The Case Against Medical Paternalism

When people need expert legal advice, they seek the counsel of a lawyer. During the next few months, many of us will hire accountants to help navigate the tax code and fill out the necessary paperwork to satisfy the IRS. When my friends needed help planning their wedding, they sought the services of a wedding planner. In each of these situations, special knowledge and services are sought. A third party would likely conclude that these specialists are better informed than those who seek their services.

Few would argue either philosophically or pragmatically that people who are going to court, filling out tax forms, or planning a wedding should only be allowed to do so if they first seek the advice of licensed professionals or that companies selling such services should not be able to directly advertise to potential consumers. Yet, Henry Farrell makes this very argument against drug companies being able to advertise directly to consumers.

None of this is to say that the European system is perfect - drug companies pour an awful lot of money into “seminars” in nice places, golf excursions etc where they try to persuade doctors to prescribe their drugs. But there is a strong pragmatic case to be made that doctors are going to be better informed as a rule than their patients over the benefits and drawbacks of particular courses of treatment (otherwise why use them in the first place?). Thus, they’ll be better able, most of the time, to figure out when pharmaceutical companies are trying to con them into prescribing expensive and potentially dangerous medications where off-the-shelf drugs would work as well or better. Of course, this is not to say that consumers shouldn’t be able to get their hands on relevant information (doctors aren’t infallible) - but it’s surely a bit of a stretch to argue that aggressive TV advertising campaigns provide such information. Thus, I’m pretty well convinced of the case for banning direct marketing of drugs to consumers - it’s a relatively mild form of paternalism, which seems to me to have quite substantial payoffs. Any dissenters out there?

(emphasis mine)

I dissent. There are thousands of services we seek that are provided by specialists, everything from lawyers to accountants to wedding planners to computer engineers to university professors. Hyper-specialization is a feature of the complex, modern division-of-labor economy. Yet, there is no compelling reason to limit access to these services via gatekeeper specialists simply because they are more knowledgeable.

There is a lot of information in the world. Some of it is ambiguous and some of it is misleading while some of it immensely helpful. It can originate from from a variety of sources including businesses, specialists, media, and word of mouth - a competitive economy of information vendors, each with their own interests and goals. One reason why specialists exist in the first place is to provide a means to sift through the mountains of information around us in the modern world and advise on making decisions based on our unique desires. There is no reason why someone cannot take the information gained from a vendor and ask the specialist help in evaluting it.

Limiting information from one source - companies - only hurts competition between the information vendors. And it gives a more powerful position to the remaining participants who themselves can fall to corruption. In fact, one common complaint about drug companies is that they spend too much money on fancy lunches and resort vacations to convince doctors to prescribe their particular drugs. One can imagine what the power of physicians will be if direct-to-consumer advertising is banned. Who shall gatekeep the gatekeeper?

More information is not the problem and limiting information is not a solution. Rather, the opposite is true. Monopolies such as the AMA and the FDA need to be broken up to allow a more competitive market for information dispersal, filtering, and evaluation.

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This also assumes that

This also assumes that doctors are both perfectly and perpetually (1) fully-informed and (2) unbiased. Do we ever assume that of our lawyers or accountants, or even our wedding planners?:deal:

But there is a strong

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

In the post-reductio world,

In the post-reductio world, I'm not quite sure that Henry Farrell would disagree with your paraphrase, digamma.

Is anybody going to expand

Is anybody going to expand on what these "substantial payofffs" would be? Also, digamma, are you saying as well that you're in favor of banning all direct-to-the-voter political advertising?

In the wake of the Vioxx

In the wake of the Vioxx situation, doctors or looking ot shift blame for the fact that millions of prescriptions for Vioxx were written incorrectly. Of course, who better to point the finger at than drug companies and advertising?

Digamma was being facetious-

Digamma was being facetious- his comment is Farrell's comment with a politician filled in for physician.

Monopolies such as the AMA

Monopolies such as the AMA and the FDA need to be broken up to allow a more competitive market for information dispersal, filtering, and evaluation.

While I always look forward to monopolies (particularly monopolies by force) being broken up, is this really a prerequisite for good information to be disseminated? Is it illegal for an independant pharmaceutical lab, funded directly by consumers, to offer general information and even specific consultations?

I would guess the boundary conditions are set by:

1) It is illegal to give drug advice unless you are a licensed pharmacist or doctor.

2) Pharmacists/doctors may be liable for their advice and need malpractice insurance to protect themselves.

3) Taxpayer funded monopolies provide the semblance of such a service and thus reduce the market.

4) A government-backed insurance industry subsidizes monopoly services, but not independent services.

But as the monopoly services grow worse, isn't there an opening for a business plan for an independent providor of medical advice?

"One can imagine what the

"One can imagine what the power of physicians will be if direct-to-consumer advertising is banned. Who shall gatekeep the gatekeeper?"

Ah yes, doctors will be held in check by TV-watching consumers who rely on 30 second advertisements for their information. And as all of us know, advertisements, drug commercials especially, are designed to appeal to our rational sensibilities, and almost never prey on manufactured anxieties.

Since people are stupid and

Since people are stupid and incapable of rationally understanding risk or taking responsibility for it, shouldn't we have gatekeepers for really dangerous things like vehicles, electronics, home machinery (gas furnaces! yikes!), etc? Why stop at pharmaceuticals?

Straw man aside, the point remains that advocates *are* kept in check by advertisers, watchdog groups, and media outlets. There are plenty of private testing & vetting agencies that provide information to the public, and, more importantly, people have informal networks that tell them facts A, B, and C about any given item that inform their consumption decisions.

I think it is rather simplistic (as well as wrong) to imagine that consumers rely solely on 30 second commercials for consumption decisions.

In addition, I think it you ascribe far too much power to advertising to actually influence consumption decisions. If advertising had the power you claimed, a great many businesses would still be around (instead of bankrupt & moribund)...

I know I don't like to be

I know I don't like to be caught off-guard by anything, let alone by a doctore suggestion a medication for me that I've never heard of, or am not familiar with! I think the commercials are great. Patients are likely to at least have heard the name of a medication their health-care provider may suggest to them. Anything that encourages people to get involved in their own health has to be a plus.

--Diana

I rather enjoy reductio ad

I rather enjoy reductio ad absurdum. Frankly, one could argue that we must all have professional chauffeurs, that we should all have computer/internet insurance, and that no one should be allowed to vote without the assistance of professional representatives of a registered political party. I wonder how many of the books surrounding me I shouldn't have selected without an expert librarian or literary critic to guide me. But, as should come as no surprise in this forum, my views on politics, economics, religion, computing, medicine, law, literature and many other topics have not been approved by anyone else.

"Ah yes, doctors will be

"Ah yes, doctors will be held in check by TV-watching consumers who rely on 30 second advertisements for their information. And as all of us know, advertisements, drug commercials especially, are designed to appeal to our rational sensibilities, and almost never prey on manufactured anxieties."

Last year, I bought my first new car. Now, prior to purchasing the car, I had seen, as is custom, a plethora of different car commercials (most were...*GASP*...30-second spots!). Some offered low APR. Some offered cashback. Some offered extended warranties. But all claimed that theirs was the best deal under the sun.

So, being an ignorant, mindless consumer who relies only on 30-second advertisements for my information (as Cain described above), I was confused. Blasted liars! I mean, if Toyota had the best deal, then why was Kia claiming that they had the best deal? And then, just as I thought that I had it figured out, Ford airs a spot where they claim that their trucks are the #1 selling in America. I mean, how could I turn THAT offer down, huh? Then, on my way to the Ford dealership, I saw a sign in front of the Chevy dealer indicating that they were having a year-end "blowout" of some sort. Again, being a mindless consumer, incapable of conducting any sort of meaningful research, I was forced to pull in and buy the first car that the salesman showed me!

If only I had had a government-mandated "professional car expert" to do all my research for me, and "prescribe" the best automobile for my needs!

Rrrrrriiiiiiiggghhhhtt.

Ahem, now, let's get back to reality and tell the real story. I was in the market for my first new car. I had already been a subscriber to Consumer Reports, and they offered a great deal of objective research. I also fished around the internet, using places like Epinions.com, and found both expert and consumer peer reviews of the cars I was thinking about. I also took several test drives and talked to family and friends. After all this, I finally decided on a car, and I couldn't be happier. I made an informed decision, all without the help of a government-mandated "expert". While this all seems inconceivable to Cain, it did actually happen. We all make decisions every day that have an effect on our lives, ranging from the trivial to the profound. Given that the car was a major purchase, and my life could depend on the quality of the car, this was not a decision I took lightly.

His assertion that people would solely rely on a 30-second commercial for their information is assinine. Ok, maybe for a trivial decision like whether to get Bounty or Quilted Northern. But for a major decision like a car purchase, home purchase, or health care purchase? Please. Just because the government, in your lifetime, has not allowed the free market to regulate the health market, doesn't mean that it can't do so.

Hilarious stuff -- really,

Hilarious stuff -- really, guys. I apologize for the delayed response (I only discovered this website through the trackback link on Crookedtimber.org/).

Evan-
The government has already intervened in the choices of cars available by making sure they meet certain emissions and safety standards. This is not only to prevent negative externalities (pollution; roll-overs that can kill peaceful pedestrians), but personal safety as well (which also has an indirect external effect).

So-called *reductio ad absurdum* arguments in this case really are often nothing more than inflammable straw-men.

There are a few difficulties with your libertarian fantasy land. Most obviously there's the information problem (a barrier to optimal market performance). Why do you think doctors need so many years of schooling? Even if readily available, good information is highly technical and difficult to understand. This isn't so much the case in the purchase of automobiles or electronics, where you can weigh the opinions of Jdog243 against SuperGeek1977.

A second related problem is that mistaken choice is costlier and less reversible than with other commodities (with dying and all). How many cars will you own in your lifetime? How many people do you personally know who own X and love it? Well, I'm afraid medicine is a different beast altogether. You cannot get rid of adverse side-effect the same way you can unload a Jetta that just "doesn't do it" for you anymore. Jumping off this point we must remember that a person with a pressing medical condition does not have the luxury of shopping around for a medicine. Which leads to another point: intellectual property presents a serious barrier, and consumers cannot choose between a number of (more or less) similar treatments. Finally, good information in the form of unbiased long-running clinical trials is expensive and often controversial (and difficult to understand). Crash tests, horespower, and the aesthetics of an automobile are much easier for the common person to grasp. Even then the government intervenes by outlining the parameters of the contract you sign, what the dealer has to tell you, and so on.

Why do so many people spend so many dollars per year on a proven quack nostrum like homeopathy?

Ask your doctor about

Ask your doctor about cocaine! yeah - direct to consumer - brilliant - for the drug companies - but in the case of vioxx may be hazardous to your health. let's fill the doctors' office with patients flush with the knowledge of the latest happy sixty second advert and watch gleefully as the physician with years of education attempts to explain the vagaries of pharmacology and the hazards of jumping to the latest and greatest. Personally, if direct to consumer adverts are ok, then let the drugs be OTC and let all liability rest on the shoulders of the FDA, the FTC and the Pharms.