Medical Ethics in Antibiotic Prescription and Use: a Comprehensive Review

Antibiotics are among the most consequential medical discoveries of the twentieth century, yet their effectiveness is a shared and depletable resource. Every prescription simultaneously serves an individual patient and exerts selective pressure that contributes to antimicrobial resistance (AMR), a condition now associated with millions of deaths each year [1,2]. This dual character places clinicians in a distinctive ethical position: the duty to act in the best interest of the patient in front of them may pull against the duty to preserve antibiotic effectiveness for present and future populations. This review examines the ethical dimensions of antibiotic prescription and use across the continuum from bedside decision-making to global governance. We first summarise the epidemiological and behavioural context of antibiotic misuse and overuse. We then analyse the issue through the four principles of biomedical ethics, public health ethics, the commons framework, contractualism, virtue ethics and relational approaches, and discuss specific dilemmas including patient expectations, diagnostic uncertainty, defensive practice, vulnerable populations, end-of-life care, access and equity, conflicts of interest, agricultural use, and the ethics of antibiotic research and development. We consider policy, legal and institutional responses, with attention to low- and middle-income settings and to India, and present a practical ethical decision framework, illustrative case vignettes, and a research agenda. We argue that antibiotic stewardship should be understood not only as a technical quality-improvement programme but as an ethical obligation grounded in justice, professional integrity and intergenerational responsibility, and that ethical competence in antibiotic use should be taught, assessed and supported systemically rather than left to individual conscience.