Marijuana, Prescription Requirements and the Doctrine of Informed Consent

by on November 7, 2012 at 8:09 am in Law, Medicine, Uncategorized | Permalink

It used to be common for physicians to withhold information and even to misinform patients “for their own good.” Authorities as venerable as Hippocrates advocated that some information be concealed from patients. Today, most of us would find it outrageous if a physician misinformed his patient to perform surgery regardless of the reasons. Changes in public opinion and a series of court cases have overruled medical paternalism. In the 1914 case Schloendorff v. Society of New York Hospital, Benjamin Cardozo wrote:

Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages. This is true except in cases of emergency where the patient is unconscious and where it is necessary to operate before consent can be obtained.

It wasn’t until the late 1950s and in particular the 1957 case Salgo v. Leland Stanford, however, that the doctrine of informed consent (DIC) became well accepted in practice and in medical ethics. The doctrine of informed consent has both consequentialist and deontological justifications. On the consequentialist side, informed consent generally leads to better medical outcomes. Patients are also better able to understand their own overall interests than are others so the DIC leads to better overall welfare. On the deontological side, it is today widely accepted that all patients have a right to autonomy and that physicians cannot justly abrogate that right even in the patient’s own interest. It would be wrong to require someone to undergo surgery even if such surgery was necessary to save their life.

In an interesting paper in the Journal of Medical Ethics Jessica Flanigan argues that the same reasons which support the doctrine of informed consent also support a patient’s right to use pharmaceuticals without a doctor’s prescription. Based on Peltzman and Temin she argues that the consequential outcomes of prescription-only have not been good, at least not overwhelmingly so. Most importantly, patient autonomy applies just as much to the choice to medicate as to the refusal to medicate:

Citizens have rights of self-medication for the same reasons that they have rights of informed consent. The prescription drug system has bad consequences and it privileges regulators’ and physicians’ judgements about a patient’s health over the patient’s judgement about her overall well-being. Most troublingly, the prescription drug system violates patients’ rights.

Instead, I propose that prohibitive pharmaceutical policies, which are a kind of strong paternalism, be replaced by nonprohibitive policies that enable patients to obtain whatever medicines they choose while promoting informed consumer choices by making expert advice readily available.

Notice that the argument is not simply that prescription only requirements are against social welfare but rather that support for the doctrine of informed consent also supports the right to use pharmaceuticals without getting the consent of an official.

I am pleased that the voters in Colorado and Washington approved adults to use marijuana for any purpose. In the future people will be shocked that we arrested millions for marijuana use in the same way that we are shocked that doctors used to perform surgeries without a patient’s informed consent.

Andrew' November 7, 2012 at 8:19 am

How could someone go against my wishes in my own interests? My wishes are my interests.

Brian Donohue November 7, 2012 at 8:54 am

Do you really want to go there?

/meta’d

Andrew' November 7, 2012 at 9:01 am

I’ve been “going there” all my life.

Brian Donohue November 7, 2012 at 9:56 am

You missed my drollery. Too bad- it was hilarious.

Semi-seriously, though- I just got done with Kahneman’s very good book, and it’s not always clear to me what “I” want, or what I “want”, or even who “I” is referring to all the time.

sunbomb November 7, 2012 at 9:59 am

So … did ‘you’ read Kahneman’s book?

Andrew' November 7, 2012 at 10:07 am

I don’t know if I want to go there, I just always have ;)

prior_approval November 7, 2012 at 8:28 am

‘The prescription drug system has bad consequences and it privileges regulators’ and physicians’ judgements about a patient’s health over the patient’s judgement about her overall well-being.’

As is so often the case at this blog recently, facts can easily be used to see what happens in the real world, with the use of ‘pharmaceuticals without getting the consent of an official.’

Like in the American food industry -

‘Antimicrobial Resistance

Bacteria and other microorganisms that cause infections are remarkably resilient and can develop ways to survive drugs meant to kill or weaken them. This antibiotic resistance, also known as antimicrobial resistance or drug resistance, is due largely to the increasing use of antibiotics.’

http://www.fda.gov/animalveterinary/safetyhealth/antimicrobialresistance/default.htm

And in the science based world, the FDA had to do this, to protect human health in a world where animal antibiotic use was unregulated, with utterly sicentifically predictable results –

‘Cephalosporin Order of Prohibition Goes Into Effect

April 6, 2012

The U.S. Food and Drug Administration (FDA) announced today that the order of prohibition of cephalosporins originally published on January 6, 2012 is now effective.

The order prohibits certain uses of the cephalosporin (excluding cephapirin) class of antimicrobial drugs in cattle, swine, chickens and turkeys.

FDA is taking this action to preserve the effectiveness of cephalosporin drugs for treating disease in humans. Prohibiting these uses is intended to reduce the risk of cephalosporin resistance in certain bacterial pathogens.’

http://www.fda.gov/AnimalVeterinary/NewsEvents/CVMUpdates/ucm299054.htm

For anyone more interested in how uncontrolled use of antibiotics causes serious human harm, this FDA document is available – http://www.fda.gov/downloads/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/UCM216936.pdf

From section III -

‘III. Key Reports and Peer-Reviewed Scientific Literature on the Issue
Questions regarding the use of antimicrobial drugs in food-producing animals have been raised and debated for many years. A variety of recognized international, governmental, and professional organizations have studied the issue. We have briefly summarized below the findings and recommendations from some of the notable reports that have addressed this issue over the past 40 years. These reports provide context to FDA’s current thinking on this issue, and highlight the longstanding concerns that have been the subject of discussion in the scientific community as a whole.
We have also provided a list below of some of the more recent primary scientific literature that FDA has considered. This is not intended to represent an exhaustive summary of the scientific literature, but rather to highlight some of the more recent scientific research related to the use of antimicrobial drugs in animal agriculture and the impact of such use on antimicrobial resistance. We acknowledge that a significant body of scientific information exists, including some information that may present equivocal findings or contrary views.
Unless otherwise indicated, the page numbers cited in this section refer to the relevant page numbers in the referenced report. A complete list of the reports summarized in this section is provided at Section IX of this document.’

Wer have already run a multi-generation test on the efficacy of letting anyone who wanted to use antibiotics. As expected, the results are things such as the increasingly common multiply resistant strains of TB that are now no more curable than they were back in 1910, when TB was the leading cause of death in the U.S.

Alex Tabarrok November 7, 2012 at 8:56 am

prior_approval is correct that antibiotic resistance is a problem. Were he a loyal reader he would know that this is a point I have made many times, e.g.

http://marginalrevolution.com/marginalrevolution/2011/06/antibiotic-resistance.html

Indeed, this exception is noted at my web page FDAReview.org precisely in the Peltzman and Temin link given in the post. Needless to say an exception does not vitiate the rule.

Andrew' November 7, 2012 at 9:30 am

A slightly different way of saying this is the government sucks at creating new antibiotics. It’s one of those areas that makes a great stagnation obvious. Technologies are thresholds rather than marginal.

Also Doctors are really irrelevant if the problem is use in industrial farming animals. And as a parent I’ve never pushed the doctor for antibiotics, they almost throw them at us. If anything I try to resist the antibiotics, so the oft-claimed doctor whining about parents who won’t take no antibiotics for an answer is a myth I think.

Andrew' November 7, 2012 at 9:52 am

Additionally, prescription drugs are dangerous because they are extremely powerful because doctors don’t act until a subclinical problem becomes a clinical problem.

It is speculation on my part, but we will be moving to a more engineering maintenance approach to healthcare. We will know genetic predispositions and we will get molecular diagnoses before major health damage is done. We will ‘prescribe’ milder drugs because we will be steering the ship more gradually further in advance. It will all come in a box from Wal-Mart.

Andrew' November 7, 2012 at 11:21 am
Urso November 7, 2012 at 9:48 am

“Needless to say an exception does not vitiate the rule.”

Except where, as here, the exception swallows the rule.

What about these “pain management clinics” that will give Oxy to anyone who walks through the door? While there’s still technically a prescription involved, it’s less than a formality. You care to defend the consequences of those?

And what the fuck is with the MR bloggers’ constant references to “loyal” readers? Is there an ideological purity oath we’re all supposed to take?

Andrew' November 7, 2012 at 9:59 am

“Is there an ideological purity oath we’re all supposed to take?”

Yes: Reading.

I can’t tell what point you are making with Oxy?

Cliff November 7, 2012 at 10:10 am

In what way does this one exception swallow the rule? Do you understand what that phrase means?

Urso November 7, 2012 at 10:32 am

If you do away with the prescription requirement, there are two types of drugs that people will feel comfortable self-prescribing: antibiotics, and pain medicine. (And, for a certain demographic, Viagra.) But Tabarrok wants to keep antibiotics restricted, apparently, so we’re only talking about Oxy and Viagra. And, as I point out, we’ve already got a regime where Oxy is available without prescription,or at least without a *meaningful* prescription, and I’ve yet to see anything in the way of incredible societal benefits.

Put otherwise, once Tabarrok starts making “exceptions” for wide classes of drugs, he is no longer really arguing that we should “do away with prescriptions.” What he’s really arguing for is “keep prescriptions, but move more drugs onto the over-the-counter list.” But I guess that doesn’t sound as good.

Andrew' November 7, 2012 at 11:03 am

Why is our standard “incredible social benefits”? Have we seen incredible social damage?

Letting people do what they think is right is a success if we don’t notice anything.

Andrew' November 7, 2012 at 11:05 am

It’s not an ‘exception’ for antibiotics.

It is understanding a distinction. If antibiotics pose an externality, and I dispute even that, then address the externality.

If recreational drugs only externality is that someone else thinks they have a right to my body, then tough.

John Thacker November 7, 2012 at 11:07 am

I am fairly certain that there are other types of drugs beyond that, Urso. For example, I am pretty sure that women would purchase the birth control pill OTC if they could do so.

What he’s arguing is “do away with prescriptions predicated on the idea that patients don’t know their own good, and keep them only for drugs where patients would see a benefit themselves but impose significant externalities, like antibiotics.”

I have a hard time seeing how the intrusive regime against Oxycontin or Sudafed brings more benefits than harms. You correctly note that many people evade the restrictions; why is that necessarily an argument for the status quo or tightening the restrictions? It seems to me that in the current situation we get quite a lot of downside of prohibition (including people going through hoops and paying more to get what they need) without purported societal benefits.

To turn your argument around, we require prescriptions for Oxycontin, and I’ve yet to see anything in the way of incredible societal benefits for doing so.

John Thacker November 7, 2012 at 11:08 am

Also, I think that plenty of people would take statins daily for cholesterol just like vitamins, if they were OTC. Do you disagree?

Your Neighbor November 7, 2012 at 12:52 pm

“What about these “pain management clinics” that will give Oxy to anyone who walks through the door?”

Show me one, just one, clinic that operates like this. Sorry, but you cannot, and you are completely ignorant to pain management clinics, how they operate, what the requirements are, who attends and why and how often.

These drugs are so tightly controlled that they are very difficult to get legally. I am a patient at a pain management clinic due to chronic problems with my back. The staff there regularly turn people away –in person and on the phone, I have personally witnessed it both ways– to even get an appointment to be seen (let alone a prescription) without extensive documentation of their medical issue. Patients are randomly drug tested to check for other drugs, legal and non-legal alike, and pills are counted at every visit to be sure you are not taking too much. The initial and on going paperwork involved for staff (and patients for that matter) is very significant. They must do it all to satisfy the very regular audits by authorities.

I believe that if there truly were places where one could go and get OxyContin just for walking in the door they would be shut down in a matter of weeks by the authorities in any state and any provider operating there would lose their license in as much time.

The tight regulatory environment that doctors operate in has forced the market to provide clinics that specialize in this kind of treatment. The *vast majority* of doctors will not prescribe drugs along the lines of OxyContin at all, forget getting it on a regular basis. They are, rightly, scared of being sued, investigated, or losing their medical license so they would rather not prescribe them at all.

prior_approval November 7, 2012 at 9:49 am

Well, that was interesting, seemingly contradicting exactly the point which was highlighted in my comment, which was prefaced with this statement – ‘Most importantly, patient autonomy applies just as much to the choice to medicate as to the refusal to medicate:’

Because if misuse of antibiotics is rampant in the food industry, it will be nothing compared to the targetted resistance which will develop among human infectious bacterial agents when people begin hitting every viral infection with antibiotics (a problem already, as doctors far too often give in to patient pressure for pills). A point you are seemingly very well informed about, writing back in 2011 ‘…the benefits of maintaining the effectiveness of our stock of antibiotics is so high that I see more intelligent but reduced use as an important goal.’ A statement utterly contradicted by this – ‘Notice that the argument is not simply that prescription only requirements are against social welfare but rather that support for the doctrine of informed consent also supports the right to use pharmaceuticals without getting the consent of an official.’

Obviously, for antibiotics, that second statement is simply wrong, as you accurately noted back in 2011. Nothing has changed scientifically between 2011 and now, at least to my knowledge, which is why that point was worth highlighting, even if the intent of letting patients self-medicate was made without connection to the actual reality of increasing human fatalities directly tied to the ongoing misuse of antibiotics, world wide.

Andrew' November 7, 2012 at 9:54 am

Some things are and some things are not. If antibiotics pose externalities, address them. Our government sucks balls, so it hasn’t.

albatross November 7, 2012 at 9:58 am

I recall seeing some doctor comment online, years ago, that if he were in charge, opiates would be over the counter, and antibiotics would be as hard to get as opiates. It might be a sensible decision to restrict access to antibiotics and antivirals for preservation-of-commons reasons, even if you let patients use whatever other medicines they wanted. On the other hand, Mexico and I think many other countries sell antibiotics over the counter, and whatever changes we make will probably not change their practices.

Andrew' November 7, 2012 at 10:01 am

Unfortunately doctors don’t know what they are doing, either. Every couple years they come out in favor and then against antibiotics for ear infections and strep throat. Just sayin,’ when people don’t know what they are doing, don’t give them too much power.

Andrew' November 7, 2012 at 10:02 am

And now “we” think the main problem is industrial farming animals being fed antibiotics not even for disease but to bulk up. So, doctors and patients may even be irrelevant.

Finch November 7, 2012 at 10:47 am

> And now “we” think the main problem is industrial farming animals being fed antibiotics not even for disease
> but to bulk up.

I’m under the impression that this is a fringe concern but that antibiotics in humans are a real, known problem producing drug-resistant forms of human diseases right now.

I’m also with Urso in arguing that the list of things that shouldn’t be OTC includes antibiotics, antivirals, Oxy and related compounds. Heck, I’m not convinced Oxy is worth the societal harm in prescribed form…

This makes Alex’s informed consent point much weaker. Look, I voted for my state marijuana legalization measure, but I’d never vote for one that made Oxy more accessible.

Finch November 7, 2012 at 11:04 am

Never say never.

I’d need a lot of convincing that loosening up access to Oxy wouldn’t cause a great deal of human misery.

Andrew' November 7, 2012 at 11:07 am

The point is we don’t know. It is a matter of research.

And I go to the doctor with a kid’s throat infection, they thrown an antibiotic prescription at us, we go get it for FREE, and then all I hear on NPR is doctors whining about how moms strong-arm them for antibiotics for viruses.

Mike November 7, 2012 at 8:32 am

I’m a big fan of medical MJ – and use it myself for that purpose, illegally – but open access to all prescription drugs would be a tragedy.

Drug regulation is not a black and white thing, because drugs are not all the same. It’s a sliding scale of competing benefits and hazards. Alcohol and pot and advil are fine; oxycotin and antibiotics and steroids and heart medicines? Not so good. Even if I were to take the position that the foolish should be allowed to ruin themselves, the misuse of antibiotics would be a serious threat to everyone.

I despise paternalism but it does, regrettably, have a place. If anyone can buy prescription drugs, then can anyone offer advice to other on how to use them? Should we allow the unregulated practice of medicine as well? It’d be a fine way to rid the world of the foolish, but probably not a sound social policy overall.

John Thacker November 7, 2012 at 9:20 am

Antibiotics, certainly, I understand, but heart medicines? I’m afraid I don’t understand why you’re drawing the sliding scale there. In the case of oxycotin, I don’t see how the arguments about prohibition are any different from other commonly abused drugs. I see the dangers of legalization, but the downsides of continued prohibition seem tragic, especially since patients seem to be able to doctor shop to get prescriptions anyway.

So long as doctor shopping is common, it’s hard to see exactly how much a difference prescriptions make, other than making everything more expensive and inefficient. (Even antibiotics are, I think, much prone to doctor shopping from patients.)

If anyone can buy prescription drugs, then can anyone offer advice to other on how to use them?

Your own use of medical MJ would seem to rely on advice outside the government approved establishment, would it not?

It’d be a fine way to rid the world of the foolish, but probably not a sound social policy overall.

It would also be a fine way to improve the access for medicine for the poor.

Mike November 7, 2012 at 9:41 am

The difference between MJ and heart medication is one of risk; a person who attempts to diagnose and treat themselves for a heart condition may very well die if they get it wrong. A person who misuses MJ as a treatment goes to Taco Bell and takes a short nap on the couch.

It’s a sliding scale of benefits and hazards. A one-size-fits-all approach is crude and inappropriate.

A responsible poor person with an apparent heart problem would still need to see a doctor, still need to be told what drugs to take and when, and still need to be followed up. The only cost savings would be a modest reduction in the cost of the medications themselves. If even ten percent of these people misused their drugs and harmed themselves, what would the cost curve look like then?

Andrew' November 7, 2012 at 9:48 am

I believe you are begging the question. You need to look at the process in totality. What about the person who can’t get the doctor to prescribe the medicine? They die too. There are also more medically induced deaths from drugs than almost anything.

I don’t know if we believe this kind of thing. But they claim no deaths from vitamins while pharmaceuticals kill more people now than auto accidents.
http://www.naturalnews.com/034372_vitamins_pharmaceuticals_deaths.html

Pshrnk November 7, 2012 at 11:03 am

And if they fall asleep while driving to Taco Bell and run over me?

RA Student November 7, 2012 at 5:02 pm

Then they get in trouble, duh. You are legally responsible for failing asleep and killing someone high or otherwise, no?

John Thacker November 7, 2012 at 11:12 am

Hmm, when I think of “heart medicines” I’m thinking of someone getting a quick and easy cholesterol test, possibly at work, possibly at a pharmacy or DIY, and then taking a statin like vitamins. I don’t think that the risks are very high from statins of someone killing themselves. Not compared to the risk from Tylenol, to take one example.

It’s a sliding scale of benefits and hazards. A one-size-fits-all approach is crude and inappropriate.

I couldn’t agree more. But from my perspective, you’re the one arguing for a one-size-fits-all approach. You’re arguing that someone be forced to consult with a doctor every time, a one-size-fits-all approach. I think that that’s worth it for some people, but many other people would get along with statins or birth control pills as well as they do with more dangerous drugs like Tylenol.

Cliff November 7, 2012 at 9:21 am

I think we lack the empirical evidence to say that outcomes would be worse in either of those two scenarios. Outside of antibiotics, do you really know that the others are so terrible? I mean steroids were legal before the 1990′s and are still in widespread use today and are getting better and better. Oxycotin isn’t exactly in short supply. We probably suffer more from the artificial scarcity of medical professionals than we would from a surplus.

Keith November 7, 2012 at 12:39 pm

I disagree. I want life-saving drugs to be “open-access” not recreational diversions like pot. How can anyone claim that legalizing a readily available, recreational drug is a landmark event when drugs that matter are prescription-only?

While we are on the subject, can we make it ok to sequence our own genes in states like New York?

Andrew' November 7, 2012 at 12:54 pm

We take what we can get. It’s why politics is so depressing.

“While we are on the subject, can we make it ok to sequence our own genes in states like New York?”

I wish we had some Hansonian (how did he get squatters rights to such ideas anyway?) where if you think at-home gene sequencing is wrong you have to put up something. Then if it comes to pass with no problems you lose.

Rahul November 7, 2012 at 2:01 pm

Is there evidence that life-saving drugs are under-prescribed when needed?

Keith November 7, 2012 at 3:23 pm

Pain medication is under-prescribed, and of course the morning-after pill are two that come to mind. My larger point is I don’t want the doctor as a gatekeeper. They are using the AMA to stop the adoption of technologies like gene sequencing. I don’t want to have to get a prescription for hair growth drugs like Propecia. I don’t want to have to pay a dentist a lot of money for them to just hand me Invisalign retainers.
I want them to be service providers that are separate from the product sold by the drug companies. I still want to be able to buy the product by myself though.

Guest November 12, 2012 at 6:03 pm

I disagree paternalism has a legitimate place in medicine. It has caused untold harm and suffering and benefited only a small number of exceptionally stupid people – and of course the self-proclaimed paternalists who essentially use fake benevolence to justify their social parasitism.

If a substance is correctly labeled and information about its properties is correct and available, any person whatsoever should have the right to freely buy it and introduce it into their own body.

SamChevre November 7, 2012 at 8:41 am

This argument works well for drugs where the prescription requirement is intended to protect the patient; it does not work for antibiotics and other drugs where the prescription requirement is intended to protect society as a whole.

Andrew' November 7, 2012 at 9:14 am

Then let us fix the near universal confusion about public goods and externalities.

Andrew' November 7, 2012 at 10:29 am

Ask yourself, I don’t know the answer, why we do this bass ackwards? I can’t get my doctor to give me a drug sample for things that only affect me, but we get our antibiotics LITERALLY for free.

mulp November 7, 2012 at 1:27 pm

By “drug that affects only me” are you talking about the $7 bioengineered drug based on cloning your DNA?

Or are you looking for the sample of the $50,000 per dose drug that cures in one dose?

The samples are for the high volume drugs which are taken continuously with the high margins supported by third party payers. You take the sample, and you think it works, so you get the coupons for the drug store rebate so your insurer will pay $200 and the drug company rebates $40 of your $50 copay, or a different insurer pays $125 and the drug company rebates $105, so you pay only $20 out of pocket. If you have no drug coverage, the price is $250 regardless, or maybe $200, but if you can pay $200, you can pay $250 every month for a drug with $5 marginal cost.

Andrew' November 7, 2012 at 2:47 pm

I’m talking about if I take a drug that does nothing other than allow me to work that is different from inappropriately using an antibiotic that supposedly presents an externality to others.

Why is it really hard to get the former and extremely easy to get the latter which is even free, when the right way to do it would be to add a tax to the antibiotics and use the proceeds to research new antibiotics and antibiotic resistance.

DanO November 7, 2012 at 12:01 pm

Even if people are fully informed about externalities, they’d still make the same decision. That’s why externalities exist.

Andrew' November 7, 2012 at 12:10 pm

Yes and no.

People use the “some regulations are good, and you are anti-regulation, therefore I’ll be pro-regulation argument.”

The argument that we need prescriptions because some drugs have externalities is like that. No, we just need to address the externalities. The problem is, people use the legitimate regulation of externalities to promote the illegitimate regulation of everything else.

Mark Thorson November 7, 2012 at 9:43 am

Someday, we could have a little machine so we can make our own drugs at home. A 3D printer for molecules could do it, but much more primitive technology can do it too. Already, many people make their own antibiotics by growing a Russian folk medicine called Kombucha mushroom. The anticancer drug cisplatin was originally made using an apparatus you might find at a high school science fair. I make a precursor for tetrahydrobiopterin in my kitchen, which may be of value in the treatment of Alzheimer’s Disease.

Rahul November 7, 2012 at 12:39 pm

Let me assure you that day isn’t near. We aren’t even at a stage where state-of-the-art labs have a fantasy machine like that. Drugs are (typically) fairly complex chemicals; and chemistry isn’t even close to the point where we can build molecules-on-demand from simple building blocks in an automated machine. The closest we are is probably in the genomics and proteomics sectors but then again nature gives them a natural advantage.

It might be the goal of a lot of fancy research but we aren’t even close yet.

Mark Thorson November 7, 2012 at 2:09 pm

I disagree. There are several promising lab-on-a-chip technologies, and droplet movers in particular seem fairly close to being able to do useful work. They use various forces (usually electrostatic) to move small droplets around, typically on a plate with a photolithographed pattern. Being able to move droplets at will to arbitrary locations on the plate allows them to be used for storing a library of reagents and enzymes, bring the reactants together, perform a reaction, and store the results. Soon, it may be possible to replace the chemical stockroom and lab bench with a little desktop machine that has the same capabilities on a smaller scale. Anything you can make in test tubes is a potential candidate for making in the machine, and that includes a vast array of pharmaceutical products.

Rahul November 7, 2012 at 3:31 pm

What’s the state of the art for lab-on-a-chip? Forget synthesizing all drugs, how many meds. can the best lab-on-a-chip make yet?

Unless there is a major breakthrough (and that’s hard to predict) a machine of the sort you describe is still in the realms of fantasy.

Mark Thorson November 7, 2012 at 5:05 pm

They are still in development, like aircraft in the 1890′s. To ask how many meds the best machine can make presupposes all of the practical problems have been solved, but we’re not there yet. On the day we can make aspirin, we can make all or nearly all of the pharmacopeia. But like the aircraft technology of the 1890′s, progress is being made and there is no inherent reason why any problems can’t be overcome. I can’t believe we won’t be able to make aspirin 10 years from now in such a machine.

Andrew' November 8, 2012 at 7:57 am

Mark, you are basically describing work similar to what I do.

But the chemistry required for synthesis is mostly a separate issue.

I could see someone being able to order the raw materials and then order a chip that they plug into a USB port where the temperatures and micropumps are controlled by some software, but that’s a far cry from a Star Trek replicator.

DK November 7, 2012 at 9:53 pm

It’s still a fantasy. Nothing even remotely approaching this fantasy in the next 100 years minimum. More likely, never. Chemistry is inherently dirty and buzzwords like lab-on-a-chip can’t change this fundamental fact.

Mark Thorson November 7, 2012 at 10:44 pm

These images show examples of droplet microfluidics and should suggest why they will make test tube chemistry obsolete:

http://www.google.com/images?hl=en&as_q=&as_epq=droplet+microfluidics

DK November 7, 2012 at 11:43 pm

“should suggest why they will make test tube chemistry obsolete”

Only to someone who knows no chemistry. I’ve seen this stuff for a good decade now. Some nifty things, certainly some promise in few narrow niches but ultimately still toys for adults. This will not change. It can’t.

Andrew' November 8, 2012 at 7:59 am

The truth is in between. What I use them for is to manipulate cells. Cells are great chem labs. And the chips will hopefully break off a bit of the Moore’s Law effect. I’ll bid 50 years.

Andrew' November 8, 2012 at 8:03 am

I would also speculate that synthesizing DNA and RNA is probably easier since they are “designed” to be easy to assemble as opposed to standard chemicals requiring complex thermo and novel catalysts.

But there can certainly be some simple chemistry on a chip. I’m not sure why we got to the point about talking making anything. We made TNT in a Solo cup in chem lab.

Tom West November 7, 2012 at 9:54 am

While it’s pretty hard to see MJ as a threat to Western civilization, anyone care to hazard a guess as to what the effect on society unrestricted access (and marketing of) various prescription opiates would have?

Cliff November 7, 2012 at 10:13 am

There isn’t unrestricted access to and marketing of alcohol, so I don’t think we have to worry about that.

John Thacker November 7, 2012 at 11:15 am

Yes, alcohol is perhaps a good comparison.

People often exhibit a status quo bias. Many of the arguments I’m seeing against changing things here would seem to equally well apply to restricting alcohol, Tylenol, or other things available over the counter.

Though sometimes those do fall in for scrutiny. After all, the FDA decided to ban premixed caffeine and alcohol, at least when accompanied by bright garish colors, while allowing bartenders to continue to mix them.

Andrew' November 7, 2012 at 10:11 am

People see things as distinct. You can already cook up Meth in your kitchen. Soon will be something easier. We call these “meth labs.” Do we really know they aren’t “desperate people in pain”? And would these people really do this to themselves if there was a legal and affordable alternative? Suggested listening is the Planet Money podcast about the alternative to heroin that people take so they can function without heroin. It’s illegal. We assume laws do some good in preventing use, but for users, many of whom manage to function, drugs MAY ruin your life. A no-knock raid WILL ruin your life.

RPLong November 7, 2012 at 10:14 am

We diabetics understand very well how cruel it is to have to justify to our doctors every single meal we eat and every single injection we take – to the tune of a six-month history of every bite! – just to have our prescriptions refilled. For shame.

FredR November 7, 2012 at 10:28 am

If marijuana had been as available as alcohol when I was a kid, I probably would have permanently damaged my brain and my future by over-use.

John Thacker November 7, 2012 at 11:16 am

Did you permanently damage your brain and future by over-use of alcohol? Many people have, just as many people did not permanently damage themselves with marijuana who used it. If you didn’t abuse alcohol, what makes you so sure you would abuse pot?

FredR November 7, 2012 at 11:52 am

Because I liked pot a lot more than alcohol, and used it whenever I could. This is not to say that I think it’s totally a great thing that alcohol is so easily available.

John Thacker November 7, 2012 at 12:22 pm

You don’t think that the appeal of pot being illicit encouraged you to use it whenever you could? I’m not sure pot couldn’t be controlled like alcohol or stigmatized like tobacco.

FredR November 7, 2012 at 12:49 pm

“You don’t think that the appeal of pot being illicit encouraged you to use it whenever you could?”

No, I never liked breaking the rules.

“I’m not sure pot couldn’t be controlled like alcohol or stigmatized like tobacco.”

I’m not sure either.

mw November 7, 2012 at 11:00 am

This argument is irrational. Nothing connects legalization of marijuana–a drug which is *scientifically proven* to be no more dangerous than already-legal alcohol–to allowing people who more often than not will not make medically or scientifically informed decisions to take whatever drugs they feel like. This would be like saying that CA passing its tax increase initiative for education is a good first step toward society’s ultimate goal of giving all income to the federal government to decide what to do with it.

John Thacker November 7, 2012 at 11:19 am

You don’t think that people taking marijuana or alcohol “more often than not will not make medically or scientifically informed decisions to take” them? And certainly many, indeed most, drugs that remain prescription only are also scientifically proven to be no more dangerous than already-legal alcohol or Tylenol.

There’s not a necessary connection, and there’s no reason to assume that it will happen or even desirable necessarily, but I don’t think that the argument is irrational. I for one see a connection.

mw November 7, 2012 at 12:19 pm

I strongly disagree that most prescription drugs have as few side effects as marijuana. The whole point for most drugs and most people is whether the risk of side effects outweighs the potential benefit given one’s medical condition which is often a far from trivial calculation–imagine self-medicating cancer treatments. This is only going to get much more complicated as drugs become specialized based on what class of genetic phenotype a person’s particular instantiation of a disease comes from.

Cliff November 7, 2012 at 12:52 pm

Are you proposing a regulation banning the consultation of doctors?

sourcreamus November 7, 2012 at 12:08 pm

How does Mr. Tabarrock know what people in the future will be shocked by?

Andrew' November 7, 2012 at 12:15 pm

We can predict with reasonable confidence that people in the future will be shocked by electricity. Beyond that it is more speculation.

Rahul November 7, 2012 at 12:44 pm

The situation in India might be a good case study. Anything outside of opiates and abortion-drugs is available without prescription (for all practical purposes).

I won’t make a value-judgement but we do have a large-scale experiment of the alternative scenario (no-prescriptions) that has been running for decades.

Cliff November 7, 2012 at 12:53 pm

What’s your opinion?

Rahul November 7, 2012 at 2:00 pm

My opinion is that the issue is a red herring and largely irrelevant. Yes, meds are easier to access in India but that’s mostly because they are cheaper.

Is there a large cohort in the US that wants to use a med but can’t because their doctor won’t prescribe them? Outside of the addicts? Ok, maybe I want some fancy drug but even without a prescription could I afford it?

To me this is less about utility and more about ideology.

Keith November 7, 2012 at 4:53 pm

Yeah, there is a lot of ideology in this. Especially since the original post was about a drug that is easily obtainable now.
I would like to know more about the India example. I had no idea the situation is as it is.

Rahul November 7, 2012 at 11:11 pm

It absolutely is. With a little persistence and tact you can even get the opiate-class meds. from some of the pharmacies. They are supposed to track all sales so they just have a bunch of dummy prescriptions lying around.

Really, shopping for meds. in India is no different from shopping for groceries in the US.

Andrew' November 8, 2012 at 6:17 am

“Is there a large cohort in the US that wants to use a med but can’t because their doctor won’t prescribe them? Outside of the addicts?”

Again, and because I’m a crashed narcissist (whatever that means) ;) since I myself would like a particular drug and my doctor won’t give it to me, I would assume the answer is yes.

The other fact that I point to above refers to the NPR Planet Money podcast about the drug that can be used by heroine addicts but remains either illegal or overpriced due to doctor’s unwillingness to prescribe.

Elsewise, we have a situation where almost all drugs are probably both underprescribed AND overprescribed which is why we have thousands of medically induced deaths from pharmaceuticals.

Then there is the point someone linked to above that for some drugs doctors don’t want to take on the hassle and liability of prescribing them at all.

Also, I’ve brought drugs to my doctors attention. For a relative with MS new drugs are in trials all the time and the doctor cannot possibly know about them as well as I do.

And we are also talking about a margin here where doctors simply make it more difficult to self-medicate. So, the null hypothesis, irregardless of a pile of data that we probably have no way to measure, has to be that a system to make things hard actually works.

Nathan November 7, 2012 at 2:15 pm

I would hope that an exception would be made for antibiotics where improper use can carry extreme externalities.

Andrew' November 7, 2012 at 2:48 pm

Again, it’s not an exception, it is dealing with externalities, which we are already doing bass ackwards.

King Cynic November 7, 2012 at 5:45 pm

I assume that Alex’s intent with this proposal is to accelerate the improvement of our species by facilitating Darwinian self-selection against the stupid.

RA student November 8, 2012 at 8:39 am

While I cannot wait (seriously Colorado and Washington had revert real victories over absolute BS laws) to sit in a bar and legally smoke a little cannabis instead of drinking alcohol while watching some football on a wondeful fall Sunday, I must say I am on the fense with respect to opiates. I mean markets work only when individuals act rationally. Problem with opiates i fear is that the addiction is strong enough that I don’t believe addicts act rationally. Withdraw from opium is a b$tch. I could be convinced either way, but I am quite sure we would have to prepare for opium bums x 10 as compared to now under OTC opium.

Nathan W November 8, 2012 at 3:13 pm

It’s my body. If the doctor prescribes various other treatments that don’t work or that work “too well”, I find it outrageous that a society would criminalize the ability to make ones own choices with respect to alternative treatments, namely including marijuana, but I also follow the general argument that patients should have more control over their own body. I can’t think of too many things that should seem more naturally to be a fundamental right as a human being

Even worse is that fact that millions have been criminalized and imprisoned along the way.

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