Comments on: The Case for Medical Paternalism

By: Bill Gardner

Bill Gardner — Thu, 27 Jan 2005 17:40:13 +0000

Nick wrote: “And in a private market, physicians know that if they don’t prescribe drugs that their patients have just seen on TV, they’re likely to lose those patients. So, as long as there aren’t any obvious contraindications, they’ll sign off on the prescription.” There are two additional variables to consider: does the patient need the medication (a complicated question on its own!) and does the DTC medication cost more (as it frequently does)? DTC is clearly harmful if it encourages prescription in the absence of need or the prescription of more expensive drugs (everything else being equal). Consider, however, a situation in which the patient needs a drug and there are no obvious contraindications to the DTC drug. I think a doctor might legitimately prefer to prescribe a drug requested by the patient even if it costs more, assuming that the patient knows that it costs more. Over and above her duty to honor the patient’s wishes in the absence of a compelling reason not to, the doctor might prefer to prescribe a drug requested by the patient because he might be more likely to actually take it. It would be interesting to see if DTC affects adherence to prescriptions.

By: nick

nick — Thu, 27 Jan 2005 00:50:51 +0000

people who see DTC ads can’t buy the drugs unless their physicians agree that they’re appropriate and write a prescription. And in a private market, physicians know that if they don’t prescribe drugs that their patients have just seen on TV, they’re likely to lose those patients. So, as long as there aren’t any obvious contraindications, they’ll sign off on the prescription. And if you deny that, your own knowledge of the American healthcare profession is sadly lacking. we don’t need to ‘help’ people even more by keeping them in the dark as to new developments in medicine. Please, tell us the medical knowledge that is gained from watching a Levitra commercial, other than the need to go to the ER to deal with a four-hour erection. DTC dumbs down non-clinicians appreciation of new developments: at worst, it gives them false hopes and misinformation. Your point was?

By: Nicholas Weininger

Nicholas Weininger — Wed, 26 Jan 2005 19:05:08 +0000

Ophelia: that’s a fair point if limited to antibiotics and other drugs for communicable diseases, but we’re not talking about those (and how often have you seen DTC ads for those anyway?), but about anti-arthritis drugs. Is there any reason to believe that overuse of Vioxx by some will make arthritis treatment less effective for anyone else?

By: Ophelia Benson

Ophelia Benson — Wed, 26 Jan 2005 18:55:35 +0000

But paternalism doesn’t really cover the subject. Most of these comments (in good libertarian style) talk as if decisions about what drugs to take affected only the one person taking the drug. I have only one word to say: antibiotics.

By: digamma

digamma — Wed, 26 Jan 2005 14:31:12 +0000

But there is a strong pragmatic case to be made that politicians are going to be better informed as a rule than their citizens over the benefits and drawbacks of particular courses of policy (otherwise why use them in the first place?)…. Of course, this is not to say that citizens shouldn’t be able to get their hands on relevant information (politicians aren’t infallible) – but it’s surely a bit of a stretch to argue that aggressive TV advertising campaigns provide such information. Thus, I’m pretty well convinced of the case for banning public political advocacy – it’s a relatively mild form of paternalism, which seems to me to have quite substantial payoffs.

By: John Isbell

John Isbell — Wed, 26 Jan 2005 14:29:56 +0000

Clearly the Vioxx marketing campaign is the fault of the trial lawyers. Just listen to the doctors.

By: Nicholas Weininger

Nicholas Weininger — Wed, 26 Jan 2005 14:27:26 +0000

Doctors are probably more likely to be informed about the general properties of drugs, but a doctor is much less likely to be informed than a patient about the patient’s own values, level of risk tolerance, etc. In a perfect world we might hope that a doctor would give an objective, disinterested explanation to each patient of the tradeoffs involved in various treatment options, and then allow the patient to make up his/her own mind. In the real world, doctors have many biases, some but far from all of which spring from drug company marketing practices, and it is foolish to expect those biases not to have an effect. So allowing DTC advertising gives patients access to another source of info with which to make decisions about their own bodies. A biased source, to be sure; but it is surely reasonable to expect that adults should be able to recognize it as such and add salt accordingly, and its biases are different from, and thus can potentially serve as a check on, the doctors’ biases. That’s the consequentialist anti-paternalist argument. The snarkier libertarian argument is, of course, that protecting people from the consequences of their own stupidity is a bug, not a feature—especially when, as in the case of anti-arthritis drugs, their stupid decisions clearly hurt no one but themselves.

By: mw

mw — Wed, 26 Jan 2005 14:21:27 +0000

Aaach. These are prescription drugs which means not only have they been FDA approved but that people who see DTC ads can’t buy the drugs unless their physicians agree that they’re appropriate and write a prescription. That’s plenty of paternalism as it is—we don’t need to ‘help’ people even more by keeping them in the dark as to new developments in medicine. What’s more—as blog readers should be well aware—trying to keep information the exclusive property of experts and prevent it from reaching the general public is not really feasible any more. Ban DTC TV ads for new drugs and be prepared for ‘viral’ marketing via email, blogs, web forums, etc to take up the slack.

By: jet

jet — Wed, 26 Jan 2005 13:39:10 +0000

weboy, Why wouldn’t the most obvious solution be to limit marketing of fast tracked drugs? That seems the most effective compromise possible.

By: Anna in Cairo

Anna in Cairo — Wed, 26 Jan 2005 12:52:47 +0000

The suggestion that you ban drug consumer oriented advertising and make all drugs available without a prescription is exactly the situation ehre in Egypt, whree you can walk into a pharmacy and get virtually any drug you want including antibiotics, Tegretol, Prozak and Viagra without any prescription whatsoever. However, there is no drug advertising allowed in the country. Doctors tend to overprescribe because drug companies give them incentives and because they are undereducated and often don’t take the time to do a careful diagnosis but just throw tons of antibiotics at anyone who comes in complaining of cold-like symptoms. But what is the real danger of a system like this is that people tell each other “well I took this really good antibiotic for my flu last week, I think you should take it for your stomach ailment” and then go out and buy this stuff on each other’s advice. It’s a totally insane system. Not to mention that there’s no consumer-oriented language in the pharmaceuticals’ packaging, so non-doctors really don’t understand what it says. For all these reasons I think that idea is insane and will exacerbate the situation you’ve got in the U.S.

By: asg

asg — Wed, 26 Jan 2005 01:41:16 +0000

jroth, My mistake; I must have missed where Congress passed a law removing the discretion over whether to have surgery from a patient’s hands. There’s a difference between speech, which is what advertising is, and brain surgery.

By: nick

nick — Wed, 26 Jan 2005 01:19:39 +0000

I first visited the US in 1998, when DTC advertising (on television, at least) was still quite highly restricted. Now I live here, and we have ads for stiffy-pills in prime time. (Remember, a four-hour erection requires immediate medical attention.) My wife has also told me that doctors actually ask her if she wants to be put on the latest-and-greatest beneficiaries of pharmaceutical marketing. Add in the fact that she works in the mental health sector, and sees psychiatrists regularly given meals, deductible junkets and truckloads of tchotchkes to prescribe brand-name medicines for Medicaid recipients with schizophrenia, and it’s all very depressing.

By: weboy

weboy — Wed, 26 Jan 2005 00:56:31 +0000

Because of the protests from people with AIDS (remember ACT UP?), the time to approval for drugs has been sharply reduced – it was felt that some drugs can show compelling need to be in market with large scale, but short term, safety and efficacy studies. In fact, some side effects take longer to be seen, or to be seen so that significance can be fully understood – like heart problems. DTC doesn’t cause the problems, it exacerbates them. By making drugs that have received fast track approval widely used in a short period of time (which is the goal of DTC - fast, early adoption of a drug treatment), drug companies are, in effect, conducting their long term longitudinal studies in market. Slowing down the approval process to complete and analyze longer term results would help improve safety and efficacy. The dilemma is that some very useful drugs would be waiting to go in-market when they could be saving larger numbers of lives. The dilemma is very real, but one can argue that we have gone too far in the direction of letting not quite ready for market drugs into the system.

By: Alison

Alison — Wed, 26 Jan 2005 00:05:42 +0000

spd said In order for the ban you suggest to have a positive effect, we must assume that the level of consumption of drugs will remain constant without advertising I think the level of drug use would fall, and this would be a good thing. Americans take a lot more prescription drugs than anyone else on Earth, and this is surely linked to the aggressive marketing that goes on in your country. (‘More than 40 percent of the population is taking at least one prescription drug, and about 16 percent take three or more’ as of Dec 2004.) These are high levels of medication. And it’s not as if you see lower mortality rates compared to countries with more moderate drug use.

By: Xavier

Xavier — Tue, 25 Jan 2005 23:57:50 +0000

How about this for a compromise: DTC marketing is banned, but all drugs are available over the counter. That way consumers will be able to make decisions about the drugs they take without undue influence from the industry, but they won’t be limited by FDA restrictions or the need to consult a doctor.