The Proximal Tubule

• Prescription only regulation restrict liberty by mandating that consumers seek the guidance and permission of physicians for pharmaceuticals.
• The regulation is legally unique in that it gives some citizens authoritative powers over others. Also the current state of affairs is contradictory to the stated intentions of those who passed the regulation.
• Because of this, those who want to restrict this freedom carry the burden of proof that this is necessary and beneficial.
• People assume that it is true that this regulation is beneficial, but I was wanting to step back and examine the arguments and evidence.
• Economically, this regulation definitely raises the cost of the drugs. This really can't be seriously disputed.
• Medically, what littel evidence of study that exists claims that it is not beneficial in general, and is just as likely to harm patients has to help them.
• Thus, I conclude that the burden of proof has not been met, and the health care system has to answer for this.

There are some drugs, like prescription allergy medication, and ulcer medication which are fairly harmless and don't really need monitoring or the help of a doctor to decide whether or not they're needed. But there are others - heart medications, cancer drugs, blood pressure drugs, etc. that either need the expertise of a physician to make the correct diagnosis for their appropriate use or that need to monitored closely for potential side effects. Even drugs as seemingly benign as blood pressure drugs need to be monitored periodically to make sure they aren't having adverse effects on the kidneys or, in some cases, the heart or the balance of the body's electrolytes. That isn't being paternalistic, just responsible.

If you have congestive heart failure, I have a complex drug regimen to prescribe. Adjusting these medications requires repeated visits. I must understand the side-effects of each medicine, alone and in combination. I must consider your renal function, and your electrolytes. Finally, I must prescribe the medications with an understanding of your other medical problems (and few patients have CHF alone).

Tamoxifen: This is a medication that has a wide variety of side effects such as thromboembolism, endometrial cancer, and cataracts. One use of Tamoxifen is the prevention of breast cancer in selected high-risk women. A woman who was not at high risk may have such a fear of cancer that she may take the medication if offered over the counter, needlessly exposing herself to risks.

Coumadin: A medicine that is hard even for experienced physicians to manage. The therapeutic range is narrow and can be affected my so many variables (diet, other drugs) . A patient may be going on a plane trip and wants to avoid "economy class syndrome" and takes some OTC Coumadin. Suppose this patient has protein C or S deficiency?

Thyroid hormone: With the recent ban on ephedra, patients could achieve the same results with OTC Synthroid.

Both of these responses seem to me to miss the point. Sure, one should generally have a professional diagnose one's medical problems and control one's drugs. But one would also probably be better off if one let a professional work on your car transmission, do your taxes, o, to draw an example closer to my heart, hiring a professional to design your computer security system rather than trying to do it oneself. Certainly 99% of the time the professional would do a better job, but only the customer can decide whether that justifies the inconvenience and expense of seeking a professional.

What's paternalistic is that in the medical field--as opposed to computer security or auto repair, the professionals have managed to lobby to make it illegal for people to serve themselves. There are lots of fields that are so complicated that one could argue that consumers would be better off to hire a professional--in fact this is the standard argument that guilds have used to justify legislated monopolies for centuries. Neither DB nor Medpundit seems to me to have made a particularly good argument for why they should be able to use the force of law to maintain that monopoly.

You operate from the assumption that general wellfare would be harmed by removing these regulations. Well, I just stepped back from that assumption and tried to look and see if it were really true. There is not much evidence out there, but all there is says that that assumption is false. Think of it like EBM for medical policy. I liken it (though loosely) to the history of antiarrhythmic therapy. People assumed it was true that these drugs saved lives and so they used them. When they actually looked at the evidence, they found they were actually killing patients. Well, here we're working from the assumption that this regulation saves lives. But I've shown some evidence that it might actually be neutral or harmful. So the question is are you ready to examine this further and see what the evidence says, or do you want to just keep working on assumptions?

One day in 1984 (I think it was) ibuprofen became legal to sell OTC. The day before, it wasn't. Now what changed on that day? Did ibuprofen become a different drug? Did the fundamental laws that rule the universe change? No. It was a buraeucratic decision just as it was a bureaucratic decision to make it prescription-only. Now, one of those polar opposites decisions was wrong. And once you realize that, you realize they may be wrong about others. So, do you want to require prescriptions for ibuprofen, or do you want to sell others OTC. To have the same answer for both questions is most likely inconsistent. And do people claim that none of the drugs currently taken by prescription-only might need to be OTC? Or are people willing to accept that maybe we're wrong about some of them?

The practical consequences of removing the physician as gatekeeper to medications might be, in the short term, disastrous. The reason is that the current regulatory regime has induced a widespread belief among the public that OTC medications are, by and large, safe. Libertarians might not like this, but it's a fact, and a fact that extends to virtually the entire consumer market. Caveat emptor died two or three generations ago. Any changes in the law ought to be (as usual) done with a lot of forewarning.

You are right here to the extent that in any deregulation that is on balance a good thing, the costs are usually payed up front and the benefits accrue later. These are the ugly transaction costs, of course. But here's the thing - transaction costs are a finite value, where as benefits (like the ones I describe in this debate) occur every year into infintiy (or until the US collapses or the sun implodes - whichever happens first). I think we can safely assume the present value of those benefits are greater than the transaction costs. Thus, generally, I find transition costs arguments, while to be taken into account when formulating the transition, are not persuasive when arguing the merits of the transition when it in total is beneficial. So how do we do it? I don't know, but peolpe with some imagination could probably figure a way. Maybe switching drugs slowly so patients get used to the liberty and the responsibilty that comes with it.

• Part I: Introduction

Prior to 1938, consumers could buy any non-narcotic drug without first obtaining a doctor's prescription. Consumers often obtained prescriptions or at least sought the advice of physicians before self-medicating, but were under no legal compulsion to do so.¹

• The most obvious is safety. This, of course, is the proposed justification for most legislation, especially in the realm of health care. The assumption is that unknowing consumers must be protected from harmful drugs that, if taken without physician guidance and permission, would lead to adverse outcomes.
  
• In addition, with the war on drugs that is currently being waged, nobody would dare suggest that certain classes of prescription drugs should be available over the counter. Benzodiazepines, narcotics, barbiturates, etc. would be cheaper to obtain and would have much greater potential for abuse.
  
• With antibiotic resistance becoming a greater problem, OTC antibiotics would be used for non-bacterial illnesses and would quickly become less efficacious.

Your May 7 editorial praising the switch of Claritin from prescription to over-the-counter status does not mention the effects such switches have on patients seeking medical attention for serious illnesses.

Americans have a tendency to self-medicate rather than seek expert advice if possible. Allergies are serious illnesses, and, especially coupled with asthma, they can kill. Moreover, many individuals benefit from therapies other than antihistamines, but only doctors can properly advise them.

The current debate about whether to allow emergency contraception over the counter also illustrates the fact that Americans would choose not to go to a doctor if they could receive medications without one -- a testament to the inability of Americans to see doctors quickly and affordably, and a serious deficiency in our health care system.²

...antibiotics are available through the pharmacy without a prescription or they can be bought through the black market. To some extent, the ease of procuring antibiotics relieves some of the problems created by the paucity of medical personnel for these people. Still, a safe balance between the health needs of the people and the efficacy of antibiotics must somehow be realized.

While over-the-counter sales have been one solution to the problem of too few doctors, the situation has created menacing results. The easy availability has contributed to the emergence and spread of resistant strains so that readily accessible drugs no longer cure common infections. Yet antibiotics continue to be used. Consequently, rather than kill off the disease-causing agent, they enable them to thrive in the patient and spread easily to others.ˆ

Licensed doctors, therefore, became deputies and spoilsmen in the growing system of controls. Consumers had to pay for the drug and a visit to the doctor. These new privileges for doctors were the bounty of the government's regimentation of the drug industry and assault on consumers' freedom to self-medicate. Dependence on doctors was further institutionalized and legitimated by making it difficult for consumers to gain information, in particular by the labeling and advertising controls that prohibited information or mandated unintelligibility. Thus, licensed doctors gained wealth and relative status by stripping others of freedom and by dumbing down consumers.¹

The FDA's decisions are not supposed to be based on anecdotes, which are emotionally compelling but scientifically unreliable. Instead the agency prides itself on demanding evidence from controlled, randomized, double-blind clinical trials. Such studies provide no evidence of an association between antidepressants and suicide in adults and only weak evidence of such a connection in children and teenagers.

As far back as 1999, a U.N. agency proposed taxing all e-mail messages to pay for development aid. "There is an urgent need to find the resources to fund the global communications revolution to ensure that it is truly global," the 1999 report said. "The costs for users would be negligible: Sending 100 e-mails a day, each containing a 10-kilobyte document (a very long one), would raise a tax of just 1 cent."

The United Nations hastily backed away from that proposal, however, after prominent members of the Congress slammed it as a "bureaucracy looking to get its greedy mitts on the Internet through new taxes."

• A 16-year-old Palestinian with a suicide bomb vest strapped to his body was caught at a crowded West Bank checkpoint Wednesday, setting off a tense encounter with Israeli soldiers whom the army said he was sent to kill.
• The European Union slapped Microsoft Corp. with a $613 million fine Wednesday for abusively wielding its Windows software monopoly and ordered sanctions that go well beyond the U.S. antitrust settlement — setting up what could be another lengthy court battle.
• Kobe Bryant's accuser testified about her sex life for more than three hours Wednesday during a closed-door hearing that will determine whether any of the information can be introduced at the NBA star's rape trial.
• The Bush White House scaled back the struggle against al-Qaida after taking office in 2001 and spurned suggestions that it retaliate for the bombing of a U.S. warship "because it happened on the Clinton administration's watch," a former top terrorism adviser testified Wednesday.

• 16 college basketball teams who have survived the first weekend are still battling for the NCAA championship.
• Cubs' star pitcher Mark Prior will open the season on the DL.
• In light of the recent gay marriage debate, an Oregon county has placed a moratorium on all marriages.
• Celbrity birthdays for today include: Harry Houdini, Steve McQueen, Peyton Manning, and Kelly LeBrock.

The latest outbreak in a spring filled with daily accusations came Monday, when comments by former Baltimore Orioles pitcher and Hall of Famer Jim Palmer to a radio station found their way into print, suggesting former Orioles outfielder Brady Anderson had used steroids when he hit 50 home runs in 1996.

"I like Brady, and it doesn't mean he's a bad guy because he took steroids," Palmer, a television commentator on Orioles telecasts, told Baltimore radio station WIYY-FM in an interview that was broadcast Sunday. "But I'm sure he wanted to enhance his performance." The comments were printed in the Baltimore Sun in Tuesday's editions.

"Because I only hit 50 home runs once, it was, in fact, an aberration. However, it was not a fluke," he told The Sun yesterday. "Nothing can be considered a fluke that takes six months to accomplish. Rather it was a culmination of all my athleticism and baseball skills and years of training peaking simultaneously. This was my athletic opus.

"Hitting in front of [Roberto] Alomar, [Rafael] Palmeiro, [Bobby] Bonilla and [Cal] Ripken didn't hurt, either."

"You've said if someone is unaware of things like sexual assaults occurring under their watch, they must be hellbent on not knowing, right?" I asked him in his office yesterday. "And a fourteen year-old girl says she was raped in your home, right? Well why wait to prove your innocence?" I then provided the name and phone number of Mike Marnell at Alverson & Associates, a private polygraph administrator in Denver, a short drive from his Cherry Creek home. I told him what Marnell had told me: If any person wants evidence that they are telling the truth, all he has to do is make an appointment and take a polygraph."

• dialate should be dilate - "The [i] in this word is so long there is time for another vowel but don't succumb to the temptation."
• herb should be pronounced with the h - "Does, "My friend Herb grows 'erbs," sound right to you? This is a US oddity generated by the melting pot (mixed dialects). Initial [h] is always pronounced outside America and should be in all dialects of English."
• often is pronounced without the t - "We have mastered the spelling of this word so well, its spelling influences the pronunciation: DON'T pronounce the [t]! This is an exception to the rule that spelling helps pronunciation."

• I am here to tell you what you need to know in order to respond sensitively and supportively to your own introverted family members, friends, and colleagues. Remember, someone you know, respect, and interact with every day is an introvert, and you are probably driving this person nuts.
  
• My own formula is roughly two hours alone for every hour of socializing. This isn't antisocial. It isn't a sign of depression. It does not call for medication. For introverts, to be alone with our thoughts is as restorative as sleeping, as nourishing as eating. Our motto: "I'm okay, you're okay—in small doses."
  
• Extroverts have little or no grasp of introversion. They assume that company, especially their own, is always welcome. They cannot imagine why someone would need to be alone; indeed, they often take umbrage at the suggestion. As often as I have tried to explain the matter to extroverts, I have never sensed that any of them really understood. They listen for a moment and then go back to barking and yipping.
  
• The only thing a true introvert dislikes more than talking about himself is repeating himself.
  
• Also, it is probably due to our lack of small talk, a lack that extroverts often mistake for disdain. We tend to think before talking, whereas extroverts tend to think by talking, which is why their meetings never last less than six hours.
  
• How can I let the introvert in my life know that I support him and respect his choice? First, recognize that it's not a choice. It's not a lifestyle. It's an orientation. Second, when you see an introvert lost in thought, don't say "What's the matter?" or "Are you all right?" Third, don't say anything else, either.

Rhea County commissioners unanimously voted to ask state lawmakers to introduce legislation amending Tennessee's criminal code so the county can charge homosexuals with crimes against nature.

"We need to keep them out of here," said Commissioner J.C. Fugate, who introduced the motion.

County Attorney Gary Fritts also was asked by Fugate to find the best way to enact a local law banning homosexuals from living in Rhea County.

I'm pretty sure that this is unconstitutional, under current legal doctrine. Of course, if Congress enacts this and then stares down the Supreme Court when the Court strikes it down -- for instance, if a majority of the public will be on its side -- perhaps Congress will win, and current doctrine will thus be changed. I doubt, though, that this will ever be enacted, or that the people will side with Congress rather than the Court here (setting aside whether they should).

But I want to ask a different question: Let's say that this does indeed get enacted and validated -- for instance, assume for the sake of argument that it's implemented as a constitutional amendment. How does Congress expect even obedient judges to abide by its "revers[als]"?

Assume that the Court strikes down an abortion ban, based on some legal argument and legal precedents that the Justices would find persuasive (e.g., the right to privacy, and Casey). Congress reverses the judgment. The judgment will thus no longer be effective; the parties to the case would be free of it. But then someone else files a similar though not identical challenge to the same law.

Presumably the Justices would still find persuasive the same argument and precedents they found persuasive in the first case. True, the first decision was reversed -- but the arguments underlying it and the precedents supporting it still remain. The right of privacy, as defined by Casey, still leads the Court to think that the abortion ban is inconsistent with that precedent. Why should the Court do anything but strike the law down, at least so long as there's any conceivable distinction between this case and the preceding one (for instance, this challenge is an as-applied challenge applied to different facts, or this challenge is brought by a litigant who has a subtly different interest, and so on)? After all, the Congressional veto didn't purport to wipe off the books the preexisting precedents; it only reversed one particular Supreme Court judgment. So the Congressional veto might not be terribly effective -- again, even if the Justices really do want to obey the veto process.

Ah, you might say, the Court should defer to the Congressional judgment as a precedent itself, albeit one set by Congress and not the Court, and say "We won't strike the law down, because of this new precedent set by Congress." But, at least these days, courts don't just view the result of a case as a precedent; they apply the reasoning of the case.

The Congressional reversal includes no reasoning; it's doubtless based on legislators' reasoning, but the reasoning doesn't appear in the Congressional action (or at least nothing in this proposed statute suggests that it would). Did the Congress reverse the decision because it thought all abortion bans were permissible? Just this particular abortion ban? Just this particular abortion ban as applied to this particular litigant? The Court would have no clear way of telling this, except through guesswork. The Justices really couldn't apply the Congress's decision as a precedent even if they wanted to. (There is one potential analogy here: When the Court had a practice of summarily affirming lower court decisions without opinions, the theory was that lower courts at least should abide by that result in logically indistinguishable cases, but weren't bound by it otherwise; but that also proved not to be very helpful to courts, and the Supreme Court itself felt much less bound by its past summary affirmances than it was by its past reasoned opinions.)

So who is HR 3920 really going after? The nine justices on the Supreme Court, who "were not elected and are serving life terms" and who should not have the final word on what "the American people must do and not do." The bill serves as a warning that the court had better vote for majoritarian values or risk becoming irrelevant.

“The recent actions taken by courts in Massachusetts and elsewhere are demonstrative of a single branch of government taking upon itself the singular ability to legislate. These actions usurp the will of the governed by allowing a select few to conclusively rule on issues that are radically reshaping our nation’s traditions.”

...let lawmakers reverse Supreme Court decisions if the court rules that laws passed by Congress are unconstitutional.

Under the measure, two-thirds of the House and Senate would have to agree to the override.

Lewis said he would pursue a constitutional amendment if his measure failed. About a dozen Republicans are sponsoring the bill.

I'm no authority on constitutional law, or astrophysics, for that matter. But it's a safe bet that if this bill were to pass, and the Supreme Court ruled it unconstitutional, something significant would happen to the fabric of space-time.

Clause 2: In all Cases affecting Ambassadors, other public Ministers and Consuls, and those in which a State shall be Party, the supreme Court shall have original Jurisdiction. In all the other Cases before mentioned, the supreme Court shall have appellate Jurisdiction, both as to Law and Fact, with such Exceptions, and under such Regulations as the Congress shall make.

• Eugene Volokh from The Volokh Conspiracy coming in at #6.
• Tyler Cowen taking two spots - #32 for his work at The Marginal Revolution and #153 for The Volokh Conspiracy.
• Cowen's partner at MR, Alex Tabarrok is #85.
• VC has a few other entries - David Bernstein is #58, Jacob Levy is #157, Randy Barnett is #176, and Sasha Volokh is #200.
• Matt Welch is #120.
• Cato's Radley Balko is #162.
• Virginia Postrel's Dynamist Blog is #174 and her NY Times column is #193.

"I don't want to start banning things," Thompson said. "Prohibition has never worked."

Give an economist the actual output growth of 7.8 percent over three years (roughly 2.5 percent per year) and ask the economist to "predict" the breakdown between growth in employment and growth in output per person. Almost any economist would have said something like "Well, the output growth sounds pretty close to trend. So, assuming that trend productivity growth is about 1.5 to 2 percent per year, I figure 5 or 6 percent total productivity growth and 2 or 3 percent total employment growth."

No economist in his or her right mind would have predicted that we would have gotten 7.8 percent growth in output with 11.3 percent growth in productivity and a loss of 3.1 percent in employment. That is completely outside the experience of history.

By attacking the Administration's credibility in forecasting employment, Krugman and others are implicitly criticizing its failure to forecast the unprecedented burst in productivity. In fact, Krugman's tone all but suggests that the Administration knew about the coming productivity miracle and was engaging in a cover-up!

If you gave me a blindfold and asked for my analysis of the Bush tax cuts, I would say that they trouble me in the context of the Administration's failure to address entitlement spending. Because the President has not touched the long-term Medicare and Social Security deficits -- other than to add to them with the prescription drug benefit -- I find it quite offensive that he wishes to claim credit for cutting taxes. Long term, he has done no such thing.

A President who has only added to future entitlement obligations ought to be judged as having acted to increase taxes. To call this Administration a tax cutter is like taking a spoiled kid who does not touch dinner but takes a double portion of chocolate cake for dessert a "good eater."

More importantly, The New Atlantis has its new issue out with a strong piece from Charles Rubin on "Man or Machine." Interesting outtake:

The possibility of harmful side effects from enhancement technologies will always be worrisome. But the deeper dilemma is not simply the regulatory question of what is safe but more fundamental questions about the proper shape of a human life. Some danger, after all, is central to noble activity. The pursuit of excellence in one area of life will inevitably create distortions in others. The question is how far such distortions can go before the quest for excellence becomes destructive of the very humanity of the one undertaking it.

This is the problem with the discussion -- or absence of discussion -- about the steroid controversy today. Most players taking them probably think this way (although they won't admit it in court). Yes, steroids pose some sort of risk, but players feel they take plenty of risks as it is, so steroid use is a question of degree, not kind.

• The media? Due to all the hysteria, it's most likely they just like the controversy and the stories that follow. Steroids give them an audience for their pontification.
• The fans? Even with all the indignation and the appeal to the sanctity of past records, one can't deny that the "steroids era" has coincided with an attendance boom. Steroids brought them to the park.
• Management? See above.
• The players? Now here's the interesting thing. As mentioned before by Nick Schultz and The Marginal Revolution, players should all agree to ban steroids. If every single player takes them, they get no net benefit but bare all the risks. So if the players don't want to ban them, well so what?

Given that she had been thrown out of the house by 13 for declaring herself a lesbian, spent her teenage years sleeping on subway trains and rotting piers and yet still managed to get her G.E.D., Laura Melendez figured she had kept her nose pretty clean.

Sure, there had been a few arrests for smoking marijuana, but after an entire adolescence spent on the streets, with far more visits by the police than by her parents, what did those offenses really amount to?

"It means I'll be denied an education," said Ms. Melendez, who is from the Bronx, now 22 and applying to college.

If Ms. Melendez had been an armed robber, a rapist, even a murderer, she would not be in the same predicament. Once out of prison, she would have been entitled to government grants and loans, no questions asked.

But under a contentious provision of federal law, tens of thousands of would-be college students have been denied financial aid because of drug offenses, even though the crimes may have been committed long ago and the sentences already served.

"It is absurd on the face of it," said Representative Mark Souder, Republican of Indiana.

Mr. Souder, who wrote the law, says the Clinton and Bush administrations have both turned it on its head, taking a penalty meant to discourage current students from experimenting with drugs and using it to punish people trying to get their lives back on track.

"I am an evangelic Christian who believes in repentance, so why would I have supported that?" he said. "Why would any of us in Congress?"

On the other hand, there is the case of Marisa Garcia, a junior at California State University, Fullerton. A few weeks before her freshman year began, Ms. Garcia received a ticket for having a small marijuana pipe in her car. (It had some ashes in it, she admits.)

That was her first and only offense. Accordingly, she paid a $415 fine. But she also lost her federal grants and loans for a year, amounting to thousands of dollars. Under the revised rules, her penalty would be no different.

"It doesn't make sense," Ms. Garcia said. "To punish someone by taking away their education? It's counterproductive."

The law does allow students to win back their aid by going through drug treatment. But when Ms. Garcia looked into that option, all she could find was residential counseling that cost as much as her tuition.

"If I couldn't afford to pay for school," she said, "then how was I supposed to pay for these programs?"

As more people are free to join the pursuit of excellence, the bounds of what's necessary to compete move farther and farther from what's mainstream. And even, what's healthy. It's easy to sit and the sidelines and shake one's head at the spectacle: female skaters and gymnasts with stunted development, or biathletes with cardiomegaly that will kill them in their fifties.

And the fact that many of these athletes have freakish traits and proportions to begin with doesn't seem fair, either.

But using this to justify steroids for pro athletes is a big leap. To be fair, the folks at the Proximal Tubule don't explicitly make the case for steroids or hormones. They're just pointing out that media coverage is pretty slanted, steroids aren't all harmful, and the issue is more nuanced than what's being reported.

They're right on those counts. But on the issue of whether it's cheating, there's no contest. I think what confuses a lot of people is the mixing of athlete's goals with those of the audience and the organizers. The athletes want to win, so they train hard and feel the urge to bend the rules. The public, on the other hand, wants to see who's the best. So they make rules about eligibility for competing, just as they make rules about triple axels and free throws. No one in the audience wants to see a team win because the officials blew a call, but I think the athletes would say they trained hard, the other team got breaks too, and a win is a win. I think athletes make similar excuses about steroids.

TPT points out the dichotomy between 'natural' and 'unnatural' is artificial -- and they're right. But the designated hitter rule for half of Major League Baseball is kind of arbitrary, too. If the media reports on steroids with on a scolding, superior tone, it's because dozens of baseball's best players are, be definition, cheating. They're entitled to be critical: they're disappointed, too. It's no different than Sammy's corked bat.

I wrote that post way too quickly and I wonder if it made sense or if it was stream of consciousness. With a chance for re-direct I would break the argument down thusly:

Should steroids be legal for the average Joe? For pro athletes? My answer to the first question is an unequivocal yes and to the second is a definite maybe. Basically pro sports should be able to make their own rules either way. Leading to:

Are steroids cheating? Should they be considered cheating? Again the answer to the first is yes and the second is "I don't know." I personally believe, based on my post, that calling steroids illegal and other things legal is arbitrary. And a good debate would begin by ending all the damned hysteria.

"...anybody expecting another wheezing Philippic in the manner of Bernard Goldberg's Bias or Ann Coulter's Slander -- books in which the new media elite hurl invective, Animal Farm-style, at the old media elite -- will be disappointed. Without a doubt, Stossel is part of the media elite. He's just honest enough to admit it."

• They are unnatural (even though they are identical to natural products and "natural" vs. "unnatural" is a false dichotomy)
• They are unfair because they trump given talent (even though the distribution of genetic athletic spoils is unfair)
• They force otherwise clean athletes to undertake unhealthy measures to keep up (even though the "natural" measures to become a world-class athlete are just as unhealthy - do you think becoming a 300-pound NFL lineman or dedicating your life to one solitary thing is healthy?)
• They are dangerous (even though the medical evidence is uncertain in this regard and it is currently illegal to do the proper scientific studies to know the truth)