Hello and welcome to the She Research Podcast. I'm your host, Diego Silva. Before introducing our guests, I want to acknowledge that we're recording on the unceded territory of the Gadigal people. This is, and will continue to be, Aboriginal land, and I pay my respects to those who have and continue to care for country. Today, I'm joined by Dr Jane Williams. I'm very excited to discuss their paper, Distributive Justice and Value Trade Offs in Antibiotic Use in Aged Care Settings. Jane, welcome.
Thank you very much, Diego. I'm excited to be here.
So, to get us going, as I usually ask guests, if you can just summarize the paper and what the arguments in it are.
Yeah, this is an empirical ethics paper where we used a method called dialog groups. And I'm just going to really quickly, this is, this a long elevator ride, we're going to pretend that we're in a building and like.
It's as long as you want to make it, yeah.
Hong Kong or somehting, with a lot of floors. The paper is about value trade offs in antimicrobial resistance and antimicrobial stewardship in the aged care sector in Australia. This, as I said, is an empirical ethics paper where we spoke to people who have a parent in aged care, we used a dialog group method, and that's something that was developed by Jackie Leach Scully, actually, who's now at UNSW, go Jackie. She and, she and her colleagues kind of came up with this idea that is intended to get at values. So it's like a focus group, except in the discussion, people are given a scenario, a very realistic scenario, and the scenario that we used for this was a woman in her 70s, with mild dementia, with a suspected UTI. She's living in a residential aged care facility. And then we asked the group who were all caring for an elderly parent, their responses to certain questions, and they told us what they thought. And then we kind of complicated the scenario a bit. So basically, Mary got a wee bit sicker, and then we asked the same questions, and people started to slightly change, you know, nuance, some of their responses a bit, and then basically, the situation becomes more and more complex, although, of course, still staying within that sort of real life situation and people's responses, they were having to really think about why they were changing their responses. So from the original situation, like what had happened, you know, maybe Mary, who was invariably then, then starting to talk about their mom was becoming sicker, or she seemed more vulnerable, whatever. So we were really able to draw on people's values, what sorts of things were important to them in the situation of giving of antimicrobial stewardship, really in the aged care sector in Australia. This paper is about the value trade offs they talked about. So it's one of two papers that came from this study. So this is, the other one was much more descriptive and sort of policy oriented. This one, for me, was super interesting, because we found that the the value trade offs that they were making, and I want to say this, this was not areas of value disagreement. This was a situation where they valued the same things, you know, many things at once. I guess is better way of putting it, and how they were trying to come up with a solution while valuing several things that couldn't necessarily be valued at the same time. What we found was that they, like a lot of the ethics literature, actually would speak to, I suppose, they tended to make exceptions for loved ones that they valued a kind of certain now, and need that they saw now, over an uncertain future, and a lot of it, yeah. So the most interesting thing, can I get to the most how many floors have we been on? Let's say we're getting to 100. Feel free to jump in Diego. The most interesting thing for me, and I guess this is a spoiler, is that they didn't really like the scenario that we put to them. And this is what I really love about the empirical part of ethics. The way that I do ethics anyway, really applied ethics, was that we had these scenarios very realistic. We're asking them these questions, and they kept coming back to, but why is she getting all these infections in the first place? You know what's going wrong in the system that we're needing to make these decisions about antibiotics, and that was something we hadn't really considered. It seems so obvious, and that's kind of where the paper ends up landing. And now we're at like, floor 153.
No look, it was a fantastic elevator ride. I appreciate it. What I like about it is actually a lot of what you described isn't in the paper in terms of, I think of, especially the last thing that you mentioned, in terms of the difficulty that they had with the actual case itself. There's perhaps some intimations in the paper, but you don't come out and say it. So I think that's really interesting, and I think that kind of shapes maybe some of the questions that I want to sort of ask and follow up on. Before I do though, I'm wondering what prompted this project? You mentioned there was a couple of papers. What was the motivation behind it?
Oh, well one of them is by Diego Silva,. That, my friends, was Diego wanting a shout out. I'm kidding. So there were kind of two avenues. One is that people, including Diego, have have talked about the really difficult to grasp problems of antimicrobial resistance and the slipperiness and the trickiness of trying to solve these massive problems. So that was part of it, and the other part of it was much smaller. So we were actually funded to do this work by an aged care organization that is mostly based in the Illawarra, and they were hearing, and this is quite a common trope I think. They were hearing that doctors and prescribers working in the aged care sector get heaps of pressure from family members to inappropriately prescribe antibiotics. And so their take was, well, prescribers don't really want to do it, but they get so much hassle from families that they end up doing it anyway. And so part of our other interest really was testing whether or not that was true. And so that's why we came up with the study group that we did. You know, we spoke, all of the people we spoke to had an elderly parent in care. And I think the answer was, honestly, that's partly true, but as with everything, it's just not that simple.
Thanks for that, and now I feel obliged to say that, for the record, I wasn't fishing, and the paper that you're referring to was led by Jasper Litman and Adrian Viens. I was just along for the ride. So thank you, Jasper and Adrian. So one of the things that you claim in your paper is, "balancing value trade offs about end of life care are increasingly common experience in high technology palliative settings, and not central to debates about AMR and AMS, so anti microbial resistance and anti microbial stewardship." I thought that was a really great observation, that we don't often see sort of discussions about anti microbials in the context of palliation, in the context of being a technology. Why do you think this is the case? How can we begin to change the conversation about it?
Yeah, I think that is a really good question. I'm going to answer in two ways. My, I mean, I didn't know until I started this study that, that antibiotics were used in palliative care, and I think it's something that's really common in the aged care sector. But also, we don't really pay heaps of attention to the aged care sector in ethics. That's a huge, sweeping statement. I should say, maybe I haven't paid much attention to the aged care sector. But I think, I think it's an under valued and under studied area, aged care broadly. I think also we're probably quite uncomfortable with the idea of antibiotics as palliation, like antibiotics that don't cure infection, right? So they can make you more, they can make you more comfortable. They can keep your infection sort of lower. Chris, my co author and colleague at University of Wollongong, Chris Degeling, called it mowing the lawn. So it's using antibiotics to just kind of keep things vaguely under control, so that you feel a bit better. So, that's a really hard thing, right? Because it's, it's not necessarily a good use of antibiotics, in the, when we're thinking about antimicrobial resistance. With that said, we really struggle with knowing that people are suffering or uncomfortable. You know, who wants to condone that? So that's a really difficult thing as well. But I guess using antimicrobials for palliation is different from using other forms of palliation, because they, antimicrobials, are necessarily a bit more sort of finite, unfortunately, in the usefulness that they have for us. I'm not quite sure whether that answers the question, except for... I think another thing actually, is that in places like Australia, where we are used to being able to control infection, the idea of not treating an infection is quite hard to get your head round. And so I think there's that as well. You know, I talked about the discomfort, but I think it's also just this idea that if someone's got an infection, you've got to get rid of it, because it's, that's just not the way we do things, you know?
But I'm wondering, the thing I took away from that quote was that we don't see it as a high tech thing. We don't see antimicrobials as high tech, right, like a ventilator or, you know, now I'm showing my lack of knowledge about end of life care. This is what happens when you specialize in public health, but it's not something that we sort of associate as high tech. And I'm wondering, why is that? Is it because, like, vaccines have been around forever that we keep thinking of them as like, low tech and old fashioned, old timey kind of solution? But it is interesting that we don't think of it as high tech.
Yeah, I think. So my memory of the paper, and I will say that this was submitted quite some time ago. I don't have time to look right now. I think we were referring to it as high tech. Part of the technology that's used, like antibiotics are a technological solution to what is often a preventable or a social problem. You know? Where infection might occur because of background settings, like, I don't know, maybe you, maybe you've got somebody who's incontinent and they're not getting their... Oh my gosh. I don't even know what they're called. They're not getting changed as often as they should, you know? So there might be issues with cleanliness. For example, there might be issues with, it's easier to keep someone in a nappy than it is to help them toilet, that sort of thing. So all of those, I wouldn't call tech, and I would call, so the reason I'm talking about incontinence, by the way, is Mary, the person in the scenarios that we used, was receiving antibiotic care for a UTI, which is the most common use of antibiotics in an aged care setting. So, and it's also, you know, it's also the kind of reason, I think, why the, the participants in the study were picking up on things that could have been done to prevent the infection in the first place. But they're all really intense. They're all really sort of human resource intensive, and in some ways, it's unfortunately easier and much less expensive to give someone antibiotics if they do develop an infection. So we would, I wouldn't call it high tech, but I would call it a technological solution to a kind of systemic problem.
Hmm. This actually kind of gets to one of the questions I wanted to ask, which is, are we as humans, victims of our own technological success, particularly when it comes to trading off goods for today versus future goods? And I asked this in part, just based on the last thing that you just mentioned there. You note in the paper how participants in your study presumed that there would be new antimicrobials or other tech solutions in the future, when trading off values of antimicrobials today versus what is needed for tomorrow. You also note, I found this interesting that, you know, there's this parallel public discussion around the climate emergency, and I agree we have this sort of same idea, which is, well, things are particularly bad right now, but there'll be something in the future that will save us. And then I think about, well, isn't that a reasonable thing for people to assume in the first place? Right? Look at the examples of the vaccines that we have for SARS, Covid Two. During covid, we developed them in seeming record time. I know that there was a lot of preliminary data and experiments that occurred before that. You know, the speed of technology just just changes more rapidly. It's seemingly and I think empirically, it's been verified that it's changing more and more rapidly. On the other hand, all this kind of reminds me of Bertrand Russell's parable of the chicken and the problem of inductive reasoning, which is this idea that the chicken thinks every time the farmer goes in the morning to the coop that it's going to be fed until the very last morning when it, you know, gets its head chopped off. So I'm in a muddle. Apparently given your face, Jane, you've not heard that problem of induction explained that way before, but I'm wondering to what extent, going back to the technologies, to what extent are we a victim of our own success? And is it a reasonable thing to assume that we're going to be able to tech our way out of problems?
Uhm, I'm quite shaken. I did not know that was where that parable was going and... However, just focusing on the task at hand. So I'm really interested by this question, if I can just sort of pick on the Covid example. Covid was an immediate problem. It was an immediate problem right at the moment that was in front of us, and people were dying in large numbers, and everything was different. Climate crisis and AMR is not like that. It's just like slowly chugging along, as is the chicken slowly just getting through its days until things are terrible. So I do think that it was different in Covid because we were all so, so deeply aware of the problem, and there was so much political will to fix it. So, I looked some stuff up. To develop a new antibiotic takes between 10 and 15 years and costs about a billion dollars. And in new classes of it. So, so it's comparatively easier to make new antibiotics in existing classes of antibiotic, but they're really only going to be a marginal benefit. To develop new classes of antibiotic, I read about half an hour ago, that one in every 30 drugs is likely to make it to market. So if each, I honestly think it's just a thing that people don't want to put money into, until they know that they will profit from it. When I say people, I mean, I guess pharmaceutical companies. Covid vax, if you think about it, like governments were already making orders for Covid vaccines before we even knew if they were going to work out or not, right? So, so the one that was developed in Australia by University of Queensland, they had the purchase agreements in place already. So you know that you have a thing that's going to pay back. That's just not something that's likely. And also, I suppose, with Covid, you had this idea that every single person in the world was going to need it at the same time. So, so financially, that makes sense. So honestly, I would love to hope that we would tech our way out of this. I don't know if we will in my lifetime, but you're younger than me, Diego. You might be fine. Yeah, I don't feel hopeful.
Yeah, look. I don't think necessarily that it's the best bet to always think that we're going to tech our way out of problems. And in fact, given my track record and research, I would say I'm on the side of, ah, being suspicious of the farmer coming every morning, thinking that something bad might happen one of these days. So there you have it, folks, antimicrobial resistance. We're just all Bertrand Russell's chickens. Changing gears slightly, in the paper you talk about how the use of antimicrobials in residential aged care facilities. It's a matter of balancing the values of what's generally good for the patient versus what's good for the general and often future populations. I understood as sort of the one of the main things that you kind of were testing empirically, and that this parallels the cost benefit analysis that health economists usually engage in. You also claim that this means balancing, "incommensurate things". So I actually want to pick up the potential tension in the methods functioning in the background of your paper. Note that health economists usually reduce descriptions of the good, of what's valuable, to one metric for the very purposes of balancing and trading off. In other words, in other words, for health, economists would generally treat goods as commensurable for the sake of comparison, even if they don't think that goods are commensurable per se. I'm wondering how you envision this trade off of incommensurable goods, especially given the work that you do that combines empirical and applied normative bioethics.
Yeah, so when I leapt into my elevator speech, one thing I should possibly have mentioned was that we weren't asking participants to think in terms of value trade offs. We weren't asking them at all about value trade offs. You know, when they when they told us something, we said, Oh, why do you think that, or, or what's important about this situation? So we weren't asking them to do any trade offs. It was me trying to do the trade offs. So I just wanted to kind of make that clear methodologically. I, I sort of... appreciate that the the measures that health economists use are really valuable in a particular setting, you know? I think it is important to be able to compare things using a common metric. I don't think that that sort of thinking should be employed more generally, to be honest. They definitely have their place. But for me, exploring the kind of incommensurateness, if that's a word, yeah, let's just use it incommensurability. Thank you, Diego. Like what matters to who? Why it matters. You know, who gets to decide what matters? For me, that's at the heart of public health ethics, or the kind of applied public health ethics that I like. I think it's really tricky. And one thing that I think is important is that we're really explicit when we answer those questions. So quite often there's an assumption, like an implicit sort of thing that happens when people are talking about health, they're talking about public health measures, they're talking about benefits and harms. It's not very common that they are explicit about what matters and why. They're often saying, Oh, well, it might save some lives, or if it can save one life, then it's all worth it, all of that sort of thing. And I understand the primacy of saving lives, you know, everybody wants lives saved. But we seldom, when we're using that sort of rhetoric, we seldom talk about all of the other things that happen while our life is being saved, for example. And so, you know, I was thinking about, how do you decide what is more beneficial to a community out of, say, more green parkland with lots of trees in it? I don't think that trade offs are ever easy to compare. I don't think any time we're talking about, oh, it's a matter of maximizing benefits over harms, that sort of thing, I always want to dive a little bit deeper in and say, well, which benefits are you talking about? And which harms are you talking about? And what's the background context that you're talking about them in? So I understand that for people who don't love really applied work, that can be super annoying, and for some people, that is a bit of a sort of drift into relativism. And I don't intend that at all, but I think that when we're talking about benefits and harms, often, not only are they not necessarily commensurate, but they're not being experienced and felt by the same people. So you might be doing something that benefits the greater good, the wider population, whatever, while burdening a very specific population. And I'm trying to think about how to tie this back into the AMR but, but I keep coming back to Covid. Because, you know, Covid is always this thing that keeps on giving, right? And, you know, there were so many really obvious examples of that where it was technically, maybe probably not beneficial to have things like curfews or five kilometer or two kilometer, or whatever there were, radiuses for where you could go outside, those weren't necessarily beneficial to the people who were bearing the burdens of them. In fact, I would say they weren't. And so for me, the thing I like is the messiness about thinking about what constitutes a benefit, what constitutes a harm, who for? Why? And maybe the health economists do that. There's some really cool health economy stuff, actually, but I never read it.
Yeah, look, you know, I'm thinking of health economics colleagues who do, I think, a lot of really great work and a lot of really nuanced work. So I don't think, yeah, I didn't mean to kind of paint everybody with a broad brush, but there is at least sort of a sense of, there's a version of health economics that collapses into, I would say, sort of kind of simple utilitarianism. So here, I don't even mean actual utilitarianism, but sort of more simplistic versions of it, and probably fraudulent versions of it, perhaps. But I think what you're referring to is the idea of justice, and just distribution of the benefits and burdens related to AMR, or the burdens of AMR and the benefits of AMS, of stewardship. And I think that that's something that really comes out clearly. And you mentioned a couple of times the idea of the background conditions and how that was something that the participants picked up on. It's something that is there in the literature as well, as you note in the paper. And I think this kind of points to, you know, to something else, which is, we do a better job in Aboriginal health and Aboriginal Torres Strait Islander health, to try to not think about things in a deficit model. To try to think about it from a strength based perspective, and to try to think creatively. And it strikes me that one of the things that we sort of run into as problems with regards to antimicrobial resistance, and thinking through stewardship, is that we do run sort of a deficit model to borrow that term. We're sort of taking it as a given that things are dire, rather than sort of trying to think about sort of novel solutions. So I think one example is in a paper that I co-wrote with colleagues, including Kari Pahlman and Anson Fehross from, from Sydney Health Ethics. It was a different context that we were looking at AMR and AMS, but we were looking at about it in the context of regional health security or health security more broadly. And one of the things that we sort of posit in the paper is, you know, we see sort of anti microbials and its misuse of sort of tragedy of the commons. Is there a way that we can sort of think about actually, they were only ever meant to be limited resources, and so it's not that we have to compete for them, but rather that thinking about how to distribute them fairly ought to have always been there from the outset? So our problem isn't that we have to trade off. The problem is that we forgot that this is something that we needed to think about. It's just distribution from the get go. So it doesn't resolve the problem. But I guess what I'm wondering is whether we can at least frame things differently, so that at least we think we have less entitlement to antimicrobials. I don't know. Yeah, that was a long rant on my part, but I'm wondering whether, I'm wondering about whether this idea of kind of thinking about things creatively, whether publics in groups are better at than than we are, perhaps?
Yeah, I really like that. And actually it's interesting. I was in the, in an earlier iteration of this paper, I was writing about tragedy of the commons, and got some really strong pushback from a mentor. I do think that, that, as I said earlier, because our participants really wanted to reframe the question that that, to me, is a really interesting thing, you know? That that is not a really narrow look at, this is the problem of antibiotics, and we just have to decide. We just have to make rules, basically about who gets it and when. I'm going to digress a little bit, because one thing that was super interesting to me was that there was the idea in this conversation that we were having with the participants that if they, I guess, spruiked for antibiotics for their mum now, their mum was always the person they were talking about, then future people might not be able to have it. But then it was really interesting to me. One guy said, If my mum gets antibiotics now, then maybe I won't be able to get them when I'm old. And I thought, Okay, now that is super interesting, because that's two known people. You know, that's two known individuals, rather than this kind of vague, imaginable future population. And nobody really picked up on it. And what I really wanted to say was, if it's a matter of choosing between your mom getting them now and the possibility of your kid not having them, then what would that do for the conversation? And like this is not really going to what you, what you're asking about in terms of creative solutions. I think that maybe that's the kind of hard thinking that needs to happen. I mean, there's a bit of magical thinking about new ones. But instead of being sort of vague about, oh, what's going to happen in the future, maybe we need to actually think, well, if you're thinking specifically about whether or not you would give them to a sick parent now, you need to think about what you're willing to give up for yourself in the future, what you're willing to give up now, in terms of your parents comfort at the end of their life, and what you're willing to give up for yourself, for your children, say, in the future. To me, though, I think the fact that they did keep wanting to change the scenario, essentially, I mean, it wasn't always perfect, they didn't really just come down on the the residential aged care workers, you know, because that's easy I guess, that was a bit disappointing, but, you know, reframing the problem was something they were doing.
So Jane, what are you working on right now? What can we look forward to seeing in the future?
Well, I have a few few bits and pieces going on. The thing that I'm finding the most fun, and I know I did this podcast, like, a year ago, and I'm really hoping I didn't say the same thing. But a thing that I'm really enjoying is a project that I'm working on with a crew in, based in University of Western Australia, about vaccine mandates And that is a thing that's really fun to think about, because there has been quite a lot of work in public health ethics in the past about what we can do to improve uptake of childhood vaccines. But this one came out of the pandemic, and it's about what's reasonable in terms of mandating vaccines for adults in an emergency situation. And that's fun.
Yeah, that one seems like it won't have any shortage of permutations. And I think that'll get you on the ABC, on the Australian Broadcasting Corporation. Thanks for listening everyone to this episode of the She Research Podcast. You can find the paper we discussed linked in the episode's notes, along with a transcript. She Pod is produced by She Network and edited by Regina Botros. You can find our other episodes on Spotify, Radio Public, Anchor, or wherever you get your podcasts of qaulity. Thanks again for listening. Bye, bye.