I'll be. Even a troll's ass gets some sunshine. Course, this isn't a new suggestion or anything. And wouldn't the Clinton/Gingrich drugs-over-the-net plan have the effect of breaking the pharmacists' monopoly? I'll have to check on that, but it seems so.
Not sure this quite makes up for "Sigh. I wish he were wrong.", but I guess it just demonstrates that nobody is capable of being a total asshole all the time. Which is a pretty low standard, if you ask me. Not that you did.
Damn... good memory. I had a feeling I must've posted something about Simmons at some point, but I couldn't for the life of me figure out how you would've come up with that so quickly.
Yeah, well, that's like the last time I saw you post, I think. A friend of mine read Ilium last week, so I got to talking/thinking about it again, and, damn, I realized that all the mysteries in Ilium have left him plenty of room to choke if he doesn't resolve them in sufficient fashion. I remember not being satisfied by the "love" think in Rise of Endymion, though it has been awhile.
Yeah, I wasn't so thrilled by the end of Rise either. Definitely went way off on the Disneyesque "love" tangent. But the quality of the rest of the series more than makes up for the sub-par conclusion. In fact, I think I'll go start myself a Church of the Shrike, just for shits and giggles.
a mispelling, I meant to write "thing." Love in a certain fashion was revealed as a fundamental force of the universe, IIRC. Sorry I can't be more specific.
a) In the interest of anality, I should note that "go out" is not the correct characterization of the experience a body undergoes on the Tree of Pain. As it is a machine which desires to rattle the bushes, as it were, in order to out an empathetic entity, it to that end does not kill, but merely causes terrible pain.
b) Such a theoretical paper would probably be based off of this.
On Clives - I think I once heard some gossip about the other Clive (though I'm vague enough on this that it could be Clive Barker, or someone who is not named Clive at all). The story was that he gets off by punching women very hard, and being punched by them in return. His girlfriends walk around with black eyes, but it's a consensual thing.
I heard about this because a friend of a friend left her husband for this guy, whoever he is. And in the conversation in which she declared she was leaving, she very dramatically took off her sunglasses revealing a black eye and said, "You never pleased me sexually." To which the husband said, "If that's what you want I'm glad I didn't."
Not to actually comment on the topic here (we've already moved past that to cock jokes), but I had a different reaction than the rest of you. I thought Instapundit was STILL nuts.
Pharmacy is a six year program, requiring a fair amount of biology/chemistry/hard sciences and learning quite a bit about drug interaction. Part of it is simply pill-dispensing; but the part we worry about ('I'm on six different medications and my doctor prescribed a seventh -- will they interact?') seems to require a fair amount of training and is the sort of stuff a doctor doesn't notice..
What am I missing here, as you guys all seem to be in agreement? (I mean, a lot of good could be done by having more people available to practice medicine, but no one's suggesting that medical licenses are just a goverment-created monopoly.)
Speaking for myself, I am not a big fan of credentialing, especially of credentialing processes under government monopoly. Typically, they are used by industry participants to restrict supply, drive up wages, and engage in other guild-like behavior.
Also, whenever the government touches anything in any way, people often assume that give the government rights to regulate it in ridiculous ways. I think forcing a pharmacy to stock drug x, y, or z is basically as bogus as forcing a book store to stock books x, y, and z. On the last thread, everyone said this was bogus because pharmacists are "licensed by the state."
And I'll join Cala on thinking that licensing pharmacists is a Good Idea, for much of the same reasons I'm glad there are medical examinig boards and the FDA. Keeping idiots and quacks away from practicing medicine, making drugs or dispensing them are all good places for collective action by a neutral, reasonably objective state.
Glenn's suggestion is typical power fantasy. Feh. Indeed.
Well, I split from Insty on 'licensing pharmacists is a good idea', but he gets some minimal amount of credit for recognizing that so long as pharmacists are licensed, requiring them to fill everyone's prescriptions rather than just the ones they approve of isn't an unconscionable intrusion on their freedom.
I'm not sure I do disagree with him about the government-granted monopoly. What if there weren't one? Would you be inclined to go to a pharmacist who didn't have the proper training? Neither would just about anyone else. But if you lived in a small town with one conservative pharmacist, chances would be much better that someone nearby would dispense the drugs you need (you could conceivably just get them yourself, no?). And the kind of knowledge Cala mentions needn't be local. As long as there's someone somewhere who can answer your question, it doesn't much matter if your local pharmacist knows anything at all.
Even if pharmacists weren't licensed, all we'd have to do is get users of reproductive medicines recognized as a suspect class, and then civil rights would take care of the rest, no?
Of course, this problem reduces to that of colonic simian projection, as yet unsolved.
I think forcing a pharmacy to stock drug x, y, or z is basically as bogus as forcing a book store to stock books x, y, and z.
Nobody will die if they can't get a specific Italo Calvino novel, so I'd assign a somewhat lower level of bogosity. Health care is a qualitatively different market than x, y, or z consumer item. Doesn't behave the same, can't really be treated the same.
I agree with the narrow point, in case that wasn't clear; if the pharmacists enjoy the protection of a monopoly, they should expect to have to deal with the rest of the government regulations.
That said, I'm pretty sure my local pharmacy, in a poor area of town, run by a big corporation, would lose its pharmacist quickly if it weren't required to have one. Why would Wal-Mart pay a pharmacist when they could pay a kid $7 an hour to put pills in bottles? And while *I* can do the research -- I'm healthy, most medicine I buy is OTC -- I'm not sure that's fair to ask of everyone.
And allowing Internet purchases of medicine seems to be a separate problem; why can't there be licensed on-line pharmacies?
Do you know how many idiots would take a "more is better" approach to their medicines if we deregulated pharmacists? Dicks would be dropping off left and right from all the idiots who popped a dozen Viagra and got a three-week boner, not too mention all the mouthbreathers who destroyed their livers by mixing their prescription antifungals with alcohol. I'd guess that within a year of enacting any such legislation, you'd have a 100,000+ deaths.
I think Wal-Mart has an incentive to not kill customers. I think it's also true that most pharmacueticals are not truly emergency products. For those that are truly time-sensitive: fine, it's a public health issue. Otherwise, let's let people sell what they want. If a pharmacist with animal rights concerns doesn't want to sell products that he believe didn't warrant animal testing (an anti-acne drug, maybe) that's fine with me.
What are we talking obout here? Dropping prescriptions entirely -- you'd be able to buy Prozac over the counter -- or something else? Because if you're not doing the first, you have to license pharmacists somehow, otherwise how do you tell the difference between a retailer who's allowed to buy prescription drugs for resale and a consumer who isn't.
Chopper, c'mon, people take illegal prescription drugs all the time. It's quite popular down here as recreation. (Not college kids only. I know quite a few middle-aged republican men who are big users). These people don't go off the deep end. It's funny that you listed viagra as an example - viagra isn't hard to get. I'm against the illegalization of marijuana and basically I take the same approach to prescription drugs. (Age limits are fine, though) I suppose I go farther than Insty. Heck with bothering with the pharmacists - get rid of prescriptions. I don't think it's the role of the government to ensure that you take care of yourself.
And I really do think danger here is being exaggerated. Certainly one could imagine all sorts of terrible scenarios of what might happen if drugs are released onto the ignorant, self-destructive masses, but, I really don't think they would become reality. People are responsible for their own bodies. (Which does not preclude government-sponsered help if they need it.) If they go on a binge (as people already do with different substances), it may be unfortunate (not necessarily of course; it all depends on what you can do and still be productive. Faulkner, anyone?) but, again, the government shouldn't be in the role of regulation of life-choices.
Pure speculation, because I haven't read any liberterian theorizing on licensing and regulatory agencies that I can recall: Assume some future enlightened administration decides the FDA causes more harm than good and abolishes it. Now anyone can sell any pharmaceutical product they want, and consumers have no way to tell what is a true claim about a particular product and what is a false claim. But it's very valuable to consumers to have accurate information about drugs, and there's also value to pharmaceutical manufacturers in consumers having that information, insofar as they can charge more if the consumer has reason to believe that the drug will work. This is a market failure and market failures would all magically cure themselves if that damn government would get out of the way. So consumer groups, industry groups, and possibly combinations of the two will create their own drug testing agencies. Further, these agencies will have an incentive to convince the public that they are the one providing the most accurate information, since they'll want more people to test their drugs via that group.
The problems with this story are numerous (transaction costs, assuming a really low level of ignorance) but presumably this is the story of how things would look, and an analogue can be created for how pharmacists would be licensed without government involvment.
53: Michael's "get rid of prescriptions" is close. The reason I talked about it in those terms is because the FDA is my framework for thinking about these types of issues and I think the liberterian ideal story about how the pharmacist market would look without government licensing is really similar. Also, I'd have to have written "pharmacy licensing bodies of each of the 50 states" which takes longer to write than FDA.
54: I can't believe I forgot to use the pony line. I hope it was clear that I'm not saying 52 would happen, but rather that it's a position certain people who advocate for abolishing the FDA (or agencies with similar functions over other domains) might take.
And I really do think danger here is being exaggerated. Certainly one could imagine all sorts of terrible scenarios of what might happen if drugs are released onto the ignorant, self-destructive masses, but, I really don't think they would become reality. People are responsible for their own bodies.
Michael, no offense, but this is either sheerest idiocy or complete ignorance. Take a look at this site for some of the problems involved with prescription compliance as they exist today, with pharmacists and doctors and all of the controls currently in place.
I'm involved in the development of tools (prescription logs, education, etc.) for patients with heart failure. Can you honestly tell me that you feel confident that if you had heart failure, you could balance the interactions between your angiotensin receptor blockers and beta blockers, with your diuretics and blood thinners? Should you take aspirin while you're on heparin? You're a smart guy, maybe you could. Now imagine you're 78, and you also have diabetes, perhaps with the early stages of Alzheimer's. But you're high functioning, and your even more ailing spouse needs you to feed them meals and get around. What then? Do you really have the time to objectively assess whether you need to be on Warfarin, and plan your dosage around your dietary restrictions, etc.? You're in chronic pain for your arthritis, but also at high risk for heart attacks--do you take Vioxx?
Libertarian fantasies aside, medicine is at a point today where people can kill themselves very easily, either through neglecting to take their meds or not taking them in the right way, and the average person (much less the below average person) is not in a position to make the right choices about their medical needs. It's already a crisis. What you suggest would make it infinitely worse.
Were acupuncture or psychology drugs, they would be removed from the market. They are medical interventions that have not been proven safe and effective by randomized clinical studies. Herbal supplements would also be removed from the market if Rx. Any takers for that?
I am not generally an FDA-skeptic, but it is clear FDA review introduces massive, massive costs that we all pay. Sometimes those are costs we want to bear, othertimes not. But it's not libertarian pony land to ask the question.
but washer, I'm not against the FDA and government-testing.
And ending prescriptions may in a certain way increase the need for pharmacists. People may just want to ask their pharmacists which drug to take for minor ailments rather than booking a Dr's appointment.
Can you honestly tell me that you feel confident that if you had heart failure, you could balance the interactions between your angiotensin receptor blockers and beta blockers, with your diuretics and blood thinners?
No. Again, I'm not against pharmacists and doctor's. Just because you don't need a prescription doesn't mean you shouldn't go to the Dr to get a recommendation. Y'know, I could bankrupt myself buying car parts, but I usually just get the ones my mechanic recommends. (not a perfect analogy, but still.)
medicine is at a point today where people can kill themselves very easily, either through neglecting to take their meds or not taking them in the right way,
I think this is part of my point. Once we get the drugs, we're trusted to use them correctly (following the advice given). People do know it would be stupid to use their drugs incorrectly.
As a fellow who is actually employed in the pharmaceutical research field, I can personally attest to what a pain in the ass it can be to deal with the FDA. I can also attest that, even with the FDA's policing, pharma companies are entirely willing to cut whatever corner they feel they can get away with cutting. I deal with these companies five days a week and believe you me, I'm very, very grateful that the FDA is there.
Ogged, you may think that nobody would go to an underqualified pharmacist, but I think that mostly reveals your economic position. baa, you may think that by and large, medicines aren't emergency situations, but that mostly reveals your age. The older folks having to choose between groceries and medicines will absolutely go to an unqualified pharmacist if the prices are lower, as you'd expect them to be.
Regulatory agencies, despite what Joe Libertarian believes, do not exist in order to decrease economic efficiency; they are there to protect the citizenry against amoral, predatory corporations. We license people to drive cars because without proper training, they are likely to kill somebody. So with pharmacists.
Psychology sometimes involves drugs, n'est-ce pas? And those are regulated. The talking to people bit doesn't need to be regulated because it's, well, talking, not putting funny substances in your body.
Acupuncture close to the same--I don't know if there's any danger. Maybe there is, in which case I'd be fine with regulating it.
And is the herbal supplement thing supposed to be a reductio? Cause I'm a taker for that. The only reason they aren't regulated is Orrin Hatch won't let them be. They can be quite goddamn dangerous, and I'd be happy to see them disappear. (Note: Not sure if ephedrine counts as herbal. The Hatch remark still stands.)
I guess I should clear up that FDA comment. There would still be a need for an agency to test drugs for their effects and to maintain quality control. Ending prescriptions wouldn't change the need for that.
apostropher -- agree generally on the point that FDA serves a essential watchdog role. Although, again, we pay for that big time. Looking for places to trim (new indications for approved drugs?) doesn't seem to me crazy. Also, by "emergency" I meant "time-sensitive." If pharmacy X doesn't want to stock drug X, Y, Z, usually you will have time to find another pharmacy. This isn't all about tPA and morning-after pills.
I think perhaps I'm posting too much, but I just want to say that I think I'm coming off too strongly for my position. It's an idea I've exploring for a bit, but I readily concede I haven't considered every possible angle. I put it out there in order to be attacked, so, fire away.
Matt's and Chopper's examples have led me to reevaluate the principle I'm advocating. The principle I'm advocating is that the government should not regulate what harm one can do to oneself knowingly. (this, by the way, is why the driving analogy fails. While driving, you are a danger to others.) However, there must be a reasonable expectation of what one should know. For the ephedrine example, I think we can safely say that there is no way that the users could have known of the harmful effects, and so the drug could be regulated.
As regards prescription drugs, I suppose the question we have to ask is there sufficient awareness of "these things can be harmful." There is some precedent for this, for adults are trusted with all sorts of harmful objects. (We could certainly trade stories of overdoses for shoots-himself or burns-himself or blows-himself-up, or boils-himself or crushes-himself) So the mere fact that they can be harmful shouldn't be sufficient to regulate them. But then, as Chopper points out, it takes specialized knowledge to use these drugs correctly. And while this is not wholly unique, it is somewhat different from any other class of objects available to consumers, where special might be necessary but also readily available. But, if we're going to look at it this way, we're going to have to split the prescription drug class into two. In one half, the fairly common drugs: EC, amoxicilian, etc.., and the more rares in the other, certainly probably larger, class.
I tend to think that libertarian fantasies end up being just that because they have (as we all do) a wildly simplistic model of human behavior. IIRC, Nader used to argue that seat belts should be mandatory in cars b/c people, on the whole, were too stupid to do something as simple as demand a car that had seat belts. I think his basic point was that if you can't fix the problem, you should at least minimize the damage.
The same thing is true here. Distribution of condoms in schools works (if it does) because kids are too stupid to overcome initial embarrassment and get a box at the pharmacy. Small increases in the cost of acquiring medicine could, I imagine, lead to pretty bad results.
But even there, you'll find societal costs. It's well established that Americans will demand and pop antibiotics when they have a viral infection, for which antibiotics do nothing except help produce antibiotic-resistant superbacteria, which pose a pretty severe public health risk already.
Cool discussion. I will endeavour to respond to all of it at once.
1) I agree with apostropher that the sentiment 'no one would go to an unlicensed pharmacy' only makes sense within a certain socio-economic class. Let's not call them unlicensed pharmacies; let's call them Wal-mart's cheerfully blue-smocked certified pharmaceutical technicians. Let's have the savings for the cherubic children in the commercials be 40%. Proud parents beaming, chatty with their Nebraskan accents about how great it is, and how fast, and how cheap!
And let's hope the guy reading the computer screen that tells him what pills to dispense can count them correctly, because that's all he's qualified to do. For many people -- good health, just need an antibiotic now and then -- no problem. For a lot of others? Not good. (And do you think insurance will cover the nice private pharmacist if a cheap Wal-marted option is available?)
We don't need to invent crazy doomsday scenarios of a nation engorged on Viagra while high on Oxycontin. The real problems are likely to be a lot quieter but just as dangerous: high blood pressure medication interacting with a painkiller. Depression meds interacting with everything.
2) Sure, patients can educate themselves. Patients should. But we're not talking about car parts or new computers here; health is more important. Worse, the people most likely to take advantage of the cheaper pharmacist-free places are probably not the highly educated sort who can understand the chemical interactions; it's the poor, the elderly (and the elderly are often on multiple medications.) A good pharmacist often knows more about what the patient's taking than the doctor, and is in a position to say, 'Oh, that anti-depressant you're taking? It reduces the effectiveness of the Pill.'
3) A good pharmacist can be a money-saver. You have the option to substitute generic? She'll know when it's a good idea. When the OTC medicine works just as well? That too.
Re: 30: (though I'm vague enough on this that it could be Clive Barker, or someone who is not named Clive at all).
ac - Clive Barker's gay, so the girlfriend bashing/bashed by person ain't he.
Re: Drug oversight: Eliminate it all, and the snake-oil salesmen will be out in force. OTOH, requiring the CEOs/CFOs of drug companies to take doses of drugs subsequently found to have nasty side-effects might make them think twice. [Well, OK, I'm actually in favour of executing them out of hand, but, for some reason, most people seem to find that a bit extreme.]
I'm waiting for someone to challenge the state laws that allow pharmacists to refuse to dispense legally prescribed drugs based on "conscience". [Of course, she said cynically, that may have to wait until some pharmacist refuses to fill a prescription for Viagra.]
I'll be. Even a troll's ass gets some sunshine. Course, this isn't a new suggestion or anything. And wouldn't the Clinton/Gingrich drugs-over-the-net plan have the effect of breaking the pharmacists' monopoly? I'll have to check on that, but it seems so.
Posted by Michael | Link to this comment | 06- 7-05 9:03 PM
Not sure this quite makes up for "Sigh. I wish he were wrong.", but I guess it just demonstrates that nobody is capable of being a total asshole all the time. Which is a pretty low standard, if you ask me. Not that you did.
Posted by Walter Sobchak | Link to this comment | 06- 7-05 9:10 PM
22 days, Walt.
Posted by Michael | Link to this comment | 06- 7-05 9:12 PM
???
Posted by Walter Sobchak | Link to this comment | 06- 7-05 9:15 PM
What's this? I try to share my joy but no one understands me? I'm gonna fucking go read Ayn Rand.
">22 days.
Posted by Michael | Link to this comment | 06- 7-05 9:19 PM
Grrr.
Posted by Michael | Link to this comment | 06- 7-05 9:20 PM
First of all, how in the Christ-humping name of all that is holy did you know I was a Dan Simmons fan? Second of all, it's twenty-one days.
So you see my confusion.
And how does that relate to Instahack anyway?
Posted by Walter Sobchak | Link to this comment | 06- 7-05 9:26 PM
Geez.
Posted by Michael | Link to this comment | 06- 7-05 9:29 PM
Damn... good memory. I had a feeling I must've posted something about Simmons at some point, but I couldn't for the life of me figure out how you would've come up with that so quickly.
Dan Simmons rocks my world.
Posted by Walter Sobchak | Link to this comment | 06- 7-05 9:39 PM
By the way, have you read the A Song of Ice and Fire series? I'd go so far as to say it's in the same league as Hyperion.
Posted by Walter Sobchak | Link to this comment | 06- 7-05 9:41 PM
I read the first book of that series when it came out. Maybe the second too? When did the second come out?
Posted by ben wolfson | Link to this comment | 06- 7-05 9:44 PM
A while ago. The fourth one is coming out next month. I can honestly say that after the first book, it only gets better.
Posted by Walter Sobchak | Link to this comment | 06- 7-05 9:46 PM
Yeah, well, that's like the last time I saw you post, I think. A friend of mine read Ilium last week, so I got to talking/thinking about it again, and, damn, I realized that all the mysteries in Ilium have left him plenty of room to choke if he doesn't resolve them in sufficient fashion. I remember not being satisfied by the "love" think in Rise of Endymion, though it has been awhile.
Posted by Michael | Link to this comment | 06- 7-05 9:46 PM
I haven't read that, but, oddly coincidental, I think a friend of mine was telling me about it earlier today. I'll have to pick it up.
Posted by Michael | Link to this comment | 06- 7-05 9:48 PM
Yeah, I wasn't so thrilled by the end of Rise either. Definitely went way off on the Disneyesque "love" tangent. But the quality of the rest of the series more than makes up for the sub-par conclusion. In fact, I think I'll go start myself a Church of the Shrike, just for shits and giggles.
Posted by Walter Sobchak | Link to this comment | 06- 7-05 9:54 PM
I remember not being satisfied by the "love" think in Rise of Endymion
What was this love think?
(And Ogged, this place is like crack.)
Posted by ac | Link to this comment | 06- 7-05 10:02 PM
a mispelling, I meant to write "thing." Love in a certain fashion was revealed as a fundamental force of the universe, IIRC. Sorry I can't be more specific.
Posted by Michael | Link to this comment | 06- 7-05 10:05 PM
Gentlemen, the topic is how even a stopped clock is right twice a day. Thank you.
Posted by oggedbot | Link to this comment | 06- 7-05 10:07 PM
Would the Church of the Shrike sacrifice aesthetes on the Tree of Pain, or would that be too Clive Barker?
Posted by Michael | Link to this comment | 06- 7-05 10:07 PM
I liked the Orwellian suggestion of it. Lovethink.
Posted by ac | Link to this comment | 06- 7-05 10:07 PM
I bet I could write a philosophy paper on that. (But I'm not gonna)
Posted by Michael | Link to this comment | 06- 7-05 10:11 PM
sacrifice aesthetes on the Tree of Pain
Well, at least we'd go out in style.
Posted by Standpipe Bridgeplate | Link to this comment | 06- 7-05 10:12 PM
Is there another horror writer whose name is Clive?
Posted by ac | Link to this comment | 06- 7-05 10:14 PM
Michael, your teasewrite is ungood.
Posted by Standpipe Bridgeplate | Link to this comment | 06- 7-05 10:15 PM
ac, ?
SB,
a) In the interest of anality, I should note that "go out" is not the correct characterization of the experience a body undergoes on the Tree of Pain. As it is a machine which desires to rattle the bushes, as it were, in order to out an empathetic entity, it to that end does not kill, but merely causes terrible pain.
b) Such a theoretical paper would probably be based off of this.
Posted by Michael | Link to this comment | 06- 7-05 10:27 PM
I love it when Michael gets pedantic. Specifically, his "a" followed by "based off of".
Posted by ogged | Link to this comment | 06- 7-05 10:29 PM
I just hope it's clear that I intend to be somewhat amusing, and it's not purely lagniappe for your amusement.
Posted by Michael | Link to this comment | 06- 7-05 10:36 PM
I believe that you are always drunk.
Posted by ogged | Link to this comment | 06- 7-05 10:40 PM
Far be it from me to get in the way of another's amusement. I shall get a drink.
Posted by Michael | Link to this comment | 06- 7-05 11:07 PM
On Clives - I think I once heard some gossip about the other Clive (though I'm vague enough on this that it could be Clive Barker, or someone who is not named Clive at all). The story was that he gets off by punching women very hard, and being punched by them in return. His girlfriends walk around with black eyes, but it's a consensual thing.
I heard about this because a friend of a friend left her husband for this guy, whoever he is. And in the conversation in which she declared she was leaving, she very dramatically took off her sunglasses revealing a black eye and said, "You never pleased me sexually." To which the husband said, "If that's what you want I'm glad I didn't."
Posted by ac | Link to this comment | 06- 8-05 5:30 AM
What was the topic again?
Posted by ac | Link to this comment | 06- 8-05 6:24 AM
"Instapundit is making sense"
Posted by baa | Link to this comment | 06- 8-05 6:27 AM
Not to actually comment on the topic here (we've already moved past that to cock jokes), but I had a different reaction than the rest of you. I thought Instapundit was STILL nuts.
Pharmacy is a six year program, requiring a fair amount of biology/chemistry/hard sciences and learning quite a bit about drug interaction. Part of it is simply pill-dispensing; but the part we worry about ('I'm on six different medications and my doctor prescribed a seventh -- will they interact?') seems to require a fair amount of training and is the sort of stuff a doctor doesn't notice..
What am I missing here, as you guys all seem to be in agreement? (I mean, a lot of good could be done by having more people available to practice medicine, but no one's suggesting that medical licenses are just a goverment-created monopoly.)
What am I not seeing?
Posted by Cala | Link to this comment | 06- 8-05 6:41 AM
Speaking for myself, I am not a big fan of credentialing, especially of credentialing processes under government monopoly. Typically, they are used by industry participants to restrict supply, drive up wages, and engage in other guild-like behavior.
Also, whenever the government touches anything in any way, people often assume that give the government rights to regulate it in ridiculous ways. I think forcing a pharmacy to stock drug x, y, or z is basically as bogus as forcing a book store to stock books x, y, and z. On the last thread, everyone said this was bogus because pharmacists are "licensed by the state."
Posted by baa | Link to this comment | 06- 8-05 6:47 AM
P.S. Hyperion is incredible.
Posted by Cala | Link to this comment | 06- 8-05 6:53 AM
Instapundit. So many sharks. Jumped so long ago.
Posted by Doug | Link to this comment | 06- 8-05 7:16 AM
And I'll join Cala on thinking that licensing pharmacists is a Good Idea, for much of the same reasons I'm glad there are medical examinig boards and the FDA. Keeping idiots and quacks away from practicing medicine, making drugs or dispensing them are all good places for collective action by a neutral, reasonably objective state.
Glenn's suggestion is typical power fantasy. Feh. Indeed.
Posted by Doug | Link to this comment | 06- 8-05 7:21 AM
But don't let me keep the talk from returning to either Simmons or cock jokes.
Posted by Doug | Link to this comment | 06- 8-05 7:21 AM
Well, I split from Insty on 'licensing pharmacists is a good idea', but he gets some minimal amount of credit for recognizing that so long as pharmacists are licensed, requiring them to fill everyone's prescriptions rather than just the ones they approve of isn't an unconscionable intrusion on their freedom.
Posted by LizardBreath | Link to this comment | 06- 8-05 7:28 AM
I'm not sure I do disagree with him about the government-granted monopoly. What if there weren't one? Would you be inclined to go to a pharmacist who didn't have the proper training? Neither would just about anyone else. But if you lived in a small town with one conservative pharmacist, chances would be much better that someone nearby would dispense the drugs you need (you could conceivably just get them yourself, no?). And the kind of knowledge Cala mentions needn't be local. As long as there's someone somewhere who can answer your question, it doesn't much matter if your local pharmacist knows anything at all.
That's it, I'm voting libertarian.
Posted by ogged | Link to this comment | 06- 8-05 7:36 AM
Would you be inclined to go to a pharmacist who didn't have the proper training?
Would you have any way of knowing who had proper training? That's rather the point of certification.
Posted by apostropher | Link to this comment | 06- 8-05 7:50 AM
Sure; they either have a diploma posted or they don't. Fraud would still be illegal.
Posted by ogged | Link to this comment | 06- 8-05 7:51 AM
Even if pharmacists weren't licensed, all we'd have to do is get users of reproductive medicines recognized as a suspect class, and then civil rights would take care of the rest, no?
Of course, this problem reduces to that of colonic simian projection, as yet unsolved.
Posted by Standpipe Bridgeplate | Link to this comment | 06- 8-05 7:54 AM
Cf. porcine aviation; infernal refrigeration.
Posted by LizardBreath | Link to this comment | 06- 8-05 7:56 AM
I think forcing a pharmacy to stock drug x, y, or z is basically as bogus as forcing a book store to stock books x, y, and z.
Nobody will die if they can't get a specific Italo Calvino novel, so I'd assign a somewhat lower level of bogosity. Health care is a qualitatively different market than x, y, or z consumer item. Doesn't behave the same, can't really be treated the same.
Posted by apostropher | Link to this comment | 06- 8-05 7:57 AM
I agree with the narrow point, in case that wasn't clear; if the pharmacists enjoy the protection of a monopoly, they should expect to have to deal with the rest of the government regulations.
That said, I'm pretty sure my local pharmacy, in a poor area of town, run by a big corporation, would lose its pharmacist quickly if it weren't required to have one. Why would Wal-Mart pay a pharmacist when they could pay a kid $7 an hour to put pills in bottles? And while *I* can do the research -- I'm healthy, most medicine I buy is OTC -- I'm not sure that's fair to ask of everyone.
And allowing Internet purchases of medicine seems to be a separate problem; why can't there be licensed on-line pharmacies?
Posted by Cala | Link to this comment | 06- 8-05 7:59 AM
Do you know how many idiots would take a "more is better" approach to their medicines if we deregulated pharmacists? Dicks would be dropping off left and right from all the idiots who popped a dozen Viagra and got a three-week boner, not too mention all the mouthbreathers who destroyed their livers by mixing their prescription antifungals with alcohol. I'd guess that within a year of enacting any such legislation, you'd have a 100,000+ deaths.
Posted by Chopper | Link to this comment | 06- 8-05 8:20 AM
I imagine you'd also spend an awful lot of law enforcement money investgating all the franchises of Ozark Otto's Oxycontin-Only Emporium.
Posted by apostropher | Link to this comment | 06- 8-05 8:25 AM
I think Wal-Mart has an incentive to not kill customers. I think it's also true that most pharmacueticals are not truly emergency products. For those that are truly time-sensitive: fine, it's a public health issue. Otherwise, let's let people sell what they want. If a pharmacist with animal rights concerns doesn't want to sell products that he believe didn't warrant animal testing (an anti-acne drug, maybe) that's fine with me.
Posted by baa | Link to this comment | 06- 8-05 8:44 AM
What are we talking obout here? Dropping prescriptions entirely -- you'd be able to buy Prozac over the counter -- or something else? Because if you're not doing the first, you have to license pharmacists somehow, otherwise how do you tell the difference between a retailer who's allowed to buy prescription drugs for resale and a consumer who isn't.
Posted by LizardBreath | Link to this comment | 06- 8-05 8:53 AM
Chopper, c'mon, people take illegal prescription drugs all the time. It's quite popular down here as recreation. (Not college kids only. I know quite a few middle-aged republican men who are big users). These people don't go off the deep end. It's funny that you listed viagra as an example - viagra isn't hard to get. I'm against the illegalization of marijuana and basically I take the same approach to prescription drugs. (Age limits are fine, though) I suppose I go farther than Insty. Heck with bothering with the pharmacists - get rid of prescriptions. I don't think it's the role of the government to ensure that you take care of yourself.
And I really do think danger here is being exaggerated. Certainly one could imagine all sorts of terrible scenarios of what might happen if drugs are released onto the ignorant, self-destructive masses, but, I really don't think they would become reality. People are responsible for their own bodies. (Which does not preclude government-sponsered help if they need it.) If they go on a binge (as people already do with different substances), it may be unfortunate (not necessarily of course; it all depends on what you can do and still be productive. Faulkner, anyone?) but, again, the government shouldn't be in the role of regulation of life-choices.
Posted by Michael | Link to this comment | 06- 8-05 9:05 AM
Pure speculation, because I haven't read any liberterian theorizing on licensing and regulatory agencies that I can recall: Assume some future enlightened administration decides the FDA causes more harm than good and abolishes it. Now anyone can sell any pharmaceutical product they want, and consumers have no way to tell what is a true claim about a particular product and what is a false claim. But it's very valuable to consumers to have accurate information about drugs, and there's also value to pharmaceutical manufacturers in consumers having that information, insofar as they can charge more if the consumer has reason to believe that the drug will work. This is a market failure and market failures would all magically cure themselves if that damn government would get out of the way. So consumer groups, industry groups, and possibly combinations of the two will create their own drug testing agencies. Further, these agencies will have an incentive to convince the public that they are the one providing the most accurate information, since they'll want more people to test their drugs via that group.
The problems with this story are numerous (transaction costs, assuming a really low level of ignorance) but presumably this is the story of how things would look, and an analogue can be created for how pharmacists would be licensed without government involvment.
Posted by washerdreyer | Link to this comment | 06- 8-05 9:14 AM
Wait, are we now talking about doing away with drug testing? Has anyone advocated that? (In this thread.)
Posted by ogged | Link to this comment | 06- 8-05 9:16 AM
So consumer groups, industry groups, and possibly combinations of the two will create their own drug testing agencies.
Providing ponies for all.
Posted by LizardBreath | Link to this comment | 06- 8-05 9:16 AM
53: Michael's "get rid of prescriptions" is close. The reason I talked about it in those terms is because the FDA is my framework for thinking about these types of issues and I think the liberterian ideal story about how the pharmacist market would look without government licensing is really similar. Also, I'd have to have written "pharmacy licensing bodies of each of the 50 states" which takes longer to write than FDA.
54: I can't believe I forgot to use the pony line. I hope it was clear that I'm not saying 52 would happen, but rather that it's a position certain people who advocate for abolishing the FDA (or agencies with similar functions over other domains) might take.
Posted by washerdreyer | Link to this comment | 06- 8-05 9:29 AM
And I really do think danger here is being exaggerated. Certainly one could imagine all sorts of terrible scenarios of what might happen if drugs are released onto the ignorant, self-destructive masses, but, I really don't think they would become reality. People are responsible for their own bodies.
Michael, no offense, but this is either sheerest idiocy or complete ignorance. Take a look at this site for some of the problems involved with prescription compliance as they exist today, with pharmacists and doctors and all of the controls currently in place.
I'm involved in the development of tools (prescription logs, education, etc.) for patients with heart failure. Can you honestly tell me that you feel confident that if you had heart failure, you could balance the interactions between your angiotensin receptor blockers and beta blockers, with your diuretics and blood thinners? Should you take aspirin while you're on heparin? You're a smart guy, maybe you could. Now imagine you're 78, and you also have diabetes, perhaps with the early stages of Alzheimer's. But you're high functioning, and your even more ailing spouse needs you to feed them meals and get around. What then? Do you really have the time to objectively assess whether you need to be on Warfarin, and plan your dosage around your dietary restrictions, etc.? You're in chronic pain for your arthritis, but also at high risk for heart attacks--do you take Vioxx?
Libertarian fantasies aside, medicine is at a point today where people can kill themselves very easily, either through neglecting to take their meds or not taking them in the right way, and the average person (much less the below average person) is not in a position to make the right choices about their medical needs. It's already a crisis. What you suggest would make it infinitely worse.
Posted by Chopper | Link to this comment | 06- 8-05 9:36 AM
Were acupuncture or psychology drugs, they would be removed from the market. They are medical interventions that have not been proven safe and effective by randomized clinical studies. Herbal supplements would also be removed from the market if Rx. Any takers for that?
I am not generally an FDA-skeptic, but it is clear FDA review introduces massive, massive costs that we all pay. Sometimes those are costs we want to bear, othertimes not. But it's not libertarian pony land to ask the question.
Posted by baa | Link to this comment | 06- 8-05 9:37 AM
but washer, I'm not against the FDA and government-testing.
And ending prescriptions may in a certain way increase the need for pharmacists. People may just want to ask their pharmacists which drug to take for minor ailments rather than booking a Dr's appointment.
Posted by Michael | Link to this comment | 06- 8-05 9:38 AM
Can you honestly tell me that you feel confident that if you had heart failure, you could balance the interactions between your angiotensin receptor blockers and beta blockers, with your diuretics and blood thinners?
No. Again, I'm not against pharmacists and doctor's. Just because you don't need a prescription doesn't mean you shouldn't go to the Dr to get a recommendation. Y'know, I could bankrupt myself buying car parts, but I usually just get the ones my mechanic recommends. (not a perfect analogy, but still.)
Posted by Michael | Link to this comment | 06- 8-05 9:40 AM
medicine is at a point today where people can kill themselves very easily, either through neglecting to take their meds or not taking them in the right way,
I think this is part of my point. Once we get the drugs, we're trusted to use them correctly (following the advice given). People do know it would be stupid to use their drugs incorrectly.
Posted by Michael | Link to this comment | 06- 8-05 9:45 AM
As a fellow who is actually employed in the pharmaceutical research field, I can personally attest to what a pain in the ass it can be to deal with the FDA. I can also attest that, even with the FDA's policing, pharma companies are entirely willing to cut whatever corner they feel they can get away with cutting. I deal with these companies five days a week and believe you me, I'm very, very grateful that the FDA is there.
Ogged, you may think that nobody would go to an underqualified pharmacist, but I think that mostly reveals your economic position. baa, you may think that by and large, medicines aren't emergency situations, but that mostly reveals your age. The older folks having to choose between groceries and medicines will absolutely go to an unqualified pharmacist if the prices are lower, as you'd expect them to be.
Regulatory agencies, despite what Joe Libertarian believes, do not exist in order to decrease economic efficiency; they are there to protect the citizenry against amoral, predatory corporations. We license people to drive cars because without proper training, they are likely to kill somebody. So with pharmacists.
Posted by apostropher | Link to this comment | 06- 8-05 9:46 AM
Psychology sometimes involves drugs, n'est-ce pas? And those are regulated. The talking to people bit doesn't need to be regulated because it's, well, talking, not putting funny substances in your body.
Acupuncture close to the same--I don't know if there's any danger. Maybe there is, in which case I'd be fine with regulating it.
And is the herbal supplement thing supposed to be a reductio? Cause I'm a taker for that. The only reason they aren't regulated is Orrin Hatch won't let them be. They can be quite goddamn dangerous, and I'd be happy to see them disappear. (Note: Not sure if ephedrine counts as herbal. The Hatch remark still stands.)
Posted by Matt Weiner | Link to this comment | 06- 8-05 9:47 AM
I guess I should clear up that FDA comment. There would still be a need for an agency to test drugs for their effects and to maintain quality control. Ending prescriptions wouldn't change the need for that.
Posted by Michael | Link to this comment | 06- 8-05 9:48 AM
apostropher -- agree generally on the point that FDA serves a essential watchdog role. Although, again, we pay for that big time. Looking for places to trim (new indications for approved drugs?) doesn't seem to me crazy. Also, by "emergency" I meant "time-sensitive." If pharmacy X doesn't want to stock drug X, Y, Z, usually you will have time to find another pharmacy. This isn't all about tPA and morning-after pills.
Posted by baa | Link to this comment | 06- 8-05 9:49 AM
I think perhaps I'm posting too much, but I just want to say that I think I'm coming off too strongly for my position. It's an idea I've exploring for a bit, but I readily concede I haven't considered every possible angle. I put it out there in order to be attacked, so, fire away.
Posted by Michael | Link to this comment | 06- 8-05 9:52 AM
Ditto Michael's last; I'm just musing here--I have no doubt people would harm themselves if it were left up to them.
Posted by ogged | Link to this comment | 06- 8-05 10:01 AM
(thinking out loud. or, is Michael drunk?)
Matt's and Chopper's examples have led me to reevaluate the principle I'm advocating. The principle I'm advocating is that the government should not regulate what harm one can do to oneself knowingly. (this, by the way, is why the driving analogy fails. While driving, you are a danger to others.) However, there must be a reasonable expectation of what one should know. For the ephedrine example, I think we can safely say that there is no way that the users could have known of the harmful effects, and so the drug could be regulated.
As regards prescription drugs, I suppose the question we have to ask is there sufficient awareness of "these things can be harmful." There is some precedent for this, for adults are trusted with all sorts of harmful objects. (We could certainly trade stories of overdoses for shoots-himself or burns-himself or blows-himself-up, or boils-himself or crushes-himself) So the mere fact that they can be harmful shouldn't be sufficient to regulate them. But then, as Chopper points out, it takes specialized knowledge to use these drugs correctly. And while this is not wholly unique, it is somewhat different from any other class of objects available to consumers, where special might be necessary but also readily available. But, if we're going to look at it this way, we're going to have to split the prescription drug class into two. In one half, the fairly common drugs: EC, amoxicilian, etc.., and the more rares in the other, certainly probably larger, class.
Posted by Michael | Link to this comment | 06- 8-05 10:10 AM
Yeah Michael, that will teach you to even suggest scaling back the regulatory state in any way, you heartless anarchist you!
Posted by baa | Link to this comment | 06- 8-05 10:12 AM
I tend to think that libertarian fantasies end up being just that because they have (as we all do) a wildly simplistic model of human behavior. IIRC, Nader used to argue that seat belts should be mandatory in cars b/c people, on the whole, were too stupid to do something as simple as demand a car that had seat belts. I think his basic point was that if you can't fix the problem, you should at least minimize the damage.
The same thing is true here. Distribution of condoms in schools works (if it does) because kids are too stupid to overcome initial embarrassment and get a box at the pharmacy. Small increases in the cost of acquiring medicine could, I imagine, lead to pretty bad results.
Posted by SomeCallMeTim | Link to this comment | 06- 8-05 10:16 AM
amoxicilian
But even there, you'll find societal costs. It's well established that Americans will demand and pop antibiotics when they have a viral infection, for which antibiotics do nothing except help produce antibiotic-resistant superbacteria, which pose a pretty severe public health risk already.
Posted by apostropher | Link to this comment | 06- 8-05 10:19 AM
Cool discussion. I will endeavour to respond to all of it at once.
1) I agree with apostropher that the sentiment 'no one would go to an unlicensed pharmacy' only makes sense within a certain socio-economic class. Let's not call them unlicensed pharmacies; let's call them Wal-mart's cheerfully blue-smocked certified pharmaceutical technicians. Let's have the savings for the cherubic children in the commercials be 40%. Proud parents beaming, chatty with their Nebraskan accents about how great it is, and how fast, and how cheap!
And let's hope the guy reading the computer screen that tells him what pills to dispense can count them correctly, because that's all he's qualified to do. For many people -- good health, just need an antibiotic now and then -- no problem. For a lot of others? Not good. (And do you think insurance will cover the nice private pharmacist if a cheap Wal-marted option is available?)
We don't need to invent crazy doomsday scenarios of a nation engorged on Viagra while high on Oxycontin. The real problems are likely to be a lot quieter but just as dangerous: high blood pressure medication interacting with a painkiller. Depression meds interacting with everything.
2) Sure, patients can educate themselves. Patients should. But we're not talking about car parts or new computers here; health is more important. Worse, the people most likely to take advantage of the cheaper pharmacist-free places are probably not the highly educated sort who can understand the chemical interactions; it's the poor, the elderly (and the elderly are often on multiple medications.) A good pharmacist often knows more about what the patient's taking than the doctor, and is in a position to say, 'Oh, that anti-depressant you're taking? It reduces the effectiveness of the Pill.'
3) A good pharmacist can be a money-saver. You have the option to substitute generic? She'll know when it's a good idea. When the OTC medicine works just as well? That too.
Posted by Cala | Link to this comment | 06- 8-05 10:21 AM
I think to avoid drug-drug interactions, there should only be one pharmacist, the trusted C. Everett Koop.
Posted by baa | Link to this comment | 06- 8-05 10:45 AM
Let's compromise and give it to Jocelyn Elders. I hear she has special expertise in stroke medications.
Posted by apostropher | Link to this comment | 06- 8-05 10:57 AM
Nice!
Posted by baa | Link to this comment | 06- 8-05 11:26 AM
Re: 30: (though I'm vague enough on this that it could be Clive Barker, or someone who is not named Clive at all).
ac - Clive Barker's gay, so the girlfriend bashing/bashed by person ain't he.
Re: Drug oversight: Eliminate it all, and the snake-oil salesmen will be out in force. OTOH, requiring the CEOs/CFOs of drug companies to take doses of drugs subsequently found to have nasty side-effects might make them think twice. [Well, OK, I'm actually in favour of executing them out of hand, but, for some reason, most people seem to find that a bit extreme.]
I'm waiting for someone to challenge the state laws that allow pharmacists to refuse to dispense legally prescribed drugs based on "conscience". [Of course, she said cynically, that may have to wait until some pharmacist refuses to fill a prescription for Viagra.]
Posted by DominEditrix | Link to this comment | 06- 8-05 11:39 AM
ac - Clive Barker's gay, so the girlfriend bashing/bashed by person ain't he.
Yes I think I knew this. Was just trying to confuse the issue.
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