March 30, 2004

Paternalism in medicine

Trent McBride, over at The Proximal Tubule, has started an interesting discussion among medical bloggers about medical paternalism. DB's Medical Rants has a good response, and so does Educated Guesswork.

Since issues of regulation, public safety, and profit take center stage here, this one might be interesting for the law bloggers to follow as well.

As a self-styled libertarian, McBride is understandably opposed to what he considers the paternalism of prescription-only restrictions on access to pharmaceuticals:

In no area is this more apparent than in the prescription-only status of most medicines. It always amazes me that this fact is never called into question, especially among my medical school colleagues. There is no shortage of debate in and about medicine on just about any other topic, but we accept this culture of the gatekeeper almost without question. You would think just once you would here somebody say, "Doesn't anybody find it odd that it is illegal for this patient to buy this drug unless I write it down on a little piece of paper and then sign it." Maybe I lack imagination, but I can't think of another aspect of the human experience where one set of people, not members of the government, wield that amount of power over others.

McBride provides an interesting history of the (surprisingly recent) legislative movement towards prescription-only drugs. He then offers up some solid critiques of this legal regime, citing to studies showing that regulation hasn't made us any safer. He concludes that, except in the case of antibiotics, the requirement for a physician's prescription should be scrapped.

As is often the case when things taken for granted are squarely confronted, the case for prescription-only drugs does look weaker after reading McBride's critique. I'm not so sure I disagree with him. Some thoughts come to mind, however:

1) The practical consequences of removing the physician as gatekeeper to medications might be, in the short term, disastrous. The reason is that the current regulatory regime has induced a widespread belief among the public that OTC medications are, by and large, safe. Libertarians might not like this, but it's a fact, and a fact that extends to virtually the entire consumer market. Caveat emptor died two or three generations ago. Any changes in the law ought to be (as usual) done with a lot of forewarning.

2) Let's not play fast and loose with the word "paternalism." It muddies the discussion if we don't restrict it to a precise and limited meaning. I would suggest that we use "paternalism" to refer to cases in which one person's judgment is arbitrarily or unjustifiably substituted for another's. This would mean that when a patient, upon rational and deliberate reflection, decides to defer to a doctor's expertise, the doctor is not being paternalistic when he makes the decision. Restricting the use of "paternalism" would enable defenders of a physician's judgment to make a stronger argument than "I support paternalism sometimes." Paternalism is a pejorative term. McBride, as a libertarian, might have good reason for using it to describe virtually all physician decisions. But those who disagree with McBride are not obliged to use terms in the way that McBride does.

3) I'm extremely sceptical of McBride's assertion that the price of Claritin and Prilosec dropped because of the move to OTC status, and not because they went off-patent. I'd like to see more evidence for this, so I'll keep an open mind. Also, a question: aren't the OTC dosages much less than prescription-strength? If so, this is another possible reason for the price-per-pill drop. Let's make sure we're comparing equivalent dosages.

That's enough griping, though. I love Trent's post. Especially this:

My purpose in writing this is to get health care personnel, especially medical students, to think about it. It is not something that is ever discussed, but it no doubt should be. We must come to terms that this is a violation of liberty, and then ask ourselves two questions. Is this violation justified? And can we look ourselves in the mirror if it is not?

Anyone who can get medical students to question the status-quo deserves a big 'ol Texas-size thumbs-up!

Posted by Carey at March 30, 2004 10:23 PM