Prescription Paternalism: The Morality of Restricting Access to Pharmaceuticals
Robert M. Veatch
Although physicians are clearly experts on the facts of health and illness, they are not experts on the value judgments that necessarily are incorporated into prescription-writing. Two policy options are explored: (1) A libertarian view holds that all medications that pose danger primarily to the patient himself or herself should be available without prescription for use by mentally competent adults. (Restrictions on drug access to children do not constitute paternalism as usually defined nor do restrictions on those that pose a danger to others—amphetamines and alcohol, for example.) (2) A more modest option is to replace the act of prescription-writing with a requirement that adults who purchase pharmaceuticals possess a certificate from a physician testifying that the purchaser has an adequate knowledge of the agent and possibly that the purchaser has a condition for which the agent is typically recognized as useful.
Luke Braddock, a 45-year-old business professional left his New England home on a Friday afternoon with his wife and two children for a weeklong Florida vacation. On arriving at their Clearwater hotel late that evening, Mr. Braddock realized that he had left his medication at home. He took daily propranolol, 20 mg., to help control a ventricular arrhythmia.
His physician had told him he should not miss any doses since an abrupt stop could trigger a rebound cardiac arrhythmia that could well be fatal.
He knew that he could not reach his physician in New England and that, even if he could, that physician could not prescribe in Florida. He explored his options: (1) go to the hospital emergency room, wait perhaps hours, and pay an enormous fee to get an additional week’s supply of the propranolol; (2) go to a local pharmacy and try to persuade a pharmacist to give him enough capsules to get through the week; or (3) take a chance and go without the drug for a week.
The first option was unattractive. It would involve getting a taxi to the hospital, making use of the ER personnel, spending perhaps many hours, and generating significant costs.
R.M. Veatch (*)
© Springer Science+Business Media B.V. 2017
D. Ho (ed.), Philosophical Issues in Pharmaceutics, Philosophy and Medicine 122, DOI 10.1007/978-94-024-0979-6_9
The second option might not work. Mr. Braddock knew that it would be illegal for the pharmacist to provide the drug without a prescription, and he wasn’t sure it would be ethical to ask. He chose the third option. Fortunately, there were not adverse events. Mr. Braddock asked himself why it was necessary to have a prescription from a physician to gain access to drugs, especially a drug that was not subject to significant abuse and was reasonably safe.
This true story is, no doubt, repeated daily by those who need or want pharmaceuticals that are, by law, restricted to prescription access. Some drugs are surely more dangerous and more subject to abuse than propranolol. Some consumers are surely less well educated about the risks and benefits of pharmaceuticals that they might want to access. This example raises the larger question of whether the widespread policy of restricting access of lay people to pharmaceuticals that have been prescribed by physicians or other authorized healthcare professionals is philosophically sound and morally justified. Many chemicals, often not conceptualized as pharmaceuticals, are as dangerous (or more dangerous) than many drugs, and yet in a liberal society, they are made available “over the counter” for sale directly to consumers without a physician’s review and approval. Alcohol is certainly responsible for more abuse and harm to the consumer (not to mention other parties) than almost any pharmaceutical. Cigarettes are a drug delivery system with enormous potential for harm, yet they are available from informed and usually uninformed sales people (or even from vending machines without any interaction with a human seller). Ammunition for firearms is sold without certification from a recognized expert that the consumer will use the item properly. Even rat poison can be bought over the counter in spite of its lethal potential for misuse.
This raises the question why American and most other liberal societies make these lethal chemicals available so readily and yet restrict even many benign pharmaceuticals to cases in which an intermediary has decided that the consumer should have access. This is surely the height of paternalism, a feature that is generally frowned upon in liberal society. Consistency requires that pharmaceutical access be at least as open as these other toxic agents.
After spending some time defining paternalism and teasing out some of its implications for access to pharmaceuticals, we will consider two arguments for questioning the current restrictive policy: what we will call the liberal critique and the empirical critique. We shall suggest that current policies regarding legend drugs are unacceptably paternalistic and violate the ethical principle of autonomy, which is in other contexts considered fundamental. This we will call the liberal critique. Then we shall examine whether the empirical evidence supports the assumption that patients are, in fact, better off with a restrictive policy that strives to protect them from themselves.
Having found the current restrictive policy indefensible, we will explore two alternatives: a libertarian policy that would permit unrestricted purchase of pharmaceuticals (while still permitting restriction of sales to children and the mentally incompetent as well as restriction of agents that pose significant third-party risks) and a policy that would require that anyone who wants to purchase a drug deemed potentially dangerous would have to show a certificate from a physician indicating that the physician has judged that the patient has an adequate understanding of the drug, its effects, its possible dangers, and treatment alternatives. As part of that discussion, we will consider a modification in which the physician must also certify that the patient has a condition that is generally viewed as amenable to the drug the individual desires to purchase.