Papers by Jasper Littmann

Public Health Ethics, 2015
In this paper, we provide a state-of-the-art overview of the ethical challenges that arise in the... more In this paper, we provide a state-of-the-art overview of the ethical challenges that arise in the context of antimicrobial resistance (AMR), which includes an introduction to the contributions to the symposium in this issue. We begin by discussing why AMR is a distinct ethical issue, and should not be viewed purely as a technical or medical problem. In the second section, we expand on some of these arguments and argue that AMR presents us with a broad range of ethical problems that must be addressed as part of a successful policy response to emerging drug resistance. In the third section, we discuss how some of these ethical challenges should be addressed, and we argue that this requires contributions from citizens, ethicists, policy makers, practitioners and industry. We conclude with an overview of steps that should be taken in moving forward and addressing the ethical problems of AMR.

European Journal of Public Health, 2017
Background: To reduce the effect of antimicrobial resistance and to preserve antibiotic effective... more Background: To reduce the effect of antimicrobial resistance and to preserve antibiotic effectiveness, clinical guidelines and health policy documents call for the rational use of antibiotics, which aims to reduce unnecessary or minimally effective antibiotic use. Methods: Through ethical analysis, we show that rational use programmes can lead to ethical conflicts, because they sometimes place patients at risk of harm-for example, a delayed switch to second-line antibiotics for community-acquired pneumonia can lead to substantial increases in mortality. Results: Implementing the rational use of antibiotics can lead to conflicts between promoting patients' clinical interests and preserving antibiotic effectiveness for future use. The resulting ethical dilemma for clinicians, patients and policy makers has so far not been adequately addressed. Conclusions: Existing guidance for acceptable risks in clinical research can help to define risk thresholds for the rational use of antibiotics. We develop an ethical framework that allows clinicians and policy-makers to evaluate policies for rational antibiotic use in six practical steps. This framework can help guide clinical practice and health policy.
Sustainable development levers are key in global response to antimicrobial resistance
The Lancet
Tidsskrift for Den norske legeforening
Jasper Littmann er fagdirektør for strategi og utvikling ved Folkehelseinstituttet. Forfatteren h... more Jasper Littmann er fagdirektør for strategi og utvikling ved Folkehelseinstituttet. Forfatteren har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter.
Antimicrobial Resistance - a threat to the world's sustainable development
Authors: Dusan Jasovsky, Jasper Littmann, Anna Zorzet, Otto Cars
This commentary examines how sp... more Authors: Dusan Jasovsky, Jasper Littmann, Anna Zorzet, Otto Cars
This commentary examines how specific sustainable development goals (SDGs) are affected by antimicrobial resistance and suggests how the issue can be better integrated into international policy processes. Moving beyond the importance of effective antibiotics for the treatment of acute infections and health care generally, we discuss how antimicrobial resistance also impacts on environmental, social, and economic targets in the SDG framework. The paper stresses the need for greater international collaboration and accountability distribution, and suggests steps towards a broader engagement of countries and United Nations agencies to foster global intersectoral action on antimicrobial resistance.

Exploring the evidence base for national and regional policy interventions to combat resistance
The effectiveness of existing policies to control antimicrobial resistance is not yet fully under... more The effectiveness of existing policies to control antimicrobial resistance is not yet fully understood. A strengthened evidence base is needed to inform effective policy interventions across countries with different income levels and the human health and animal sectors. We examine three policy domains—responsible use, surveillance, and infection prevention and control—and consider which will be the most effective at national and regional levels. Many complexities exist in the implementation of such policies across sectors and in varying political and regulatory environments. Therefore, we make recommendations for policy action, calling for comprehensive policy assessments, using standardised frameworks, of cost-effectiveness and generalisability. Such assessments are especially important in low-income and middle-income countries, and in the animal and environmental sectors. We also advocate a One Health approach that will enable the development of sensitive policies, accommodating the needs of each sector involved, and addressing concerns of specific countries and regions.

In this paper, we provide a state-of-the-art overview of the ethical challenges that arise in the... more In this paper, we provide a state-of-the-art overview of the ethical challenges that arise in the context of antimicrobial resistance (AMR), which includes an introduction to the contributions to the symposium in this issue. We begin by discussing why AMR is a distinct ethical issue, and should not be viewed purely as a technical or medical problem. In the second section, we expand on some of these arguments and argue that AMR presents us with a broad range of ethical problems that must be addressed as part of a successful policy response to emerging drug resistance. In the third section, we discuss how some of these ethical challenges should be addressed, and we argue that this requires contributions from citizens, ethicists, policy makers, practitioners and industry. We conclude with an overview of steps that should be taken in moving forward and addressing the ethical problems of AMR.
The problem of antimicrobial resistance is so dire that people are predicting that the era of ant... more The problem of antimicrobial resistance is so dire that people are predicting that the era of antibiotics may be coming to an end, ushering in a ‘post-antibiotic’ era. A comprehensive policy response is therefore urgently needed. A part of this response will require framing the problem in such a way that adequately reflects its nature as well as encompassing an approach that has the best prospect of success. This paper considers framing the problem as a slowly emerging disaster, including its potential benefits and difficulties, from a conceptual and policy perspective.

Antibiotic resistance: An ethical challenge
In this paper, we argue that antibiotic resistance (ABR) raises a number of ethical problems that... more In this paper, we argue that antibiotic resistance (ABR) raises a number of ethical problems that have not yet been sufficiently addressed. We outline four areas in which ethical issues that arise in relation to ABR are particularly pressing. First, the emergence of multidrug-resistant and extensively drug-resistant infections exacerbates traditional ethical challenges of infectious disease control, such as the restriction of individual liberty for the protection of the public's health. Second, ABR raises issues of global distributive justice, both with regard to the overuse and lack of access to antibiotics. Third, the use of antibiotics in veterinary medicine raises serious concerns for animal welfare and sustainable farming practices. Finally, the diminishing effectiveness of antibiotics leads to questions about intergenerational justice and our responsibility for the wellbeing of future generations. We suggest that current policy discussions should take ethical conflicts into account and engage openly with the challenges that we outline in this paper.

Antibiotika-Resistenz: Ethische Aspekte einer drängenden Herausforderung
Dieser Artikel beschreibt die ethischen Herausforderungen, die sich durch das Problem der Antibio... more Dieser Artikel beschreibt die ethischen Herausforderungen, die sich durch das Problem der Antibiotikaresistenz (ABR) ergeben. Wir legen die Ursachen für ABR dar und argumentieren, dass eine effektive Bekämpfung der ABR es erforderlich macht, den derzeitigen Antibiotikagebrauch drastisch zu reduzieren. Allerdings müssen hierbei auch die ethischen Probleme, die durch ABR entstehen, berücksichtigt werden. ABR führt zum einen zur Verstärkung bereits bestehender Herausforderungen im Infektionsschutz, zum anderen wirft sie neue ethische Probleme auf. Wir argumentieren, dass sich diese Probleme vor allem in Bezug auf kollektive Handlungsentscheidungen und gerechte Ressourcenverteilung ergeben. Um den Konsum von Antibiotika fair zu reduzieren, entwickeln wir anschließend sowohl ein kontraktualistisches Prinzip für die Rationierung, als auch erste Vorschläge zu dessen Implementierung. Hierbei skizzieren wir Risikogrenzen für die Patienten, bei denen ein Verzicht auf Antibiotikatherapie gerechtfertigt werden kann.
In this article the ethical challenges posed by antibiotic resistance (ABR) are discussed. We outline the causes of ABR and argue that an effective policy to combat the challenge in the future will necessitate a drastic reduction of antibiotic use. However, such a reduction will lead to ethical problems, which policy makers must take into account. ABR not only exacerbates existing normative challenges in infectious disease control, but creates new problems that have not yet been addressed. In this article, it will be argued that these new problems arise mainly with regard to the fair distribution of scarce resources and the regulation of collective actions. In this paper a contractualist approach to establish fair policies for the restriction of antibiotic use is suggested and its practical implications are discussed. To this end, we introduce and defend a threshold for the acceptable risk of an adverse outcome to which a patient may legitimately be subjected.
How high is a high risk? Prioritising high-risk individuals in an influenza pandemic
Pandemic contingency plans frequently define priority groups that are given preferential access t... more Pandemic contingency plans frequently define priority groups that are given preferential access to influenza vaccine. One of the most commonly named groups for prioritisation is that of high-risk individuals. However, current models of categorisation are unsatisfactory in a number of ways. It will be argued that existing vaccination strategies fail to adequately define what kind of risks are being considered and how, as well as on the basis of which information, these risks are calculated. Moreover, it will be suggested that existing vaccination strategies fail to specify of what magnitude a risk has to be, in order to be categorised as 'high'. Finally, it shall be argued that a mere focus on the size of a risk factor may lead policy makers to overlook underlying concerns of distributive justice.
Accounting for the Cost of Contact Tracing Through Social Networks
Public Health Ethics, Nov 2013
This article critically engages with Mandeville et al.'s case discussion of using social networki... more This article critically engages with Mandeville et al.'s case discussion of using social networking services for the purposes of contact tracing in infectious disease outbreaks. It will be argued that their discussion may be overstating the utility of such approaches, while simultaneously underestimating the ethical concerns that arise from this method of contact tracing. The article separates between ethical and technological concerns and suggests that due to the particular design of networking sites such as Facebook and the usage patterns of subscribers, the positive effect of contact tracing through such services may be overstated. At the same time, using social networking sites raises serious concerns regarding the privacy of patients and the ownership of information posted online.

Distributing Vaccine Fairly During Influenza Pandemics – A Case Study from Berlin
Ethics in Public Health and Health Policy
At the beginning of an influenza pandemic, scarcity of vaccine is unavoidable. This raises questi... more At the beginning of an influenza pandemic, scarcity of vaccine is unavoidable. This raises questions about fair distribution and prioritisation of particular groups. During the H1N1 pandemic in 2009 and 2010, the prioritisation of patient groups for the vaccination against influenza raised a series of ethical concerns. These related to the problems of uncertainty about outcomes at the onset of a pandemic, the difficulty of defining a clear goal of vaccination campaigns, and the practical problems brought about by the intense challenges that health care systems are faced with in a pandemic. In this paper, Berlin is used as a case study to show that at least some of these problems are related to a failure to integrate pandemic policy between different organisational levels. This failure proved problematic in two instances, first where policies overlapped and contradicted each other, and second where the minutiae of vaccine provision created problems for more abstract assumptions about fair allocation of scarce resources. It will be shown that some aspects of these problems may be remediable by applying principles of procedural justice. However, in order to properly integrate the micro and the macro scale, bioethicists will have to work alongside those with clinical expertise, and deploy models of thinking both from conventional doctor-patient bioethics and more population-level public health ethics.
Comment on Marchman Andersen et al.: Social inequality in health, responsibility and egalitarian justice
Journal of public health (Oxford, England), 2013
Trials, Jan 1, 2012
For the protection of commercial interests, licensing bodies such as the EMA and health technolog... more For the protection of commercial interests, licensing bodies such as the EMA and health technology assessment institutions such as NICE restrict full access to unpublished evidence. Their respective policies on data transparency, however, lack a systematic account of (1) what kinds of commercial interests remain relevant after market approval has been granted, what the specific types of public interest are that may override these commercial interests post approval, and, most importantly, (3) what criteria guide the trade-off between public interest and legitimate measures for the protection of commercial interest. Comparing potential commercial interests with seven specifications of relevant public interest reveals the lack of proportionality inherent in the current practices of EMA and NICE.
To overcome failure to publish negative findings: the OPEN project
Maturitas, 2013
Thesis by Jasper Littmann

The rapid emergence of Antimicrobial Resistance (AMR) over the past decades together with a lack ... more The rapid emergence of Antimicrobial Resistance (AMR) over the past decades together with a lack of research into new drugs presents health care systems with serious challenges and threatens their ability to effectively treat serious bacterial infections. As a result, it is realistic to expect that effective treatment options for some infections will run out in the future. The thesis begins by outlining the mechanisms and consequences of AMR and argues that AMR differs from other distributive problems, due to the specific characteristics of antibiotics. It is suggested that for considerations of distributive justice, antibiotic effectiveness should be treated as a resource, which can be depleted and which must be fairly distributed between people and generations.
The thesis then goes on to examine the distinctive moral challenge posed by AMR. It begins by considering a consequentialist account, which suggests that AMR is a moral problem due to the bad health outcomes it entails. However, this approach is subsequently dismissed because it struggles to account for some of the particular features of AMR. An alternative is to consider AMR as a morally wrongful harm to individuals, which requires not only that AMR has adverse effects, but also violates the victim’s rights. It is shown that the harm caused by AMR is morally wrongful and that people have a right to be protected from adverse health outcomes, which AMR violates. However, it is difficult to specify correlative duties that result from such a rights claim.
As an alternative, the thesis suggests and defends a form of Scanlonian contractualism, which offers the best model to represent and address issues of distributive justice in the case of AMR. It is shown that a principle of antibiotic use, which rules out the use of antibiotics for infections that do not pose a serious risk of irreversible harm, offers a convincing contractualist argument. The thesis examines the concerns for intergenerational justice that arise as a consequence of AMR and shows that contractualism is capable of addressing them. The thesis concludes by suggesting a new way of framing AMR as a specific type of policy challenge, which better captures its complexity and advocates a reduction of future dependency on antibiotics.

MPH thesis
Hiermit erkläre ich, dass diese Arbeit von mir selbstständig verfasst wurde und keine anderen als... more Hiermit erkläre ich, dass diese Arbeit von mir selbstständig verfasst wurde und keine anderen als die angegebenen Hilfsmittel benutzt wurden. Datum Unterschrift 3 Abstract Influenzapandemien wie die H1N1-Variante des vergangenen Jahres treten regelmäßig auf und ziehen erhebliche Mortalität und Morbidität nach sich. Als wirksamste Form der Bekämpfung einer solchen Pandemie gilt die Schutzimpfung. Da es jedoch zu Beginn einer Impfkampagne gegen Influenza aus produktionstechnischen und logistischen Gründen unausweichlich zu einer Verknappung von Impfstoff kommt, können nicht alle Impfwilligen gleichzeitig geimpft werden. Deswegen sehen viele Influenza-Krisenpläne eine Priorisierung bestimmter Gruppen, wie besonders gefährdeter Patienten und medizinischem Personal vor. Da es hier zu einer Benachteiligung der nicht-priorisierten Patienten kommt, ist es wichtig, dass die Entscheidung darüber, wer bevorzugt geimpft wird, so fair wie möglich getroffen wird. Ziel dieser Arbeit ist es deshalb, die ethischen Implikationen einer
Background Paper by Jasper Littmann
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Papers by Jasper Littmann
This commentary examines how specific sustainable development goals (SDGs) are affected by antimicrobial resistance and suggests how the issue can be better integrated into international policy processes. Moving beyond the importance of effective antibiotics for the treatment of acute infections and health care generally, we discuss how antimicrobial resistance also impacts on environmental, social, and economic targets in the SDG framework. The paper stresses the need for greater international collaboration and accountability distribution, and suggests steps towards a broader engagement of countries and United Nations agencies to foster global intersectoral action on antimicrobial resistance.
In this article the ethical challenges posed by antibiotic resistance (ABR) are discussed. We outline the causes of ABR and argue that an effective policy to combat the challenge in the future will necessitate a drastic reduction of antibiotic use. However, such a reduction will lead to ethical problems, which policy makers must take into account. ABR not only exacerbates existing normative challenges in infectious disease control, but creates new problems that have not yet been addressed. In this article, it will be argued that these new problems arise mainly with regard to the fair distribution of scarce resources and the regulation of collective actions. In this paper a contractualist approach to establish fair policies for the restriction of antibiotic use is suggested and its practical implications are discussed. To this end, we introduce and defend a threshold for the acceptable risk of an adverse outcome to which a patient may legitimately be subjected.
Thesis by Jasper Littmann
The thesis then goes on to examine the distinctive moral challenge posed by AMR. It begins by considering a consequentialist account, which suggests that AMR is a moral problem due to the bad health outcomes it entails. However, this approach is subsequently dismissed because it struggles to account for some of the particular features of AMR. An alternative is to consider AMR as a morally wrongful harm to individuals, which requires not only that AMR has adverse effects, but also violates the victim’s rights. It is shown that the harm caused by AMR is morally wrongful and that people have a right to be protected from adverse health outcomes, which AMR violates. However, it is difficult to specify correlative duties that result from such a rights claim.
As an alternative, the thesis suggests and defends a form of Scanlonian contractualism, which offers the best model to represent and address issues of distributive justice in the case of AMR. It is shown that a principle of antibiotic use, which rules out the use of antibiotics for infections that do not pose a serious risk of irreversible harm, offers a convincing contractualist argument. The thesis examines the concerns for intergenerational justice that arise as a consequence of AMR and shows that contractualism is capable of addressing them. The thesis concludes by suggesting a new way of framing AMR as a specific type of policy challenge, which better captures its complexity and advocates a reduction of future dependency on antibiotics.
Background Paper by Jasper Littmann