Research Article: Impartiality and infectious disease: Prioritizing individuals versus the collective in antibiotic prescription

Date Published: March 25, 2019

Publisher: Taylor & Francis

Author(s): Bernadine Dao, Thomas Douglas, Alberto Giubilini, Julian Savulescu, Michael Selgelid, Nadira S. Faber.


Background: Antimicrobial resistance (AMR) is a global public health disaster driven largely by antibiotic use in human health care. Doctors considering whether to prescribe antibiotics face an ethical conflict between upholding individual patient health and advancing public health aims. Existing literature mainly examines whether patients awaiting consultations desire or expect to receive antibiotic prescriptions, but does not report views of the wider public regarding conditions under which doctors should prescribe antibiotics. It also does not explore the ethical significance of public views or their sensitivity to awareness of AMR risks or the standpoint (self-interested or impartial) taken by participants. Methods: An online survey was conducted with a sample of the U.S. public (n = 158). Participants were asked to indicate what relative priority should be given to individual patients and society-at-large from various standpoints and in various contexts, including antibiotic prescription. Results: Of the participants, 50.3% thought that doctors should generally prioritize individual patients over society, whereas 32.0% prioritized society over individual patients. When asked in the context of AMR, 39.2% prioritized individuals whereas 45.5% prioritized society. Participants were significantly less willing to prioritize society over individuals when they themselves were the patient, both in general (p = .001) and in relation to AMR specifically (p = .006). Conclusions: Participants’ attitudes were more oriented to society and sensitive to collective responsibility when informed about the social costs of antibiotic use and when considered from a third-person rather than first-person perspective. That is, as participants came closer to taking the perspective of an informed and impartial “ideal observer,” their support for prioritizing society increased. Our findings suggest that, insofar as antibiotic policies and practices should be informed by attitudes that are impartial and well-informed, there is significant support for prioritizing society.

Partial Text

Antimicrobial resistance (AMR) is a global public health disaster with significant human and economic costs. Yearly estimates of the human lives lost to resistant infections have reached 700,000 people globally (O’Neill 2016) and are expected to exceed 10 million lives per year by 2050 if no actions are taken against AMR (O’Neill 2016). Patients with resistant infections are more likely to develop complications, and are up to three times more likely to die than patients with nonresistant infections (Cecchini, Langer, and Slawomirski 2015). In the United States alone, AMR accounts for 20 billion USD in excess health service costs annually (Smith and Coast 2013).

One hundred and sixty-three U.S.-American participants took part in our survey online via Amazon MTurk. Five participants were excluded from data analysis because they failed attention checks or did not complete the survey, leaving a total N of 158. We analyzed the data using SPSS software, checking for differences depending both on context (generic doctor vs. own doctor) and on case (general health case vs. AMR).

Which public attitudes should inform medical policy and practice? As mentioned in the preceding, ideal observer theory suggests that if public attitudes are to be given a role in determining or evidencing the ethical acceptability of medical policies and practices, we should seek the attitudes of better informed and more impartial observers. Our study suggests that those observers are likely to be more sympathetic to withholding antibiotics than the attitudes of less well-informed individuals taking a more self-interested perspective.

Our study provides empirical data on attitudes to antibiotic prescription of the wider public—rather than patients awaiting their consultation. It is also the first to examine the sensitivity of attitudes to awareness of AMR risks and to presentation of scenarios in terms of the first or third person, and to ask people about the trade-off between individual interests and society’s interests. We found that participants were significantly more willing to prioritize society when they were made aware of AMR risks and when they were presented with scenarios framed in the third person. We found significant associations between the OUS and prioritizing society over self, which probably reflects a greater orientation to impartiality.

All authors contributed to conception, design, and drafting of the article. In addition, Bernadine Dao collected the data and wrote a first draft of the article and Nadira Faber analyzed the data.


Ethics approval was granted from the Social Sciences & Humanities Inter-Divisional Research Ethics Committee (IDREC) of the University of Oxford on June 30, 2017 (reference number: R52226/RE001). A Confirmation of Registration was also granted from Monash University Human Research Ethics Committee (MUHREC) on July 17, 2017 (project number: 9973).




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