The rise of antimicrobial resistance (AMR), driven by relentless microbial evolution, threatens the foundations of global healthcare. Rather than following the so far undeliverable promise of evermore broad-spectrum antibiotics, infectious disease treatment can follow the example of oncology, which has, over a short period, augmented a platform of commodity anti-cancer agents with precision medicines and diagnostics to combat cancer evolution on a personalised basis. It is this shift that has allowed a significant extension in survival and has created entirely new subsectors of biotech. Sophisticated thinking and concerted action have also made changes to clinical practice and pathways. Applying these principles, precision antimicrobials, guided by rapid diagnostics and used alongside commodity products, offer a way to target resistant infections more effectively. Moreover, thinking about medicines that target multi-drug resistant infections as precision agents for rare occurrences opens up precedented reimbursement frameworks that could break the economic logjam that has smothered the sector for a generation. This is not the science of the future. The foundations of precision antimicrobial approaches are already emerging, with an ecosystem of initiatives to wrap around and support their development. Among these, Pathways to Antimicrobial Clinical Efficacy, a global AMR R&D platform that funds and offers wrap-around support for the development of new diagnostics and therapeutics, provides crucial infrastructure for emerging pipelines. Precision approaches have the potential to save lives that could otherwise be lost to resistant infections, while preserving the effectiveness of existing antimicrobials for future generations. Change is starting but cannot be left in the ‘too difficult’ tray. Microbial evolution and our own actions guarantee that we will need to adopt a new approach in our antimicrobial battle, and our lessons from the COVID-19 pandemic are that we need to act in advance, not in crisis.

What exactly is a “wicked problem”? It is a social or economic problem that is so complex and so interconnected with other issues that it is extraordinarily difficult or impossible to resolve. This is because all proposed resolutions generate equally complex, equally wicked problems. In this essay, I argue that precision medicine, especially in the context of the U.S. healthcare system, generates numerous wicked problems related to distributive justice. Further, I argue that there are no easy solutions to these wicked problems. The need for trade-offs is inescapable. Rough justice is the best outcome we can hope for, and that outcome requires a commitment to processes of public reason that are fair and inclusive.