A question of ethics

Doctors say selling CAMs is a violation of medical ethics

Most doctors believe it is unethical for pharmacists to sell complementary medicines without an established evidence based.

A new poll in the Medical Journal of Australia revealed that 76% of doctors who voted said ‘No, it’s unethical’ in answer to the poll question ‘Should pharmacists sell complementary and alternative medicines with little evidence base’.

Of the 173 respondents to the poll, 22% said ‘Maybe, if they inform their customers of the evidence’.

Only 2% said ‘yes, they’re entitled to make a profit’.

The poll was following on from an earlier MJA InSight article which quoted a Canadian pharmacist, Scott Gavura, who argued pharmacy 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 said.

“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 argued that 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 teamed 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.

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  1. RL

    Pharmacy stock choices are often difficult. You have consumer demand, profit incentive and ethical choices. With schedule 4+ medicines making very little money, and CAM’s the largest growth area it’s no wonder people struggling to pay the rent and wages are opting to put these things instore. I would be very surprised to see a pharmacist “recommending” a product with poor evidence of efficacy. If they are they should change their practice. If they are expected then those people expecting should change their demands for the better of the profession and therefore themselves.
    A conundrum though is that if we don’t stock them, and people know we don’t so therefore go to a health food store or colesworth, isn’t their health in even more jeopardy as there is no one there to give an educated opinion or advice? I agree there is a great deal of crap in the CAM marketplace and I believe the stuff that is clearly not suitable for a professional health environment should be excluded. But there seems to be a great deal of grey area CAM’s. Do we catch those patients dabbling in CAMs and offer them sound advice or do we axe 90% of the CAM department and let all those people free on Google and end up at a homoeopath?

    • Peter Crothers

      Agree. Better questions to ask (I think) are to what extent should consumers have the right to self medicate and what controls/restraints should be applied to them? Pharmacists occupy a somewhat different – and in many ways broader – place in the health care spectrum than doctors. Our ‘place’ encompasses self care (non-medically directed care) – said by some to be 70% of all health care actions – and in this space evidence is much more contestable than in ‘primary care’, at least partly because the healthcare establishment chooses not to actively engage ordinary people in such decision-making, but also because less effort has gone into testing claims – let’s face it, there aren’t many Nobel Prizes to be had in the CAMS research space. One of the legitimate roles of pharmacists is to try to ensure that self-care decisions are medically informed: to improve peoples’ health literacy and challenge their non-evidence-based beliefs, and we do that every day. Part of being able to do it is to get into the relevant conversations in the first place, which becomes impossible when you turn your back on CAMS altogether. We would all welcome more assistance from the medical authorities in this regard: for example, much tighter rules from the TGA about therapeutic claims for AustL medicines and – gasp! – some actual evaluation. Similarly, we would all welcome some moderation of the marketing practices of CAMS product sponsors – or any product sponsors for that matter. Consider also that not all the available evidence is anti-CAMS – some treatments seem to have a scientific basis, and on that basis why would we deny people have a right to try them or to seek advice about them from a variety of sources? And if even my own mother swears that Garlic and Horseradish is the only thing that controls her post-nasal drip, who am I to deny her? Medical science cannot hope to coerce peoples’ medical choices. The best we can aspire to is to engage people in sensible dialogue and encourage them to make better choices. That’s what I do most days in any case.


    CAMs were the largest growth area in the 1980s…. When some of us learned about things like fish oil and were howled down. I suppose the announcements about the use of fish oils and other “CAM s” with antidepressants will be explained away ? Has always fascinated me the the trials showing the inefficacy of CAMs almost always do not indicate dosage strengths or use subtherapeutic levels and/or length of trials.

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