Beyond the Age of Snake Oil

In thinking about the Conversation pieces that both Dr. Flanigan, Ms. Sandefur, and Dr. Bateman-House have written, I appreciate their perspectives and engagement on the argument. I am also positive that while we may all think more deeply about this issue, that none of us has been persuaded to change our minds. This experience has led me to fascinating conversations with colleagues and friends so no doubt my thinking on this topic will continue. That said, I did have a few points that I wanted to address.

Ms. Sandefur suggests that the free system of pharmaceuticals would encourage people to rely on the vast information at their fingertips—at least for the two-thirds of adults who have access to broadband and the thirteen percent more who use the internet through a smartphone. My question is, what about the other 21 percent who either live in areas without access or cannot afford it? Do they guess about what drugs to take? Rely on friends to do research for them? Why should they not benefit from the bounty of information online? This is a perfect case of social injustice where those with the least would be hurt the most.

Now consider the information that would be available. Ms. Sandefur recommends that one source of information is professional journals—that the public can read these articles and decide for themselves. The problem here, again, is access. Journal subscriptions are expensive, running from hundreds to thousands of dollars per year. If one is not affiliated with a medical institution, it is unlikely that she or he will have access to these journals. I teach at a very large undergraduate university, and since we do not have a medical school or a hospital, I have to order most medical journal articles on a fee basis.  Even purchasing access to a single article can be pricey. To “rent” an article from the Journal of the American Medical Association costs $30 for 24-hours of access. If you want to read the article in the 25th hour, you pay again. Thus only those with the financial means can have access.

The second source would be peer-review websites similar to Yelp and TripAdvisor. Presumably people would give reviews stating which drug they took, for what symptoms, what their result was, and what side effects they experienced. I think we can all accept that this is an incredibly unscientific way to collect data. Like many others, I have often found that people who leave reviews are those who had excellent or poor experiences, but rarely in the middle. Often, I find myself disagreeing with reviews which leaves me feeling misdirected. I could spend time and figure out which reviewers have tastes similar to mine and then trust their opinions more than others but the these reviews are not backed by science. When I am picking a hotel, the lack of meaningful ratings and scientific sampling is not an issue. However, when choosing what drug to take for my health—that could help me or make my condition worse—then this unscientific sampling is a problem. Also consider that many companies pay to have their products and properties reviewed positively or to post negative reviews against a competitor. Drug manufacturers are also likely to use these services to improve their ratings and increase sales.

The third option Ms. Sandefur suggests is that the role of testing and assuring safety would be taken up by non-profit organization similar to Consumer Reports and Good Housekeeping. The former is a subscription service for which you need paid access (print subscription or online). Again, this would leave a substantial proportion of the population without access to these voluntary test results unless the agencies were required to publicize their data, an idea that would seem to go against the free market position that her writing here has represented. Of the three ideas, this is the most palatable and the most potentially scientifically rigorous. However, I once worked for a magazine that did competitive reviews of products and the reason I left that position was because of the pressure to give more positive reviews to products that bought ads in the publication.

Ms. Sandefur also claimed that one of the problems with FDA testing is the long period when companies cannot charge for the drug (such as during clinical testing). This statement presumes that making money is the goal of pharmaceuticals rather than helping people. I have written elsewhere that the notion of making profit off of the pain and suffering of others is grotesque. There are some spaces that should be outside the realm of profit seeking, and health care is one of them. I truly believe that all health care related industries should be nonprofit, dedicated to helping others rather than the pursuit of the bottom line. Ideally I’d like to see single-payer, but that discussion is outside the scope of this conversation.

In her response to my essays, Dr. Flanigan stated that in the nineteenth century people were free to choose and consume any drug that they wished. I will agree with her facts and history on this issue. What she did not state is that few of these drugs were effective at treating diseases, never mind curing them. Taking many of these “tonics” did make one feel better because most contained substantial amounts of alcohol, cannabis, cocaine, morphine, or opium. The patient felt better, but their symptoms and disease were left untouched. Certainly, some drugs had an effect: quinine, digitalis, mercury, aspirin, though dosing was uncertain and these agents were as likely to poison as to help. The nineteenth century did not have the plethora of drugs available today, many of which are created in laboratories rather than found in nature. I would hope that nearly 120 years later, with thousands of clinically proven drugs available, that we would not be looking at snake oil, tinctures, and poisons as our role model.

It seems that Dr. Flanigan and I will agree to disagree on the role of pharmaceuticals in extending lifespan. She relies on an economist’s analysis, while I relied on the epidemiologists at the U.S. Centers for Disease Control & Prevention and the World Health Organization. Apparently public health and finance do not view the world or the facts in the same way.

Dr. Flanigan demonstrates an inconsistency in her arguments where she says that we should not be required to wear seatbelts in the same way that we should be able to freely buy our prescriptions. However, she also feels that there should be limitations on taking drugs if there is a concern of antibiotic resistance. She stated that there should be limits on driving under the influence. The question then, is where to draw the line between what the government can regulate and restrict for public and personal safety and where it cannot.

At the base of our debate is a question: what is the proper role of government in regulating pharmaceuticals? As Dr. Flanigan and Ms. Sandefur have stated, they believe in a government that does not take on the role of the “nanny state”—that we should be free to make decisions that may endanger ourselves, such as taking pharmaceuticals and driving without a seatbelt. As long as we are fully informed and give our consent, they hold, then we should be able to choose. On the other hand, Dr. Bateman-House and I see a role for the government in ensuring our safety and protecting us from avoidable harms. I could even begin to agree with the smaller government role for drugs if indeed the consequences of such behaviors affected only the person who made the choice. But a person’s actions always affect other people. The person who is seriously injured by not wearing a seatbelt will get medical care at a hospital, and if she does not have health insurance than taxpayers will cover the cost. Her children will be without a parent, even assuming they were not injured in the crash. Of course, police, doctors, a tow truck driver, and others had to work to help the driver, clean up the scene, and to get traffic flowing again. The consequences of our actions are never born solely by ourselves.

Also from this issue

Lead Essay

  • Physicians are ethically bound respect patients’ medical choices whenever patients wish to refuse care. Yet both they and government regulatory agencies are altogether willing to prohibit patients from taking medical interventions into their own hands. In particular, many drugs are unavailable without prescriptions, and this impinges meaningfully on patients’ rights to self-medicate. Jessica Flanigan argues that we should take these rights more seriously. The results, she argues, will include greater respect and trust in medical settings, better health outcomes, and improved overall wellbeing for patients.

Response Essays

  • Patients’ autonomy is a key principle of bioethics, says Alison Bateman-House, and with good reason. Yet others must also be protected, including justice and benificence. These principles mean that many of the regulatory safeguards of modern American medicine are indeed justified. Bioethics must never disregard autonomy, but it is far from the only consideration at hand.

  • Craig Klugman argues that in the field of medicine we need a measure of paternalism to keep from hurting ourselves and others. Doctors and pharmacists train intensively for years to develop an extensive knowledge of which therapies are best for which cases, and to know when they can and cannot be used together. Patients lack this knowledge. They also commonly lack the time to acquire any of it during an illness. As a result they often risk hurting themselves and others when they self-medicate.

  • Christina Sandefur argues that our system of drug regulation is fundamentally unjust: While some dangerous drugs are authorized government, whether with a prescription or without, some other drugs are not available by any legal means, even when patients are informed and willing to bear the risks. Regulation even goes so far as to prohibit certain parties from discussing off-label use of prescription drugs. These are not merely theoretical impositions, either, because individuals stand to live or die in consequence.