There are quite a number of medications

 

There are quite a number of medications that I think more than likely should be taken by almost all adults (except when there are contraindications) and, moreover, at certain ages, as routine. There are disincentives in the system for this: the legal exposure of doctors created by the system requiring prescriptions and, of course, costs created by the pharmacy system in the States that produces price gouging and insurance resistance.

Yes. I think you're identifying a genuine structural problem, although I'd put one important qualification on it: there are some drugs for which a population-wide, age-based default makes sense, but many others where the benefit depends too strongly on individual risk factors.

The prescription system creates an interesting asymmetry. Once a drug requires a prescription, the doctor isn't merely saying “this is probably beneficial”; he is effectively taking responsibility for deciding that this particular patient should receive it, and continuing to prescribe it. That naturally encourages defensive medicine.

And the American pricing system adds another layer. A drug can be pharmacologically cheap while its medical-system cost is enormous. That makes some remarkably sensible preventive interventions harder to deploy than they ought to be.

A good example is vaccination. We've already decided, for many vaccines, that the appropriate solution isn't “wait until your doctor individually decides whether you're a suitable candidate.” We establish schedules by age and risk, with contraindications and exceptions. That's essentially a population-health decision.

There are also drugs where I think your idea becomes particularly interesting:

• Statins — not literally everyone, but increasingly based on age/risk rather than waiting for manifest cardiovascular disease.

• Antihypertensives — when blood pressure crosses appropriate thresholds, although this is much more individualized.

• Bisphosphonates — age and fracture risk can make routine consideration sensible.

• Antidiabetic/cardiometabolic drugs — potentially, although here the risk/benefit and the evidence are considerably more complicated.

• Antiplatelet drugs — this is the classic warning against making the rule too simple. Aspirin looked like an obvious universal preventive drug for decades, but bleeding risk eventually demonstrated why age alone isn't enough.

In fact, aspirin is almost a perfect illustration of your point and its limitation. For decades it was treated almost as a routine middle/old-age preventive medication. We eventually learned that the cardiovascular benefit in people without established disease is often offset by bleeding, particularly as age increases. So the correct policy isn't necessarily “don't routinely prescribe drugs”; it is “make the default evidence-based, and explicitly account for contraindications and changing risk with age.”

I would go one step further than your legal-exposure argument, though. The prescription requirement itself isn't necessarily the fundamental problem. The deeper problem is that the American system makes a physician the gatekeeper for a huge number of low-complexity risk/benefit decisions while simultaneously making drugs expensive and insurers bureaucratic.

One possible alternative would be an intermediate category: age/risk-based preventive medications that are legally available without an individual prescription, but with standardized screening and contraindication checks. Pharmacists could handle much of the routine assessment, rather as they increasingly do with vaccinations.

That would preserve a safety mechanism without requiring an 83-year-old, for example, to make a doctor's appointment merely to obtain something that evidence says virtually everyone in his risk category should take.

And there's a fascinating philosophical distinction here: medicine has historically been organized around treating individuals, whereas prevention sometimes works better when organized around populations. The vaccination schedule is basically public-health engineering; the traditional doctor-prescription model is individualized medicine. Some medications sit right on that boundary.

In Cambodia I get what I decide I want and it is just prudence that causes me to clear it with my clinic and my Kaiser system in the States as well as asking you and checking other medical sources. Cost has not been an issue, because prices here are appropriate to production cost and I have the resources.

Right—and that changes the practical problem considerably.

You're essentially using Cambodia as the dispensing system and the U.S. medical system as one of several safety/verification systems. That's quite different from simply ignoring medical advice and buying whatever happens to be available.

In your situation, the workflow is roughly:

1. You identify something worth considering.

2. You investigate the evidence yourself.

3. You ask me to examine the risk/reward and interactions.

4. You run it past your Cambodian clinic.

5. You can also ask Kaiser to review it.

6. If nobody identifies a compelling reason not to, you can obtain it locally at a reasonable price.

7. You then decide whether the expected benefit is worth the inconvenience and risk.

That's actually a pretty interesting model of patient autonomy with multiple independent checks.

And the cost point matters. In the U.S., “Should this person take drug X?” can become entangled with “Will insurance pay for X?”, “Will the pharmacy have it?”, “Does it require prior authorization?”, and “Will the doctor prescribe it?” Those are not pharmacological questions at all.

Your Cambodian arrangement strips most of those variables away. The remaining question is much closer to the one that ought to matter:

Given this person's age, health, expected remaining lifespan, other medications, and the evidence, does taking this drug have a favorable expected value?

That's particularly relevant to our earlier discussion about new preventive or longevity-oriented drugs. At 83, chronological age shouldn't automatically terminate the discussion. It changes the calculation because the time available to realize a delayed benefit is shorter and adverse effects matter more—but that's a quantitative change in the calculation, not a magic cutoff.

And your willingness to spend time investigating something is itself an important resource. If a drug costs very little but requires keeping up with the evidence, monitoring, and occasionally getting a blood test, then the real cost to you may be quite small. In the U.S., the same decision can acquire an entirely unnecessary economic and bureaucratic dimension.

So I think your description is more accurate than saying you have simply “self-prescribed.” You're making the initial selection yourself, but you're deliberately subjecting the decision to several independent checks. That's a considerably more defensible arrangement.