Antimicrobial prescribing matters: the irreconcilability in moral ranking systems

Abstract

Antimicrobial resistance caused by widespread use of antimicrobials is a defining challenge of our time. This article presents antimicrobial prescribing among physicians as a morally irreconcilable endeavour. Particularly, the physician may have no good option when antimicrobial resistance is seen as both (1) a global threat to be addressed at the population level, and (2) a threat to the individual patient to be addressed in clinical practice. This research demonstrates that in practice, the physician is presented with an irreconcilable dilemma between caring for the population or caring for the individual. The author utilizes an extended ethnographic case study of infectious disease specialists to show that physicians are pressured to use antimicrobials more responsibly for the benefit of society, yet at the same time treat the individual patients with care by administering the most effective and appropriate agents. The author concludes by suggesting that there is no straightforward answer for the practicing physician, since what ultimately matters is unlikely to satisfy either moral ranking system.

Keywords:

• Antimicrobial prescribing
• antimicrobial stewardship
• moral economy
• moral ranking system
• population health

Acknowledgements

The author would like to thank the Wenner-Gren Foundation for Anthropological Research and the Department of Anthropology at Washington University in St. Louis for their support. Thank you also to the anonymous reviewers for their thoughtful and considerate comments. The following colleagues provided valuable feedback throughout previous drafts of this manuscript: Dori-Michelle Beeler, Yulia Egorova, Heather Reisinger, Brad Stoner, Talia Dan-Cohen, and Carolyn Barnes.

Ethical approval

This research is conducted under Institutional Review Board (IRB) protocol #16-072 at Cook County Health and Hospitals System, approved for data collection during the period 2017-2018.

Disclosure statement

The author acknowledges no conflict of interest.

Notes

1 This is a pseudonym, as are all names mentioned in this extended ethnographic case study.

2 Physicians often refer to antibiotics as in common parlance. When participants used the term antibiotics, that language is unchanged in this text. Otherwise, antimicrobials are used in this article to refer to the broad group of not only antibacterial medications but also antifungal medications used commonly in hospital practice and targeted by antimicrobial stewardship.

3 Laidlaw introduces some distinctions between ethics and morals (2014) but also acknowledges that “for the most part it may be assumed that these words are interchangeable” (4). Since ethics is used primarily in the referenced text, I will continue with Laidlaw’s use when referencing his work.

4 While the second moral ranking system may also apply to veterinary practice, here I am focusing on antimicrobial use in medical practice with human patients.

5 Though resident physicians and physician fellows both are technically in possession of medical degrees, it was common practice (and in accordance with rigid medical hierarchies) to use their first names while with the physician team. Only the attending physician was regularly referred to as “Doctor” by other members of the team. Significantly, this naming practice did not carry over to nursing personnel, patients or their families, or other healthcare professionals in the building.

6 Typing up my fieldnotes at the end of the day corresponded to the hours that residents and physician fellows spent typing up their visitation notes and recommendations for the patients on the consult list. Fellows would relay to me that on long days they would continue with typing patient notes into charts until 11pm. Infectious disease specialists would then open up the completed chart note and sign off (or make changes and then sign off).

7 Infectious disease specialists often worry about patients spreading antimicrobial resistance by moving frequently between several medical institutions, thereby creating a regional network of antimicrobial resistant infections.

8 Other potential harms from antimicrobial use could include allergic reactions, antibiotic-associated diarrhea, the high cost of some antimicrobials. In this case, the patient was not expected to live long enough to be at significant risk for these harms. Additionally, the patient’s costs were covered at this institution.

Additional information

Funding

This work was supported by the Wenner-Gren Foundation for Anthropological Research under grant # 9557.

Notes on contributors

Katharina Rynkiewich

Katharina Rynkiewich, PhD, is a sociocultural anthropologist studying the rise of antimicrobial resistance in the United States. Dr. Rynkiewich utilizes hospital ethnography to grapple with the tensions, conflicts, and struggles of infectious disease practitioners as they aim to implement antibiotic control policies and influence the antimicrobial prescribing practices of other physicians in American medical institutions. She is currently a Postdoctoral Scholar in Anthropology at Case Western Reserve University.