From: rkaplan@netcom.com (Richard Kaplan)
Newsgroups: talk.politics.medicine
Subject: Re: Repealing medical licensure laws
Date: 23 Nov 92 03:28:55 GMT
Distribution: usa
Organization: Netcom - Online Communication Services  (408 241-9760 guest)

In article <1992Nov22.075851.17845@genie.slhs.udel.edu>
 starr@genie.slhs.udel.edu (Tim Starr) writes:

>}made you the most money.  But evaluating a doctor-rating
>}agency is very different; there is no clear-cut bottom
>}line which shows which agency is better (or even
>}competent) at rating doctors.
>
>Good point, but there must be some way this can be done.  Competition would
>certainly provide the incentive for standards of evaluation to be discovered
>if truly none exist.  How are licensing agencies evaluated?  I can't see
>a private medical ratings agency letting a competitor go by giving a quack
>an A rating without trying to woo away its customers, can you?

I cannot conceive of a way to evaluate doctor-rating
agencies without licensing the rating agencies themselves --
and then that is just further enlargement of government which
we do not need.  Since you proposed doctor rating agencies,
I will leave it to you to propose how we properly 
evaluate them.  At the same time, I must ask how new doctors
will be trained under your system.  Must one go to medical
school?  Can it be to any medical school?  How does a 
non-rated doctor enter practice?  How does the first
patient for a non-rated doctor have any idea what his
credentials are?

>There are financial emergencies, too.  Decisions about what was to be done
>about the 1987 crash, the crash of 1929, etc., are both analogous.  How
>would a coercive monopoly of investment bond rating agencies be an improvement
>for dealing with financial emergencies?

If you invest in bonds, you should have already established 
a contingency plan for such "emergencies"; medical emergencies
cannot be planned for in such a manner.  More importantly,
the tragedy involved in a true, unexpected  medical emergency cannot
reasonably be compared to the loss of money in an investment
known in advance to carry risk.
 

>}If you are in a motor
>}vehicle accident and are brought to an emergency room
>}unconscious, you deserve to know that the doctor treating
>}you is competent; your free market system does not address this.   
>
>I do deserve this?  It's not clear to me why.  We've had claims that we dese
>all sort of things used to justify tyranny in this century.  It's important   
>not to take them for granted.

I hope that you are simply taking a Devil's Advocate stance
here in order to promote discussion.  If not, the reason
for our differences is clear and we need not discuss the 
issue further.  

Yes, I take it by inspection that in an enlightened society
an unconscious person in an emergency room is entitled to
know that the doctor treating him will be competent.
You are free to feel otherwise and I will defend your
right to your opinion; however, in this case you are
out of synch with the vast majority of persons on
the globe.  

>it turns out that he got his degree and passed the tests fraudulently by
>bribery, as many Soviet doctors did, or that he still wasn't able to treat
>my condition.

Fraud will still be possible under a free enterprise rating
system.  The answer is the same in either case: appropriate
anti-fraud laws.  That is a separate issue, one which I
would also be glad to discuss.  


>}Rating doctors is not like rating stocks or bonds.  You
>}can't just publish how many lives a doctor saves or how
>}many of his patients die during surgery because often
>}the best doctors at the best hopsitals treat the sickest,
>}highest risk patients.  
>
>Why can't this be taken into account?

Because people are not machines and there is no end
to the number of unquantifiable variables which would
need to be taken into account.  To create a
reasonable model would require an unreasonable expenditure
of administrative effort.


>What way do we have of knowing the quality of public agencies?

We have a tremendous credentialing and licensing system which 
inspects medical schools and hopsitals.  You are welcome
as a citizen to challenge any of this.  If this were
to be duplicated by the private sector it would create
an unreasonable and impractical burden upon hospitals
and doctors.  The only way a private agency truly
could evaluate my skills would be to observe me with
patients and to visit my medical school in detail.  Should
I and my medical school do this for every rating agency?
I suppose you will say that I should do this for any
rating agency I want to be rated by.  Well what if 
I am the only doctor in a small town emergency room and I
have chosen to be rated by only one agency and I as a patient
do not like that agency?  You can see the problem.... it
may be a good idea in theory but not in practice.


>}(2) in an emergency situation
>}there is no time to check a rating agency.
>
>Wouldn't that depend on the particular emergency situation?  

Yes, it would depend on the particular emergency situation.
But what about a true, seconds-to-spare emergency
situation?  Your rating system does not address this problem. 

>I won't contest your claim for abnormal patients for now.  But how does this
>lead to the conclusion that all patients must get the same form of medical
>regulation as them?  What about those who might want to patronize unlicensed
>doctors without their being barred from entering into competition with
>licensed ones?  Why shouldn't they be permitted to opt out of licensure?

If the person making such a decision is a competent adult,
I would agree with this proposal if and only if
that person also agreed to pay for all his subsequent
medical care out of his own pocket and never to ask for
government-sponsored health care (e.g. Medicare/Medicaid).
Even if such an unlicensed doctor did no direct harm,
he could delay the patient's seeking more effective
care and thus might cost significant money to the 
public.  I do not feel we as a country are willing to
allow complete abrogation of one's rights such as
this, and thus we cannot allow the unlicensed
practice of medicine.

>but we don't have prescription laws for auto parts and tools.  Use of these
>can impair the safety of a car.

Yes, you are correct that virtually anything you do can 
impair the safety of oneself or of the public.  However, we have to be
reasonable and regulate those activities which are most likely
to cause injury to oneself or to others if used by
an improperly trained person.  


>But my mother's a medical technologist, and has picked up some knowledge of
>medications in her decades of experience.  Why should she or anyone who does
>know what's wrong with them be deprived of their right to self-medication?
>Why should they have to get anyone's permission to put whatever they want
>into their bodies?  Why should they have to pay a doctor a cent for this
>"privilege"?

See above under not signing away one's inherent rights
to health care and the resultant cost to society of 
inappropriate health care.


>>Besides, much of the reason why many are ignorant of medication is because
>of the fact that they aren't permitted to act on it by getting the medication
>they need on their own judgement.  The value of this knowledge to many will
>increase if prescription laws are abolished.

Definitely not..... You are perfectly willing to purchase the
same pharmacology textbooks I studied in medical
school, yet abuse of even over the counter medications
is common.  Furthermore, there is a limit to what you 
can learn from books; to a large extent, you can learn 
about pharmacology only by hands-on diagnosis of
patients and experience under supervision.


>I simply don't buy the argument that prescription laws are justified because
>impartiality is necessary to evaluate the effect of drugs.  If you weren't
>licensed to prescribe drugs and you took some codeine to anesthetize yourself
>against some pain you were experiencing, why should you be punished?  Why
>should the law PRESUME that non-doctors are incompetent or not impartial
>enough to decide these things for themselves?  This is highly elitist.

Elitist?  Not at all.  We all are good at whatever we
choose to learn.  If what we do has potential harm, we need to
prove we can do so safely before doing so.  If you are
an air traffic controller I would not argue that you are elitist
by saying I cannot do your job without proper training.

And codeine is not an anesthetic..... it is an analgesic.
 
>Perhaps you don't understand the economics of prohibiting chemical substances
>like alcohol, opiates, etc.  By relegating them to the black market, it tends
>to do three things to the products: raise their price and their potency, and
>decrease their quality.  The magnitude of these effects can be quite big.

And as I mentioned previously, LEGALIZING these unproven
substances legitimizes them and thus may result in patients
who delay more effective diagnosis/treatment.


>Why must they show their efficacy to a coercive monopoly and not to a free,
>competitive market of agencies?  We have something like this now: global
>competition between coercive monopolies.  Piracetam is approved by the
>equivalent of the FDA in other countries; why shouldn't we be able to buy
>it here?

Because maybe it would be thalidomide # 2.  Under your
system, thalidomide in this country would have resulted
in a significant number of tragic births. 

>Except that it now turns out that thalidomide has been approved in other
>Countries besides the USA for some uses.  Why hasn't the FDA done this too?
>Because it's a monoculture that's unaccountable to those who might need it
>to treat what ails them.

You are completely correct that significant reform and
streamlining of the FDA drug approval process is needed....
many physicians are in complete agreement with you.  But
that does not mean that it is not necessary, just that it
neeeds to be reformed.  Again, remember the tragedy that the
FDA helped avoid when it refused to allow thalidomide
on the market.  Although it may well be sold now
in other countries, it surely is contraindicated during
pregnancy... and we need the FDA to prevent similar 
tragedies in the future.



>Marijuana has medicinal benefits, yet it's effectively prohibited even for
>medical use.  Why?  Same reasons.  The FDA has banned companies from even
>telling consumers that taking some aspirin daily will reduce their risk of
>heart attack by about half.  They've restricted the importation of "smart"
>drugs and nutrients, prohibited their commercial sale and advertisement,
>and broken down the doors of a clinic in Tahoma, Washington, with guns
>and bullet-proof vests because they were field-testing a new bureaucratic
>tool to use.

I would appreciate further information regarding the FDA
breaking down clinic doors; clearly they are subject to
search warrant procedures, etc.

Regarding marijuana, there is no known use for marijuana
for which less abusable drugs cannot substitute. But
even if you are correct, that's not an argument to 
abolish the FDA.... just an argument to correct one
specific inequity.


>The ban on the aspirin information alone is probably accounting for the
>death of 100,000 Americans per year.


The ban on aspirin information should not cause any deaths
at all.  Patients who are educated enough to read 
medical literature in depth or who consult with their
physicians will be told if it is appropriate for them to
take aspirin.  However, there are significant contraindications
to the use of aspirin to prevent myocardial infarction and
such information would not fit on an aspirin bottle.  Thus to
prevent incorrect use, no mention at all of this use
is made.  This in no way prevents an informed patient from
purchasing and using the medication as he desires. 

>This conservative approach is leading to untold thousands of deaths.  It's
>precisely because human life is so important that we must let people take
>responsibility for their own without prescription laws.

No, the history of medicine has proven time and time again that
the conservative approach is the way to PREVENT deaths.  In
fact, "orthodox" medicine may not be conservative ENOUGH in 
its approach to medication and, in particular, to surgery.
If the leading physicians in the world, after years of
study, do not know how to best manage many medical
conditions, how  do you know better?  

The first rule of medicine, as any medical student will
tell you, is to first do no harm.

-- 
Richard Kaplan M.D.           Medical Software Exchange BBS
806 2nd St. SW # 104          (507) 281-1989 14,400 HST
Rochester, MN  55902          (507) 281-1689 Voice
PP-ASEL-IA     N4VRB          rkaplan@mayo.edu|netcom.netcom.com  
Newsgroups: talk.politics.medicine