Tuesday, March 30, 2004

Trent McBride over at The Proximal Tubule has started a serial debate over paternalism in medicine. While I was going to wait until he got to something related to procedures and informed consent I have been moved to comment on his post about the requirement to obtain a doctor's prescription to obtain certain medications.
I'm too tired after a hard day seeing patients at the Acme Surgical Corp to debate the main point, mainly should prescriptions be required for certain medications. I will however throw in my two cents worth about some medications that should not be sold over the counter. My take on this is different than say, DB, who prescribes many different medications, since the main prescriptions I write (antibiotics and narcotics) have already been addressed.
Tamoxifen: This is a medication that has a wide variety of side effects such as thromboembolism, endometrial cancer, and cataracts. One use of Tamoxifen is the prevention of breast cancer in selected high-risk women. A woman who was not at high risk may have such a fear of cancer that she may take the medication if offered over the counter, needlessly exposing herself to risks.
Coumadin: A medicine that is hard even for experienced physicians to manage. The therapeutic range is narrow and can be affected my so many variables (diet, other drugs) . A patient may be going on a plane trip and wants to avoid "economy class syndrome" and takes some OTC Coumadin. Suppose this patient has protein C or S deficiency?
Thyroid hormone: With the recent ban on ephedra, patients could achieve the same results with OTC Synthroid.
But according to Mr. McBride the potential for misuse is a secondary concern:

If somebody was stupid enough to buy and take very toxic drugs without physician supervision, I still don't think that takes away from the point that they should still have that right.

What of "first do no harm"? Is paternalism the same as protectionism?
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