In my work leading the AMR Action Fund, I spend much of my time focused on one of the most consequential challenges in modern medicine: how do we ensure that patients continue to have effective antibiotics when they need them? Working at the intersection of antibiotic innovation, investment, public health, and policy has reinforced for me that antimicrobial resistance (AMR) is not simply a scientific problem with ethical implications. It is fundamentally a problem of human choices—and therefore an ethical problem.
AMR is commonly characterized as a public health crisis associated with millions of deaths and the possibility that routine infections may once again become life-threatening. Although accurate, this framing is incomplete. Antibiotics do not “fail” autonomously. Resistance emerges through innumerable human decisions about how these drugs are developed, financed, prescribed, regulated, distributed, and used across health care, agriculture, and global markets. My work makes the resulting moral pluralism especially visible: addressing AMR requires simultaneously considering the patient who needs an antibiotic today, the patients who will need that antibiotic tomorrow, populations that lack adequate access now, and the economic conditions necessary for new antibiotics to exist at all. These interests are morally significant but not always commensurable.
Principlism illuminates one of the most immediate tensions. Clinicians have an obligation of beneficence toward the individual patient and the responsibility to provide the treatment most likely to benefit that person. Yet antibiotic use generates consequences beyond the individual encounter. Each use can contribute incrementally to the rise and prevalence of resistance and diminish a drug's utility for future patients. Antibiotic stewardship, policies and practices intended to help clinicians optimize treatment while reducing unnecessary or inappropriate use, therefore introduces population-level nonmaleficence into an ethical relationship traditionally centered on the individual patient – a tension between clinical and public health ethics.
This creates a paradox I encounter frequently in antibiotic innovation. We invest in developing urgently needed antibiotics and, once they reach patients, appropriately encourage clinicians to use them judiciously. The more successfully we steward a new antibiotic, however, the smaller its commercial market becomes. Society therefore asks companies and investors to assume considerable scientific and financial risk to develop medicines whose consumption we intentionally seek to constrain. This is rational from a public health perspective but economically self-defeating under conventional pharmaceutical market structures. The resulting market failure has diminished private investment, weakened the antibiotic pipeline, and contributed to a paucity of new innovative antibiotics reaching patients.
This is more than an economic anomaly; it is an ethical problem of institutional design. If society regards effective antibiotics as indispensable infrastructure for modern medicine yet creates an economic system in which their responsible use undermines their commercial viability, responsibility for market failure cannot be assigned exclusively to pharmaceutical companies or investors. Governments, health systems, payers, and other institutions become moral agents whose policy choices determine whether antibiotic innovation is sustainable and whether we will continue to have effective antibiotics in the face of rising drug-resistant infections.
Questions of distributive justice become even more difficult globally; I spend considerable time finding strategies to accelerate and expand access to needed antibiotics. Low- and middle-income countries often bear a disproportionate burden of drug-resistant infections while having less access to diagnostics, sanitation, infection prevention, and both existing and newly developed antibiotics. Asking health systems in these countries to exercise greater restraint, limiting antibiotic use, without simultaneously addressing inadequate access risks transforming stewardship into an inequitable allocation of sacrifice. Stewardship cannot mean the same thing in a setting characterized by antibiotic excess as it does in one characterized by scarcity. Responsible antibiotic use must encompass both avoiding unnecessary treatment and ensuring that patients who need antibiotics can receive them.
Rawlsian justice makes this asymmetry particularly salient. AMR policies should be interrogated according to whether they improve or worsen the position of the least advantaged. This applies not only to access but also to financing innovation. Antibiotic development requires substantial capital and entails extraordinary scientific and financial uncertainty. Investors reasonably expect returns, yet effective antibiotics possess characteristics of a global public good. The normative challenge is therefore to design economic arrangements that sufficiently reward innovation while ensuring equitable access, including for populations that cannot generate commercially attractive returns.
This tension is central to my work at the AMR Action Fund. Investment and public health are sometimes conceptualized as competing moral domains—one associated with private returns and the other with collective welfare. In AMR, that dichotomy is untenable. Without sustainable investment, promising antibiotics will never reach patients. Yet an innovation ecosystem that successfully produces antibiotics that substantial portions of humanity cannot access is equally deficient. The ethical objective is therefore not to choose between markets and public health, but to build incentive structures in which private investment and social value are better aligned and burdens and benefits are equitably shared.
Communitarian and public health ethics further illuminate AMR as a collective-action problem. Antibiotics are unusual medicines because their value is simultaneously individual and communal. Infections also possess a dual nature: an infected individual is both in danger but also poses danger to others if the infection is highly transmissible. This also lends a social and emotional dimension to antimicrobial use and prescribing that is not seen with other drugs. Withholding or curtailing use can create tensions around perceived and real communal or individual risk, inequities in access, and on occasion resulting in AMR infections transforming from local, sporadic cases to a new community norm. As such, their preservation requires coordinated action among clinicians, governments, pharmaceutical companies, investors, agriculture, health systems, and patients. No actor can solve AMR independently, yet the rational decisions of individual actors can collectively produce an irrational outcome. A clinician prescribes because the individual patient may benefit or because the healthcare system restricts the time they have to explain that an antibiotic is not needed; a payer minimizes expenditures; an investor allocates capital toward more predictable returns; and a pharmaceutical company exits an economically unattractive field. Each decision may be individually rational, while their cumulative effect is a world in which effective antibiotics progressively disappear.
This is, in many respects, a tragedy of the commons complicated by a second and seemingly contradictory imperative: unlike many scarce resources, antibiotics must not only be conserved but continually replenished through innovation. We therefore have simultaneous moral obligations of stewardship and innovation, conservation and access. The ethical problem is not simply how to consume antibiotics less, but how to preserve their effectiveness while ensuring their continued availability.
Virtue ethics asks a different question, one that increasingly informs how I think about policy advocacy: what qualities should characterize those entrusted with this shared resource? Prudence, temperance, responsibility, solidarity, and stewardship apply not only to clinicians prescribing antibiotics but also to companies developing them, investors financing them, and policymakers designing the incentives that govern them. Ethical leadership in AMR requires phronesis because these responsibilities cannot always be reduced to rules or reconciled through calculation. They require judgment about competing goods under conditions of profound uncertainty.
Finally, AMR presents a problem of intergenerational justice. Decisions made today determine which therapeutic options remain available decades from now. Antibiotic consumption creates temporal externalities: present actors receive immediate benefits, while some costs are transferred to future patients who have no opportunity to participate in today's decisions. The analogy with climate change is compelling. In both cases, short-term incentives encourage behavior whose cumulative consequences degrade a shared resource and externalize burdens onto future generations.
For me, this is ultimately why AMR cannot be understood as merely a scientific challenge. Science can discover new antibiotics, characterize resistance mechanisms, and improve diagnostics. It cannot tell us how much society ought to pay to preserve antibiotics, when individual claims should yield to collective interests, how benefits and burdens should be distributed globally, or what obligations present generations owe future patients. These are normative questions.
My work at the AMR Action Fund places me inside these tensions rather than outside them. We seek to support innovation while advocating for stewardship, attract private capital while advancing a public good, preserve antibiotics for tomorrow while ensuring access today, and create sustainable markets while confronting profound global inequities. These objectives cannot be reconciled by appealing to a single ethical principle. AMR instead requires moral pluralism: acknowledging that beneficence, autonomy, utility, justice, solidarity, and obligations to future generations all have legitimate moral claims that sometimes conflict.
Ethical deliberation does not eliminate these conflicts. Its value lies in making them visible and demanding that we ask who benefits, who bears the burdens, whose interests remain invisible, and which institutions should be accountable for the consequences. Making the ethical tensions inherent in addressing AMR explicit at the individual, community, and systems levels reinforces the understanding that this challenge cannot be addressed in isolation. It also underscores that the moral imperative to confront AMR is as fundamental as its scientific and clinical dimensions. Perhaps most importantly, the language of ethics provides a common framework, a lingua franca, through which stakeholders from diverse professional, socioeconomic, and geographic backgrounds can articulate shared values, bridge differences, and communicate the urgency and significance of this work. In doing so, ethics can help transform a complex scientific and public health challenge into a collective moral undertaking, inviting broader participation from those who may not yet recognize their role in addressing it.
Ultimately, solving AMR will require more than discovering new antibiotics. It requires deciding how we collectively value them, how we distribute responsibility for sustaining and preserving them, and what obligations we are prepared to assume toward patients we will never meet.
Henry Skinner, PhD, MSc, MJur, graduated with a Master of Science in Bioethics from the Center for Bioethics at Harvard Medical School in 2024. He has a background in science (PhD in Microbiology, The University of Illinois at Urbana-Champaign) and pharmaceutical research and development. He is currently Chief Executive Officer of the AMR Action Fund, where he leads efforts to advance the development of urgently needed antibiotics and address the scientific, economic, and policy challenges associated with antimicrobial resistance.
The Bioethics Blog, hosted by Harvard Medical School Center for Bioethics, features short, conversational pieces from Center alumni and faculty on pressing issues in bioethics. Posts are curated by alumni editors Rebecca Li, Carolyn Baker Ringel, and Risa Jampel. Through these contributions, we aim to share ethical insights, invite further dialogue, and connect bioethicists across the globe working in related areas of research and practice. The views and opinions expressed in this article are those of the author and do not necessarily reflect the views, policies, or positions of the Center for Bioethics at Harvard Medical School.
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