serious antimicrobial-resistant infections went up by 2.2 per cent in 2021 compared to 2020 levels – equivalent to 148 more serious antimicrobial-resistant infections per day. Meanwhile, 66 per cent of all antibiotics worldwide are used in livestock. The scale and complexity of the problem, and the reluctance of the general population and the farming community to change their behaviour, seems to call for state interference like fines, prescription requirements and mandated guidelines.
But does that mean such interference would be ethical? Most of us believe that coercion can be ethically acceptable, in some cases. Even classical liberal philosophers like J. S. Mill thought that coercion can sometimes be the right thing to do. His “harm principle” says that the only time third parties can intervene in your actions is when doing so prevents harm to others. They can’t intervene to serve their own ends, or to protect you from harm. That would be paternalistic. But if your actions threaten harm to others, then it might be all right for them to stop you. The concept has been used to justify criminal law enforcement by political philosopher Joel Feinberg. It has been applied in the public health context as well, where one person’s actions can affect another’s health.
We might think that coercive measures are ethically justifiable, then, if they prevent harm to others. That’s intuitive, but it doesn’t get us very far. The reason many of us complied with Covid-19 mandatory quarantine is that we could very easily see the risk to our friend if we met up with them in a café and managed to infect them. The harm arising from antimicrobial resistance is a lot less clear. My taking my friend’s leftover antibiotics doesn’t appear to pose any direct harm, to any particular identifiable individual, over any short timeframe. Instead, the harm of antimicrobial resistance is probabilistic, statistical, aggregative, and continues from now into the long term.
We can break some of this down. When we think about who is experiencing the harms of antimicrobial resistance now, it’s often those who lack sufficient access to antimicrobials, or who are more exposed to resistance because of poor sanitary conditions. Often, this means people in low- and middle-income countries who already experience structural disadvantage.
In informal settlements just outside Kampala in Uganda, for example, households are faced with a lack of private latrines alongside a shortage of affordable clean water or the means to boil it. This results not only in diarrhoea and water-borne disease outbreaks, but the need for residents to take small quantities of antibiotics regularly. Despite this contributing to antimicrobial resistance, they are left with little choice, as many residents rely on daily work to feed their families, which they are unable to do if they face longer illnesses. It is these kinds of communities that currently face the most urgent threat of resistance.
So it is not only a big problem, it is also an unfair one. But maybe not for long. Antimicrobial resistance will soon balloon and reach across the globe to endanger the boy with a broken ankle who needs minor surgery in the UK, the young woman in Chile who needs antibiotics to prevent infection whilst undergoing surgery for complications during birth, and the farmer in Malaysia who has caught a viral infection on his pig farm. All might die without
access to effective antimicrobials.
Given the scale of the challenge and the fact that most of the issue is attributable to our collective actions, surely coercive measures to protect antimicrobial effectiveness are ethically warranted?
Building on the harm principle
Luckily, the harm principle can be backed up by other ethical principles often used in public health. One of these is the “duty of easy rescue”. You may have heard of the philosopher Peter Singer’s drowning child thought experiment. It goes like this: There is a child drowning in a pond outside my office. I walk past, and think to jump in to save the child, but this will ruin my new suit. Do I have a moral duty to save the child, anyway?
Many of us share the intuition that there is a moral duty to save the child. That’s based on two factors. First, if we weigh the harm to the child against the harm to the office worker, ruining a suit seems like a tiny sacrifice compared to the child’s death. Second, if we think about the harm to the office worker alone, a ruined suit doesn’t seem like an unreasonable harm to bear.
The duty of easy rescue can be applied to preventing antimicrobial resistance, too. Many restrictions require only small sacrifices for people, like suffering from symptoms of a mild sickness for a few extra days – equivalent to ruining the suit – for the sake of large benefits to others through continued antimicrobial effectiveness – equivalent to the child’s life being saved.
How does this build on the harm principle? When considering this ethical justification, the harms or benefits to others don’t need to be as direct. In fact, Peter Singer’s original point was that there is no moral difference between saving the drowning child and donating to a charity to alleviate poverty in another part of the world where a child is starving.
The duty of easy rescue says more about what level of sacrifice we should be prepared to make – small, reasonable sacrifices. If we already have a duty to suffer from our mild sickness for a few extra days, then it might be ethically acceptable for a government to coerce us into doing so by stopping doctors from prescribing antibiotics for mild illnesses.
Still, this ethical justification seems to miss something important. Most of the people we’re talking about who will suffer from antimicrobials being ineffective are not drowning now. They are our future selves, or future people. They are statistics on the WHO website. In the western world, they are only occasional deaths – a high-profile case every now and then of mortality from a resistant pathogen, like the four deaths in the US in May from drug-resistant bacteria found in eye-drops that were later recalled. But there is no recalling all of the hospital walls and beds, the waterways, the meat and plants that we consume that carry resistance. Recalling products cannot prevent the full development and spread of resistance. It is our actions that will save others.
The question is, what do we owe current and future people suffering the outcomes of antimicrobial resistance that could justify governments coercing us – and not just briefly, but with regulations that, to be effective, might need to continue for a long time?
A hidden emergency
Antimicrobial resistance isn’t the only slow-moving, complex threat to human health. Our understanding of climate change and its human causes has been developing over recent decades. At the same time, sea levels have been rising, natural disasters have become more frequent and more diseases with animal origins have been spreading in biodiverse areas – all excruciatingly slowly.
The case is a little different for antimicrobial resistance, because individual uses of antibiotics can contribute significantly to the development of resistance. But there are some parallels we can draw. The worst effects of both of these crises will be felt by future generations in countries in the global north, and are already being felt by people in the global south. There is not as much conflict between existing individuals’ interests. My current use of an antibiotic in the UK is unlikely to make someone else currently on the other side of the word suffer from a resistant disease. But it will contribute, incrementally or probabilistically, to the emergence of a resistant strain of a virus or bacterium.
Ultimately, the effects of all our individual uses over time – and especially larger-scale misuses by agricultural and pharmaceutical corporations – will lead to future people around the world suffering the devastating effects of antimicrobial resistance.
It would seem, then, that the harm principle and the duty of collective easy rescue aren’t alone sufficient as ethical justifications for protecting future people through coercion. We need a final addition to our set of principles: intergenerational justice. This points to the moral responsibility we bear toward future generations, regardless of when they are born (already or in the future). Governments should consider benefits to their future citizens just as valuable as the same benefits to their current citizens. If we are presented with an exchange between someone suffering from a mild sickness and saving a life from drug-resistant sepsis acquired during routine surgery, it’s only fair to accept the mild sickness. That applies even if that sickness is now and the drug-resistant sepsis is in 50 years.
To help us do the fair thing, states might be justified in coercing us or doctors to make us accept the mild sickness. The same goes for preventing farmers from using critically important antibiotics to prevent infections in livestock.
This might make sense philosophically, you might say, but what about the real world? One final concern might be that states are limited in what they can do without a democratic mandate. To what extent can states do what is best for human health if it is not popular with voters, if it is considered overreach? In reality, state coercion alone cannot solve the problem. The public needs to know more about the risks to themselves and their children from antimicrobial resistance. They need to be informed of the size of the problem: exceeding Covid-19, exceeding HIV and malaria combined, perhaps even exceeding cancer deaths by 2050. It is true that states need public support for their actions, but the public voice must be informed to ensure we weigh liberty infringements against the harms of antimicrobial resistance accurately.
Some of the sourdough bread bakers among us might not be inclined to comply with the coercive measures needed to address antimicrobial resistance. Others will challenge any new restriction, just as they did with quarantine and social distancing, measures taken against the more immediate threat of Covid-19. But reacting to significant threats – whether chronic or immediate – is the very reason for coercive state action, and for further public education surrounding antimicrobial resistance.
If we are going to stop the superbugs, we need to accept some restrictions to our freedoms, and we need to do it now.
This article is from New Humanist's autumn 2023 issue. Subscribe now.
