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Notes -
Testosterone/Estrogen (for hormone replacement, not trans issues). Any scheduled or formerly scheduled substances. Any medication with significant CYP interactions or other related interactions. Any drug that requires lab work and/or monitoring. Any medication that can impact renal or hepatic function if used chronically or to excess acutely. Any drug that makes someone feel good in a non-addictive way but causes significant side effects like steroids.
And that's just taking 30 seconds. Do you know which drugs you'd want to prescribe yourself show up in which categories? Do you have any idea the number of ways you could kill yourself or cause yourself permanent harm?
No.
We had a guy on here a few weeks ago who describing Tylenol usage that could have easily gotten him killed in a slow and agonizingly painful way, and this forum is mostly stuffed with high intellect and education people. And Tylenol is over the counter...
You have no idea what you don't know.
I have seen plenty of patient mortality and morbidity associated with misuse of prescribed medications, bullying NPs into giving them non-indicated medication, or outright ordering meds from another country. And that's right now with the safeguards we have in place.
Ok, great. Let's start here. What I'm missing in your comment is an argument concerning anything having to do with it. You just named the substance. What's the argument?
Do patients ask for these? What's the ratio of people who actually need them versus just think they need them? Are their side effects? Are they bad? Are the risks something that someone can easily understand and make informed decisions based off of? Are patients willing to try safer and more effective interventions first?
What's the evidence base and recommendations, how sure are we about them? Are their bad actors involved who are incentivizing certain behaviors? What is the level of excess supplementation that production can carry?
How many of these questions can you answer?
If you can't answer the analog of those questions for an item of auto repair, does that mean we have reason to ban people from doing it?
My read is that all of those things are directly in the vein of "they can hurt themselves" and "there is still possible value in expertise", not externalities. It's telling that you started with the one example of a clear externality, and as soon as we took that off the table, you completely abandoned the externality argument. Or should I pull a you and say, "If you want to continue this conversation please explain what testosterone stewardship and why it's important, or argue why it isn't." Because if that's not a thing, you're jumping to an entirely different class of argument and not even bothering to acknowledge it.
The point is Chesterton's Fence.
You know nothing about medicine or the risks and benefits of what you are proposing. Medicine is not auto repair.
That's kind of important.
This is a nice moment to take stock of the situation. Up to this point, you have lost and abandoned every single object-level argument you have made, over and over again. In this comment, you have implicitly acknowledged that you have again abandoned another argument that you've lost.
This is also a nice moment to reflect on the fact that while, "You're stupid," is a great and effective argument on the third grade playground, it's not very becoming in a place like The Motte... especially when you've just lost and abandoned every single argument you've made so far.
Now, to get to Chesterton's Fence, which is in a sense moving up to the meta level, mostly abandoning any actual argument that would benefit from real in-depth domain expertise at the level of the practice of medicine, but instead moving up to the question of the history/intent of the government action.
One thing that is always a bit tricky about Chesterton's Fence is its conceptualization of "intent". One doesn't have to go full Scalia to know that, when it comes to law, 'legislative intent' can be a tricky beast. Things are sometimes done for a variety of motives affecting multiple agents. Sometimes, it is just a banal compromise (something that no one really intends, but merely accepts). Sometimes, it's a confluence of surprisingly different intents; see also the famous Bootleggers and Baptists theory. So, with that in mind, let's go through a little of the history, and see what all we can say about it.
One could have a more expansive history, but I only have so much time in a day, so I think an acceptable place to start is 1937. Prior to this point, USP was a private organization that published their own compilations of drug information. (As Mitch Hedberg would say, they still do, but they used to, too.) Alongside this, the government did have a legitimate reason to ensure that consumers at least had some understanding of what products they were buying, so the 1906 Pure Food and Drugs Act adopted the USP and said that a drug was "adulterated" if it failed to meet the USP's standards. Then, a company brought an "elixir" to market that used diethylene glycol, causing lots of harm and about a hundred deaths. There was a clear gap in the law and standard, because if the product had been called a "solution" instead of an "elixir", there would have been no legal violation. (Note that liability damages are a separate question and plausible pathway to accomplishing some fence-like goals and may be a useful tool in the toolbox.)
Enter the Food, Drug, and Cosmetics Act of 1938. This was "intended", in the Chestertonian Fence sense, to be a more robust labeling law, in an extremely pre-information-age era. This fence was not intended to restrict a person's ability to self-medicate. With the above caveats about divining intent for fences from legislative history, FDA chief Walter G. Campbell said:
Sen. Royal S. Copeland (D-NY) said:
The House committee reported:
It wouldn't have made sense for the elixir tragedy to be the impetus for a law requiring prescriptions, because almost all of the deaths that came from the elixir were under the direction of a government-licensed physician. (Prior to any mandates, I'll note, some manufacturers voluntarily made their products "prescription-only", and one would have to have a separate exploration as to whether the intent there was commercial or something else. That said, I don't believe that they had required this drug to be prescription-only, but I'm not sure.) Having a prescription requirement would have saved almost none of the precious lives in question. Since then, we have not had any splashy self-medication string of deaths that would justify a prescription requirement, either. One other additional note at this point is that, even in the absence of such government requirements, the vast majority of people who took this drug did so under the direction of a doctor; many many people leveraged the expertise of medical professionals, because they found it valuable. It was not banned to leverage a doctor's expertise. (It just happened to get them killed when they followed the doctor's advice in this case.)
So what happened? Who intended it? Who built the fence and why? Turns out, the problem was mostly that the FDA was part incompetent, part just unfortunately operating in a pre-information-age era. They set out extremely vague, but strongly-worded labeling requirements. Manufacturers were scared off by how vague the requirements were, not even being sure how much stuff they really needed to put on the label to remain compliant, and in a world where all that information pretty much had to be printed directly on the little bottle, at great expense, many manufacturers were unhappy. Of course, in every regulatory scheme where half the job is keeping consumers happy and half of the job is keeping producers happy (and rich), and especially when the latter group is likely the buddy-buddy industry counterpart to the regulators with a revolving door, sometimes, you gotta do something to make the industry happy. So the FDA, on their own, without Congressional intent or authorization, just exempted medications that the manufacturer designated as prescription-only from their labeling requirements. How much of this is due to the fact that they were just not competent to come up with a more acceptable and precise labeling requirement and how much of it is just due to pre-information-era constraints? Not sure.
In any event, since manufacturers found the FDA's hamfisted labeling requirements so vague/onerous, they generally preferred to just take the exception, presumably with the Chestertonian intent to make more money and reduce their regulatory risk. I'm not even sure that the physicians were part of the bootleggers or baptists; they might not have even lobbied for this exception, only realizing later how lucrative the arrangement would be for them as well as the manufacturers. The result was that many drugs which were actually totally safe to self-administer suddenly became prescription-only, primarily because the FDA went out on its own in making new rules, did a kind of bad job at it, and manufacturers would now make more money this way.
In the next decade or so, there was clearly some confusion. The rules didn't make sense. There was no consistency or logic in whether a drug was prescription-only or not. It was entirely up to the manufacturer, who would presumably decide based on money and risk (mostly regulatory risk rather than safety risk). So, two professional pharmacists in Congress (unsurprisingly named Durham and Humphrey) created the Durham-Humphrey Amendment of 1951, which codified the prescription-only/OTC divide and put the decision under the purview of the FDA. Of course, don't forget, those drugs would be dispensed by professional pharmacists, folks near and dear to those two congressmen.
So, that's the story. What is the "intent" of the fence? Well, sure, consumer protection is in there somewhere. But it's pretty confused with tales of differing motives, incompetence, and plain difficulty of living in the past. Is it a messy story of how we got to where we are today? Absolutely. Does that mean that there aren't possible good features of the system we have today? Of course not. Does anything in there imply that this is the only plausible way of doing things and we'll have megadeaths if we do anything differently? I doubt it. But since we've now gone through the exercise of going through how the fence got there and why, perhaps we can turn back to the real questions: today, right now, what are the real, serious, justifications for such mandates/bannings?
In order to have a conversation about increased patient autonomy you need to know the risks and benefits of increased autonomy. I'm not saying you are stupid, I'm saying you don't know anything about medicine or prescribing, which is the thing you are trying to alter. Demonstrating knowledge of the regulatory landscape is not the same as demonstrating the risks and benefits and you certainly have not intimated any knowledge of the many, many discussions about patient autonomy that have been going on for the last several hundred years.
You don't. And that's normal. If I was arguing for deregulation of nuclear energy and you told me you were an expert and that was insane and I blew you off by mumbling about something else, well...no bueno.
You are arguing that people have a right to walk along the train tracks without knowing about the existence of trains.
Since the 1938 date-
How much has the number of drugs increased since then? How much has polypharmacy increased since then? How much has comorbidity increase since then? How much has personal behavior in response to healthcare changed since?
Do you know to think about any of these things?
Sophistry is not a substitute for domain specific knowledge.
Let's go a bit slowly here, as you've shown yourself very prone to erratically jumping between different arguments, without much logical connection to what has been said. We were discussing a specific aspect of medicine, and after you struggled mightily in using your vast domain-specific knowledge to make a coherent argument, you invoked Chesterton's Fence, again sort of erratically and not weaved into a coherent argument. Chesterton said:
This was your pithy attempt to just tell me to shut up and go away. However, Chesterton explicitly said that one is to come back after they can explain what the use of it was, where usually, this is interpreted to mean that one has understood that reasonably intelligent humans went through the effort to erect the fence, and so this must have happened for some use for someone. In our case, the fence is the requirement that basically every drug requires a prescription.
I'm going to start needing some clear affirmations of the progress we've made if I'm going to believe that you're arguing in good faith and are willing to have an honest back-and-forth rather than just erratically lurching in every which way, mostly trying to wave your degree around and telling me to shut up. Do you clearly affirm that I have, in fact, described how humans found value in setting up this fence and why it came to be?
If you do not agree, then we need to return to that question. If you do agree, then we can come back to where we were. Let's talk testosterone. Let's hear your argument (only after you explicitly agree that we have satisfied the last demand you made, but before we lurch off onto another hundred erratic demands you'd like to make).
Sophistry (and gish gallops) is not a substitute for a coherent argument.
I don't agree with your characterization of the fence, previous message describes why.
With respect to test, previously I said:
"Do patients ask for these? What's the ratio of people who actually need them versus just think they need them? Are their side effects? Are they bad? Are the risks something that someone can easily understand and make informed decisions based off of? Are patients willing to try safer and more effective interventions first? What's the evidence base and recommendations, how sure are we about them? Are their bad actors involved who are incentivizing certain behaviors? What is the level of excess supplementation that production can carry? How many of these questions can you answer?"
Given your lack of response and changing the subject I think I can safely assume you can answer none of these things.
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-Benefits and risks of a given action exist, for oneself and for others.
-In order to determine the benefits and risks of this substance as a medication you need to know the answers to those questions, and others.
-You do not know the answers to these questions.
-Therefore you do not know the benefits and risks of testosterone.
-Other medications may or may not have similar risks and benefits.
-You do not know them.
-Therefore you do know if medications are safe, for the taker or for others.
-Expanding on that, you do not know the cost to the patient or others have a given medication.
-Decisions should be made with an awareness of the costs and benefits.
-You personally, and patients in general do not have the information to make these decisions.
-Therefore you shouldn't.
Smuggled in there is the premise that people should not be allowed to grossly harm themselves or others, if you are fine with that ....then sure, but if that's the case I'm not sure how you are going to argue against me putting one in the head when someone hurts others with their decisions.
You may say "well sure but they can harm themselves a little bit" but the same frame holds and you don't have the knowledge to know what actions will cause no, a little bit, or significant harm.
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