CMs: what are your ethical responsibilities?

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A clash between pharmacists’ ethical responsibilities and their business role has been highlighted by a review of complementary medicines literature

Researchers from the University of Queensland reviewed the academic literature which explores pharmacists’ responsibilities when selling CMs and identified a lack of “explicit normative advice” as to how they should fulfil these responsibilities.

The review also shows a gap between how pharmacists perceive they should act when communicating with patients about CMs, and how they act in practice.

“The studies discussing the ethical perspectives of selling complementary medicines mainly describe the ethical conflict between a pharmacist’s business and health professional role,” write Amber Salman Popattia and Adam La Caze from UQ’s School of Pharmacy, and Sarah Winch from its Faculty of Medicine, in the International Journal of Pharmacy Practice.

“No attempt is made to provide guidance on appropriate ways to resolve the conflict,” they warn.

The researchers searched for studies published internationally between 1995 and 2017 which addressed pharmacists’ responsibilities.

They identified 58 empirical studies which discussed pharmacists’ practices or perceptions, consumers’ expectations and normative studies discussing ethical perspectives or proposing ethical frameworks.

Pharmacists and consumers identified counselling and safe use of CMs as pharmacists’ primary responsibilities, but the studies which surveyed pharmacists about how they discuss CMs in practice found that they rarely initiate communication with consumers on the subject.

Several studies attempted to identify barriers that pharmacists feel make it more difficult to fulfil their responsibilities in regard to CMS, and these consistently showed that pharmacists experience a lack of confidence in their skills and knowledge on the subject, as well as discomfort with answering specific questions.

Several studies also identified concerns about the lack of evidence supporting the efficacy of many preparations.

Consumers, on the other hand, wanted to be able to ask pharmacists specific questions and felt that they should be in control of the discussion.

“Although pharmacists identify a concern regarding the lack of scientific evidence for complementary medicines, this does not appear to affect them selling these products,” the authors write.

“A secret-shopper investigation by a consumer advocacy group found that nearly one-third of Australian pharmacies recommended a complementary medicine for stress, most of which lacked scientific evidence for effectiveness.

“Pharmacists and pharmacy support staff often provided misleading or false information regarding the effectiveness of the product. The studies included in this review suggest that, when asked, pharmacists tend to justify the sale of complementary medicines in terms of consumer demand or their own or a family member’s personal experiences regarding complementary medicines.

“Despite identifying the responsibility in general terms, pharmacists appear to fulfil these responsibilities only in situations in which the consumer explicitly seeks advice from the pharmacist.”

But how the pharmacist should handle their responsibility when the customer does not explicitly seek information is not addressed in the literature, they say.

“What, for instance, are the limits on consumers’ autonomy? Does the pharmacist have a responsibility to prevent harms in relation to complementary medicines in circumstances in which the consumer does not explicitly seek the advice of the pharmacist?

“The sale of complementary medicines without rigorous scientific evidence for effectiveness raises important ethical concerns regarding the responsibilities of pharmacists.”

Some of the studies identified the responsibilities of pharmacists selling CMs in terms of conflict between their business and health professional roles.

“This conflict is most easily seen in relation to the sale of complementary medicines that lack scientific evidence for effectiveness,” the authors write.

“However, the studies identifying the conflict make no attempt to provide guidance on appropriate ways to resolve the conflict.”

PSA national president Dr Shane Jackson says that the organisation’s Position Statement on CMs is very clear on the subject – pharmacists should be guided by its Code of Ethics, which is cited in the review.

“The pharmacist must respect the autonomy and rights of the consumer, but must balance that with the health and wellbeing of the consumer, which is the pharmacist’s first priority,” Dr Jackson told the AJP.

He urged pharmacists to initiate conversations about CMs use and, if they are not up to date with the evidence supporting the use of some preparations, to become so.

“From a practice point of view, a lot of consumers want to use complementary medicines, and that’s an opportunity because they come into pharmacy, to talk to them about the potential benefits and also the risks in using some of these therapies,” he says.

“Also, where there’s conventional mainstream therapies available, patients need to know that they shouldn’t be using CMs necessarily and delaying conventional treatment for which there is good safety and effectiveness data.”

Pharmacists should also recognise that while there is robust evidence to support the use of some CMs, there is a “spectrum” when it comes to the data to support others.

Dr Jackson advised pharmacists to talk to patients about whether they feel a particular CM is working for them.

“We need to make sure the patient’s fully informed about the potential risks and benefits, just like with any other medicine, and if the medicines’ not working, it shouldn’t be used on an ongoing basis,” he says.

He also pointed out that the PSA does not support the use of homeopathy, citing the recent NHMRC report which “clearly stated there’s no evidence to support it”.

“Where there’s clear lack of evidence pharmacists should not be involved in the sale of those products,” he says.

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