Current Events

Antibiotic Resistance and Collective Harms

[Editor’s Note: The following is a guess post by Jonathan Anomaly of Duke University]

A few weeks ago The Economist made antibiotic resistance its cover story, and for good reason.  We live in a bacterial world.  The average person hosts about 39 trillion bacteria.[1]  Lucky for us, most bacteria are benign – they crowd out pathogenic bacteria like e. coli in our gut, staph on our skin, and strep in our mouth.  Even pathogenic bacteria usually do us no harm unless they invade our bloodstream or otherwise find their way into parts of our bodies that our immune system is poorly equipped to deal with.  Some bacteria even confer benefits by priming our immune system to distinguish friend from foe during crucial stages of our early childhood development.  For this reason, altering our children’s microbiome by giving them antibiotics every time they have a cold can make them more susceptible to a host of disorders ranging from allergies to autoimmune diseases.[2]

Since nobody wants their children to suffer from these conditions, as more information about the microbiome emerges, it is likely that parents will use antibiotics more prudently on themselves and their children.  Parents may even decide to expose their children to microbes that their immune system has evolved to anticipate, but which are often absent in the sterile environments in which citizens of wealthy countries find themselves.  These are the easy cases.

The hard cases involve antibiotics and collective harms.  When patients use antibiotics to treat themselves for problems like viral infections which they lack the power to cure, they get the trivial psychological benefit of (falsely) believing that something has been done to hasten their recovery.  When farmers use antibiotics to speed the growth of animals raised on factory farms, they benefit by bringing their animals to slaughter just a little more quickly, while consumers benefit by paying a little less for animal protein.  But since we share a microbial environment, and since the more we use antibiotics the more likely bacteria are to evolve resistance, we all face an increased risk of being infected by antibiotic-resistant bacteria that are difficult or impossible to treat.  According to the newly published British Review on Antimicrobial Resistance, an estimated 700,000 people die every year of resistant infections, and the number is expected to increase in the coming decades.

Libertarians are rightly skeptical of government intervention in many arenas of life.  But some collective harms are so grave, and the alternatives so grim, that governments should do something.

So what should they do?  One of the least controversial moves governments can make is to require a prescription by physicians before consumers can take antibiotics, and before farmers can administer them to livestock.  As I’ve argued elsewhere, antibiotics are probably the only drug that should require a prescription, since unlike almost any other drugs, the widespread use of antibiotics can impose severe public health risks in the form of antibiotic-resistant bacteria.  Yet many governments around the world impose draconian penalties on the use and sale of recreational drugs, while allowing over-the-counter sales of antibiotics.

A more controversial (but I think appropriate) move is for governments to impose Pigovian taxes or, more modestly, user fees on the use of antibiotics.  The rationale is that we should curb the low-value consumption of antibiotics, and use the revenue generated by a fee to compensate victims or facilitate the development of new ways of diagnosing and treating bacterial infections, especially those resistant to existing antibiotics.  In particular, revenue from user fees could be used to fund basic science research, which often leads to scientific insights that are not patentable, but which have tremendous social value that pharmaceutical firms can translate into novel treatments.

Hayek showed why we should use prices rather than government dictates to allocate scarce resources when externalities are minimal.  But what about cases in which prices don’t reflect most of the social costs and benefits of our consumption choices?  Jason Brennan and Jessica Flanigan have written compelling papers about why libertarians should support some vaccine mandates.  We should worry about antibiotic resistance for the same reasons.  If libertarians ignore these issues, the “solutions” that emerge in policy debates may be worse than the problems they are supposed to solve.

 

[NOTE: parts of this post are adapted from a forthcoming paper for the Georgetown Journal of Law and Public Policy]

[1] Ron Sender, Shai Fuchs, and Ron Milo (2016). “Revised estimates for the number of human and bacterial cells in the body” (BioRxiv preprint) doi: http://dx.doi.org/10.1101/036103

[2] For an engaging overview of these claims, see Martin Blaser (2015). Missing Microbes: How the overuse of antibiotics is fueling our modern plagues. (New York: Picador-MacMillan), and Moises Velasquez-Manoff (2013). An Epidemic of Absence: A new way of understanding allergies and autoimmune diseases, (New York: Scribner), 2013.

 

Published on:
Author: Matt Zwolinski
  • IEIUNUS

    Suppose a foreign country with a large population refuses to effectively regulate the use of antibiotics, creating for citizens of other countries as well as theirs, a morally relevant negative externality. Would the other countries have a right to prevent the harm to others by invasion or some other means that would otherwise be considered a violation of national sovereignty?

    It seems, by your argument (and perhaps just as well for Joel Feinberg), that the harm caused by the unregulated use of antibiotics, as serious as it appears, justifies restricting the liberty of inconsiderate (or perhaps incompetent, but I believe a country refusing help for regulating antibiotic use is more interesting) governments to consider their own affairs as they see fit.

    • TheBrett

      I think the other countries would definitely have grounds to take precautions regarding the refusenik country, including requiring all visitors from that country to get health screenings and the like.

      • Anomaly

        I agree with both of you. Some states whose citizens are using antibiotics in a reckless way, such as India, are beginning to change their policies and push information campaigns about the risks of overusing antibiotics. But in other cases, such as Pakistan and China, the use of antibiotics is skyrocketing, and they are ground zero for extensively drug resistant infections. In the last few months a new plasmid (mobile strand of DNA that can be shared by different species of bacteria) that is resistant to nearly all antibiotics was found on a Chinese pig farm, then in a Chinese hospital, then in a patient in an American hospital a few weeks later. Similar patterns are emerging for tuberculosis, gonrrhea, staph, and many other bacterial infections.

    • Matthew LeBar

      Well, one could certainly think that while we would be justified in restricting the liberty of other governments by very small extents (if such actions are possible) but not in full-blown invasion.

      One could also reasonably think that inter-state relations have different moral requirements from inter-personal moral requirements, if for no reasons other than practicality. It seems like a stretch to say that the case Zwolinski makes commits him to allowing the restricting of other governments.

    • King Goat

      “Invasion?”

  • j_m_h

    “Libertarians are rightly skeptical of government intervention in many arenas of life. But some collective harms are so grave, and the alternatives so grim, that governments should do something.”
    But isn’t a real question to address here why is that something government needs to do rather than it being something private industry could solve? In other words, what makes this a market-failue case?
    I’m not disagreeing with there bring a problem but just owndering if this isn’t just another of those “There ought to be a law” type repsonses to a situation where as what might be a more libertarian approach would be “this might be a solution” response.

    • Anomaly

      I think the best thing to do is recognize that less coercion is better than more, and we should go with the lowest cost solution that infringes liberty least. This may, however, require some policies that disincentivize the socially dangerous uses of antibiotics. Antibiotics are like guns. Great when used for some purposes, especially for those who use them, but bad when used for other purposes, especially when they kill people or impose uncompensated harms on those who did not have a chance to consent.

      Guns do this if we randomly fire them in the air in a crowded city.

      Antibiotics do this when enough people use them recklessly so that they predictably create resistant bacteria.

      Some of these bacteria are just more expensive to treat, others are impossible to treat and kill us. Most people are rationally ignorant of the problem, since their own actions only create probabilistic costs, most of which are borne by other people. Others just don’t care. But not knowing or caring about the externalities of their actions doesn’t mean they have the right to continue harming the rest of us.

      • j_m_h

        But this is not answering the question.

        Moreover, most people are rationally ignorant of most efforts at innovation that have lead to the improvements in living standards and those innovation were still managed without direct government action to produce the results. So the mere ignorance by many of the external effect is not sufficient to claim government is the proper mechanism to resolve the problem.

        And, yes, we all have some rights to harm others via externalities so the problem is correctly identifying which are part of the necessary costs of living in the world we do and which need to be addressed. I’d not argue that the problem with antibiotics isn’t one we should be concerned about and looking for solutions to avoid the costs created. It’s something that’s been known in public discussion and news stories — though admittedly probably not something most paid attention to — for at least 20 years.

        I think it’s important to ask the question I did because we know that centralization is not a solution to eliminate (and possibly not even reduce) the externalities generated in social interactions. All we’re can be certain of (and if any has pointers to literature that is fairly easily accessible by nonacademics I’d be interested) is that it will chance who how those cost are distributed within society.

      • geoih

        “But not knowing or caring about the externalities of their actions doesn’t mean they have the right to continue harming the rest of us.”
        You mean like having the State forcefully interfere with voluntary societal and market interactions?

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  • Theresa Klein

    I had thought of an answer for this a while back: intellectual property.
    IMO, what we should do is extend patent rights over antibiotics until the antibiotic is no longer effective. No generic antibiotics, either. This gives the patent holder an incentive to preserve the effectiveness of the anti-biotic as long as possible. I think this would result in the patent holder limiting who many prescibe the anti-biotic and requiring some sort of contractual arrangement with doctors wherein they agree to prescribe the medication only under certain circumstances. It would also mean that the patent holder could refuse to sell it for routine use on farm animals.

    The problem right now is that there is no financial incentive NOT to prescribe an anti-bioltic. The benefits of keeping the antibiotic viable have to, in some way, flow back to doctors and pharmaceutical companies that develop them. Extending intellectual property rights accomplishes that for the pharmaceutical companies and a schema in which doctors right to prescribe is limited by contract accomplishes that for doctors. If there’s a threat of losing access to the best anti-biotics, many doctors will begin to preciously guard their right to prescribe those medications for fear of losing the wealthiest patients.

    • Jerome Bigge

      The holders of the “intellectual property” in question are the drug companies who make the product and profit from its sale. Corporations are responsible (legally) to their stockholders. Unfortunately the majority of stockholders consist of people who obviously are only concerned with the value of the stock and the dividends they earn as stockholders. They would also be the first ones who would file lawsuits should the corporation start behaving in a manner that would reduce the value of their stocks and the dividends they collect.

      Reduced use of antibiotics and other drugs in animal husbandry would likely at least “correct” some of the problem. However the price of meat would rise (law of supply and demand) and that would likely be “political suicide” for any political party who tried to make it happen. Remember there are a lot of people involved in the present status quo and they aren’t going to vote against their own “interests”.

      • Theresa Klein

        The point is to connect future interests to present interests. There are all sorts of financial instruments for doing that if you can actually count on future profits in preserving the life of an antibiotic. If stockholders and corporations don’t see any profit in maintaining the viability of an antibiotic in the future, then we need to figure out why that is. If it is because they won’t have intellectual property rights to it in the future, then that is a problem that can be solved. If it is because they lack the contractual right to prevent doctors from overprescribing, that is a problem that can be solved.

        Instead of throwing up our hands and resorting to government coercion, it helps to think about what peoples interests are, and why the people performing a given activity don’t have a financial interest in the consequences of that activity.

        • Adam Bowers

          “If it is because they lack the contractual right to prevent doctors from overprescribing, that is a problem that can be solved.
          Instead of throwing up our hands and resorting to government coercion”

          Forgive my ignorance (really), wouldn’t creating a law preventing doctors from over prescribing be a government coercion? Or is it different because we are granting a right to the IP holders? Thanks.

    • Anomaly

      This was my first reaction too, and it might work, but most people working on the problem now doubt it (for reasons you can find in the literature). There’s also a worry that if we extend patents too long, or forever, that companies can charge just about any price they want, even if another firm would have invented the same drug a few years later and charged a lot less.

      One slightly different approach in the spirit of your proposal is so-called wildcard or transferable patent extensions, whereby pharma firms are allowed to extend the patent on their drug of choice for a few years if they develop a new priority antibiotic. But this seems unfair to consumers of whatever product would have gone off patent but no longer will because they get to extent their patent and keep prices artificially high. It also invites public choice problems whereby bureaucrats will be infiltrated by pharma reps who help determine which antibiotics should be given priority, how long patent extensions last, etc.

      The complications of lots of different proposals that have been made have led me to the conclusion that better diagnostics and treatments, as well as new vaccines, will be the best way to approach the problem. Some of these will emerge in a free market. But they depend on scientific breakthroughs in basic science research that companies rarely make because they can’t patent them. That’s why I tend to support at least a bit more government support for basic science research related to genetics, and bacterial evolution and resistance.

      • Theresa Klein

        I would say that paying higher prices for antibiotics today is really a cost of preserving the antibiotic for the future. You’re paying a premium now to reduce your risk of having an untreatable infection later. I see no reason why that cost shouldn’t fall on the users of antibiotics today. Consider that the more antibiotic resistance develops, the more expensive the still-useful antibiotics will become in the future. Extending patent rights means that costs will be shifted from future users to present users, which is exactly as it should be.

        To avoid rent seeking, I would set a uniform mechanism that governs when the patents expire, which is why I proposed making it dependent on some threshold of effectiveness. If the antibiotic is overprescribed and resistance develops, then the government would yank the patent, effectively punishing the patent holder for allowing resistance to develop. (Of course this demands the patent holder have some legal means to control distribution).

    • King Goat

      Theresa, a very neat idea. My hesitation is that the “some sort of contractual arrangement with doctors wherein they agree to prescribe the medication only under certain circumstances” is likely going to be heavily influenced by who pays what rather than any idea of medical necessity.

  • Jerome Bigge

    The majority of antibiotics (70% to 80%) are used in “animal husbandry” (Concentrated Animal Feeding Operations). They do this because continued doses of antibiotics changes the intestinal flora and causes weight gain. Growth hormones and steroids such as Prednisone are also used in gross amounts to make animals grow faster and increase appetite (I have personal experience with Prednisone) so they fatten up quicker. All in the name of profit. These “farms” exist in rural areas where Republicans usually enjoy majority status. Which is the case here in Michigan which has numbers of these “animal husbandry” operations. These drugs also pass through the animals in their “wastes” and end up in the environment where they create bacterial immunity and also enter in the food change and the water people drink. Not that the conservative politicians elected from these areas care that much as they are well aware what the “source” of much of their campaign funds comes from. In a state such as Michigan those who are concerned about these issues simply are ignored by the Republican majorities in state government. Our current administration here in Michigan has little if any concern for human welfare. Otherwise issues such as “lead” in drinking water (as is the case in Flint) would never have happened if “dollars” weren’t seen as being more important than human welfare… So you see the “aggression” of the politically powerful against the rest of us is part and parcel of what both of our major political parties do today. It may be “throwing away your vote” to vote for Gary Johnson, but neither Clinton or Trump is going to do anything about government aggression against the American people.

    • Anomaly

      Yep, this is all correct. The FDA is actually beginning to regulate this, or at least threatening to do so, which has already reduced use in the US in the last couple of years. Europe has dramatically reduced use in the last decade. The problem is that developing countries like China, Pakistan, and Egypt make our factory farms look humane in comparison, and antibiotic use is skyrocketing, as populations expand and factory farming increases. Factory farming is impossible without antibiotics. The animals would all get infected and die. So solutions are complicated, and Europe seems to have gotten this one right by banning antibiotics as growth promoters, and ensuring at least minimal animal welfare standards (in the US, farm animals are exempt from ALL federal animal welfare standards, so goldfish have more protection than pigs, which means it’s legal in most states to cram animals together in the kinds of inhumane conditions that require antibiotics for them to stay alive without infecting each other).

  • stevenjohnson2

    I think the real issue here for libertarians is confronting the biological demonstration that the libertarian notion of individuality is false to nature, or metaphysical, or absurdly idealized, or ideological, or delusional, however you put it. When libertarianism has a problem with disease control, it is a powerful symptom of something really, really wrong with the whole system of ideas.

    May I suggest political philosophy, at least that which may be of interest (use even?) to broader areas of the population, should be about how people should interact with each other in a feasible way of life? Approaching it as an analysis of how to incentivize people to live up to an imaginary ideal seems not just incompetent, but morally perverse.

    • Theresa Klein

      May I suggest political philosophy, at least that which may be of interest (use even?) to broader areas of the population, should be about how people should interact with each other in a feasible way of life?

      You mean like the idea that we should respect one another’s autonomy and individuality and engage with them only via voluntary mutually beneficial exchanges? Does that count as a way of interacting with one another that makes for a feasible way of life?

      • stevenjohnson2

        Briefly, no.

        As the biology of antibiotic resistance demonstrates, your notion of our “autonomy” and individuality is invalid. We have involuntary interactions that a priori principles drawn from some library cannot cover. You weren’t born living by voluntary mutually beneficial exchanges. The claim that somehow we can live by them is vain pretense.

        • Theresa Klein

          The question is not whether you think libertarianism WORKS, it whether it is ABOUT “how people should interact with each other in a feasible way of life”.

          • stevenjohnson2

            Since your answer is wrong, it’s hard to see how your objection is relevant.

  • martinbrock

    The problem with this argument, and with the similar argument for vaccine mandates, is your vague allusion to “governments”. You say, “Governments should require a prescription for antibiotics to limit their use” and “governments should mandate vaccines.” You seem to intend, “All governments should …” In other words, you’re saying, “A single government over the entire Earth should …”

    A single government over all of humanity regulating antibiotics and vaccines raises many questions beyond the specific questions involving antibiotics and vaccines. Even if I take everything you say about antibiotics for granted and also accept your prescription for a remedy, why would I confuse our enlightened opinion with the will of a single government over all of humanity?

    Libertarians don’t oppose governments. We rather advocate government by free association, so subjection to a government is a choice of individuals with many, practically unlimited choices. The government of a free community may restrict antibiotics and mandate vaccines among their subjects, without violating any libertarian principle, because membership in the community is voluntary; however, we can’t expect every community to regulate medicines identically, and some communities may not regulate them at all.

    The question is: are you content with persuading a variety of governments to regulate medicines as you think best and to live with the variety of regulations that many governments, subjugating people only through free association, enact, or do you imagine yourself the monarch of a global superstate imposing regulations on all communities everywhere? If the latter, how do you propose to impose these regulations? Are you monopolizing nukes and threatening to nuke recalcitrant communities or what?

    • Anomaly

      All governments should have certain minimal mandates, such as prescription requirements, and should not allow people to do anything they want with a drug that directly affects other people’s health. But we should certainly not cede our power to a world government. A voluntary international treaty, though, might help each nation overcome some free riding by other nations. The overall point is that this is one of the few externality problems that don’t have an obvious or cost-free solution that markets will inevitably converge on.

      • martinbrock

        Suppose the largest, sovereign jurisdiction on Earth is 10,000 square kilometers (roughly Los Angeles county). An individual may at will leave any jurisdiction to join another jurisdiction on terms agreeable to the second jurisdiction, but these microstates are otherwise fully sovereign. Treaties between jurisdictions exist, but the only enforcement of a treaty involves refusal to trade with a jurisdiction violating its terms.

        Are minimally sufficient mandates possible with this degree of devolution of power, or do externalities impose unacceptable costs unless states are larger and/or mobility between states is less?

      • JCL

        “The overall point is that this is one of the few externality problems that don’t have an obvious or cost-free solution that markets will inevitably converge on.”

        State-free law is part of “markets”, and it would “inevitably converge on” torts (class actions?) against those uses of antibiotics that, in the long run, impose greater negative externalities than restrictions of such uses would. In the absence of fully functioning state-free law, government legislation can be a second-best approximation.