Ethical dilemmas in antibiotic treatment.

Patients with moderate to severe infections are given less than maximum empirical antibiotic treatment in order to reduce the rise in resistance. This practice involves two ethical dilemmas: whether the danger to a present patient should be increased (even if by a small degree) to benefit future, unidentified patients; and whether this should be done without the consent of the patient, disregarding the patient's autonomy. We argue that future patients have a right to come to no harm. Future patients being unidentified, practitioners of medicine have a duty to protect their rights and weigh them against the rights of the present patient. A decision on the collective (guidelines, decision support systems) is a convenient way to do that. Using a temporal discount rate to show that the life of present patients has pre-eminence, to some degree, over future patients does not solve the immediacy of the plight facing a present, identified patient with a very severe infection. We think there are good grounds to take into less account considerations of future resistance for such a patient, or in a formal analysis, to make the ratio of benefits to the present versus future patients dependent on the severity of disease of the present patient. None of these solve the problem of patients' autonomy. We see no other way but to argue that the right of future patients to come to less harm outweighs the right of the present patient to share in decisions on antibiotic treatment.