Antimicrobial resistance is a major and increasing problem globally. Economics has engaged with this issue increasingly over the last 20 years. Much of this concerns assessments of the cost of various forms of resistance, but it also includes economic analyses of interventions and policies designed to contain resistance. Analysis has, however, thus far largely neglected possible distributional issues associated with such interventions and analysis. The article explores three normative bases for the conduct of economic analysis: welfarism; extra-welfarism focused on health (...) gain; and extra-welfarism focused on capability assessment. It then considers issues intrinsic to antimicrobial resistance in terms of the distributional implications and how these might be handled within economic analyses from each of the normative perspectives, before considering the actual focus of empirical studies on these distributional issues. The article concludes that the different normative starting points for economic analysis will affect how distributional issues are incorporated into analysis, but suggests that all analyses could benefit from greater discussion of these issues. (shrink)

'The Patient as Victim and Vector' is jointly written by four authors at the University of Utah with expertise in bioethics health law, and both clinical practice and public health policy concerning infectious disease.

Factory farming continues to grow around the world as a low-cost way of producing animal products for human consumption. However, many of the practices associated with intensive animal farming have been criticized by public health professionals and animal welfare advocates. The aim of this essay is to raise three independent moral concerns with factory farming, and to explain why the practices associated with factory farming flourish despite the cruelty inflicted on animals and the public health risks imposed on people. I (...) conclude that the costs of factory farming as it is currently practiced far outweigh the benefits, and offer a few suggestions for how to improve the situation for animals and people. (shrink)

See "What's Wrong with Factory Farming?" (2015) for an updated treatment of these issues.

Consisting of two essays, this work by a Harvard professor offers his thoughts on the idea of a social contract regulating people's behavior toward one another.

The problem of antimicrobial resistance is so dire that people are predicting that the era of antibiotics may be coming to an end, ushering in a ‘post-antibiotic’ era. A comprehensive policy response is therefore urgently needed. A part of this response will require framing the problem in such a way that adequately reflects its nature as well as encompassing an approach that has the best prospect of success. This paper considers framing the problem as a slowly emerging disaster, including its (...) potential benefits and difficulties, from a conceptual and policy perspective. (shrink)

ABSTRACT If we have a duty not to infect others, how far does it go? This question is often discussed with respect to HIV transmission, but reflection on other diseases like influenza raises a number of interesting theoretical issues. I argue that a duty to avoid infection not only yields requirements for persons who know they carry a disease, but also for persons who know they are at increased risk, and even for those who definitely know they are completely healthy. (...) Given the numerous ways in which human interaction facilitates the spread of communicable diseases, a maximum level of precaution would be very demanding – possibly unreasonably demanding. The ‘over‐demandingness problem’ is mostly invoked as a criticism of utilitarianism, as this theory requires moral agents to always maximise general welfare, even at significant cost for themselves. However, I argue that, with respect to precautions against infectious diseases like influenza, utilitarianism is able to avoid the over‐demandingness problem. A contractualist account, on the other hand, whilst able to explain how one's obligations to avoid infection can be limited, given that other persons have opportunities and responsibilities to protect themselves, in the end requires precautions that raise the over‐demandingness problem. (shrink)

ABSTRACT This paper reviews the dynamics behind, and ethical issues associated with, the phenomenon of drug resistance. Drug resistance is an important ethical issue partly because of the severe consequences likely to result from the increase in drug resistant pathogens if more is not done to control them. Drug resistance is also an ethical issue because, rather than being a mere quirk of nature, the problem is largely a product of drug distribution. Drug resistance results from the over‐consumption of antibiotics (...) by the wealthy; and it, ironically, results from the under‐consumption of antibiotics, usually by the poor or otherwise marginalized. In both kinds of cases the phenomenon of drug resistance illustrates why health (care) – at least in the context of infectious disease – should be treated as a (global) public good. The point is that drug resistance involves ‘externalities’ affecting third parties. When one patient develops a resistant strain of disease because of her over‐ or under‐consumption of medication, this more dangerous malady poses increased risk to others. The propriety of free‐market distribution of goods subject to externalities is famously dubious – given that the ‘efficiency’ rationale behind markets assumes an absence of externalities. Market failure in the context of drug resistance is partly revealed by the fact that no new classes of antibiotics have been developed since 1970. I conclude by arguing that the case of drug resistance reveals additional reasons – to those traditionally appealed to by bioethicists – for treating health care as something special when making policy decisions about its distribution. (shrink)

The issue of regularly feeding low levels of antibiotics to farm animals in order to increase productivity is often portrayed as a dilemma. On the one hand, such antibiotic use is depicted as a necessary condition for producing cheap and plentiful food, such that were such use to stop, food prices would rise significantly and our ability to feed people in developing nations would decrease. On the other hand, such antibiotic use seems to breed antibiotic resistance into pathogens affecting human (...) health. Resolving this dilemma, it is alleged, will require great amounts of research into risk/benefit assessment. Contrary to this claim, we will argue that society has all the data it needs to make a reasonable ethical decision, which would be curtailing such use. Such curtailment will not harm consumers significantly, will not harm developing nations'' evolving agriculture, and could produce hitherto unnoticed benefits, namely restoring the possibility of a more husbandry-based, sustainable agriculture to replace the high-tech agriculture that has hurt animals, the environment, small farms, and sustainability. (shrink)

This essay defends an account of the duties to the global poor that is informed by the empirical question of what makes countries rich or poor, and that tends to be broadly in agreement with John Rawlss account in The Law of Peoples. I begin by introducing the debate about the sources of growth and explore its implications for duties towards the poor. Next I explore whether (and deny that) there are any further-reaching duties towards the poor. Finally, I ask (...) about the moral foundations for the duties to the poor of the sort that earlier parts argue there are. (shrink)

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. (shrink)

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. (shrink)

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. (shrink)

n this paper, I argue that political solidarity is important to justice. At its core, political solidarity is a relational concept. To be in a relation of political solidarity, is to be in a relation of connection or unity with one’s fellow citizens. I argue that fellow citizens can be said to stand in such a relation when they have attitudes of collective identification, mutual respect, mutual trust, and mutual support and loyalty toward one another. I argue that political solidarity, (...) so conceived, is an integral element of a theory of justice. I argue that there are distinctly social bases for political solidarity and that justice requires that we promote these. Furthermore, as an example of the sort of social and political arrangements that might encourage political solidarity, I discuss Canada’s response to the recent H1N1 pandemic and the failings of this response with respect to members of the Aboriginal community within Canada. I argue that ensuring that members of the Aboriginal community had equal access to the goods they needed to protect themselves against H1N1 infection would have promoted relations of political solidarity and, in turn, would have promoted justice more effectively. (shrink)

Public health involves the use of power to change institutions and redistribute resources and deliberately to shape individual thought and behavior. This requires normative legitimation and demands ethical critique. This article explores concepts that are vital to public health ethics, but have been relatively neglected. These are membership, solidarity and the concept of place. The article argues that the practice of public health should recognize the equal rights of membership in communities of health justice. Public health should also rely on (...) a sense of obligation and mutual aid in a world of shared vulnerability and reciprocal recognition. Finally, public health achieves its goals not merely—and perhaps not most fundamentally—through information and altering the logical ratiocination of individuals or groups, but rather through the reformation of sense and sensibility. (shrink)

At the end of a thoughtful article on the future of nuclear war, Wiesner and York concluded that: "Both sides in the arms race are... confronted by the dilemma of steadily increasing military power and steadily decreasing national security. It is our considered professional judgment that this dilemma has no technical solution. If the great powers continue to look for solutions in the area of science and technology only, the result will be to worsen the situation.".

The incident in May-June 2007 involving a U.S. citizen traveling internationally while infected with drug-resistant tuberculosis involved the U.S. federal government's application of its quarantine and isolation powers. The incident and the isolation order raised numerous important issues for public health governance, law, and ethics. This article explores many of these issues by examining how the exercise of quarantine powers provides a powerful lens through which to understand how societies respond to and attempt to govern threats posed by dangerous, contagious (...) pathogens. The article considers historical aspects of governmental power to quarantine and isolate individuals and groups; analyzes the current state of quarantine and isolation law in the United States in light of the recent incident with drug-resistant tuberculosis; and explores global aspects of public health governance and law highlighted by this incident. (shrink)

Dramatic events involving dangerous microbes often focus attention on isolation and quarantine as policy instruments. The incident in May-June 2007 involving Andrew Speaker and drug-resistant tuberculosis joins other communicable disease crises that have forced contemplation or actual application of quarantine powers. Implementation of quarantine powers, which encompasses authority for both isolation and quarantine actions, is important not only for the handling of a specific event but also because the use of such authority provides a window on broader issues of public (...) health and the legal rules, ethical principles, and governance systems that support it. Debates about quarantine powers reflect political and social attitudes about public health that often tell us more about this policy endeavor than acts of isolation and quarantine themselves. (shrink)

What do we owe to our descendants? How do we balance their needs against our own? Tim Mulgan develops a new theory of our obligations to future generations, based on a new rule-consequentialist account of the morality of individual reproduction. He also brings together several different contemporary philosophical discussions, including the demands of morality and international justice. His aim is to produce a coherent, intuitively plausible moral theory that is not unreasonably demanding, even when extended to cover future people. While (...) the book focuses on developing this new account, there are also substantial discussions of alternative views, especially contract-based accounts of intergenerational justice and competing forms of consequentialism. (shrink)

Tyler conducted a longitudinal study of 1,575 Chicago inhabitants to determine why people obey the law. His findings show that the law is obeyed primarily because people believe in respecting legitimate authority, not because they fear punishment. The author concludes that lawmakers and law enforcers would do much better to make legal systems worthy of respect than to try to instill fear of punishment.

In bioethics, discussions of justice have tended to focus on questions of fairness in access to health care: is there a right to medical treatment, and how should priorities be set when medical resources are scarce. But health care is only one of many factors that determine the extent to which people live healthy lives, and fairness is not the only consideration in determining whether a health policy is just. In this pathbreaking book, senior bioethicists Powers and Faden confront foundational (...) issues about health and justice. How much inequality in health can a just society tolerate. The audience for the book is scholars and students of bioethics and moral and political philosophy, as well as anyone interested in public health and health policy. (shrink)

Is it fair to leave the next generation a public debt? Is it defensible to impose legal rules on them through constitutional constraints? From combating climate change to ensuring proper funding for future pensions, concerns about ethics between generations are everywhere. In this volume sixteen philosophers explore intergenerational justice. Part One examines the ways in which various theories of justice look at the matter. These include libertarian, Rawlsian, sufficientarian, contractarian, communitarian, Marxian and reciprocity-based approaches. In Part Two, the authors look (...) more specifically at issues relevant to each of these theories, such as motivation to act fairly towards future generations, the population dimension, the formation of preferences through education and how they impact on our intergenerational obligations, and whether it is fair to rely on constitutional devices. (shrink)

This Introduction tells the story of intergerational justice and how it has influenced philosophers and political thinkers throughout history. The Introduction goes on to discuss the aims of the book, which is to offer a sustained discussion of intergenerational justice as seen by practical philosophers. The first part of the book focuses on the way in which various schools of thought in moral and political philosophy approach the domain of intergenerational justice, while the second part focuses on more specific aspects, (...) such as how these theories address the question of motivation, how they deal with demographic fluctuations, or how they can be applied to real-world issues such as climate change. (shrink)