The international dimensions of antimicrobial resistance: contextual factors shape distinct ethical challenges in South Africa, Sri Lanka and the United Kingdom

Antimicrobial resistance (AMR) describes the evolution of treatment-resistant pathogens, with potentially catastrophic consequences for human medicine. AMR is driven by the over-prescription of antibiotics, and could be reduced through consideration of the ethical dimensions of the dilemma faced by prescribers. This dilemma involves balancing apparently opposed interests of current and future patients and unique contextual factors in different countries, which may modify the core dilemma. We describe three example countries with different economic backgrounds and cultures—South Africa, Sri Lanka and the United Kingdom. Then we discuss how country-specific factors impact on the prominence of different ethical dimensions of the dilemma (equality of present and future generations; rule of rescue; prescribing autonomy and conflicts of interest; consensus on collective action). We conclude that a nuanced understanding of national prescribing dilemmas is critical to inform design of effective stewardship approaches.