Issue 10 / 21 March 2016

SCAN the shelves of your local pharmacy and chances are you’ll see a whole range of “natural” products on sale, promising everything from better digestion to a stronger immune system.

The ethics of health care professionals promoting products of, at best, doubtful efficacy have often been questioned, including by me.

Canadian pharmacist Scott Gavura has long argued his profession needs to take a more evidence-based approach, based in part on his own experience working in community pharmacy.

“If it was unorthodox, this store probably sold it,” he writes on the Science-Based Pharmacy blog. “Conventional drug products (the ones I was familiar with) were hidden off in a corner, and the store was otherwise crowded with herbal remedies, homeopathy, and different forms of detox kits and candida cleanses. All of this was unlike anything I’d ever seen or heard about in pharmacy school.”

Gavura can’t have been the only new pharmacy graduate ever to have been confronted by that reality, but he may be the first to suggest the selling of complementary and alternative medicine (CAM) violates, not just medical ethics, but even the “relatively permissive” principles of commercial ethics.

In an article in Bioethics, he teams up with business ethicist Dr Chris MacDonald to make that case, starting off with the identification of some essential ethical principles that underlie commercial transactions.

Two of these are that the product has to work, and that the purchaser has to understand the product and be able to assess whether it will meet their needs (I’m going to call that second one informed consent).

So, a consumer buying a used car is entitled to expect that it is able to be driven. And they should not be misled into believing it can sprout wings to escape traffic jams.
 
The informed consent principle implies “a general demand for honesty on the part of sellers, and a refusal to profit from the ignorance of consumers”, Gavura and MacDonald write.

So how does the CAM industry fare when measured against these principles of commercial ethics?

It’s pretty much a total fail on the first one, since few CAM products are able to provide quality evidence of efficacy.

“Empirical testing confirms what a priori plausibility suggests: there is little convincing evidence that the overwhelming majority of CAM has any meaningful medicinal effects, and some CAM, like homeopathy, has no effects at all,” the authors write.

CAM practitioners are fond of blaming the poor performance of their treatments in trials on what they consider to be inappropriate methodologies: randomised controlled trials just don’t suit their kind of practice they often claim.

All right then, these authors say, tell us what you want to use instead? Give us another rigorous method of establishing efficacy, “something beyond intuition, tradition, and anecdote, something that goes some distance to overcoming the well-documented flaws to which personal documentation is subject”.

It’s not always a question of intentional dishonesty, as the authors acknowledge. Some in the CAM industry clearly believe in the products they sell, but that doesn’t let them off the ethical hook.

“It is not plausible to excuse vendors for selling a product that does not work simply because they have either not taken the time and effort to investigate … or turned a blind eye to the evidence that is available to them,” the authors write. “There is, after all, such a thing as willful ignorance.”

The sellers of CAM also get a fail on the informed consent requirement, since most consumers have little capacity to assess the evidence base – or lack of it – for the treatments being spruiked to them.

“Consumers generally don’t know just how little reason there is to believe in the specific effects offered by purveyors of, for example, homeopathy,” the authors write. “Not only do they not know there’s no evidence that homeopathy works, they a) generally don’t have the expertise to evaluate the evidence, and they b) don’t realise that the claims of homeopathy are fundamentally at odds with basic biology and even physics.”

The selling of CAM is often defended with arguments about respect for the autonomy of the individual, each person’s right to make decisions about their own health.

But that really only holds water if the individual is fully informed before making his or her decision, something that would require manufacturers and retailers to clearly disclose the lack of evidence for the products they sell.

Imagine that: “I recommend this $29.99 potion to improve your energy levels and general sense of wellbeing. The laws of science tell us it can’t possibly do anything on a biological level, but you may experience a placebo effect that will make you feel better anyway.”

The used car salesmen would be proud.

Jane McCredie is a Sydney-based science and health writer.


Poll

Should pharmacists sell complementary and alternative medicines with little evidence base?
  • No, it's unethical (76%, 139 Votes)
  • Maybe, if they inform their customers of the evidence (22%, 40 Votes)
  • Yes, they're entitled to make a profit (3%, 5 Votes)

Total Voters: 184

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15 thoughts on “Pharmacists selling CAM doesn’t wash

  1. alex thomson says:

    Not only are chemists spruiking ineffective or harmful products when people attend with various symptoms ,  chemists  are also “co-prescribing” to  decrease the side effects of the doctors’ prescriptions. This is even more ethically and professionally dubious.

    I was unfortunately not suprised when a patient of mine went to the chemist with an URTI and wanted some sudofed – “I’m sorry we dont supply that” was the response, ” but we can give you this… ” With six various products and now $300 poorer the patient left .  The (denied) sudafed may have helped the symptoms, but this transaction, made in terms of patient safety perhaps, benefitted only the chemist.

     

     

  2. Health Directorate Library Canberra Hospital says:

    Whilst there is no evidence of efficacy for most CAM products there are a few that may be useful. For example, nicotinamide (vitamin B3) has been shown to significantly reduce the incidence of skin cancer in susceptible individuals.

  3. Dr David De Leacy says:

    Thank you Jane once again for another very good article.

    It will not widely enough read unfortunately. Maybe the AMA can own it and forward it on to the Pharmacy Guild as an exercise in backbone building?

    The Pharmacist’s argument is as equally valid as me arguing to be given the choice of driving on the right hand side of the road in this country.

    Unfortunately these highly intelligent people really seem to have become totally irrelevant in the 21st century as their present undergraduate course leads them straight into a postgraduate career as nothing but an over qualified Big Pharma, Big Vitamin shop front retailer. They clearly also are desparately looking for another raison d étre by now by trying to market themselves as miní-doctors so as to receive Medicare rebates. This loss of societal and professional value obviously has resulted in their commercial interests subsuming their ethical values.

    It is truly sad to see this nonsense exercise in double-speak coming from such an historically august organisation. 

    It truly is time for a major rethink of all undergraduate university courses so as to accurately reflect all postgradutate career streams ensuring them to be valid and ethical in current and future working environments.

  4. Dr Joe M Kosterich says:

    We need to be a little careful when throwing stones. The glass house  of “evidence” for much of what we do as doctors is flimsy too.

  5. Philippa Gavranich says:

    It is bad enough that products of any kind are sold with unsubstantiated claims of efficacy but even more appalling that in the case of pharmacies,the seller is trading on his or her professional status. Leave the selling of dubious products to the ‘health food’ shops if there is not the political will to really confront this issue.

  6. Dr Gary Champion says:

    As Rheumatologist the alternative “treatments” for rheumatic ailments is only limited by the human imagination – & of course are of no benefit. But there is an organisation in Australia that can intervene -the ACCC – they fined Coles 11 million$ after Jeff Kennett made a complaint that their bread was not really baked on the premises. Now we have the likes of Blackmores Swisse etc making outrageous claims but no ACCC or Jeff Kennett! Seems some animals are more equal than others according to the ACCC –  no burden of proof needed.

  7. Liisa says:

    I agree with Dr McCredie that pharmacists should not mislead their customers about the evidence supporting the CAMs they recommend. However not all CAMs are the same. This is like saying all wine contains grapes and hence all wine tastes the same. There is a big difference between homeopathy that has no proof of efficacy and individual herbal medicines of which some are supported by many years of clinical research. If a pharmacist or a doctor for that matter, is aware of the clinical evidence supporting a specific product ( not just a herb in general) then it is entirely appropriate  and ethical for them to consider recommending that specific product to their patient.

  8. M. K. Dunkley says:

    I agree with Dr Joe. There are also lots of doctors out their undertaking dubious practices. In addition there are lots of doctors recomending CAMS. I am no fan of CAMS but the difficulty with evidence is the lack of funding for clinical trials. The products can’t be patented (as they are natural substances) so the manufacturers are not likely to fund proper trials. Many of our modern pharmaceuticals actually originate from plants and other “natural” substances. The benefit if the CAMS coming from a pharnacy is that potentially the pharnacist can check for contraindications or drug interactions and reduce risk. If consumers buy their CAMS from the supermarket or other outlet and do not tell their GP they are taking them they risk adverse effects. While CAMS may not have proven benefit they can and do cause adverse effects and they do interact with medications. To be honest we all need more education about the risks associated with these products.

  9. Sue Ieraci says:

    It makes no sense to respond to an article about poor practices in retail pharmacy by saying that practice in not perfect in other professions – we all need to work towards best practice. If individuals are aware of doctors “undertaking dubious practices”, they should be notified to the regulatory authority. But that should not stop commentators from criticising the sale of scam “remedies” in pharmacies.

    If pharmacies are selling extracts of herbs that have been shown by good evidence to be effective and safe, purified and standardised, then they are equivalent to any other pharmaceuticals. Then they aren’t so-called “CAM”.

    The term “complementary” should be restricted to benign therapies like massage and yoga, which can improve well-being but don’t claim to cure anything, and can be used alongside effective medicine. “Alternative”, on the other hand, refers to “remedies” for which there is no good evidence of efficacy, or even, in some cases, that what is on the label even is present in the bottle or tablet. That is not just pseudo-medicine, but frank consumer fraud.

  10. Sue Ieraci says:

    And another point, “MD”, about the funding of research – Big Tincture (homeopathy manufacturers) and Big Vita (supplement manufacturers) are not short of cash. The reason they don’t do research on the efficacy of their products is that they are allowed to sell them, and people will buy them, without evidence of effect. 

  11. Simon Zilko says:

    Great article Jane, and well said Sue Ieraci.

    The whole thing reminds me of what Tim Minchin says in one of his songs: “You know what they call alternative medicine that’s been proven to work? Medicine.”

  12. Simon Zilko says:

    I encourage everyone to read the original BioEthics journal article – if for no reason other than it gives us a view from another dimension (business and market ethics) on this topic.

    It’s worth noting that the third ethical principle the authors refer to, of doing ‘no harm to third parties’, is violated from a financial point of view to some extent in Australia. With most private health insurance providers offering some combination of naturopathy, acupuncture, reflexology, kinesiology, Chinese and Western herbalism, shiatsu, aromatherapy, homeopathy, Bowen therapy, Alexander technique and Feldenkrais (that list is taken directly from Medibank’s website), we should feel rightly annoyed that our desire to get an extras package covering dental care is actually subsidising other people’s use of non-efficacious CAMs. And our premiums must go up to do so.

    Are private health insurers to some extent also playing an ethically dubious role by supporting (and some might even say promoting) the use of CAMs?

  13. Chris MacDonald says:

    I’m one of the co-authors of the original peer-reviewed article that’s referred to here. We anticipated and dealt with some of the worries noted above. 

    As for the clain that evidence is a problem for non-CAM treatments as well… well, yes, clearly. But the difference is that the effectiveness of pharmaceuticals tends to be monitored, tracked, and reported. So there’s a chance of *catching* both problems with effectiveness and problems with side effects. The same cannot be said for CAM products generally.

  14. Sue Ieraci says:

    It’s often said, by proponents of alternative “remedies”, that there is no money to test those products, which they contrast with so-called Big Pharma. Problem is, some of these supplements and “remedies” ARE maunfactured and sold by pharmaceutical companies. Others are manufactured and sold by huge multinationals that also have quesitonable ethics (see Boiron and occilococciunum) and sell inert materials at enormous mark-up, while having spent essentially nothing on R&D.

    No, these companies aren’t constrained by lack of money – just by lack of ethics, and lack of any requirement to show efficacy. If you are allowed to sell, and people will buy, without evidence, why would they eat into their own profits to do something they are not required to do?

    Alternative remedy and supplement purveyors like to promote the idea that their products are made by gentle monks on verdant slopes – but reality is far from the truth. So-called CAM is Big Business.

  15. CKN Queensland Health says:

    Yes, CAM is big business ….. and Big Pharma owns a lot of it. Brands like Cenovis, Nature’s Own, Microgenics, Bio-Organics are  actually owned by Sanofi, one of the largest drug companies in the world.

    But its our regulatory system that is at fault, because it gives CAM manufacturers free reign to make up and sell whatever products they like backed-up by whatever fairy stories they like as long as the product is said to contain “substances of low public health concern” i.e. unscheduled medicines. Based on that one regulation,  the whole CAM industry is considered to be “low risk”. Never mind that people are people ripped off,  given false hope and delaying more effective treatment. Buyer beware they say.

    Whilst the cha-ching of cash registers chime with the sale of every silly useless CAM remedy, the money changing hands keeps our economy going  and no government is ever likely to change the regulatory system. They convince themselves that no one is getting hurt and that’s what the doctors and pharmacists who flog CAMs talk themselves into believing too.

     

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