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Ethical dilemmas in antibiotic prescribing across different country-specific contexts

November, 2019

An exploration of contextual factors that shape country-specific challenges for antimicrobial stewardship programs 1


An important aspect of antimicrobial resistance (AMR) considered here is the ethical and social dilemma faced by doctors in balancing the interests of individual patients against the collective interests of future patients, which includes preserving the resource of antimicrobial efficacy.


This article describes three example countries with different economic backgrounds and cultures – South Africa, Sri Lanka and the United Kingdom, and discusses how country-specific factors impact on various ethical dimensions of the dilemma, including:
  • Visibility and moral equality of future generations.
  • “Rule of Rescue”.
  • Prescribing autonomy and conflicts of interest.
  • Consensus on collective action.

Key findings
South Africa

  • South Africa is classified as a middle-income country but healthcare inequalities are amongst the highest in the world.
  • AMR is an increasingly visible medical problem, and one that contributes to high rates of hospital-acquired infections.
  • As a result, there has been a concerted effort with the South African Antibiotic Stewardship Programme (SAASP) to implement stewardship programmes, supported by the department of health in the promotion of appropriate antibiotic use.

Sri Lanka

  • Sri Lanka is a middle-income country with free hospital care as well as an important private hospital sector – there is limited public primary care provision. Over-the-counter dispensing of antibiotics is not uncommon.
  • Antibiotic prescribing guidelines were issued in 2016 and coordinated initiatives promote antibiotic stewardship.
  • In contrast with the South African situation, little awareness exists amongst doctors about the problem of AMR. This is exacerbated by a limited choice of antibiotics and distrust in the efficacy of cheaper unbranded versions, resulting in prescribing higher doses of these antibiotics or multiple antibiotic types.

United Kingdom

  • The UK is a high-income country with public-funded healthcare. Antibiotic prescribing levels are in the mid-range (similar to other European countries) but an increase in antibiotic use has been observed despite overall hospital admissions decreasing.
  • Antimicrobial stewardship initiatives began in 2009 with more comprehensive guidelines issued in 2011 (‘Start Smart—Then Focus’ guidelines).
  • In the UK, doctors experience a lower impact of AMR than doctors in South Africa and currently have few negative patient outcomes owing to multidrug-resistant infections, so the threat is more hypothetical. This can lead to over-diagnosis due to an overriding focus on prevention of mortality from sepsis and other infections.
  • These contextual factors are at odds with the imperative for equality across generations since the current threat of AMR is masked and there is a clear prioritisation of current patients in contrast with the right of future societies to the same antibiotic treatment options as available to previous generations.

The “Rule of Rescue”, i.e. the doctor’s concern for immediate patient needs, also contributes to the ethical dilemma differently according to national context – in contrast to the UK where severe sepsis is frequently overestimated, in Sri Lanka many patients present to hospital very late and only once the infection has reached a dangerous stage. Prescribing autonomy and collective action also have different impacts, with a more defined approach in South Africa than in Sri Lanka and the UK. This probably reflects the fact that doctors in South Africa do not have to imagine the future generations whom they have a moral duty to protect from the consequences of AMR.


Better understanding of national prescribing dilemmas is critical to inform the design of effective stewardship approaches.


  1. Crockaw EM, Tarrant C. The international dimensions of antimicrobial resistance: Contextual factors shape distinct ethical challenges in South Africa, Sri Lanka and the United Kingdom. Bioethics. 2019 Jul 2. doi: 10.1111/bioe.12604. [Epub ahead of print].

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