Perfiles de Pozo

Some of the consequences of infections with antibiotic resistant bacteria such as MRSA are not confined to the experience of individuals and may have far-reaching social consequences through their effects on others. The risks associated with acquisition of Meticillin resistant

Staphylococcus aureus (MRSA) had become a substantial public concern in the United

Kingdom throughout the 1990s threatening to undermine public confidence in the English National Health Service. The Labour government responded to this loss of confidence by implementing increasingly stringent targets aimed at the control of MRSA in NHS hospitals. Public concern with MRSA was fomented by press reports of individual patient experience. These societal consequences threatened to undermine the functioning of the English NHS. “Security is valuable – insecurity is problematic if the individual is vulnerable to the risk (in probabilistic terms); if they cannot control the risk; depending on the degree of resilience; and if there is anxiety about the risk” (Wolff & De-Shalit 2007, p217). There is a considerable value in assuring individual patient experience such that public confidence in healthcare institutions such as NHS hospitals is maintained. Loss of public confidence in healthcare providers is a societal cost.

Valuing societal costs

CEA focuses on costs and benefits in a healthcare context, CBA can take a more inclusive approach. Even so deciding which costs to include, how to capture these costs and their ethical implications raises substantial difficulties. We have to question the possibility that the societal costs associated with a loss of public confidence in the healthcare system can be accurately quantified (See Burnett et al. 2010; Easton et al. 2009; Gould et al. 2009). The ‘Rule of Rescue’ (RR) refers to the imperative that most people feel that they (or someone else) should try to rescue individuals seen to be at risk of a serious adverse outcome. McKie & Richardson (2003, p2410) in discussing RR suggest that this imperative seems to apply to non-life saving and life saving conditions. Relatives, friends and bystanders (including other patients) may all feel distress when a patient is seen to be suffering from a potentially

avoidable infection. The reporting of patient experience in the media by individual patients and by others can have a profound effect on public confidence in healthcare institutions so from a consequentialist perspective an individual patient experience may become important (see the reference list for articles from ‘The Sun’). The argument that prevention has received a lower priority because the costs of the HCAI measured in added bed days is insufficient to justify spending money on preventive actions may be seen as callous, so in effect RR may undermine the maximisation of utility when utility is measured in aggregated measurable health costs and benefits. McKie & Richardson (2003, p2413-4) suggest that a value can be placed on RR because there is a social utility associated with the public knowledge that an attempt to help (or in the context of this thesis to prevent) has been made. “It is almost

humane society, and that the observation of attempts to save life, whether heroic or more mundane, reinforces this.” McKie & Richardson (2003, p2413) point out that the

psychological response of individuals and groups to a person’s health state depends on the context and information available, so in effect the utility gained or lost “depends upon circumstances extraneous to the immediate health state.” McKie & Richardson (2003) acknowledge the difficulties of placing a cost on these types of effect and discuss potential approaches to costing.

Wolff (2006) points out that the avoidance of fear (public anxiety), blame and shame are important motivations for those involved in risk management whether at the level of

individual interactions or institutions (including commercial companies) or governments. In the UK the public response to concerns about MRSA led to actions at a political level to increase the priority given to the control of MRSA. The approach focused on the control of one type of MRSA infection and can be judged successful in that media and public concerns have diminished, even though some of the actions taken to control MRSA were not cost- effective in a traditional sense (based on objective measures of risks) and were potentially harmful (see for example Millar 2009). In this case perceptions have been managed

successfully in that public fears have been allayed despite strong evidence up to 2009 that the overall burden of healthcare associated infection has not reduced (Public Accounts Committee 2009).

Should we include societal benefits?

There are circumstances in which there may be benefits to distant others when in a local context there are adverse effects on individuals or groups. Wars often lead to technological developments some of which may greatly benefit society in the future despite the adverse outcomes for many individuals alive at the time of the war. Should these benefits be included in a justification of war? Many see the battle against antibiotic resistant bacteria as a war. Infection with treatment resistant microbes may not benefit the individual sufferer but the public concerns consequent on publicised case reports have led to the development and commercial sale of a wide range of products leading to employment opportunities, improved treatments, and improved preventive strategies. Technological developments such as the development of new treatments (for example antibiotics) or new preventive measures (such as vaccines) arising from the urgent need to resolve the threat may have longer term social and economic benefits. While drug development and manufacturing companies have new antimicrobial products coming to the market they may benefit from antibiotic resistance because it creates redundancy in existing products.

Another example of a benefit that has arisen in response to the threat of infectious disease is the capacity to use computer models to predict the course of epidemics and to optimise preventive strategies (by predicting the impact of different control strategies). These models have been validated by comparison of the computer outputs with real epidemic curves. Data on how long patients transmit infections and the proportion that die is derived from

consequence(s). The human capacity to control of infectious diseases improves with the information garnered from each outbreak of infection.

There are considerable technical and philosophical difficulties with including these benefits in evaluations for example the time frame over which these benefits should be measured, and the weight that we should give to future benefits.