The questionable ethics of selling complementary and alternative medicine

Legal to sell, yes. But ethical to sell?

Complementary and alternative medicine (CAM) is no longer fringe, and anything but the mom-and-pop image that manufacturers carefully craft. CAM is big business, and most Americans today take some sort of supplement. The impetus for my blogging (and tilting at CAM windmills) emerged from years spent working in a pharmacy with a heavy reliance on CAM sales. If it was unorthodox, this store probably sold it. 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 – so I started researching.

I looked at CAM from a scientific evidence perspective, the one I was taught in pharmacy school, using the same approach I’d take when assessing a new drug. Did the evidence support the claims made about these products, or not? The answers, as you might expect, were often the same. There was little or no credible evidence to demonstrate CAM had any meaningful benefits. I started blogging my own reviews as a way of documenting my own research, while offering some information to anyone on the Interwebs who might be searching for evidence.

Over time my blogging focus expanded, as I asked myself the inevitable questions: How could implausible products with no scientific backing even be approved for sale at all? I discovered the regulatory double-standard allowed for anything considered a dietary supplement (or in Canada, a “natural health product“) and the history and politics that have made CAM the “Wild West” of health care, with a marketplace that prioritizes a manufacturer’s right to sell over a consumer’s right to purchase a product that is safe and effective. Given the retail marketplace that’s been established by regulators like the FDA and Health Canada, I’ve turned my focus on to health professionals, who have an ethical responsibility to put patient interests above that of commercial interests. From a professional practice and medical ethics perspective, I have argued that health professionals that sell or promote CAM are on ethically shaky ground, and compromise the credibility of the profession.

Despite the lack of evidence that CAM (in general) offers any health benefits at all, it’s been remarkable to watch its popularity grow, to the point where even large pharmacy chains now sell aisles of products that are implausible and often highly questionable. Generally meeting these changes with a collective shrug, the pharmacy profession has even tried to lower its own ethical standards. While I do get the occasional encouragement from some of my peers, most just say “it’s business” or “the customer wants it, and these are legal products.” My argument today is CAM fails even this lower ethical bar.

Is it ethical to market complementary and alternative medicines?

Very excited to announce that a paper I collaborated on with Dr. Chris MacDonald has now been published in the peer-reviewed journal Bioethics, as part of a series on complementary and alternative medicine.  It’s also open access (for now):

Abstract:

Is it ethical to market complementary and alternative medicines? Complementary and alternative medicines (CAM) are medical products and services outside the mainstream of medical practice. But they are not just medicines (or supposed medicines) offered and provided for the prevention and treatment of illness. They are also products and services – things offered for sale in the marketplace. Most discussion of the ethics of CAM has focused on bioethical issues – issues having to do with therapeutic value, and the relationship between patients and those purveyors of CAM. This article aims instead to consider CAM from the perspective of commercial ethics. That is, we consider the ethics not of prescribing or administering CAM (activities most closely associated with health professionals) but the ethics of selling CAM.

The full paper is here.

Reference:

Macdonald, C. and Gavura, S. (2016), Alternative Medicine and the Ethics Of Commerce. Bioethics, 30: 77–84. doi: 10.1111/bioe.12226

 

 

Is it ethical to sell complementary and alternative medicine?

I joined Professor Chris MacDonald at Ryerson University earlier this week to participate in Ryerson’s business ethics speaker series. The topic was CAM:

Is it ethical to market complementary and alternative medicines? Complementary and alternative medicines (CAM) are medical products and services outside the mainstream of medical practice. But they are not just medicines (or supposed medicines) offered and provided for the prevention and treatment of illness. They are also products and services – things offered for sale in the marketplace. Most discussion of the ethics of CAM has focused on bioethical issues – issues having to do with therapeutic value, and the relationship between patients and those purveyors of CAM. This presentation — by a philosopher and a pharmacist — aims instead to consider CAM from the perspective of commercial ethics. That is, we consider the ethics not of prescribing or administering CAM (activities most closely associated with health professionals) but the ethics of selling CAM.

You can watch it here here.

It was great to see so many public members attend and participate. There was an extended Q&A afterwards, with some very thoughtful audience questions. Watch for more on this topic from us in the future.

Upcoming talk: Complementary and Alternative Medicine: A Business Ethics Perspective

I’ll be joining Professor Chris MacDonald on January 28 for a discussion about the ethics of selling complementary and alternative medicine:

Is it ethical to market complementary and alternative medicines? Complementary and alternative medicines (CAM) are medical products and services outside the mainstream of medical practice. But they are not just medicines (or supposed medicines) offered and provided for the prevention and treatment of illness. They are also products and services – things offered for sale in the marketplace. Most discussion of the ethics of CAM has focused on bioethical issues – issues having to do with therapeutic value, and the relationship between patients and those purveyors of CAM. This presentation — by a philosopher and a pharmacist — aims instead to consider CAM from the perspective of commercial ethics. That is, we consider the ethics not of prescribing or administering CAM (activities most closely associated with health professionals) but the ethics of selling CAM.

Admission is free. Space is limited. Register here.

WHAT: Complementary & Alternative Medicine: A Business Ethics Perspective

DATE: January 28, 2015

TIME: 3:00 p.m. – 4:30 p.m.

WHERE: Ted Rogers Leadership Centre, Ted Rogers School of Management, Ryerson University, 55 Dundas Street West, Toronto.

 

Concerning Signals in Pharmacy Students’ Attitudes About Complementary and Alternative Medicine

While I’m now two full decades out of pharmacy school, I am occasionally invited to return to give a lecture or facilitate a workshop. Pharmacy education has changed a lot since the 1990’s. For me, pharmacy was a Bachelor’s degree program you started right out of high school. Today, students must have a few years of university completed before they can apply (some already have one degree), and the more common degree granted is doctorate-level, the Pharm.D. The clinical training has been bulked up and the practical training is much more rigorous. I see all this as positive change, as the practice of pharmacy has changed along with the education standard. The era of the “count, pour, lick and stick” pharmacist is disappearing as these tasks are automated or delegated to others. Today’s pharmacist has the opportunity to deliver care in different ways, including new roles like vaccine provider, and medication review/drug therapy optimizer. Many find positions that allow them to leverage their drug-related expertise to other areas of the healthcare system.

With pharmacists’ knowledge of drug products it should not be a surprise that they are consulted widely for advice by patients as well as other health professionals. Public surveys on trust show pharmacists lead other health professionals on this measure. It should also not be a surprise that pharmacists can be quite influential in shaping drug use, particularly when it comes to advice about complementary and alternative medicine (CAM), especially when it is used with conventional, science-based drug treatments. After all, drug stores are becoming (to my professional embarrassment) purveyors of all forms of CAM, ranging from homeopathic “treatments” through aisles of herbal remedies, vitamins, and other supplements. One pharmacy I used to work at sold copper bracelets, magnets, salt lamps, ear candles, homeopathic “first aid” kits, and detox packages that were purported to “balance” your pH. If there was a plausibility limit to what this pharmacy would sell, I never saw it reached. I gave the best science-based advice I could, but eventually left due to my concerns about what was on the shelves. But my time in that setting showed me the opportunity to improve care: the pharmacist is well positioned to advise on the evidence for or against any particular treatment, as well as explain the potential risks with combining CAM with evidence-based treatment approaches.

The Ethical Implications of Rexall’s Dubious Homeopathic Offerings

From ethicist Dr. Chris MacDonald, a column on Rexall’s recent advertisements promoting homeopathy:

The problem, of course, is there’s no reliable evidence that homeopathy works, nor any plausible reason to think that it even could work. In commercial contexts, that’s pretty bad. And it’s worse still when the company selling the stuff is a company people rely on for competent health advice, and when that company leverages the credibility of a licensed health profession to promote bogus wares.

And importantly:

The commercial world is full of scams, and all too often people with something to sell have unwarranted faith in their products. Greed and ignorance are nothing new, but that doesn’t mean they are excusable. Companies that claim not just to provide a product, but to educate and take care of consumers, ought to do better. They should do their best to sell only those products that they, and their customers, are justified in believing in.

More here.

I’ve written about the ethics of selling homeopathy before.  As XKCD said about pharmacies selling homeopathy,

 Telling someone who trusts you that you’re giving them medicine, when you know you’re not, because you want their money, isn’t just lying–it’s like an example you’d make up if you had to illustrate for a child why lying is wrong.

How to boost homeopathy sales? Don’t tell the customer it’s homeopathy

The other day a parent asked me if she could give her 2-year-old Tylenol liquid along with some cough syrup she had purchased at the pharmacy. I was a bit surprised, as cough and cold products for young children have been pulled from pharmacy shelves for a few years given their lack of efficacy and spotty safety record.  “What product did you give?” I asked. “Stodal” she replied. I paused, then replied. “Well the good news is that you can give Tylenol and Stodal together. But you should know that Stodal is a homeopathic product – it contains no medicinal ingredients, so what you’re effectively giving is a sugar syrup.” I explained how homeopathy is permitted for sale in Canada, and sold in pharmacies, despite the fact it is an elaborate placebo system of sugar pills and liquids. The mother was furious – at the pharmacy for selling it, at the store staff for recommending it, and especially at the regulator, Health Canada. “How can they possibly permit this to be sold?” she asked me. I had no explanation – but encouraged her to return the product to the pharmacy and demand a refund.

Homeopathy: Not good, not medicine

Caution: Straw Man Arguments Ahead

Every time I think I can take a break from homeopathy, something pulls me back to the topic. Today it’s an unbelievably poorly reasoned defense of homeopathy, in, of all places, the British Medical Journal. Glasgow-based general practitioner Des Spence writes,

It was an intentional overdose. To prove a point I poured about 30 tiny tablets into my mouth and crunched them down. Because scientifically, I do not believe that these homeopathic pills have any active ingredient.
Today, homeopathy is medicine’s whipping boy, repeatedly and systematically beaten to the ground. Yet despite explaining that the tablets are just placebos, homeopathy always gets up to take another beating. Some homeopathy is funded by the NHS, through general practice, and in the few homeopathic hospitals. This fact enrages the growling commissars of evidenced based medicine who want homeopathy purged from the NHS.

“Growling commissars of evidenced based medicine”? Perhaps he’s referring to health professionals (like me) that believe that health interventions and treatments should be evaluated based on a single, scientific standard. And that publicly-funded health systems, like the National Health Service (NHS), should fund what works. Treatments that are not medicine, but are are vitalistic belief systems without evidence of efficacy, don’t make the cut.

Homeopathy: To sell or not to sell? Pharmacists weigh in

Homeopathy is nonreturnable

Homeopathy is a popular topic here at Science-Based Pharmacy. I’ve blogged before on the ethics of the provision of these products, and argued pharmacists have an ethical responsibility not to sell, promote, or encourage the sale or use of homeopathy. It’s a question that has been put to pharmacists before. So I was I was interested to see the UK pharmacy publication Chemist and Druggist recently asked their readers about the ethics of the sale of homeopathy, setting up the scenario as follows:

You are working as a locum in a busy high street pharmacy. A customer comes in and asks about “non-drug” treatments for hayfever. The customer says she “doesn’t trust” pharmacy products and asks if you have any homeopathic remedies. The store does stock a range of homeopathic treatments, but you know they are not considered medicines by the RPS. What should you do?

I was hoping to see a discussion from pharmacists on how they’d approach a description of the products (most don’t contain a single molecule of the listed ingredient) and their efficacy (no effects beyond that of placebo) with some science-based (and perhaps non-drug) measures for allergy management. Here are some of the supportive responses:

Edzard Ernst: Alternative medicine remains an ethics-free zone

Homeopathy is nonreturnable

From today’s Guardian: