In the Eschenbach editorial, it was not that efficacy would never be tested. Instead, a drug would be marketable during the clinical trial phases. Instead of having to wait through 10 years of clinical trials, a patient, with a doctor's prescription, could use the drug once it received approval from the FDA as being relatively safe. Clinical trials would still be performed, but the company could market its drug and patients would have access to the medications. This would not be the wild-west of drug use, with everyone taking all sorts of drugs for whatever the marketers decided was the biggest market. Patients would still need a doctor's approval for the prescription. There is the potential for abuse (by companies and doctors) and misuse (by patients), but hopefully, a patient would only try these unproven drugs as a last resort and after failing to respond on multiple rounds of standard treatment.
There would be risks, costs and liabilities would have to be worked out, but perhaps such an idea, or a variation of it, could decrease the costs of developing drugs such that drugs with new mechanisms of action for common illnesses and drugs for illnesses with no treatment and small patient populations could be pursued.