Why is optimisation of antimicrobial use difficult at the end of life?

The antibiotic optimisation imperative is now ubiquitous, with national policy frameworks in Organisation for Economic Co-operation and Development (OECD) countries incorporating the requirement for antimicrobial stewardship within healthcare services. Yet in practice, the optimisation agenda often raises complex ethical- and practice-based dilemmas. Antibiotic use at the end of life is multidimensional. It includes balancing complex issues, such as accuracy of prognostic estimates, benevolence to the individual versus the broader public health, personalised value judgement of time and quality of life and the right to treatment versus the right to die. It also occurs in an emotional context where the clinician and patient (and their family) collectively confront mortality. This provides a scenario where amplification of the already strong social and behavioural forces that drive overuse of antibiotics in many other clinical settings may occur. It therefore offers an important case for illustrating how antibiotic optimisation may be limited by social, value-based and ethical dilemmas.

Medicalising short children with growth hormone? Ethical considerations of the underlying sociocultural aspects.

In 2003, the Food and Drug Administration approved the use of growth hormone treatment for idiopathic short stature children, i.e. children shorter than average due to an unknown medical cause. Given the absence of any pathological conditions, this decision has been contested as a case of medicalisation. The aim of this paper is to broaden the debate over the reasons for and against the treatment, to include considerations of the sociocultural phenomenon of the medicalisation of short stature, by means of a critical understanding of the concept of medicalisation. After defining my understanding of medicalisation and describing both the treatment and the condition of idiopathic short stature, I will problematise two fundamental issues: the medical/non-medical distinction and the debate about the goals of medicine. I will analyse them, combining perspectives of bioethics, medical sociology, philosophy of medicine and medical literature, and I will suggest that there are different levels of normativity of medicalisation. Ultimately, this study shows that: (1) the definition of idiopathic short stature, focusing only on actual height measurement, does not provide enough information to assess the need for treatment or not; (2) the analysis of the goals of medicine should be broadened to include justifications for the treatment; (3) the use of growth hormone for idiopathic short stature involves strong interests from different stakeholders. While the treatment might be beneficial for some children, it is necessary to be vigilant about possible misconduct at different levels of medicalisation.

Moral Polemics of Far-Reaching Economic Consequences of Antibiotics Overuse.

The unethical overuse of antibiotics to seek to achieve a shortening of the treatment period raises the cost of health services and poses a threat to humanity due to the gradual development of antibiotic resistance. Other consequences of our modern passion for antibiotics have appeared. Small concentrations of antibiotic residues in sewage waters slow down the metabolism of anaerobic microorganism thereby reducing the overall performance of the anaerobic fermentation used to detoxify and digest sewage and other collected organic wastes. Reduced biogas yields represents a serious threat to the energy self-sufficiency of some waste-water treatment plants, so it might change them from energy producers into energy consumers. Morally justifiable production of renewable energy from bio-waste is also threatened by antibiotic residues that remain in the bio-waste.

Pharmaceuticalisation and ethical review in South Asia: issues of scope and authority for practitioners and policy makers.

Ethical review by expert committee continues to be the first line of defence when it comes to protecting human subjects recruited into clinical trials. Drawing on a large scale study of biomedical experimentation across South Asia, and specifically on interviews with 24 ethical review committee [ERC] members across India, Sri Lanka and Nepal, this article identifies some of the tensions that emerge for ERC members as the capacity to conduct credible ethical review of clinical trials is developed across the region. The article draws attention to fundamental issues of scope and authority in the operation of ethical review. On the one hand, ERC members experience a powerful pull towards harmonisation and a strong alignment with international standards deemed necessary for the global pharmaceutical assemblage to consolidate and extend. On the other hand, they must deal with what is in effect the double jeopardy of ethical review in developing world contexts. ERC members must undertake review but are frequently made aware of their responsibility to protect interests that go beyond the 'human subject' and into the realms of development and national interest [for example, in relation to literacy and informed consent]. These dilemmas are indicative of broader questions about where ethical review sits in institutional terms and how it might develop to best ensure improved human subject protection given growth of industry-led research.