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Ethical dilemmas in antibiotic prescribing: analysisof everyday practice

I. Bjornsdottir* PhD (Pharm) and E. H. Hansen� MSc (Pharm)

*CEO, The Pharmaceutical Society of Iceland, Holtaseli 36, IS-109 Reykjavı k, Iceland and �Professor,Department of Social Pharmacy, Royal Danish School of Pharmacy and Director, FKL-Research Centre forQuality in Medicine Use, Copenhagen, Denmark

SUMMARY

Objective: To explore general practitioners’

(GP’s) views on their obligations with respect to

diagnosing infections and prescribing antibiotics.

Methods: The GP’s reflections and prioritization

were studied by means of interviews and obser-

vations. We analysed how their prioritization

complied with an ethical guidance that ranked

patient autonomy and welfare highest, then

competence obligations and obligations to soci-

ety, followed by fraternal obligations.

Results: Balancing of pros and cons was promin-

ent in our informants’ decision making but often

resulted in decisions that deviated from the ethical

guidance. The ranking varied much between the

GPs. The highest priorities in the GPs’ practice

were related to the patient’s everyday life (some-

times autonomy, sometimes beneficence in a broad

sense), doctor–patient relationship (communica-

tion competence), the patient’s perceived import-

ance on the job market (society) and relationship

with colleagues (fraternal). Perceived lack of

resources and uncertainty with respect to both

diagnostic and treatment decisions frequently

influenced decision making.

Keywords: antibiotics, general practice, Iceland,

obligations, prioritization, qualitative methods

INTRODUCTION

Physicians often experience discomfort regarding

decisions on antibiotic prescribing, and also when

internal rules are broken, even when clashes

between rules make it impossible to comply with

all of them (1).

Antibiotics have been classified as ‘therapeutic

trial’ drugs, because, although they are supposed to

be prescribed only on the basis of certain diagnosis

of bacterial infections, real life circumstances often

make certainty in diagnosing difficult or imposs-

ible (2–5).

Ethical problems in everyday practice have not

gained much bioethical attention (6, 7). The big

issues have been prioritization, end of life decisions

and recent advances in biotechnology, although

physicians’ role and behaviour, gate-keeping in

health care, usability of guidelines and paternalism

vs. autonomy have been discussed (8–14).

It still remains uncertain whether the teleological

(main emphasis on the outcome, maximizing hap-

piness, joy or good), the deontological (main

emphasis on the means, having virtuous reasons

for doing the right thing) or one of the varieties of

other ethical theories is most applicable (15).

Although the doctor–patient relationship has

traditionally been structured around the ‘clinical

model’, which has been described as utilitarian,

outcome or ends is frequently rather unpredictable

in health care, which can make a ‘relational model’

(deontological in essence) more appropriate in

many cases (16). In their Principlism Theory,

Beauchamp and Childress identify beneficence,

non-maleficence, autonomy and ⁄ or justice as the

fundamentals of health care ethics (17). Physicians

have been found to act in accordance with benefi-

cence principles rather through recognition of

expertise than because of presumed patient

vulnerability and lack of understanding, and they

Received 29 August 2002, Accepted 10 October 2002

Correspondence: Ingunn Bjornsdottir PhD (Pharm.), CEO,

The Pharmaceutical Society of Iceland, Box 252, IS-172 Seltjar-

narnes, Iceland. Tel: +354 561 6166; fax: +354 561 6182; e-mail:

[email protected]

An earlier version of this paper was a part of the results section

of a PhD thesis by the first author. It was defended in August

1999, at the Royal Danish School of Pharmacy, Department of

Social Pharmacy.

Journal of Clinical Pharmacy and Therapeutics (2002) 27, 431–440

� 2002 Blackwell Science Ltd 431

have been found to be inconsistent in their attitude

towards patient autonomy (18, 19). Furthermore,

when describing experienced ethical dilemmas,

they seem to use a somewhat broader definition

than the bioethics literature (added concerns about

own reputation and doctor–patient relationship to

the mainstream definition of conflict and choice

between values, beliefs and options for action) (20).

We have described Icelandic general practitioners’

(GPs) rationales for prescribing antibiotics earlier

(21). We found that their primary purpose of pre-

scribing antibiotics was to help patients to carry on

with their everyday activities, i.e. outcome-oriented

or teleological thinking. Lack of resources, or other

reasons, however, could cause the GPs to deviate

from evidence-based medicine. The prescribing

could occasionally be a result of respecting the

autonomy of the patient at the expense of benefi-

cence or non-maleficence, i.e. process-oriented,

deontological thinking, because of lack of time or

access to technology, or a belief in the patient’s

right to decide (21). Codes of ethics in medicine fail

to deal with the question of resources (22).

Moral obligations of health care professionals

can be divided into four groups: primary

obligations (respect for autonomy, consideration of

beneficence), preservation ⁄maintenance of profes-

sional competence (necessary for the ability to

prioritize when autonomy, beneficence, non-

maleficence and ⁄ or justice clash), societal (public

health, justice) and ⁄ or fraternal (23).

OBJECTIVES

To explore

• GPs’ views on their obligations with respect to

infections and antibiotics.

• How GPs prioritize when clashes between per-

ceived obligations occur.

MATERIALS AND METHODS

The study was conducted in Iceland, a relatively

sparsely populated country, with its roughly

280 000 inhabitants, approximately 70% of whom

live in the capital and surroundings, where the

largest hospitals and most of the specialists are also

situated. The remaining 30% of the inhabitants live

mostly in the coastal areas (rural) where GPs are

the key actors in the health service. Some solo GPs

cover an area with travel distances of up to 100 km.

Physicians have mainly specialized in general

practice in Sweden. Female GPs have been relat-

ively few, as have contractors.

Qualitative methods (in-depth interviews and

observations) were used to grasp the content of the

GPs considerations and reflections.

Interviews

The sample (10 GPs) was purposefully selected to

reflect existing variations in the GPs’ age and years

of professional experience (two <40 years, two

>55 years, mean age 48), gender (two females),

practice organization (eight state-employed, two

contractors), practice size (two in solo practice,

eight in group practice), practice location (three

rural, seven urban) and postgraduate training (six

specialized in Sweden, one in Canada, three did

not specialize), as these factors might influence

prescribing habits (24).

Informants were added to the sample until

the data were saturated. Informants and patients

exposed to observation, gave informed ver-

bal consent. The study had ethical committee

approval.

The interview-guide was aimed at exploring the

doctors’ perceived reasons for antibiotic prescri-

bing. After the first observation, it focused on atti-

tudes, common infections (symptoms ⁄diagnosis

and treatment), patient variables (e.g. age and

gender), recent antibiotic prescriptions and poss-

ible associated discomfort, pressure from patients,

resources and co-operation with other health care

workers. The physicians were encouraged to vol-

unteer any information they found important.

‘Specialists’ was an issue initiated by the

observed ⁄ interviewed physician in more than one

of the first interviews and hence added to the

interview-guide. The interviews lasted for 45 min

to 2 h, and were tape-recorded and transcribed in

full. One informant did not allow tape recording,

but detailed notes were kept instead.

Observations

Three of the GPs were observed for 3–10 h each

(rural, urban, solo practice and two different size

group practices), each one before he was inter-

viewed, creating a basis for the interview guide

432 I. Bjornsdottir and E. H. Hansen

� 2002 Blackwell Science Ltd, Journal of Clinical Pharmacy and Therapeutics, 27, 431–440

and subsequent modification of it. Detailed field

notes were taken and typed shortly after the

observation. A total of about 60 doctor–patient

contacts were observed (including telephone con-

tacts). Antibiotics and ⁄ or infections were discussed

in 15 contacts. Three antibiotic prescriptions were

issued.

Our data seemed saturated (25) after approxi-

mately seven interviews (i.e. interviews eight to 10

did not seem to add themes or nuances). This early

saturation might be due to the use of the observa-

tions in creating the interview guide and, perhaps,

also because of the data collector’s (first author’s)

experience from primary health care (10 years in

community pharmacies, with daily contact with

GPs, with whom antibiotic prescribing was

frequently discussed).

Data on ethical dilemmas were extracted and

analysed by open, axial and selective coding

(grounded theory procedures), but aiming at an

in-depth understanding of the informants rather

than developing concepts and theories (25, 26).

The interviewer’s possible biases were minimized

by researcher triangulation (authors, input from

two sociologists in the open coding). The

informants offered information about incidents

they could have handled better (such incidents

were also observed). Hawthorne effects were

therefore considered minimal (27). The results

are the researchers’ interpretation of the physicians’

attitudes and behaviour (28), but as a validity

check, the results were shown to two physicians

with experience from general practice and pre-

sented at conferences where GPs were among

the audience. These physicians confirmed the

analysis.

RESULTS

Balancing of scientific and practical considerations

was prominent in the GPs’ decision making. Many

of them described individual ‘guidelines’, or ‘rules

of a thumb’ that they had developed to work out

their practices. They considered this development

of ‘own style’ acceptable, even preferable. One

doctor described this as ‘bringing the art into the

work’. Perceived pressure from patients, society

(e.g. lack of resources) and ⁄ or other health care

professionals was interwoven into practically all

their decision making.

The inspiration for the order of our presentation of

the GPs’ prioritization is the classification of pro-

fessional obligations, described in the Introduction.

Primary obligations towards the client

The GPs’ tendency to refer to their clients as ‘peo-

ple’ rather than ‘patients’ (emphasizing the person

rather than the case) was reflected in their decision

making.

Respect for autonomy. The GPs generally paid

regard to patient preferences when deciding on

diagnostic procedures or treatment, but varying

from respecting her right to refusal to meeting her

demands. Co-operation with patients was consid-

ered important, especially regarding treatment.

The use of the ‘wait-and-see’ method depended on

the patient’s preferences.

An easy access to the GP (appointment within a

few hours) was considered an important patient

right, although not necessarily justified by health-

related needs:

when you let someone diagnose there is of course a

risk of a wrong diagnosis, but letting you see… it

dictate your getting to the doctor, whether you get

wrong treatment or not, of course that is no good,

you see. One has a right to get to the doctor when

the need arises A

It sometimes seemed unclear, whether respect for

the patient’s autonomy influenced the GP’s deci-

sions. For example, when they ‘helped’ patients to

avoid sick leave, they sometimes did so on the

basis of beneficence rather than patient request.

Beneficence ⁄ non-maleficence. The GPs defined bene-

ficence ⁄non-maleficence in a broad sense, not just

in terms of health. Their arguments for different

service levels for different patient groups were

circumstances in the patients’ life in general, rather

than specifically their health.

1. Job: The patient’s vulnerability on the job market

was considered during decision making. Children

were considered to need quick service, because of

parents’ limited rights (generally 7 days ⁄ year) to

stay home with ill children. People, who were

regarded to be at risk of losing their jobs because of

sick leaves, were also considered to need quick

service.


Ethical dilemmas in antibiotic prescribing 433

2. Nuisance: Doctors in the rural area thought they

ordered fewer ‘to-be-certain’ investigations than

colleagues in the large towns, to avoid unnecessary

hassle for the patient (implying that avoiding has-

sle might be more important than certainty in

diagnosing). A doctor working in a rural area felt

that he had to keep admittance to a hospital low,

because of the inconvenience inherent in a hospital

stay, far away from home.

3. Economy: Some GPs stated that they would

omit a test if (in their opinion) the patient could not

really afford it.

Actually, the price is only 900 kronur (approxi-

mately 9 US$). But […] if you have three kids in a

row, and if you intend to take a swab, then you

don’t take a swab from the whole row, not unless

you have tried to treat and it doesn’t work D

A GP who used tests, sometimes ‘forgot’ to bill

people for them, thereby ranking the unbilled

individual’s economy higher than cost to society.

Professional competence

This section deals with background knowledge,

technical skills and communication skills.

Background knowledge. Own experience from work

in hospitals and discussions with older colleagues

were considered very important sources of

knowledge, seemingly more important than

formal education. Hence, varying experience is

among the causes of variations in decision

making.

Technical skills. Technical skills were perceived to

increase with increasing experience, justifying

highly individual necessity for evidence, to confirm

a diagnosis.

I think this is a very personal style […] what we

are taught, really, is that for sinusitis then this

treatment is needed and so on, sinusitis can be

diagnosed by this… by X-ray… and then perhaps

when one gets more confident in the clinic, then

one can perhaps allow oneself a bit more C

One doctor described how he had learned to use

the smell and appearance of a urine sample to

distinguish between bacteria. He did not elaborate

on the success of that method as compared with

tests.

‘Educated guesses’ regarding causative agents in

adults occurred. For example, urinary tract infec-

tion (UTI) causing bacteria in elderly women were

considered likely to be different from those causing

UTI in younger women, based on the women’s

assumed (lack of) sexual activity. Examples were

also given based on the ‘educated guess’ on the

patient’s job.

We are a bit in connection with the basic industries

here […] this is just a feeling really, but I get many

fishermen… who get hooks in their bodies… which

of course is dirty in itself but penicillin seems to

work well for that, these slime-bacteria. Then again

here in the countryside where one knows that there

is… at least clean soil, clean soil bacteria, […] other

people, let’s say here from the local meat industry or

something… someone falls on to the floor, and opens

a wound, […] then I go over to Staphylococcus

medicines F

A GP who stated that, at the beginning of their

careers, doctors always ‘wanted to have culture’,

thought that now he perhaps ought to require

culture a bit more often than he did, implying that

his behaviour might be somewhat substandard.

1. Access to technology: Information from tests

was considered a waste of resources unless it could

be used in decision making regarding treatment.

Laboratory access ranged from full access during

all working hours to a distance of 200 km or more

to the nearest laboratory. A GP who had full

laboratory access always used cultures on ‘slightest

doubt’, whereas GPs with poor access did not

always send cultures when in doubt. Decreases in

laboratory access, resulting from cuts in the health

care budget were described.

Some GPs omitted cultures because of generally

receiving results too late for use in treatment

decisions and some started treatment before results

were known.

2. Uncertainty: Many GPs described it as charac-

teristic for general practice, as opposed to hospitals,

that 100% certainty of a diagnosis practically did not

exist. Doubt regarding own competence could cause

uncertainty. Uncertainty could also occur because of

gaps in existing knowledge:

one sees something that one does not find [typical],

then one takes [culture], then Streptococcus is

cultivated. How on earth is one supposed to know



whether it is the Streptococcus that caused the

infection? … I don’t have any method for judging

which of the patients are carriers and have viral

infections J

Our informants considered diagnoses to vary in

certainty, but opinions varied regarding which

diagnoses were the less certain ones. Some GPs had

experienced discomfort because of uncertainty.

Communication skills. Some GPs considered it

important to find the ‘real’ reason for the patient’s

appointment, even by digging into the patient’s

subconsciousness, in order to meet their expecta-

tions or be able to explain adequately why meeting

expectations was not feasible (be the ‘people’s

educator’).

Inadequate communication was observed. A

woman mentioning antibiotics to a GP after des-

cribing her cough was asked whether she smoked

at the time. The woman complained that it was

unfair to be accused of something that she had

never done. The GP explained that the question

was for the observer’s information. A GP asking a

young female patient with pain in the lower

abdomen for a urine sample explained to her that

he was going to check for chlamydia. Afterwards,

he told the observer that the health care authorities

had requested GPs to screen for chlamydia, but left

the patient unaware of the fact that this was part of

a routine screening programme.

1. Patient autonomy at the expense of doctor

autonomy: Most of the doctors gave examples of

patient pressure and some described how they

might give in to such a pressure:

and then it occasionally happens […] that I don’t

have the time to sit for 20 min, and explain that the

kid can get well even though he does not take

antibiotics […]. If it doesn’t work in the beginning,

of course I take CRP, I take a strep-test, the whole

lot, try to convince them that there is nothing, but

on rare occasions, one gives up and prescribes when

people are totally, well determined and they do not

intend to step outside, until they have gotten

something G

On rare occasions our informants felt pressed to be

more service-oriented than they felt comfortable

with, mostly due to fear for complaints from

patients.

2. Pressure of time: Our informants felt that they

often lacked time to do everything that is required

of them, with two exceptions: one who described

himself as being in the latter half of his career, and

another (solo practice, sparsely populated rural

area) who normally did not experience time pres-

sure.

A GP mentioned that under pressure of time,

one quite quickly started omitting investigations

that would not ‘make any difference’. He also

mentioned that it was difficult to face the fact that

time pressure affected one’s work.

3. ‘Slaves of the green forms’: The GPs’ salaries

depended on a contract with the authorities and

consisted of a mixture of wages and a fee-for-

service part, which was collected by means of

green-coloured forms, signed by the patients.

Some GPs described themselves as ‘slaves of

the green forms’, indicating that they dealt with

more patients each day than they felt comfortable

with. Others were more neutral about the green

forms, and one thought that this mixture of

wages and fee-for-service was better than an

income based on wages alone, because, as exam-

ples had confirmed, wages alone could make the

doctors ‘work-shy’. The doctors did not think that

the income and fee-for-service composition inter-

fered in their diagnoses, but as they gave exam-

ples of lack of time affecting their diagnoses,

there indeed seemed to be some interference. A

possible explanation for this discrepancy might

be that diagnosing infections (the way our

informants did it) was not time consuming,

whereas diagnosis according to recommendations

might be.

Obligations towards society

The nature of the patient’s job could influence

decision making. Some occupations, for example

farmers and fishermen, were regarded as needing

treatment more quickly than others.

a man who coughs a little […] either during the

mating or lambing season for the sheep or some-

thing, and does not at all want to… lose a single

day… then… I would… perhaps also… prescribe

penicillin to him, I



and

if well… there is a substantial economical question

involved… A man who perhaps might miss a few

fishing days, at sea, or if he did not get a

prescription… […] [It is] quite OK I

People holding jobs, for which no stand-in was

available, might need quick service (because the

GPs perceived that the job needed to be done), as

opposed to people working in large companies,

like supermarket chains (where someone else

would simply do the job). In most of the exam-

ples where the nature of the patient’s job was

considered important, the reason seemed to be

concern for keeping society going. One GP, who

considered that farmers needed quick service, did

not consider it necessary to culture from, or to

treat old ladies (in the retirement home) with

suspected UTI, if it was relatively symptom-free.

A GP in a rural area gave cost and short shelf-life

as a reason for not using the rapid Streptococcus

tests, thereby ranking cost to society higher than

better diagnosis.

All strategies for keeping antibiotic consump-

tion at a minimum can be seen as concerns for

society as a whole. Although our informants’

societal concerns dealt more with keeping the

trades and industries going, they were neverthe-

less aware of the need for restricting antibiotic

consumption:

every single prescription that is beneficial to the

individual, is at the same time also a step towards

breeding… multiresistant (bacteria) strains, that

then… cause these same antibiotics to become

useless I

Fraternal obligations

There were variations in the ranking of obligations

towards colleagues. A young doctor working as a

stand-in for another doctor felt that one should

work in ‘the spirit of’ the doctor one was substi-

tuting, even to the extent of deviating from one’s

own ideals. Many GPs complained about lack of

time to discuss problems with colleagues.

The colleagues were also criticized, for example,

for taking cultures without intending to use the

results or putting on a diagnostic label as an excuse

for treatment. Some informants implied that ‘other

doctors’ did something irrational, but more often a

neutral description was used, i.e. referring to

investigations that had shown this.

The GPs characterized cooperation with other

health care professionals as anything from excel-

lent to demanding. The GPs working in the most

sparsely populated areas, sometimes used nurses

as their ‘eyes and ears’. Nurses could also be gate-

keepers for the GPs, by taking phone calls if the

receptionists could not judge on the acuteness of a

patient’s complaint. One informant complained

that nurses always wanted antibiotics, without

elaborating on his basis for that opinion. He was

observed to refuse a request for antibiotics from a

nurse. He also sometimes felt that the receptionists

were too demanding.

The GPs’ experience of pressure from competi-

tion varied from feeling the need to limit the

number of patients.

If people live outside the area and want to keep

coming here, then [we don’t mind] to the extent we

are able to, but then, for example, people don’t get

house calls J

to thinking that GPs were too numerous:

I’m into the second half of all this I’m not more busy

than so that it is just adequate and I’m not allowed

to advertise for patients H

and

it can just be said quite… clearly, we are many

enough, and, if not too many. That’s the heart of the

matter H

The solo GPs in the rural areas did not feel pressure

from competition, but could feel lack of profes-

sional support, i.e. be very aware of the fact that

whatever medical problem arose; they had to deal

with it.

One GP was highly sceptical of reports from the

bacteriological department of the University Hos-

pital about research results showing increased

resistance. He implied that the doctors there might

have created the resistance themselves:

Dr A: ‘and perhaps a slump of what they have

caused themselves, you see…Interviewer: ‘At the University Hospital, you

mean?

Dr A: ‘Yes… I don’t know it, you see, I

don’t know where those pneumococci have come

from A

Nevertheless, he sent cultures to the bacteriological

department, because of good connections.



DISCUSSION

Two patterns of studying consultations, the

explorative and the normative, have been identi-

fied. The normative one might tend to take over,

when quality assurance becomes the major issue.

The consequences of that might be counteraction of

curiosity and thus limitations in the scope of

research (29). Our research might best be described

as explorative.

Rudnick suggests that the autonomy of the

patient may be breached, for his own good, for the

good of the public, or for the good of the patient’s

immediate environment (30), thereby acknowled-

ging the possible dilemmas in prioritizing auton-

omy, beneficence, non-maleficence and justice.

Disharmony regarding management of infec-

tions seems mainly to arise through different

interpretations of how the principles of benefi-

cence ⁄non-maleficence ought to be put into prac-

tice. The interpretation of our informants results in

concern for the person as a social being in a broad

sense, while the rational clinic paradigm is con-

cerned with beneficence in the narrow sense of

health care. The prioritization made by Icelandic

GPs may or may not apply to other settings, drug

groups or situations.

Our informants occasionally gave-in to patient

pressure. Pellegrino states that both doctors and

patients are worthy of respect as persons and each

have prima facie claim to respect for their autonomy

(31). Patient pressure may on rare occasions violate

physician autonomy.

Icelandic GPs’ resources are in many respects

limited, as has been confirmed by other researchers

(32). Other researchers have also found that lack of

time might contribute to substandard performance,

as might concern for the doctor–patient relation-

ship, which seems to be a common reason for dis-

comfort and worry (1, 33, 34). Uncertainty,

although rarely disclosed, is also often associated

with discomfort (1, 35, 36). Physicians tend to cope

by being biased towards illness (37, 38), i.e.

emphasize beneficence more than non-maleficence.

Our results indicate that doctors might emphasize

more on the eradication of doubt if they do not ‘do’

anything, which is in accordance with Jensen’s

findings, that diagnostic work is often more thor-

ough for patients who are not prescribed medicines

(39). Using time on dealing with psychosocial

issues may, at least in the case of antibiotics,

improve prescribing (40).

When confusion about prioritizing occurs, dis-

comfort arises. However, if the GP does not feel

confused about prioritizing, he does not experience

discomfort, although his decisions may neither be

in accordance with scientific rationales nor the

‘rules’ regarding ethical dilemmas. The lack of

abilities to fulfil the perceived obligations is fre-

quently caused by lack of resources, but the order

of prioritization adhered to by the individual doc-

tor, when working out his practice, is mainly a

consequence of experience.

Other researchers have found that gaining

experience, and ‘pearls’ (‘words of wisdom’ from

more experienced colleagues), was more important

to medical students than learning from books (41).

This agrees quite well with our informants’ ranking

of sources of knowledge, but deviates from the

practice of evidence-based medicine (42).

A Dutch GP and researcher has argued that

physicians may integrate societal arguments into

their practice in a morally acceptable way (take on

a gate-keeper role), but in order to do so, they need

resources such as specific information (e.g. about

prices), diagnostic machinery, guidelines and time,

in addition to training to perform the ‘balancing

act’ (9). Others have argued that it might be

unethical not to consider costs (43).

Freidson describes how doctors ignore incom-

petent colleagues without criticizing them openly

and argues that the reason is their fraternal

socialization (37).

Irrational use of antibiotics poses a threat to

humankind, even to animals. The balance between

ecological considerations and concern for individ-

uals, when antibiotics are prescribed is therefore an

important, yet difficult dilemma. In order for rules

and guidelines regarding infection diagnosis and

antibiotic prescribing to be successful, practising

doctors’ real decision making must be taken into

account. Decisions that might be judged as

‘irrational’ or ‘non-prudent’, according to evi-

dence-based medicine, can seem ‘rational’ to the

GPs. Our research indicates that this might be the

case because both the scientific and ethical guide-

lines tend to be general, whereas GPs’ decision

making is patient-specific and case-specific. In

another study, GPs most commonly considered

themselves to depart from evidence-based practice



because of reluctance to jeopardize their relation-

ship with the patient (44). Physicians have

tended to express extended responsibility for

patients they have known for a long time (45).

Donchin warns that growing dependence on

instrumentation and laboratory reports contributes

to devaluation of both clinical diagnosis and sub-

jective knowledge of patients (46). DeVito, in his

discussion of the concepts of health and disease,

finds it absolutely necessary to take the patient’s

interests into account. He states, ‘there is nothing

vicious about the bacteria except how we feel

about the bacteria’ (47). This may be interpreted to

mean that there might be acceptable variations in

balance between the ‘wait-and-see’ approach and

the tendency to treat immediately, which agrees

well with what Icelandic GPs actually do. Veatch

expresses doubts about the doctor knowing best,

and warns them about trying too much to benefit

the patient, thereby emphasizing the need to

respect patient autonomy (11). Furthermore, he

points out that in some cases patient benefit might

have to be sacrificed to fulfil duties to others.

Rogers finds both the principle of respect for

autonomy and the principle of beneficence insuf-

ficient to ground the practice of medicine, and

argues that reciprocal trust between patients and

GPs provides the atmosphere in which patient’s

interests may best flourish (48). Tsai recommends a

Confucian approach, which is two-dimensional:

the ‘autonomous person’ and the ‘relational

person’, where the ‘relational person’ promotes the

welfare of fellow persons (13). The Confucian

approach might work, but its usefulness depends

very much on the acceptance of the patients.

Arnason emphasizes discussions as means of

solving ethical dilemmas (23).

CONCLUSION

Evidence-based prescription of antibiotics needs to

take justice into account, i.e. the GPs need to think

of more than just the individual patient when

prescribing antibiotics, and the prescribers might

even need to expand the societal thinking to global

thinking, i.e. every time they prescribe, they need

to balance the therapeutic benefit for the individual

patient against the ecological harm for everyone

living on the globe. Furthermore, they need to keep

their competence for doing this up-to-date.

Whether these are unachievable goals remains to

be answered.

ACKNOWLEDGEMENTS

We would like to thank the two medical doctors

who commented on an earlier version of this

manuscript and the two sociologists who helped in

the initial open coding.

The Nordic Research Academy, the Icelandic

Science Council, the Icelandic Research Fund for

Graduate Students, the Pharmaceutical Society of

Iceland, the NM Pharma Research Fund, the Ice-

landic Alfred Benzon Prize Fund, the A. P. Møller

Fund for Icelandic Students at Institutes of Higher

Education in Copenhagen provided funding.

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