Present-day ethical frameworks for public health may be insufficient to evaluate the risks of clinical public health programs (CPHPs) because they overlook the best clinical interests of current patients, according to an article published in Bioethics. Authors contended that applying ethical practices commonly employed in clinical trials may help inform and guide the evaluation of risks posed by such CPHPs.

The authors used the “rational antibiotic use” guideline to demonstrate how the ethics of risk from one setting can be applied to another setting. Antimicrobial resistance (AMR) is considered one of the most pressing issues in public health today, but policy responses aiming to reduce the spread of AMR have been largely variable. The United Kingdom’s AMR strategy supports “rational” antimicrobial prescription, or “use of the right drug, right dose at the right time and for the right duration to limit unnecessary antibiotic exposure.” The authors indicated that such policies aim to spare current patients from the side effects of unnecessary treatment and curb the spread of AMR while also maintaining the efficacy of existing antimicrobial treatments. However, some rational-use programs can also limit the use of beneficial antibiotics, putting current patients at risk.

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A potential solution to such problems is to refer to existing ethical frameworks in the field of public health. However, the authors explained that such frameworks often fail to fully address the distinct ethical questions raised by programs that compromise the best clinical interests of present patients. These include the program’s level of risk, the conditions of acceptable risk, and the upper-limit of acceptable risk. As a result, the authors argued that the ethical frameworks of public health are insufficient in the context of risk-evaluation for CPHPs.

They suggested that one way of addressing these limitations is to use the ethical frameworks of clinical research as a guide for such programs. In this scenario, the framework for risk-benefit evaluations used in research can shed light on ways of balancing potential social benefits and individual risks that are missing from existing ethical frameworks for public health. The cumulative net risks of all procedures in a trial are restricted such that they do not exceed certain upper limits, even if the trial were to produce extremely valuable insight. These considerations add to existing ethical frameworks of public health by providing conditions in which it is ethically permissible for clinicians to compromise the best clinical interests of their present patients for the sake of other patients, individuals, or society.

The authors also concluded that health policymakers and others who develop and implement CPHPs should turn to the ethical frameworks of clinical research for guidance on how to modify the ethical frameworks of public health.


Rid A, Littmann J, Buyx A. Evaluating the risks of public health programs: rational antibiotic use and antimicrobial resistance. Bioethics. 2019;33:734-748.