Doctor's Orders

When will Americans be allowed to make their own health decisions?


There are perks to being governed by an insane military dictator. Creating a whole system of repression is a big job for one general, and anarchy bubbles to the surface in the empty spaces totalitarianism has yet to fill. Last year, while living in the Southeast Asian nation of Myanmar, my phones were tapped, my journals were read, my work was censored, and for the first time in my life, I was given the authority to care for my own body.

There is no prescription drug system in Myanmar, but there are plenty of illnesses waiting to befall an effete Western immune system. My expatriate colleagues and I were free to treat our ailments as we saw fit. We staved off food poisoning and bouts of malaria with frequent trips to the local pharmacy, consulting doctors when necessary, but ultimately responsible for our own medical decisions. We formed doctor-patient relationships that were partnerships rather than paternalistic hierarchies, and each of us lived to tell the story.

Coming back to the States in the midst of hand-wringing about direct-to-consumer advertising, the restriction of life-saving cholesterol drugs, a wrenching process to make the morning-after-pill readily available, and now a push to put Sudafed behind the counter, it's increasingly hard to understand why Americans cede crucial health decisions to the bureaucratic dithering of the FDA. In an age of empowerment through information, it is mind-boggling that patients are still willing to be silent spectators while their doctors call the shots.

From allergy medication to birth control to Viagra, hundreds of harmless pharmaceuticals still require the costly nod of an M.D. On the rare occasion that any of these comes up for over-the-counter status, a coalition of doctors stands ready to slam easy access. This isn't surprising in a system where the arbiters of choice are the very people who stand to lose most if patients are empowered. For every medication that makes the leap from prescription to OTC, the gatekeepers of American medicine shed financial gain and social prestige. Like early Catholic priests jealously guarding their bibles, FDA advisors tell us we can't understand the sacred texts of medicine or simply follow basic directions. Labels like "do not take if pregnant" are not lucid enough for the common American, who must hear the words from the hallowed lips of a physician.

Take Mevacor, a drug recently up for over-the-counter status and quickly slapped down by an FDA advisory panel. Mevacor is one of a class of drugs known as statins that has been credited with saving thousands of lives every year. In the vast majority of cases, statins produce no negative side effects. But based largely on the fear that pregnant women will join the ignorant stampede of statin-poppers, the panel has advised the FDA to prevent Americans from lowering their cholesterol without a doctor's permission. One alarmist USA Today headline reads "Statins: A Risk to Your Baby?" Well, yes, and as with most medications, you shouldn't pop them if you're pregnant or spoon feed them to an infant. That's hardly a reason to deny them to a 65 year old man who can't afford to see a doctor.

The FDA panel had a few dissenters, one of whom, a Vanderbilt medical professor, was quoted by the Boston Globe saying that the majority of patients "are receiving no therapy right now and should" and that the decision to deny these patients therapy was "disturbing." Indeed. One wonders how many people die each year from the FDA's efforts to save us from ourselves.

When it advised against statins, the FDA panel had the decency to cough up a medical reason. In the case of Plan B, or the morning-after-pill, the FDA's dallying is moral rather than medical. High on its own regulatory power, the agency wants to keep America chaste as well as healthy. Unfortunately, that won't help anyone put a dent in the country's 3 million unwanted pregnancies each year. The pill, which is more reliable the earlier it is taken, is literally made less effective by the FDA's regulatory barriers.

Talk to most people about liberalizing prescription drug laws, and the word "disaster" tends to drop into the conversation. The prevailing image seems to be CVS repackaged as Willy Wonka's candy store, the friendly pharmacist swinging from shelf to shelf dropping tabs of Paxil like gumdrops into opened mouths. The assumption is that if people can be irresponsible, they will be.

But the effect on my colleagues in Myanmar was more, not less, attention to proper diagnosis and dosage. When doctors are seen as consultants rather than demi-gods, patients are forced to accept responsibility. Uniquely aware of our own medical histories and issues, we kept up on potential new medications better than our doctors, who had rosters of disparate patients to consider. Sure, we could have shred our livers by overdosing on anti-malarial meds, but the freedom to mess with our internal machinery was never much incentive to do it.

There are reasonable objections to freeing up antibiotics based on fears of creating resistant strains of deadly diseases. Where resistance has become a major problem, as with malaria in Africa, doctors have responded by developing effective combination therapies that the parasite will never evolve to resist. But antibiotics are only one class of drug in a long list of restricted medications, the vast majority of which only concern the wellbeing of an individual patient.

The FDA is fielding a lot of criticism from pro–Plan B women, who say the organization is denying them the right to make basic health decisions. This is nothing new for the agency; it's something the FDA's decision-makers do every time they create costly barriers to medications. A doctor's advice is a wonderful resource, but it shouldn't be one Americans are compelled by law to seek. As long as the FDA offers a tiny minority of Americans control over what the rest of us put into our bodies, Myanmar will have something to teach us about human liberty. And that's scary.