Viagra to your door via the Internet

Consider these recent developments:

C. Everett Koop finally chucked the saint act and formed an alliance with Rite Aid, the drugstore chain, to sell prescription refills on the Internet.

Longs Drugs announced it is moving online.

One of Bill Gates' top lieutenants, Peter Neupert, resigned to join a venture with Amazon.com to be called Drugstore.com.

And I visited a Web site - not any of the above - and easily bought a bottle of Viagra, without speaking to a single doctor. (Or to anyone at all.)

These events are all linked to perhaps the most important trend in modern health care: the growing desire of American consumers to decide exactly what medications they want, when they want them, traditional physician approval be damned.

The prime apostle of the patient-as-doctor movement may well be New York physician Steven Lamm. Over the past few years, Lamm, a practicing internist and assistant professor at the New York University Medical School, has authored a number of books extolling the wonders of "breakthrough" medications that improve lifestyle.

"Today, it's actually possible to lower age barriers, make our minds and bodies even better, and maintain that hard-won competitive edge through a combination of breakthrough medical discoveries and the aggressive use of what I call Vitality Medicine," Lamm proclaims in his last book, Younger at Last.

And just how does one obtain this medicine? First find a cooperative doctor, Lamm says. "In your search, you are going to come across physicians who may initially be skeptical of any medication, technique or new technology that has not already been proven to be successful with an indisputable double-blind study," Lamm says. "This would not be the right physician for you."

Instead, he advises, find one who has "a willingness to 'experiment' with new drugs and techniques." Certainly Lamm is willing to experiment with his readers. In Thinner at Last, he proclaimed the diet combination known as Fen-Phen to be safe and effective - only a few months before the FDA recalled the drugs for causing severe heart problems. His new book, The Virility Solution, which touts "The Amazing Drug Viagra" as "a new medical miracle," names another impotence drug, Vasomax, as "effective and well-tolerated" - despite the fact that Vasomax wasn't even submitted to the FDA for review until a month ago. It's still illegal to market it for erectile dysfunction. (That double-blind-study thing again.)

The doctor and his co-writer, Gerald Couzens, first jumped on the Viagra story more than a year before the drug was approved by the FDA. In March 1997 their literary agent, Herb Katz, knowing that Lamm was one of a number of doctors engaged by Zonagen Inc., to run clinical trials of Vasomax, approached Simon and Schuster editor Fred Hills with an idea for a "virility book." Hills signed on, but with one key proviso: There would only be a book if one of the drugs passed FDA approval. Lamm agreed.

The keen mind will here discern something the deal makers did not, or at least would not: Lamm, as a clinical investigator for Vasomax, now had a financial interest in the successful outcome of a drug he was supposed to be objectively "studying." Did he disclose that to the drug's developer, Zonagen Inc.? Both Lamm and Zonagen, which recently applied to the FDA for approval of Vasomax, refuse to say. (Some disclosure is now legally required when a trial involves government funding or is carried out through a public institution; but even then, the disclosure need only be made to the institution, not to the public.)

Did Lamm ever think he had a conflict of interest? "Absolutely not," the doctor finally told me in a terse phone interview. "But now I have to go. I elect not to talk to you. I choose that. I elect not to answer your questions. You can do what you want, but I elect to choose not to answer you."

Lamm's response didn't surprise me; press coverage of the Viagra phenomenon has largely been confined to questions like "Does it work?" and "Will it kill me before I come?" This is due in large part to a brilliant marketing strategy by Pfizer, the drug's manufacturer, which has refined the art of publicizing a "blockbuster drug" in stages, not unlike the way Hollywood releases a summertime action flick.

But what happens when a physician, a person bound to "first do no harm," becomes a cog in the wheel of commerce? What happens when the good name of, say, NYU Med is used for purposes that might best be called enlightened shilling?

Back arrow to Lamm's own self-promotional Web site (www.virilitysolution.com - more than 32,000 visitors since May 11), from which one can obtain autographed copies of The Virility Solution. From here, a link entitled "About Wellness" leads to www.thepillbox.com, site of the Pillbox Pharmacy of San Antonio, Texas, and an animated banner: "This month's special: Viagra."

Click here. What quantity would you desire? What strength? (The pillbox.com sells the drug for about $10 a tablet, pretty much the going rate.) "If you would like an Online Consultation with a licensed physician to obtain a Viagra Prescription," the text directs, "if appropriate to your medical condition and history, click here." Click. "There will be an $85 charge for this physician consultation." Click.