New evidence shows that mass administration of azithromycin (MDAA) can significantly reduce child mortality in high-burden, low-resource settings. However, the 2020 WHO guidelines approach this cautiously due to concerns about antimicrobial resistance. These guidelines cite ethical principles, but do not adequately address intergenerational justice, equitable burden sharing, and structural determinants of health. Global antimicrobial resistance (AMR) policies often prioritize protection over access, placing a disproportionate burden on low-income countries, even though high-income countries bear responsibility for the emergence and spread of AMR. What is needed is a balanced ethical framework that integrates contextual values such as justice across generations, historical inequalities and community contributions. The revised WHO guidelines should expand MDAA eligibility based on contextual criteria, establish thresholds for monitoring mortality and resistance, and encourage investment in sustainable health systems. This article calls for greater consideration of the ethical trade-offs between antibiotic storage and access in WHO guidelines.