AMA Journal of Ethics^®

Abstract

The AMA Code of Medical Ethics does not directly address the issue of antimicrobial resistance, but parts of the AMA Code contain relevant guidance. This article summarizes how the AMA Code may be applicable to antimicrobial resistance.

The World Health Organization and Antimicrobial Resistance

The World Health Organization (WHO) declared antimicrobial resistance 1 of the top 10 global public health threats in 2023.¹ Antimicrobial resistance happens when bacteria, fungi, viruses, and parasites adapt over time and no longer respond to medicines, making it more difficult to treat disease and prevent its spread.¹ For common bacterial infections, high rates of antibiotic resistance have been observed around the world.¹ For example, the rate of resistance for ciprofloxacin, an antibiotic used to treat urinary tract infections, varied from 8.4% to a staggering 92.9% across 33 countries.²

To combat this ongoing threat, a transdisciplinary approach is necessary that includes physicians. While there may not be a specific opinion in the American Medical Association (AMA) Code of Medical Ethics to guide physicians, there are principles and opinions that may be applied to the issue of antimicrobial resistance. Principle V³; Opinion 2.2.1, “Informed Consent”⁴; and Opinion 8.5, “Disparities in Health Care”⁵ offer guidance to physicians on ethical issues that may arise in conjunction with this important issue.

Principle V

Principle V states: “A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health care professionals when indicated.”³ Because bacteria, fungi, viruses, and parasites all can become resistant to drugs over time and it is difficult to predict when and how this will happen, physicians must continue studying antimicrobial resistance and sharing knowledge with colleagues and the public. For example, in 2015, the WHO launched the Global Antimicrobial Resistance and Use Surveillance System to work towards filling knowledge gaps and getting information out to all levels working on the issue.¹

Informed Consent

Informed consent to treatment is an essential part of medical ethics. Physicians must inform their patients of any risks, benefits, or other important elements of their treatment so that patients can make an informed decision. Opinion 2.2.1 states that, to gain a patient’s informed consent, a physician should:

(a) Assess the patient’s ability to understand relevant medical information and the implications of treatment alternatives and to make an independent, voluntary decision.
(b) Present relevant information accurately and sensitively, in keeping with the patient’s preferences for receiving medical information. The physician should include information about:
     (i) the diagnosis (when known);
     (ii) the nature and purpose of recommended interventions;
     (iii) the burdens, risks, and expected benefits of all options, including foregoing treatment
(c) Document the informed consent conversation and the patient’s (or surrogate’s) discission in the medical record in some manner. When the patient/surrogate has provided specific written consent, the consent form should be included in the record.⁴

As with any treatment, physicians should explain to patients the risks of overprescribing antimicrobial medications.

Inequity in Health Care

Antimicrobial resistance is also relevant to existing disparities in US health care, as it has many effects on microbiological, individual, societal, and ecological levels. In particular, antimicrobial resistance poses a danger to medically disadvantaged populations. The main drivers of antimicrobial resistance are the misuse and overuse of certain drugs, lack of access to clean water, poor sanitation and hygiene (in animals and humans), and lack of access to affordable medicines.¹ Many of these drivers arise in poor, marginalized communities.

Physicians have an ethical duty to increase awareness of these disparities and to strive to improve outcomes in medically underserved communities. Opinion 8.5 discusses how physicians should go about addressing disparities and how to avoid perpetuating them further. Specifically, Opinion 8.5 states that the medical profession has an ethical responsibility to:

(g) Help increase awareness of health care disparities
(h) Strive to increase the diversity of the physician workforce as a step toward reducing health care disparities
(i) Support research that examines health care disparities, including research on the unique health needs of all genders, ethnic groups, and medically disadvantaged populations, and the development of quality measures and resources to help reduce disparities.⁵