Ethics and antibiotic resistance.

Introduction or background: Antibiotic resistance raises ethical issues due to the severe and inequitably distributed consequences caused by individual actions and policies.

Sources of data: Synthesis of ethical, scientific and clinical literature.

Areas of agreement: Ethical analyses have focused on the moral responsibilities of patients to complete antibiotic courses, resistance as a tragedy of the commons and attempts to limit use through antibiotic stewardship.

Areas of controversy: Each of these analyses has significant limitations and can result in self-defeating or overly narrow implications for policy.

Growing points: More complex analyses focus on ethical implications of ubiquitous asymptomatic carriage of resistant bacteria, non-linear outcomes within and between patients over time and global variation in resistant disease burdens.

Areas timely for developing research: Neglected topics include the harms of antibiotic use, including off-target effects on the human microbiome, and the lack of evidence guiding most antibiotic prescription decisions.