Chapter 28

I defend a broadly libertarian approach to medicine (Flanigan 2017). The main idea is that people’s bodily rights extend beyond the mere right to refuse medical treatment and also include the right to choose and access medical treatment. I develop this argument in section 1 from the perspective of the patient. There, I argue that the same considerations that favor the doctrine of informed consent also support patients’ rights of self-medication, which include the rights to access and use pharmaceuticals without a prescription or approval. I argue that self-medication ought to be understood as a civil rights issue and that patients are justified in resisting unjust drug policies and advocating for reform. More generally, some of the arguments against medical paternalism also challenge other paternalistic public health policies, such as soda bans and antismoking policies.

I address the ethics of pharmaceutical regulation, manufacturing, and distribution Section 2, where I consider the perspectives of other institutional actors. I argue that policies that prevent patients from accessing potentially lifesaving or beneficial treatment are unjust laws that kill people, whereas drug manufacturers do not unjustly kill patients by selling dangerous drugs as long as they disclose all known risks. Manufacturers are therefore morally entitled to market drugs to patients, and officials should not censor pharmaceutical advertising. And though patients have rights of self-medication, physicians and providers are not required to facilitate patients’ risky treatment decisions. Legal barriers to treatment, including occupational licensing policies, are unjust, but officials also should not enforce legal requirements to provide treatment. I then consider whether the fact that taxpayers provide citizens with health care can justify limiting people’s rights to make risky or unhealthy choices. In response, I argue that people are not liable to be preemptively coerced into making healthy decisions even if taxpayers will predictably be required to pay for their unhealthy choices.

1PATIENTS’ RIGHTS

All liberals, including libertarians and classical liberals, believe that there are some foundational decisions that all people are entitled to make for themselves. These include intimate and personal bodily choices, decisions about intimate associations, decisions about religion, and occupational choices. Though the scope of these rights is a matter of considerable debate, most liberals agree that people at least have rights to make medical decisions about their bodies. In this section, I argue that the same reasons in favor of the doctrine of informed consent, which protects adult patients from unwanted medical interventions, are also reasons in favor of rights of self-medication (Flanigan 2012).

The doctrine of informed consent protects competent patients’ rights to make informed medical decisions without being unjustly forced or coerced.1 The doctrine thus has three components. It only applies to people who are capable of understanding and autonomously making a medical choice, so it does not apply to children or mentally incapacitated people. The doctrine requires that patients be informed about the risks and benefits of a treatment choice as well as alternative treatment options, to the level that a reasonable person could expect to be informed. And the doctrine prohibits force and coercion by physicians and also by third parties. According to this principle, which is reflected in the law, patients are entitled to refuse medical treatment even if refusing would endanger their health. Patients are even entitled to refuse life-saving treatments.

Three arguments are commonly cited in favor of the doctrine of informed consent. The first reason is that by respecting patient’s rights to make medical decisions physicians can promote better health outcomes in the long run. Patients are more likely to seek care and comply with physicians’ recommendations if they can reasonably trust their physicians to refrain from coercing or deceiving them. A second consequentialist reason focuses on the epistemic asymmetries between patients and medical experts. Though physicians may be experts about whether a treatment will make their patients healthier, patients know whether treatments will improve their lives on balance. Third, there are rights-based justifications for the doctrine of informed consent that do not appeal to the good effects of informing patients and refraining from coercion. Namely, when physicians force, coerce, or deceive patients, they violate patients’ rights to make intimate and personal bodily choices.

These three arguments also support rights of self-medication, though unlike informed consent, patients’ rights of self-medication are not generally respected or legally protected. Rights of self-medication include the rights to purchase and use medicine without being coerced or deceived. Yet public officials in most jurisdictions coercively prevent patients from using many drugs, including unapproved drugs, prescription drugs, recreational drugs, and deadly drugs. I argue that this asymmetry is unjustified and that patients’ medical autonomy merits the same respect within the marketplace and at the pharmacy as it merits in clinical contexts. Specifically, like the doctrine of informed consent, there is some evidence that rights of self-medication could promote good medical outcomes, that they will promote people’s wellbeing on balance, and that policies that respect people’s rights of self-medication respect people’s rights to make decisions about their bodies. For these reasons, though public officials may certify drugs in order to promote informed decision-making, they should not enforce laws that prevent people from using drugs.

Policies that prevent people from purchasing and using unapproved pharmaceuticals are generally justified on the grounds that they protect patients’ from dangerous or unhealthy drugs. Historically, restrictions on rights of self-medication followed drug disasters where patients were killed because they unknowingly used dangerous or adulterated medicines (Carpenter 2014). These policies went beyond mere informational requirements and protections from fraudulent claims, however. Today, most countries require manufacturers to obtain premarket approval before they sell a drug and require prescriptions for the use of a drug.

Do these policies promote people’s health on balance? There is some evidence to suggest that they do not. Obtaining approval to sell a drug generally takes more than 10 years and can cost as much as $2 billion.2 During this time, patients die while waiting for potentially beneficial therapies to be approved. This is known as drug lag. One may claim that this lengthy approval process is justified because it protects patients from using unsafe or ineffective drugs. Most of the approval process is spent determining whether a drug is effective at treating a specific condition for a specific patient type. Yet once approved, a drug may be prescribed off-label for any condition. That efficacy testing is not required for off-label prescribing suggests that the lengthy efficacy testing should not be required for drug approval (Klein & Tabarrok 2008).

In addition to drug lag, the costly and lengthy approval process also deters pharmaceutical innovation and makes drugs more expensive. Though it is difficult to identify the victims of the approval process who die of their diseases while waiting for access to potentially beneficial drugs, it is even more difficult to know how many lives could have been saved if the cost of innovation were lower. Economist Frank Lichtenberg finds that pharmaceuticals significantly increased life expectancy and lifetime income in the late twentieth century in the United States (Lichtenberg 1998). For this reason, pharmaceutical innovation has the potential to increase longevity in the twenty-first century as well; Lichtenberg predicts that drug innovation accounts for almost three-fourths of the gains in life expectancy from 2000 to 2009 (Lichtenberg 2014). These findings should give pause to proponents of lengthy and expensive approval requirements that potentially deter innovation.³

Additionally, policies that prohibit people from using drugs without a prescription and prohibitions of recreational drugs may also have worse health effects than a nonprohibitive approach. There is some evidence to suggest that prescription requirements are correlated with higher rates of accidental poisoning, for example (Peltzman 1987b; Peltzman 1987a). It is also not clear that policies that prohibit people from using certain prohibited drugs have good medical outcomes. For example, drug prohibitions prevent patients from using medical marijuana in some jurisdictions. The legal prohibition and criminalization of recreational drugs create black markets for dangerous, adulterated, and untested drugs and cause higher rates of disease transmission associated with using unclean needles. Criminal penalties for drug use may also prevent addicts from seeking treatment. For these reasons, the World Health Organization calls for the decriminalization of personal drug use (The Economist 2014).

The second justification for the doctrine of informed consent is that it promotes people’s overall wellbeing (Buchanan 1978). Here again, the same argument also supports rights of self-medication. Consider premarket approval policies, which prevent people from using investigational therapies on the grounds that, in light of evidence of efficacy, the risks associated with a drug may not justify the benefits. Whether a drug is acceptably risky in light of the benefits is a normative judgment not a scientific one. Public officials at agencies such as the US Food and Drug Administration are not well placed to determine whether, in the context of a person’s overall system of values, it is acceptably risky for her to take a potentially beneficial but potentially harmful or ineffective drug. Scientific experts are well placed to determine the likely effects of a drug, but each patient is the expert about whether it is worth it.

The same argument applies to rights of self-medication more generally. Patients require a prescription to use some drugs, meaning that physicians are legally empowered to act as gatekeepers and to prevent patients from using drugs if they determine that the risks do not outweigh the benefits. But patients are more qualified to determine whether the risks of drug use outweigh the benefits given their lives and values as a whole. Consider, for example, an adult patient who wishes to use a stimulant in order to better perform cognitive tasks related to her job. Prescription requirements may prevent her from legally accessing the drug if her physician determines that she does not have a medical condition that merits using a drug that has the health risks associated with stimulants. But she may not value avoiding the health risks of stimulants as much as she values professional success. If the purpose of medicine should be to improve people’s lives overall and to treat the whole patient, not specific conditions, then prescription requirements are detrimental to this end because they empower physicians to prioritize health considerations over patient’s values and to prevent people from acting in what they consider to be their overall interest.

In some cases, self-medication may not have good medical or overall consequences. Yet the doctrine of informed consent protects patient’s rights to make medical decisions even if their choices are not in their medical or overall interest. For example, patients are entitled to refuse life-saving treatment or to refrain from taking daily medication that could prevent an early death. Similarly, even if rights of self-medication did not promote people’s medical or overall interests as a general matter, public officials are nevertheless not morally entitled to prevent people from using unapproved pharmaceuticals because these policies violate people’s bodily rights or rights to attempt to preserve their lives (Volokh 2007).

Liberal and libertarian arguments in favor of the right to die illustrate this point. For example, John Rawls, T. M. Scanlon, Thomas Nagel, Ronald Dworkin, Robert Nozick, and Judith Thomson jointly published “The Philosophers’ Brief” in 1997 as an amicus curiae brief for two Supreme Court cases that addressed whether patients had a constitutional right to die. They argued that a person’s interest in making end-of-life decisions “is so central a part of the more general right to make ‘intimate and personal choices’ for himself that a failure to protect that particular interest would undermine the general right altogether” (Dworkin et al. 1997). They argued that the same considerations protecting rights to refuse life-saving treatment also supported rights to access voluntary euthanasia or physician-assisted suicide.

And just as officials violate important rights by prohibiting patients from making deadly choices at the end of their lives, they also violate people’s rights to make bodily decisions when they prohibit them from making unhealthy or dangerous medical choices throughout their lives. In this way, policies that limit patient’s rights of self-medication are coercive. Officials enforce legal penalties against those who fail to comply with restrictions on self-medication. In this way, people are coercively prevented from making intimate and personal bodily decisions and medical choices. Officials can also violate patient’s rights of self-medication even if patients do not face legal penalties for their medical choices. Consider, for example, an analogy to reproductive choice. Officials violate women’s rights to make reproductive choices if they prohibit health workers from providing contraception or abortion. This example illustrates that officials can effectively use coercion to limit a person’s medical autonomy without subjecting her to criminal sanction.

One may object that rights of self-medication are different from rights of informed consent because the right to refuse treatment does not entail a right to access anything. Yet informed consent requirements do entail a right to access information—it is wrong and illegal to paternalistically withhold medical information, for example. And rights of self-medication, like rights of informed consent, are best understood as rights against interference. Just as it is wrong for physicians to interfere with a patient’s medical choices on the grounds that they disagree with her choice, it is also wrong for public officials to interfere with medical choices that involve pharmaceuticals on the grounds that using pharmaceuticals is unacceptably risky or unhealthy.

Other libertarians and liberals have endorsed rights of self-medication as well. For example, in On Liberty, J. S. Mill opposed prescription requirements on the grounds that it would make legitimate use more expensive or impossible, when labeling requirements could effectively warn people about dangerous drugs instead (Mill 2008, 107). More recently, Michael Huemer also criticizes prescription requirements on the grounds that they are a form of rent-seeking and that public officials do not have the authority to enforce them (Huemer 2012, 141). Historically, rights of self-medication were once affirmed within the United States. Thomas Jefferson wrote in Notes on the State of Virginia that rights of self-medication were as fundamental as freedom of conscience (Jefferson 1787). In the nineteenth century, rights of self-medication were widely acknowledged in the United States, and the earliest pharmaceutical regulations specifically stated that they were not intended to limit citizen’s rights of self-medication (Carpenter 2014).

Patients and their advocates have also advocated for rights of self-medication throughout the history of drug regulation. In addition to political advocacy for the right to die, two other examples of patient-driven advocacy merit discussion in the context of libertarianism. First, patients and their advocates publically advocated for faster access to investigational therapies throughout the twentieth century. For example, the National Cancer Institute (NCI) clashed publically with the US Food and Drug Administration (FDA) in the 1970s, claiming that the agency publically undermined potentially lifesaving research by enforcing burdensome approval requirements (Carpenter 2010). Then, in 1988, the HIV/AIDS advocacy organization AIDS Coalition to Unleash Power (ACT UP) staged large protests to encourage the FDA to expedite approval for HIV/AIDS medications. These efforts continue to day in the form of a grassroots “right to try” movement, which has been instrumental to the passage of legislation that allows physicians and manufacturers to provide patients with access to investigational drugs outside the context of a clinical trial in more than 20 US states (Olsen 2015).

In addition to political advocacy, some patient advocates take drug development and access into their own hands.4 Patient-driven drug development is often driven by members of online communities who share research about promising new therapies and use technology to participate in medical research as collaborators rather than exclusively as human subjects (deBronkart 2013; Topol 2015; Marcus 2014). And in some circumstances, patients and their advocates also engage in civil disobedience to facilitate greater access to therapeutic drugs, such as medical marijuana (Galloway 2016). Many libertarians argue that citizens do not have duties to obey laws that violate people’s rights, and if so, disobedience in these circumstances is warranted.5

If citizens have rights of self-medication, as I have argued, then many policies that are currently enforced violate these rights. Instead of prohibiting people from accessing unapproved drugs, recreational drugs, and prescription-grade pharmaceuticals, public officials could achieve the same goal by informing people about their choices through a certification system. After all, if the main benefit of existing policies is that they prevent people from unknowingly making unsafe choices about drugs, officials could still provide people with this benefit by educating patients about a drug’s likely effects.

The same logic extends to other medical choices as well. Patients are entitled to choose medical procedures and to use medical devices that endanger their health just as they are entitled to refuse dialysis or to modify their bodies in ways that make a healthy lifestyle more difficult. More generally, some of the foregoing arguments for rights of self-medication are also arguments against other public health interventions such as smoking and soda bans. If people are entitled to make decisions about their own bodies, or if people generally know whether a choice is in their overall interest better than public officials do, then people should also be entitled to make choices that threaten their health for the sake of other values.

2PUBLIC OFFICIALS AND SELF-MEDICATION

If patients have rights of self-medication, then public officials, manufacturers, physicians, and pharmacists should reconsider their current practices. In this section, I argue that officials should not prohibit people from purchasing and using drugs, nor should they prevent manufacturers from marketing pharmaceuticals to consumers, even for off-label uses. In order to protect consumers, officials should instead enforce policies that protect consumers from fraudulent advertising and adulterated drug use through the system of tort law. These arguments extend to medicine as well. Officials should not require occupational licenses for health services, but they ought to enable patients to seek damages for medical injuries associated with malpractice or fraudulent medical services. In closing, I address whether libertarians should support public officials’ enforcement of intellectual property laws.

In order to respect people’s rights of self-medication, public officials should not enforce policies that prevent people from purchasing and using pharmaceuticals and recreational drugs. This is challenging in democracies, however, because public officials and regulators have political incentives to be extremely cautious when allowing drugs. Libertarians, most notably Jason Brennan and Bryan Caplan, have documented the ways in which voters’ biases can influence policy (Caplan 2008; Brennan 2016). With respect to pharmaceuticals, voters are biased in favor of excessive caution because drug-related injuries are more publicly visible and emotionally salient to them. When using dangerous drugs, such as Elixir Sulfidimide, Thalidomide, Vioxx, or opioids, voters encourage public officials to appoint and empower regulators to prevent drug disasters going forward (Carpenter 2010). Officials and voters do not see the people who are harmed by prohibitive approval or prescription policies except in rare circumstances, such as in the 1990s, when US officials passed legislation to expedite drug approval in light of patient advocacy movements such as ACT UP (Carpenter 2010). For this reason, elected officials have incentives to support regulations aimed at avoiding drug disasters, and regulators, whose funding and legal authority depends on legislative mandates, have incentives to be very cautious when determining which drugs may be sold to consumers.

Nonconsequentialists often emphasize that there is a sharp moral distinction between killing and letting die. Killing is morally worse than letting die because killing violates people’s negative rights against interference or a principle of nonaggression, and it is often a known effect of one’s action (Quinn 1989). To the public, it may appear that drug manufacturers kill people by selling dangerous drugs, whereas public officials merely allow people to die from their diseases. But the opposite moral characterization of drug regulations is apt. When officials enforce prohibitive regulations that prevent patients from accessing experimental drugs, and patients who could have been helped die from their diseases, these patients were killed by pharmaceutical regulators because regulators violated patients’ negative rights against interference by preventing them from accessing potentially beneficial drugs. Moreover, regulators know that delaying drug approval can cause patients’ deaths. In contrast, when manufacturers disclose the risks of an investigational drug, as long as patients consent to use it, manufacturers do not kill patients by selling them drugs because they do not violate patients’ negative rights.

As an alternative to the current regulatory framework, officials should instead consider tort law as a way of ensuring that drug manufacturers comply with their negative duties to refrain from harming or deceiving consumers (Solomon 2009). Torts can serve the same functions as premarket regulations and prescription requirements, but they avoid some of the dangers of regulatory capture, such as the harmful effects of drug lag and drug loss. Tort law is not a perfect solution because judges are influenced by politics too. But torts would not violate patients’ negative rights of self-medication either. Richard Epstein defends a similar approach to medical malpractice as well, arguing that a contractual model of medical liability would enable access to risky medical procedures for patients who waive their right to hold a physician accountable for adverse effects (Epstein 1976).

In addition to changes to medical liability, the principles of patient empowerment that I and other libertarians defend would call for physicians and pharmacists to rethink their role. Currently, physicians and pharmacists advise patients about their medical options and are also legally empowered to act as gatekeepers who control patients’ access to drugs. Rights of self-medication in no way threaten a physician’s or pharmacist’s epistemic authority on matters related to medicine, but such rights are incompatible with the gatekeeping role these health workers play. If public officials respected patient’s rights of self-medication though, patients’ relationships with their physicians needn’t change. People who value their health would still do well to consult with medical experts about their options.

And while physicians and pharmacists should not be empowered to prevent patients from accessing pharmaceuticals, a more liberal or libertarian approach to medicine may also empower health workers in other ways. For example, by emphasizing the importance of freedom of conscience, this approach would also support health workers’ rights to refuse to provide treatments that violated their moral commitments (Wicclair 2011). And libertarians dating to Milton Friedman generally oppose occupational licensing requirements that authorize professional guilds to determine who can legally practice medicine. In the absence of occupational licensing requirements, professional associations would still be permitted to certify health workers, but different kinds of health workers would be able to specialize or develop new models of patient care (Svorny 2004).

As with pharmaceuticals, a certification system for health workers could achieve many of the goals of a prohibitive system of licensing while also enabling patients for whom the licensing system is inadequate to choose alternative forms of health care. If patients are happy with the current system, they can follow the recommendations of certifying agencies and private “knower organizations” that provide information about the quality of a product or provider (Klein 2001). Critics of markets may worry that such an approach, which makes medical exchanges more like other commercial exchanges, could change the meaning of medical relationships (Hartzband & Groopman 2012). Libertarians generally respond that such a change in meaning is not sufficient grounds for prohibiting a market (Brennan & Jaworski 2015). These arguments extend to medical contexts as well (Taylor 2005). Even if a more consumer-oriented or market-friendly approach to medicine did change some patients’ relationships with health workers, those who valued the current system would not be prohibited from seeking medical advice or complying with the agency’s recommendations, while those who are harmed by the current system would have more options.

If patients have rights of self-medication, then public officials should also reconsider existing restrictions of commercial speech. Most countries currently prohibit direct-to-consumer pharmaceutical marketing, and even in the United States, where direct-to-consumer marketing is legal under certain conditions, manufacturers are not legally permitted to advertise drugs for off-label uses, even if they only communicate truthful information. As Eugene Volokh argues, speech restrictions are not only wrong because they prevent speakers from communicating their ideas, they are also wrong because they prevent people from hearing new ideas, and commercial speech restrictions are incompatible with this “listener-based” justification for freedom of speech. For this reason, marketing restrictions that prohibit manufacturers from communicating truthful information to consumers not only violate manufacturers’ freedom of speech, they also prevent patients from exercising their rights to make informed medical decisions.

Do the foregoing arguments require that public officials always refrain from interfering with voluntary exchanges between providers and patients or between manufacturers and consumers? If so, then should officials enforce patents that prevent generic drug manufacturers from selling to consumers? Whether officials should limit manufacturers’ intellectual property rights in order to facilitate greater access to drugs is a difficult question, and the answer will depend on the moral significance of consequences and whether people have intellectual property rights.

On one hand, libertarians may argue that manufacturers have natural rights to their intellectual property that officials have duties to protect for at least some period of time, for example, by an appeal to Lockean arguments for property rights (Cwik 2013). If manufacturers have enforceable intellectual property rights, then just as libertarians support systems of governance that protect citizens’ physical property, a system of intellectual property could be justified on similar grounds. But other libertarians are skeptical that officials do have the authority to enforce intellectual property rights and would therefore challenge whether officials and manufacturers are entitled to prohibit people from manufacturing generic drugs (Chartier 2011; Kinsella 2013).

Alternatively, libertarians may focus on the good consequences of a patent system for drugs in justifying it. One of the main reasons to reform prohibitive approval requirements is to avoid drug loss, since policies that deter pharmaceutical innovation cause a great deal of economic harm and loss of life. Patents may empower manufacturers to charge high prices for drugs, but efforts to reduce drug prices by limiting or eliminating patents would likely do more harm than good. As Frank Lichtenberg writes, “a 10 percent decline in drug prices would … be likely to cause at least a 5–6 percent decline in pharmaceutical innovation” (Lichtenberg 2006). Since patents preserve manufacturers’ incentives to create innovative lifesaving therapies that substantially promote longevity and income, calls to reconsider the patent system are morally risky. As an alternative to patents, some bioethicists propose publically or privately financed prizes to encourage pharmaceutical innovation for rare diseases (Buchanan et al. 2011; Hassoun 2012). A prize system could work alongside a patent system or, if patents are not morally defensible, it might be a promising alternative to patents.

Liberal egalitarians and libertarians may endorse many of the foregoing arguments in favor of rights of self-medication. For example, many liberal egalitarians reject paternalistic policies on the grounds that when officials enforce paternalistic policies, they also express offensive and condescending judgments toward citizens, insinuating that people are incapable of deciding for themselves (Shiffrin 2000). Yet some liberal egalitarians may nevertheless object to the antipaternalistic policies I defend on the grounds that when citizens make choices, they impose costs on their fellow citizens and undermine the fiscal or political sustainability of a welfare state that provides citizens with health care or health insurance. In contrast, a more libertarian approach to health care would not support the public provision of health care or health insurance, and so proponents of this approach should therefore not object to rights of self-medication on these grounds (Cochrane 2013). After all, if people do not have rights to publically funded health care, then even if states provided people with health care, then taxpayers cannot claim that the beneficiaries of their representatives’ beneficence harmed them by accepting it.

But for the sake of argument, assume that all citizens do have rights to publically provided health care or health insurance (Daniels 2013). Liberal egalitarians tend to agree with this assumption, unlike many libertarians. If so, then seemingly paternalistic policies may be justified without an appeal to paternalism but rather on the grounds that citizens’ harmful and unhealthy choices make the public provision of health care or health insurance more expensive and thereby harm taxpayers. It may then seem that public officials could permissibly limit people’s rights of self-medication on the grounds that risky medical choices were potentially harmful to their fellow citizens.

Even if it were permissible to compel people to pay taxes in order to provide to health-care insurance for all, though, it still wouldn’t follow that other forms of coercion were permissible for the sake of minimizing the cost to taxpayers (Flanigan 2015). For example, some people’s decision to refuse to use statins causes a greater number of heart attacks, which imposes fiscal burdens on the public health-care system. Nevertheless, public officials are not permitted not compel people to take statins against their will. Similarly, if people have enforceable rights to publically funded health care, such rights would not justify paternalistic restrictions on people’s other rights for two reasons. First, if citizens could waive their rights to health care, then a person could reasonably trade her claim to public health insurance in exchange for the right to use unlicensed health-care providers or unauthorized drugs. Or, if rights to health care cannot be waived, then people would not make themselves preemptively liable to be interfered with on the grounds that their unhealthy choices make it more expensive for taxpayers and officials to subsequently provide them with health care, just as people do not waive their rights to publish unpopular commentaries or walk through dangerous neighborhoods even if, by exercising these rights, they make it more expensive for public officials to ensure their safety.

3CONCLUSION

The case in favor of rights of self-medication has more general implications for moral assessments of public policy. It highlights the ways in which public officials often appeal to moral justifications for interfering with intimate and personal choices, such as paternalism, which would not justify coercive interference in private contexts (Flanigan 2013). Arguments for self-medication also call our attention to the unseen victims of prohibitive policies, such as patients who die waiting for drugs to be approved and those who suffer as a result of regulations that deter innovation. Finally, these arguments show that policies that respect people’s rights are not necessarily incompatible with policies and institutions that aim to promote people’s wellbeing. A more libertarian approach to medicine could preserve many of the benefits of the current system through certification programs that help patients stay informed while also respecting each patient’s medical autonomy.