Thoughts on rationalism and the rationalist community from a skeptical perspective. The author rejects rationality in the sense that he believes it isn't a logically coherent concept, that the larger rationalism community is insufficiently critical of it's beliefs and that ELIEZER YUDKOWSKY IS NOT THE TRUE CALIF.

Limiting Pharmacist Discretion

Or Pharmacists Aren't Auxiliary Doctors Anymore

I believe it’s time we stopped treating the people who dispense your prescriptions as medical professional. We should revoke the discretion given to pharmacists not to fill facially valid scripts (certainly electronic scripts) unless the computer flags a dangerous drug interaction, the pmp flags doctor shopping or the script seems to clearly contain a mistake1. The involvement of the medication dispenser as more than a glorified clerk and pill counter in filling prescriptions is a holdover from the days when the pharmacist functioned as something of a hybrid between a nurse-practitioner and sole clearinghouse for all a patient’s medications.

None of these roles for a pharmacist make sense anymore. Patients now fill prescriptions at whatever pharmacy is most convenient with no guarantee that any one pharmacy chain let alone pharmacist will process all their prescriptions2. Yes, pharmacists can access your other prescriptions via prescription monitoring programs (PMPs) but so can your doctors making your doctors, with their greater information about you, in a better position to check for dangerous interactions. Any advantage possessed by the pharmacist as a result of their narrow focus on drugs combined with the breadth of the drugs they are familiar with has been undercut by software that can automatically flag potentially dangerous interactions.

While having a second set of eyes glance over the prescription is valuable (especially running software that flags interactions with the other prescriptions listed in the patient’s PMP record) pharmacists aren’t the best way to implement such a system3. However, even if inertia means we keep employing the pharmacist in this capacity that doesn’t justify giving they discretion to refuse to fill valid prescriptions absent some indication of outright physician mistake or dangerous drug interaction unknown to them. Given this kind of discretion to pharmacists offers no benefits I can see and imposes substantial costs.

For instance, this discretion frequently ends up with pharmacists refusing to fill prescriptions explicitly because the patient is uninsured patients (happened to my father just this week) and I suspect it happens for more frequently without being explicitly acknowledged. I’ve also seen just how much more difficult this discretion makes it for acquaintances who look poor or non-white to get their prescriptions filled. Furthermore, while not quite as bad as the situation with Plan B some pharmacists judgmentally decide they disapprove of certain kinds of prescriptions, e.g. opiate maintenance therapy, and make it particularly difficult to get such prescriptions filled. One might think pharmacists might at least need a good reason to refuse to fill a prescription but apparently the law says they can do so for any reason at all.

One might think this kind of discretion is necessary to reduce prescription forgery and attempts to circumvent doctor shopping prohibitions. However, the former problem is quickly being rendered obsolete with electronic prescriptions and even when we are talking about paper prescriptions refusing to fill facially valid prescriptions just sends the prescription forger out looking for a pharmacy that doesn’t care or tacitly accepts the practice to make more money. Refusing to fill the prescription covers that pharmacist’s ass or makes them feel good but doesn’t stop the drug seeking patient from filling their script. Likely, a much bigger dent in prescription forgery and related activities would be made if reputable pharmacies filled facially valid scripts after carefully checking IDs but, when suspicious, reached out to contact that patient’s prescribing physicians.

While the drug addicts will always find some pharmacy which will fill a valid script4 the same can’t be said about patients in genuine need of their medications. Poor working parents don’t have the free time or money to drive all over town trying to get their prescription filled and they don’t have the drug abuser’s contacts letting them know where they should go nor the desperate driving need of the addict.

Horribly, despite the fact that exercising this discretion seems to be primarily a harm it appears that pharmacists can refuse to dispense controlled substances for any reason. Though if the patient is disabled (as many chronic pain patients are) this may create a cause of action.

  1. And if when asked the customer, taken as their word, indicates the doctor knew it was unusual in that way they still have to dispense 
  2. For instance, when I get a prescription from a doctor I usually just fill it at whatever pharmacy is next door to that doctor so I don’t have to call an additional Lyft. 
  3. Have the prescribing physician run the software to flag interactions using the same PMP data the pharmacist would use plus information from the patient’s records. Rather than having pharmacists be the second pair of eyes to look at the prescription require that each prescription also be run past someone with nurse or pharmacist training by the doctor (via an online service if they lack office staff). 
  4. Among addicts there are standard percentages of the prescription given in exchange for lending money to spring it from the pharmacy prescription or driving them around to pharmacies to get it filled) 

A Liberal Case Against Roe v. Wade

Why Roe Skepticism Doesn't Make One A Judicial Extremist

So I think that a right to have an abortion isn’t just a good idea but a vital component of maintaining a modern, egalitarian and free society. It’s important enough to our way of life and makes so much difference in outcomes that it should be enshrined in our constitution with other fundamental principles like free speech or freedom of religion.

Problem is that it wasn’t. Certainly not explicitly. Since I believe that it’s an appropriate function of the US supreme court to expound new legal theories, rights and remedies (as part of the great tradition of common law as the founders intended) in itself this isn’t a problem. The court certainly could have validly developed a theory of personal autonomy which coherently marked the right to receive medical treatment to terminate a pregnancy as protected in much the same way as it has coherently developed the theory of personal autonomy interests in people’s private sexual liaisons (accepting the consequences even when it reaches results like protecting fundamentalist mormon derived polygamy despite the unusual partisan valence).

Unfortunately, the court simply hasn’t done that. If banning medical treatments that would let someone terminate a pregnancy implicates personal autonomy then banning medical treatments that might let save me from dying of cancer must do so to an even greater degree. Yet the court does not recognize a constitutional right to try medication that hasn’t been approved by the FDA even when the approval was denied merely because the FDA judges the harmful side effects too severe or the evidence for efficacy too weak or not yet fully presented. In other words even when the government merely thinks my fully informed (and not mislead into fakery) judgement about what risks to take or harms to endure for a chance at a cure is unwise or ought not to be encouraged this isn’t seen as infringing on my right to personal autonomy. Even though those who want to ban abortive medical services are similarly expressing a value judgement about the relative merits of the consequences of doing so.

Nor is this some narrow exception justified by the compelling governmental need to incentivize efficacy trials or exclude quackery. Even when the government bans use of Marijuana as medicine the court doesn’t require any showing from the government that it’s not denying citizens the personal autonomy to effectively treat their medical condition as it would if it felt that any true constitutional right were implicated. It might not fall on identity based fault lines but surely being forced to lose one’s sight to glaucoma is rather than take an intoxicating medication, if not on par with having carry a child to term1, still an undeniably substantial infringement on personal autonomy. The court isn’t any more sympathetic when individuals seek to assert a constitutional right to drugs like peyote even when, as in Employment Division v. Smith, the individual is seeking access to peyote as part of a deeply felt belief in the religious principles of the Native American Church.

Intuitively, maybe you feel this is all silly. Surely none of this crap is important the way abortion is. How dare I suggest denying some wacky religious use of peyote is comparable to forcing women to carry a child to term. Indeed, I agree with you. These aren’t anywhere near as important and retaining women’s right to choose. But that’s the point. Constitutional protections for abortion don’t flow from any generally applied/developed theory of a right to personal autonomy or anything else. They flow from a value judgement about the importance (and correctness) of protecting a women’s right to choose. Even on a liberal living constitution theory of jurisprudence that’s not kosher. The supreme court is supposed to articulate general theories/conceptions of constitutional rights not weigh in individually on policy judgements simply because they happen to be really important or bad.

Having said all this I still believe that reliance interests favor respecting stare decisis when it comes to Roe. Personally, I actually believe they should respond by actually taking seriously the idea of a right to personal autonomy that is infringed by government restrictions on what medical treatments or drugs one can access. However, there is surely a strong argument that even someone who has a liberal judicial philosophy should react to the strong policy considerations that animated Roe and vote to reverse this outlying opinion.

Now, I don’t expect most people who read this to agree with this last conclusion. However, if you at least found these worries/arguments cogent, serious and requiring a substantive rebuttal you certainly can’t join the howling masses in suggesting that an unwillingness to uphold Roe v. Wade is indicative of a right wing judicial extremists. If you really believe that the Senate should confirm any academically/judicially qualified candidate without disqualifying extremist views then you can’t simply insist that Kavanaugh must be such an extremist because he happens to hold a non-crazy position that you’re convinced is not only really wrong but also really important.

It’s still perfectly reasonable to think that abortion is important enough that the Senate shouldn’t confirm anyone who will vote to overturn Roe. I hold such a position myself. But let’s not confuse that straightforward disagreement with the claim that somehow the conservatives have violated a norm of judicial non-extremism. Just admit that some principles can be important enough to vote against nominees who don’t support them no matter how reasonable or even mainstream (relative to the political landscape) their views are.

  1. Note that even if it turns out no one actually is faced with that choice, e.g., the commercial drugs now manage equal effect, the point is that the court obviously wouldn’t even require the government to demonstrate such a point to uphold the restriction of Marijuana. 

Don’t Make Drug Companies Police Usage

Is this a ridiculous amount of opiates for a single small town to prescribe. Sure thing. But I find the idea that drug companies being held to task for this, and thus implicitly the idea that they should have done something to supply fewer pills to these pharmacies deeply troubling.

I mean how would that work out? The drug companies are (rightly) legally barred from seeing patient records and deciding who does and doesn’t deserve prescriptions so all they could do is cut off the receiving pharmacies. Ok, so they could put pressure on the pharmacies to fill less prescriptions but the pharmacies also don’t have patient records so what that means is the pharmacies scrutinize you to see if you ‘look’ like someone who is abusing the prescription or a ‘real’ patient. So basically being a minority or otherwise not looking like what the pharmacist expects a real pain patient to look like means you can’t get your medicine. Worse, the people scamming pills will be willing to use whatever tricks are necessary (faking pain, shaving their head whatever) to elicit scripts so it’s the legitimate users who are most likely to end up out in the cold.

While I also have reservations about the DEA intimidating doctors into not prescribing needed medicine it is the government (who, I understand, is informed about the number of opiates being sold by various pharmacies) who should be investigating cases like this not the drug maker. Personally I think the solution isn’t and never has been controlling the supply but always about providing sufficient resources like methadone and bupenorphine maintenance so people who find themselves hooked can live normal lives.

Drug companies submerged WV in opioids: One town of 3,000 got 21 million pills

Drug companies hosed tiny towns in West Virginia with a deluge of addictive and deadly opioid pills over the last decade, according to an ongoing investigation by the House Energy and Commerce Committee. For instance, drug companies collectively poured 20.8 million hydrocodone and oxycodone pills into the small city of Williamson, West Virginia, between 2006 and 2016, according to a set of letters the committee released Tuesday.