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Sans Antibiotics: The Road Not Taken

Antibiotics provide the trivial psychological benefit of (falsely) believing that something has been done to hasten the recovery.

By Jonathan Anomaly

A few weeks ago The Economist made antibiotic resistance its cover story, and for good reason.  We live in a bacterial world.  The average person hosts about 39 trillion bacteria.[1]  Lucky for us, most bacteria are benign – they crowd out pathogenic bacteria like e. coliin our gut, staph on our skin, and strep in our mouth.  Even pathogenic bacteria usually do us no harm unless they invade our bloodstream or otherwise find their way into parts of our bodies that our immune system is poorly equipped to deal with.  Some bacteria even confer benefits by priming our immune system to distinguish friend from foe during crucial stages of our early childhood development.  For this reason, altering our children’s microbiome by giving them antibiotics every time they have a cold can make them more susceptible to a host of disorders ranging from allergies to autoimmune diseases.[2]

Some bacteria even confer benefits by priming our immune system to distinguish friend from foe during crucial stages of our early childhood development.

Since nobody wants their children to suffer from these conditions, as more information about the microbiome emerges, it is likely that parents will use antibiotics more prudently on themselves and their children.  Parents may even decide to expose their children to microbes that their immune system has evolved to anticipate, but which are often absent in the sterile environments in which citizens of wealthy countries find themselves.  These are the easy cases.

The hard cases involve antibiotics and collective harms.  When patients use antibiotics to treat themselves for problems like viral infections which they lack the power to cure, they get the trivial psychological benefit of (falsely) believing that something has been done to hasten their recovery.  When farmers use antibiotics to speed the growth of animals raised on factory farms, they benefit by bringing their animals to slaughter just a little more quickly, while consumers benefit by paying a little less for animal protein.  But since we share a microbial environment, and since the more we use antibiotics the more likely bacteria are to evolve resistance, we all face an increased risk of being infected by antibiotic-resistant bacteria that are difficult or impossible to treat.  According to the newly published British Review on Antimicrobial Resistance, an estimated 700,000 people die every year of resistant infections, and the number is expected to increase in the coming decades.

Libertarians are rightly skeptical of government intervention in many arenas of life.  But some collective harms are so grave, and the alternatives so grim, that governments should do something.

Antibiotics alter the children’s microbiome and make them susceptible to allergies and autoimmune diseases

Antibiotics alter the children’s microbiome and make them susceptible to allergies and autoimmune diseases | Photo Courtesy: Visual Hunt

One of the least controversial moves governments can make is to require a prescription by physicians before consumers can take antibiotics, and before farmers can administer them to livestock. 

So what should they do?  One of the least controversial moves governments can make is to require a prescription by physicians before consumers can take antibiotics, and before farmers can administer them to livestock.  As I’ve argued elsewhere, antibiotics are probably the only drug that should require a prescription, since unlike almost any other drugs, the widespread use of antibiotics can impose severe public health risks in the form of antibiotic-resistant bacteria.  Yet many governments around the world impose draconian penalties on the use and sale of recreational drugs, while allowing over-the-counter sales of antibiotics.

A more controversial (but I think appropriate) move is for governments to impose Pigovian taxes or, more modestly, user fees on the use of antibiotics. 

The rationale is that we should curb the low-value consumption of antibiotics, and use the revenue generated by a fee to compensate victims or facilitate the development of new ways of diagnosing and treating bacterial infections, especially those resistant to existing antibiotics.  In particular, revenue from user fees could be used to fund basic science research, which often leads to scientific insights that are not patentable, but which have tremendous social value that pharmaceutical firms can translate into novel treatments.

Hayek showed why we should use prices rather than government dictates to allocate scarce resources when externalities are minimal.  But what about cases in which prices don’t reflect most of the social costs and benefits of our consumption choices?  Jason Brennan and Jessica Flanigan have written compelling papers about why libertarians should support some vaccine mandates.  We should worry about antibiotic resistance for the same reasons.  If libertarians ignore these issues, the “solutions” that emerge in policy debates may be worse than the problems they are supposed to solve.


Jonathan Anomaly is a core faculty member in the Philosophy, Politics, & Economics program at Duke and UNC, and the faculty sponsor of the Duke PPE club. He works mostly on issues at the intersection of ethics and economics, including how we should respond to the under-consumption of vaccines and the overconsumption of antibiotics, and whether the market for biomedical enhancements should be regulated in any way.

NOTE: parts of this post are adapted from a forthcoming paper for the Georgetown Journal of Law and Public Policy

[1] Ron Sender, Shai Fuchs, and Ron Milo (2016). “Revised estimates for the number of human and bacterial cells in the body” (BioRxiv preprint) doi:biorxiv.org

[2] For an engaging overview of these claims, see Martin Blaser (2015). Missing Microbes: How the overuse of antibiotics is fueling our modern plagues. (New York: Picador-MacMillan), and Moises Velasquez-Manoff (2013). An Epidemic of Absence: A new way of understanding allergies and autoimmune diseases, (New York: Scribner), 2013.

This article was originally published on Bleeding Heart Libertarians

Featured Image Source: Visual Hunt

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