Antimicrobial resistance in the environment: ethical considerations for policy

Abstract

This thesis contributes to the field of public health ethics by examining the ethical challenges posed by antimicrobial resistance (AMR) in the environment, with a particular focus on those that are relevant to policymaking. While ethical discussions of AMR have largely concentrated on human and clinical dimensions, the role of the environment has been underappreciated. Including the environmental dimension in the debate broadens both the ethical analysis and the scope of potential interventions, raising new questions about responsibilities for addressing AMR-related harms and about fairness in implementing AMR policy. This thesis explores how these issues connect the problem of AMR with broader philosophical issues concerning distributive justice, collective harm, the allocation of remedial obligations, and the justification of liberty-limiting state intervention. The thesis analyses the case of the consumption of meat and dairy from antibiotic-intensive farming as a driver of AMR from the perspective of the harm principle. In particular, the thesis argues that consuming these products meaningfully contributes to AMR and increases related health risks and that this provides sufficient grounds to justify state intervention to limit such consumption. Moreover, the thesis examines the role of the principle of least restrictiveness in AMR policy and critiques additive interpretations of this principle. Drawing on a pluralistic public health ethics framework, it argues that a policy’s restrictiveness should be judged by the depth of its impact on the individuals most affected rather than by the aggregate extent of the restrictions it imposes on everyone in a population. Additionally, focusing on the case of AMR-driving pharmaceutical pollution from human use, the thesis argues in favour of the introduction of forward-looking considerations when allocating duties to address such pollution. Specifically, it advocates allocating such duties based on how interventions can effectively prevent harm, regardless of various actors’ causal contributions to or moral responsibility for the harm in question. The thesis further examines the market approval process for human pharmaceuticals as a means of mitigating AMR-driving pharmaceutical pollution and, consequently, reducing the related public health risks. It outlines several possible frameworks for integrating environmental considerations into this process, and argues that more stringent oversight is necessary while avoiding the potential downsides of overly restrictive measures. Finally, the thesis considers AMR as a sustainability challenge, understood as a challenge of intergenerational justice, and proposes adopting a sustainability principle as a normative guide for distributing resources in publicly funded health systems. Taken together, these arguments show that addressing the environmental aspects of antimicrobial resistance calls for ethically grounded judgment to navigate the competing normative demands that AMR inevitably involves.