Saver Richard S
Health Law and Policy Institute, University of Houston Law Center, USA.
Am J Law Med. 2008;34(4):431-91. doi: 10.1177/009885880803400401.
Antibiotic resistance menaces the population as a dire public health threat and costly social problem. Recent proposals to combat antibiotic resistance focus to a large degree on supply side approaches. Suggestions include tinkering with patent rights so that pharmaceutical companies have greater incentives to discover novel antibiotics as well as to resist overselling their newer drugs already on market. This Article argues that a primarily supply side emphasis unfortunately detracts attention from physicians' important demand side influences. Physicians have a vital and unavoidably necessary role to play in ensuring socially optimal access to antibiotics. Dismayingly, physicians' management of the antibiotic supply has been poor and their defense of population health tepid at best. Acting as a prudent steward of the antibiotic supply often seems to be at odds with a physician's commonly understood fiduciary duties, ethical obligations, and professional norms, all of which traditionally emphasize the individual health paradigm as opposed to population health responsibilities. Meanwhile, physicians face limited incentives for antibiotic conservation from other sources, such as malpractice liability, regulatory standards, and reimbursement systems. While multifaceted efforts are needed to combat antibiotic resistance effectively, physician gatekeeping behavior should become a priority area of focus. This Article considers how health law and policy tools could favorably change the incentives physicians face for antibiotic conservation. A clear lesson from the managed care reform battles of the recent past is that interventions, to have the best chance of success, need to respect physician interest in clinical autonomy and individualized medicine even if, somewhat paradoxically, vigorously promoting population health perspectives. Also, physicians' legal and ethical obligations need to be reconceptualized in the antibiotic context in order to better support gatekeeping in defense of population health. The principal recommendation is for increased use of financial incentives to reward physicians for compliance with recommended guidelines on antibiotic prescribing. Although not a panacea, greater experimentation with financial incentives can provide a much needed jump-start to physician interest in antibiotic conservation and likely best address physicians' legitimate clinical autonomy concerns.
抗生素耐药性作为一种严重的公共卫生威胁和代价高昂的社会问题，对公众构成了威胁。最近应对抗生素耐药性的提议在很大程度上侧重于供应方的方法。建议包括调整专利权，以便制药公司有更大的动力去发现新型抗生素，同时避免过度推销其已上市的新药。本文认为，不幸的是，主要侧重于供应方会分散人们对医生在需求方的重要影响的关注。医生在确保社会对抗生素的最佳获取方面起着至关重要且不可避免的必要作用。令人沮丧的是，医生对抗生素供应的管理一直很差，他们对公众健康的维护充其量也只是不温不火。作为抗生素供应的谨慎管理者，这似乎常常与医生通常所理解的信托责任、道德义务和专业规范相悖，所有这些传统上都强调个体健康模式而非群体健康责任。与此同时，医生从其他来源（如医疗事故责任、监管标准和报销系统）获得的抗生素节约激励有限。虽然需要多方面的努力来有效对抗抗生素耐药性，但医生的把关行为应成为重点关注领域。本文探讨了卫生法律和政策工具如何能够有利地改变医生在抗生素节约方面面临的激励机制。从近期管理式医疗改革斗争中得到的一个明显教训是，干预措施要想有最好的成功机会，就需要尊重医生对临床自主权和个性化医疗的兴趣，即使这似乎有些自相矛盾，也要大力推广群体健康观念。此外，在抗生素背景下，需要重新审视医生的法律和道德义务，以便更好地支持为维护群体健康而进行的把关。主要建议是增加使用经济激励措施，奖励医生遵守抗生素处方推荐指南。虽然不是万灵药，但更多地试验经济激励措施可以为医生对抗生素节约的兴趣提供急需的推动，并可能最好地解决医生对合法临床自主权的担忧。
