Pharmacy and Medical Interventions: A Christian Perspective
an address presented March 23, 1996, to the Christian Pharmacists
(Continued from previous issue)
When I can live a hellion's life and send the bills for my misdeeds to other people-insurance companies, employers, the government, or my mother-my fallen nature pulls me, urges me, implores me to do just that. We have a health care economic structure that is substantially structured like that. Have neither hope in it nor fear of it. It is destined to fall. Rather, hope for it to fall. The sooner it falls, the better, for longer delays are like falls from greater heights.
For commonplace medical and pharmaceutical bills, patients need to pay themselves. The younger ones of you here will, I believe, live to see it again.
Patients will reach into their pockets to pay. Everyone will do it, not just the poor working stiffs today who don't have medical or pharmacy insurance but who have too much income to be on the federal dole. You and I may see our total revenues fall. On the other hand, our net revenues are already falling. In the net, when the risk is again borne by the proper person, I believe we will do better. The demands upon us will have reached such a state that our extra overhead will consume all the extra money that the third parties have used to hook us. It won't hurt then to tell them to take a hike. All the pain will have already taken place. Do you feel that pain now in your pharmacy practices?
b. God has revealed to us the limits of authority and responsibility of the state. We do not have to guess. In Deuteronomy 17:14-20, God gives a constitution to His people for the limitation of a future civil ruler over them. They are in Sinai, not the promised land, but God writes the constitution for the government of the promised land. "When you come to the land which the Lord your God is giving you, and possess it and dwell in it, and say, I will set a king over me like all the nations that are around me, 'you shall surely set a king over you whom the Lord your God chooses; one from among your brethren you shall set as king over you; you may not seta foreigner over you, who is not your brother. But he shall not multiply horses for himself, nor cause the people to return to Egypt to multiply horses, for the Lord has said to you, `You shall not return that way again.' Neither shall he multiply wives for himself, lest his heart turn away; nor shall he greatly multiply silver and gold for himself. Also it shall be, when he sits on the throne of his kingdom, that he shall write for himself a copy of this law in a book, from the one before the priests, the Levites. And it shall be with him, and he shall read it all the days of his life, that he may learn to fear the Lord his God and be careful to observe all the words of this law and these statutes, that his heart may not be lifted above his brethren, that he may not turn aside from the commandment to the right hand or to the left, and that he may prolong his days in his kingdom, he and his children in the midst of Israel." In this passage we see God outlining the proper role of all civil governing authorities. People cannot just draw up any kind of constitution they wish, though they try. Properly constituted government must derive from God's Word. Forget multiculturalism. A society cannot serve two or more gods and remain cohesive as a nation.
In I Samuel 10:25 we see Samuel doing just this thing-reminding the people of the proper behavior of a civil ruler. God's people are now in the promised land and crying out for a civil ruler, a king, like all the people around them. "Then Samuel explained to the people the behavior of royalty, and wrote it in a book and laid it up before the Lord. And Samuel sent all the people away, am man to his house. " According to these texts, then, and many others like them, such as Romans 13, there is no role in health care for civil government except the isolation of contagious diseases, and waste disposal. A state which exceeds its God-given authority is warring against God! He will take care of Himself.
c. Patients are "voting with their feet" when it comes to pharmacology. They are selfmedicating. A recent study found 425 million annual "escapees" from the orthodox system in the U.S.A.' That is, there were that many visits to providers of non-standard care, practitioners who are generally outside of the government's licensure system-herbalists, naturopaths, reflexologists, colonic irrigationists, and so forth. They did not count faith healers. They did not count children. The amount of money involved was around $26 per contact. Note that that is cheaper than the visit to the average primary care physician. However, the overhead required by the orthodox medical system and the third-party apparatus that funds it chews up much of the charges. I'd be happy at $26 per contact if I could keep it all and not pay hundreds and thousands in billing costs, licensures, certifications, and such.
Voting with one's feet is an old practice. Joseph's brothers went to Egypt during the famine to get food. They were hungry and were voting with their feet. There was not enough food in Palestine. That people in the U.S. annually vote nearly a half billion times with their feet for different medical care, sorry as it may be in general, should instruct us that the people are failing to get something that they, in their subjectivity, are willing to pay for. Protected by our government-granted monopolistic licenses, we may feel secure, but that security is coming apart.
We are set to think of self-medication as bad, because we see so many problems with it. We should pause and consider a couple of other things, however.
First, the bad outcomes we see do not necessarily mean that the privilege of self-medication should be restricted. To restrict that privilege means that we think of ourselves as more than advisers and assistants. It means that we think of ourselves as controlling authorities Where in Scripture has God authorized us as having any controlling authority over our patients?
Second, we have no good denominator for the dangers of self-medication. That is, we see those who have problems, but we are not nearly as aware of those who do not have problems. Every treatment has a certain failure rate. That is, we have a numerator of failures sitting over a denominator of all treatments. Unless we know the denominator we cannot know the fraction. If we do not know the fraction, we cannot know the rate. If we do not know failure rates, complication rates, and success rates, we are presumptuous to deny people by law the ability to decide for themselves.
We tend in medicine to practice on the numerator kind of information. We make decisions based on partial information. Patients need to be able to "vote with their feet." It is a check on us "experts." We, too, have fallen natures, with pride and desires for power and money. We want to have our way.
d. The would-be divine regulatory control by the state is being eroded already. Prescribing privileges are expanding- nurse practitioners, physician assistants, pharmacists, optometrists, perhaps soon chiropractors, and more OTC drugs (ibuprofen, naproxen, some antihistamines, H, blockers, etc.) Someday, the person who cannot prescribe may be the minority, and the monopolistic jig will be up. There will be no reason to require by law a prescription from a professional before a drug can be sold. A requirement by the state that a certain privileged group (doctors) be inserted into the patient's decision is accepted by us as natural, but it is only about a hundred years old. Were things so awful before? Even if they were, has God set up civil rulers to govem the health of individuals, or has He set up the individuals as the ones who are responsible? If you think the former, what is your Biblical grounds for thinking that? Government is for the punishment of evildoers. It is an instrument of justice, the bearer of the sword. It is incongruous to see the compassion and care of the injured and ill as a part of a ministry of justice and coercion.
If all drugs were available over the counter, which is the radical position I am advocating here, what would be the roles of the doctor and pharmacist? Would we be obsolete? I believe the roles would be greatly enhanced. Rather than being treated as vending machines by patients who resent our presence between them and the vending machine, they will seek out our advice at the level that provides it best. The underutilized knowledge of pharmacists will be more used, not just in "eyewash" fashion, but really sought. Since community pharmacists at present do not as often compound their own material, what you have is your knowledge of the medicines and your knowledge of the patients. As the third-party controls and assurances erode and/or are exposed as inadequate, patients will be back on their own to find out what they want to know, and you will be there, one of the most accessible persons in the health care system.
The medical newspaper American Medical News reported last month on a pharmacy in Darien, Connecticut. "Physicians refer patients to the independent pharmacy for counseling, education, followup care and routine maintenance. For example, general practitioners refer diabetics for instruction on eye care, monitoring blood sugar levels, injecting insulin and safely disposing of syringes. And reproductive endocrinologists refer fertility patients for instruction, counseling and 24-hour-a-day support.' The pharmacy, Griebs Pharmacy, is establishing an on-line computer link with physicians. To be added are alcohol rehabilitation, antihypertension and anticoagulant therapies. They claim (I have not seen this) that insurers are beginning to pay for "cognitive services." Nice, to get paid for using your mind. This is a step toward Godly economics. Physicians have become too expensive for some of these things. In a truly free economy, it is good stewardship for persons to obtain what they want and need as cheaply as possible.
Will physicians resist this sort of movement? Almost certainly, the less competent ones and the overpaid ones will. I have confidence, however, in a Provident God, who exerts His will in ways that are partly comprehensible to us by means of principles. Our present system in many ways is trying to overrule God. Have no fear. It won't.
e. We've been taught that only huge pharmaceutical companies can do the research on and manufacture the products which work. I'm very doubtful of this. Could a day come when the community pharmacist once again actually had a hand in the production and evaluation of pharmaceuticals?
Can you see the monopolistic aspects of how pharmaceuticals are devised and marketed? There has been no literal grant of exclusive rights to one company to research drugs, but a system has been created which permits only very big fish to play in the lake. These big pharmaceutical fish submit to the onerous rules, grumbling, but they are the only legal players. No one else can play. If the FDA were closed tomorrow, the first to clamor for its reinvention would be the pharmaceutical companies, as much as they rail against it. They couldn't stand the competition in a truly free market.
John Quackwater would set up in a storefront selling remedies for peripheral vascular disease derived from snakeskins. Since his costs would be far lower, he could charge less for his product - he'd call it "Snake Legs" - than the "legitimate" pharmacy down the street charges for pentoxifylline.
LegitPharm, the chain down the street, would see its profits fall and would scream. The cry that would emerge would not, however, come out truly, "I'm making less money." It would come out, "Protect the public." Of course, since patients are tacitly and insultingly assumed to be absolutely brainless, and since God died in the 1960s, the only one left to protect the public is Caesar, and LegitPharm would lobby Caesar for an FDA. So, we get drugs like pentoxifylline, a indication if drug looking for an ever there was one, whose efficacy studies show that you can enable those with diseased arteries in their legs to walk a few paces farther than they used to, at a cost of several dollars per extra foot walked. Give me Snake Legs.
Recently, the FDA moved to increase its power over herbals and supplements. The "little guys" were playing on the field and the big guys want them chased off the field. Now, I am not very knowledgeable at all about herbals and "alternative medicine." My bias is that much, if not most, of it is poppycock. However, I am thoroughly in favor of such being allowed. I do not believe that the power of the state should be used to squash those who believe in valerian or the fruit of the saw palmetto.
The opposite of a controlled, monopolistic economy is a free economy, in which the marketplace allows people to assign values to the various products and services which are available. Value is, remember, subjective, not objective. In a truly free economic exchange, both buyer and seller come away winners. If value were objective rather than subjective, every economic transaction would produce a winner and a loser. Someone would have traded something of more value for something of less value. The best that could be expected would be a tie. But, since value is subjective, the value to me of my $20 is not as great as the bottle of medicine sitting on your shelf. To you, my $20 is more valuable than that bottle. We exchange, and both are winners. Whether the medicine solves my issues is fallibly determined by me, but better by me than "experts" sitting in Atlanta, Georgia, or Rockville, Maryland, who never met me.
f. The pharmaceutical companies research and develop where the money is--commonplace, especially chronic, diseases: peptic ulcer disease, reflux esophagitis, arthritis, congestive heart failure, cardiac arrhythmias, diabetes, hypertension, and acute bacterial infections. Who looks after the persons who have "orphan" diseases? Collectively, the number of persons who have orphan diseases is significant.
g. Pharmaceutical companies, in coordination with the medical profession, have achieved an inordinate dominance in what the American public focuses on when feeling bad. What is the "most powerful" antibiotic to take when you have an infection? Fine, as far as it goes. Who, however, speaks for the other side of the infection equation? Being exposed to a microbe is clearly not all that is required to become infected. Being ready to receive the infection is the other side. Have you slept well? Have you eaten well? Are your relationships with other people in good condition? Have you done something needful for someone who cannot do for himself? Psalm 41:1-3 says, 'Blessed is he who considers the poor, the Lord will deliver him in time of trouble. The Lord will preserve him and keep him alive, And he will be blessed on the earth; You will not deliver him to the will of his enemies. The Lord will strengthen him on his bed of illness; You will sustain him on his sickbed. "
III. There are scientific reasons for optimism.
We have been led to believe that only entities with vast resources can provide the really good information regarding treatments, such as pharmaceuticals. Large studies, wondrous statistics and careful controls lead to big expenses. The marriage of the government's FDA rules and the ever-merging megapharmaceutical companies' mega-bucks seems to provide the only way to get the information.
a. This arrangement, however, has produced great answers to sorry questions.
Take the recent study on simvastatin. It had:
· Reasonably long-term follow-up.
· Excellent matching of control groups to experimental groups. The choice of all-cause mortality as an outcome measure. It was:
· Placebo controlled. Etc.
A wonderful, and wonderfully expensive study. Showed a difference in all-cause mortality brought about by the drug. It did.
Problem. Exquisite study, but it answers the wrong question. Look at the list of who was excluded from the study: You couldn't have:
· unstable angina,
· Prinzmetal's angina,
· be a female who was fertile,
· congestive heart failure requiring treatment; couldn't have had a stroke,
· couldn't have xanthomas on your tendons.
· you had to be between 35 and 70 years of age.
· you couldn't have significant valvular heart disease,
· you couldn't be on any antiarrhythmic drugs.
· you couldn't have a history of alcohol or drug abuse.
· you couldn't have "poor mental function."
· you couldn't have "other serious disease."
· And more.
In other words, they selected a group of people who were not likely to die from anything at all.
Now both the experimental and control groups were alike in this selection, so it might seem as though it was okay. Not. The reason it is not is that not many people inhabit such a world. We are no farther along in knowing whether simvastatin will help in improving anything in a real world. I failed to mention that compliance was undoubtedly enhanced by a pre-entrance trial for everyone that tended to exclude those who would not be compliant. Very realworld. Also, though they didn't say so, I strongly suspect that the drug was free to participants. Of course, cost has nothing to do with its usefulness in the real world.
My complaint is not about simvastatin, per se, but to make the point that before we get bamboozled by excellent answers, we need to see that we have asked excellent questions. Even if simvastatin works in the real world to lower all-cause mortality, I'd still be hard-headed enough to want to know, as a steward in a world of finite material resources, whether the cost of using it could not effect more benefit if fumed to other uses. Would the all cause mortality decrease still be present if the study participants who got the real drug had to fork over $700 a year for it? Might they have spent that $700 on something more useful for their health, thus removing the benefit of simvastatin? Why don't these questions get asked.
The simvastatin study is the DCCT trial of coronary artery disease. I make the same complaint about the DCCT trial, which showed that tight control of Type 1 diabetes can indeed delay the onset of diabetic complications. Participants were selected for high motivation and surrounded by a swarm of experts who advised, cajoled, and monitored them, at a cost of $10,000/participant/year. I don't live in that world. To say that we now know practically how to prevent diabetic complications is like saying we have solved the solid waste disposal problem of the U.S. since we have hurled a couple of hundred pounds of stuff out of the solar system on a rocket.
We let ourselves be tyrannized by data, by information, and have forgotten wisdom. Good science requires good questions.
Returning to economics for a moment, look at what the pharmaceutical companies have done: They gripe and complain about the FDA, but they are "in bed with" the FDA. Because of the vast sums required to do the kind of science that they do, we get dazzling answers to mediocre questions. They have achieved implicitly a kind of monopoly not only on drugs, but on how we think about illness and health. It is reductionistic and mechanistic. Human elements of meaning and value are not considered. We are led to believe that certain medicines are "valuable" or "important" for health.
Yet, value is not an objective matter. It is subjective. How much could I sell a gallon of water to you for just now? Not much. What if we had been adrift for three days on a life raft in the mid-Atlantic? How much then?
When I spend serious time addressing this kind of information and approach to health and recovery with some of my patients, say, for example, with my patients over age 65, 1 risk legal action from the federal government. I cannot charge for advice that they consider not to be standard medicine. I cannot even not charge without their permission. Talk about a hammerlock on medicine!
Americans focus on their cholesterol and swallow billions of dollars worth of cholesterollowering drugs, in the hope of forestalling or relieving arteriosclerotic diseases. A husband may stay in a job he doesn't like just because it has a health insurance policy for his family. Zocor is expensive. As a Christian, perhaps, he reasons that it is his duty to make this provision. Maybe so. However, if the same husband is not loving his wife as Christ loved the Church, he has his priorities inside out. If he is aggravated by his job and his aggravation spills over at home, he is deceiving himself.
Where is the perspective? Who can provide it if not individuals who know God and who know individuals in need? Seventeen-year-old Latasha Simmons (fake name), unmarried mother of one, takes pills for birth control and also shops carefully at a dietary supplement display. She is deceiving herself. Her health in the long term is immensely more likely to be harmed by fornication than it is to be helped by calcium or beta carotene.
b. Science in medicine has become master instead of servant. We have viewed health and illness as an alien something that leaps upon our backs in the dark and fastens to our flesh. This model of sickness suggests that all that is needed is to peel the monster off of our outside. We can leave what we are inside, in our spirit, alone. Indeed. there is plenty of therapy which fits that model quite well. Yet, illness is more often substantially subjective.
Margaree Tatum agonizes over a blot on her skin in front of your counter. What do you have that will remove the spot? The next person, Holly Spencer, sports a tattoo in the same place. One wants the headache gone, now. Others accept the headache as a part of the job, or a part of the marriage.
c. Science confuses her definitions with explanations or proofs. We define diabetes mellitus, or attention deficit disorder, or alcoholism, or rheumatoid arthritis. It is popular today to define disorders with a Chinese menu method: two from list A and three from list B. Once the label has been placed on the patient, the third parties descend in reaction to the label. They do not know the patient. The patient is merely the jar containing the mayonnaise. The label is everything. The HMO third party wants to judge good quality medical care by seeing if I have obtained a glycosylated hemoglobin on all of my diabetic patients annually, along with one (1) random blood glucose. (!?!) Of what use is it to have Julie Crawford spend $85 getting a glycosylated hemoglobin when she has never taken ownership of her disease? Yodah of Star Wars would say of her, "Exercise she does not, eats she what she wants. Uses her glucometer rarely. Runs out of her Diabeta regularly, she does." Money is a problem with her. Her glycosylated hemoglobin will be high. Why spend $85 to prove its
I suspect you try to help patients make decisions among four medicines, costing a total of 5150, when the patient has only $82.13 to spend. The disease label often--usually--misses the nub of the matter, which is the patient, and the patient's belief system, transportation system, education, sobriety or lack thereof, and family influences, to list only a few. We can fret over such, or we can see the inevitability of it, and therefore the optimism in it. Plan they how they might, provision of medical care including its pharmaceutical aspects, will not fit completely into a corporate box.
The best drug for Latasha Simmons cannot be decided in the offices of an insurance company or a government bureau. just being themselves, fallen human beings in a fallen world, unwittingly, Holly Spencer, Latasha Simmons, Julie Crawford, and others like them are going to bring excessive central planning to its knees. The younger ones here in this meeting, I believe, are going to see it happen. Optimism! God using the humble to bring down the mighty! Be encouraged. God is again using Assyrians to discipline His chosen people and to judge those who are not His.
To summarize, there are scientific reasons to be optimistic. True science has been called "thinking God's thoughts after Him." The principles we discover in science are but manifestations of His wisdom in creation and providence. There are economic reasons to be optimistic. Right economics is but application of good stewardship of what God provides. Finally, in personality and individuality by which God has endowed us, there are reasons to be optimistic. There is an infinite-personal God who deals sovereignly with His finite-personal creatures.
Lest you miss the concepts I have tried to insinuate, I'll review them in bold statements. Now, I didn't actually say all that I am about to review, but if I'd had time, I'd have rambled on until all of the following were covered:
1. God is ruler over all. There is not one square millimeter of the universe of which He does not say, "it is mine." That includes pharmacy and medicine.
2. The ultimate rule of faith and practice is the Bible, not what we Christians think. Everything must be tested by Scripture.
3. Pharmacy, like the rest of medicine, properly centers on the treatment of persons, not diseases, and uses chemicals as its central method.
4. Chemical methods may not be divorced from consideration of the individuality of the persons dispensing and receiving them.
5. Mail order pharmacies are hindered in taking the individual into account.
6. "Objectivity" in the provision of care of persons majors in things that can be easily counted. Ease of counting does not mean that the things counted are the more important things. Technical aspects of care often assume an inappropriate dominance in decision-making.
7. The care of persons requires that responsibility remain where God has placed it. We may come alongside, but we should not try to take over. We are not our brother's keeper, we are our brother's brother. Animals in the zoo have keepers.
8. Health is not objective. It is subjective. Health is not unidimensional; it is multi-dimensional.
9. Health is therefore not a commodity to be traded on a stock exchange like pork bellies or oil barrels.
10. Any system which pretends to deal with health as a commodity is running afoul of God's structure and providence and is destined to fail. Managed care is doomed.
11. The foregoing is good news, not bad news. Watch God work.
12. Basic medical insurance is part of the problem, not part of the solution. There is no right way to do a wrong thing.
13. Human authority is deposited by God into different institutions; is always limited, and He outlines what the limits are in the Bible. This statement was only touched on, not developed, but includes such things as the authority of parents to corporally punish, the limitation of capital punishment to the civil ruler, the establishment of Caesar for justice, the deposition of mercy and charity into the hearts of individuals, into mothers and fathers, and into His Church, and much more.
14. Medical and pharmaceutical authority is informational and advisory only, not coercive.
15. Civil laws which make medical and pharmaceutical authority coercive are improper.
16. All drugs should be available over the counter, if the vendor is willing to sell them. No material thing is evil in itself, nor can material things sin. The sin is in the human being, and our institutions should recognize that location and deal with it there. As example, crack cocaine does not ruin people. Some people ruin themselves, and crack cocaine has proven to be an efficient means for the ruination.
17. As irksome as it is, quackery should be tolerated.
18. The civil ruler has no business defining medical care, nor issuing monopolies in trade, as it presently does for medicine and pharmacy.
19. The present monopolies are destined to fail. They will likely go out with a whimper, not a bang, as more drugs become OTC, as more persons obtain prescribing privileges, and as the underground free market in therapy known as quackery continues to exist. Millions of doses of legend drugs, for example, move across our border with Mexico daily, in full view of the border patrol.
20. Pharmacists should look with interest and favor in reassuming a much larger portion of medical care. You can be cheaper and better at much of it, provided that you do not repeat the mistakes of the physiciancontrolled aspect of medical care.
21. Relatively few pharmaceutical manufacturers have a practical monopoly over what drugs are sold legally.
22. The monopoly of pharmaceutical manufacturers has had the usual bad effects of shortages and high prices, especially the latter, though orphan diseases represent the former.
23. In addition, the pharmaceutical manufacturing monopoly has adversely narrowed the way we think about health and disease, promoting the reductionistic and mechanistic models to the expense of the individual and spiritual aspects.
24. Following the lead of big industry pharmaceuticals, we ask stunningly narrow questions today, to the hindrance of the health of our patients.
25. The FDA and pharmaceutical manufacturers are functionally in cahoots, and the cahoots need to be de-cahooted.
26. Pentoxifylline is not a very useful drug, and its tribe is large.
3. Eisenberg, D.M., et al., "Unconventional Medicine in the United States: Prevalence, Costs, and Pattems of Use," NEJM, 328 (Jan. 28, 1993), pp. 246-283
4. Borzo, Greg, "Pharmacist as Care Provider - Is This the Future?," American Medical News (February 26, 1996), p. 9.
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