Progress in treatment with antibiotics

In our class on Design & Society, we discuss the so-called dilemma of progress.  With any design whose introduction poses potential risk, there is a decision to make on how to regulate it.  In simplest terms, there are two possibilities:

  1. Permissive: introduce the new design until such time as it proves to be overly harmful, or
  2. Precautionary: restrict the new design until such time as it proves to be acceptably safe.

Under conditions of uncertainty, it can be difficult to know which strategy is best.

An interesting medical example illustrates that this problem applies not just to new designs but to established ones as well. 

Consider the common advice from doctors to patients receiving antibiotic treatments: Always finish the treatment, even if you feel better before its conclusion.

Alexander Fleming, the discoverer of penicillin, argued for this strategy on the grounds that incomplete exposure of disease microbes to antibiotics would just spur them to evolve resistance.  In that event, antibiotics would become increasingly ineffective over time.

However, a recent analysis concludes that it may be better for people to stop antibiotic treatments early, when they feel better, and to shorten treatments generally.  The reason is that overexposure of otherwise harmless microbes to antibiotics would spur them to dominate people's internal ecosystem, thus resulting in disease. 

Since people often demand antibiotics, even when it might not be best for them, the researchers argue that doctors should advise people to stop treatments when they feel better.

From the perspective of the new analysis, the established practise of completing prescribed courses is the permissive strategy.  It may help patients recover from illness but threatens to spread resistance among disease microbes.  The precautionary strategy is to shorten treatments.  It may help to reduce resistance among otherwise harmless microbes but means that some patients will suffer reinfection. 

The new analysis argues for the precautionary strategy based on collective risk reduction: "most of the bacterial species now posing the greatest problems do not develop resistance through [underdosing]... [Overdosing] is the predominant driver of the important forms of antibiotic resistance affecting patients today."

Even so, what constitutes a proper dosage remains unclear, so the researchers call for further research.

This example provides an interesting illustration of how the dilemma of progress is ongoing and not just a problem that occurs at the introduction of a new technology.

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