Ezekiel Emanuel proposes a “simple way to reduce suicides” that would cause previously normal people to give suicide serious consideration.
In a New York Times Opinionator column, Emanuel compares the number of suicides and unintentional deaths by poisoning and, inexplicably, compares them to fatalities from motor vehicle crashes. He says a million Americans attempt suicide each year and 38,000 succeed, half by firearms and another 20% by poisoning. He proposes to reduce these numbers by making pharmaceutical packaging more difficult to open.
There is a simple way to make medication less accessible for those who would deliberately or accidentally overdose — and that is packaging.
We need to make it harder to buy pills in bottles of 50 or 100 that can be easily dumped out and swallowed. We should not be selling big bottles of Tylenol and other drugs that are typically implicated in overdoses, like prescription painkillers and Valium-type drugs, called benzodiazepines. Pills should be packaged in blister packs of 16 or 25. Anyone who wanted 50 would have to buy numerous blister packages and sit down and push out the pills one by one. Turns out you really, really have to want to commit suicide to push out 50 pills. And most people are not that committed.
Actually, yes, it does. The reason is Emanuel accounts for only the benefit of burdensome packaging but ignores all of the costs. These costs take several forms, including:
- Higher production cost for pharmaceuticals, thus raising prices
- Reduced accessibility, most notably to those least able to accommodate
Emanuel is remarkably uninterested in these costs, and apparently has no sympathy for those who bear them.That includes the poor, on whom higher prices would take a disproportionate tool. It also includes those with arthritis, who already struggle to open conventional pharmaceutical packages. “[B]lister packaging would cost more compared with loose pills in a bottle,” he says, and “people with arthritis … might find it challenging to open the packages.” But these costs do not matter:
[C]onsidering the tens of thousands of deaths and emergency room visits, these reasons seem a bit feeble. The packaging should be changed.
As it happens, we have been down this path at least once before. In his book-length essay Rational Risk Policy, Vanderbilt economist Kip Viscusi recounts what happened when the federal government used regulation to reduce unintended poisonings:
Child poisonings from household consumer products were a leading cause of injury ad death among preschool children. As a result, the government mandated a variety of safety cap requirements on hazardous products.
…After the introduction of safety caps in the United States, the percentage of aspirin sold with safety caps was just over 50 percent. Poisonings from safety cap bottles was substantial, rising from 40 percent in 1972 to 73 percent in 1978. Much of the reason for these poisonings is that parents left the caps off the bottles altogether. The share of poisonings from open bottles rose from 41 percent in 1972 to 49 percent in 1978. Problems also arose from apparent misperception of the efficacy of the caps. Because safety caps were often referred to even by prominent Consumer Product Safety Commission officials as being “childproof” caps, parents may have been lulled into a false sense of security, As a result, after the advent of safety caps, there was a rash of poisonings from similar products that at the time did not have caps.
The incidence of poisoning from analgesics did decrease after the CPSC mandated safety caps, but it did not decline as much as had been expected. The regulators ignored very predictable behavioral responses among the4 very people who were supposed to benefit.
Emanuel’s proposal is different in important respects. In particular, the benefits he hopes to obtain by mandating burdensome packaging would accrue to those who intend to kill themselves, and those who negligently overdose without such intent. Everyone would pay higher prices for medicine, and this implicit tax on medicine would be regressive. The costs borne by arthritis sufferers would be hard to quantify.
One such cost could be under-medication. This has been reported as an unintended consequence of federal regulations restricting the sale of pseudoephedrine (Sudafed ®), which led to product reformulation and substitution in order to escape regulatory burdens. Unfortunately, substitute decongestants are notably less effective. How many avoidable ear infections have occurred because of this?