The NZ Skeptics are a voice of reason in New Zealand, and aim to promote the scientific method and evidence-based decision making throughout the public sphere. Healthcare decisions are an important part of this ideal, and we strongly support any measures that seek to follow best evidence and help protect consumers from harm. Thank you for giving us the opportunity to have a say in this consultation.
In a similar manner to the “Pharmacy Council Complementary and Alternative Medicines – Statement and Protocol for Pharmacists”, we will refer to these products as “CAM” and “CAM products” within our submission. However we are hesitant to use this acronym because of its inclusion of the word Medicine, where these products have not proven themselves to be medicines.
1. Can you think of any ethical values for the pharmacy profession that appear to be omitted from the revised code?
Yes.
We believe that the current 2011 Pharmacy Council Code of Ethics, which states (in clause 6.9) that pharmacists must “Only purchase, supply or promote any medicine, complementary therapy, herbal remedy or other healthcare product where there is no reason to doubt its quality or safety and when there is credible evidence of efficacy” is, in principle at least, a good guideline for pharmacists.
Many pharmacies currently supply and promote CAM healthcare products for which there is a very obvious lack of credible evidence of efficacy – even with this code of ethics in place. We are concerned that the general trend in New Zealand has been for pharmacies to sell more CAM over time, presumably driven by a situation where many pharmacies struggle to make enough money to remain viable businesses when selling prescription and over-the-counter medicines alone. An example of this trend is that there is an annual Pharmacy Award for the Best Complementary Healthcare Campaign.
Pharmacists, and pharmacies, enjoy a high level of trust from the public due to their knowledge and expertise, and the importance of the task of dispensing prescription medicines and advising patients that has been entrusted to them. Unfortunately, in order to improve their viability as businesses, many pharmacies appear to have decided to trade on that trust and sell CAM products that purport to improve people’s health, but which do not have good quality evidence backing their use.
The vast majority of these CAM products are unlikely to ever be shown to be efficacious (due the lack of any plausible mechanism of action), and in the short term they are harmless at best – if we ignore their direct financial cost to patients. In the long term, however, these ineffective products are likely to damage patients’ health literacy, making them less knowledgeable about what constitutes good healthcare. They will also tend to make patients less likely to seek proper medical care for their health conditions, instead relying on these unproven products for their future health needs.
If pharmacies find that they need to supplement their income by selling products other than prescription and over-the-counter medicines, there are many products that they could sell that are not health related. We think that it would be much better for pharmacists to avoid the risk of ethically unsound practices, and we would expect the Pharmacy Council’s new Code of Ethics to be an aid in ensuring that pharmacies behave ethically in this regard and do not sell any products that have not been proven to work.
Unfortunately the new code of ethics appears to weaken the stance taken by the 2011 code, rather than strengthening it; only requiring that a pharmacist satisfies themselves that a product is appropriate for the patient (clause 1g).
In essence the proposed new code seems to be worded in a way that, in a perfect world, patients would be protected from the sale of ineffective health products. All pharmacists, and pharmacy staff, would have a good level of knowledge of the evidence base for all CAM products they sold, and they would be free of all biases.
However, in reality, there are a wide range of beliefs about CAM amongst pharmacists and pharmacy staff – and not all of these beliefs accord with the best evidence for these products.
The “secret shopper” exercise undertaken by members of the NZ Skeptics two years ago showed that pharmacies, and pharmacists, are more likely to promote an ineffective product (homeopathic products, in the case of our exercise) than to warn of its ineffectiveness. If the behaviour that we saw in 2015 is indicative of the general stance that pharmacies hold with regard to CAM, and we think that this is a fair conclusion, we believe that pharmacists are often not acting in the best interests of the patient when it comes to CAM. They may not be in possession of the best available evidence, and there is also a real risk that a pharmacy’s need to make money can cloud proper judgement when it comes to selling these products.
For these reasons, we consider that leaving individual pharmacists to be the judges of what constitutes a good level of evidence for a CAM product is not prudent. We believe that it is the Pharmacy Council’s responsibility to help pharmacies navigate the myriad of CAM products that are currently on the market, and ensure that they are not selling ineffective products to patients. We think that the Pharmacy Council should not be scared to provide a robust level of guidance for pharmacists when it comes to both unproven and ineffective CAM products.
We believe that this guidance can be effected in part by creating a list of classes of CAM products that have been shown to be ineffective (such as homeopathy), and which should not be sold in pharmacies. The Pharmacy Council should also target the most popular CAM products being sold in pharmacies, and create information resources for both pharmacists and patients explaining the current evidence, or lack of evidence, for these products. These resources could include booklets that are made available in pharmacies, and given out when these products are purchased, and web pages that are placed online, either on the Pharmacy Council’s website or a site specifically for providing information about CAM products.
2. Considering the explanation of the term “patient” and equivalent terms in the key terms (key terms):
a. Do you think the term “patient” is the best word to use, most of the time, to express the relationship that exits between the pharmacist and the person they are directly or indirectly caring for or providing health care information to?
Yes.
We think that the word “patient” is a positive step towards impressing on pharmacists the importance of the relationship they have with the public, and the trust that the public place in pharmacists to behave in a way that is in individual patients’ best interests.
b. Are there any specific clauses where you can think of different term that could be more appropriate?
No
3. Considering the new clauses that relate to the sale of complementary and alternative medicines (CAM, clauses 1g, 4h and 4hh): Do you find it clear that the Council is not opposed to the sale of CAM when they have demonstrated benefits for patients, have minimal risks, and the patient is making an informed choice?
No.
We think that the clauses do not make it clear that they are not opposed to the sale of CAM “when they have demonstrated benefits for patients, have minimal risks, and the patient is making an informed choice”. What the clauses appear to do, instead, is to allow the sale of CAM when an individual pharmacist believes that these products “have demonstrated benefits for patients, have minimal risks, and the patient is making an informed choice”.
This is a subtle, but important, difference. We think that the proposed code would allow for a pharmacist to sell homeopathic products, for example, simply by holding a sincere belief that these products “have demonstrated benefits for patients, have minimal risks, and the patient is making an informed choice”. This belief would not accord with reality, but merely holding it appears to be sufficient to circumvent this code.
To paraphrase the songwriter Tim Minchin, “what do you call Complementary and Alternative Medicines (CAM) that have demonstrated benefits for patients? Medicine”
4. Are there any other comments you would like the Council to consider?
Yes.
We would like to see the Pharmacy Council produce a set of clear rules for when a product can be deemed to be ineffective; a clear, transparent process outlined for dealing with complaints against pharmacies selling products that are not evidence based; and clear penalties for pharmacies that are found to be in breach of these guidelines. The new code does not appear to allow for this to happen, and instead we suspect that it is unlikely that the Pharmacy Council will end up using this new code to censure a pharmacy for selling ineffective health products.
We would be interested to find out, given the many apparent breaches of the current code of ethics where pharmacies are selling CAM without credible evidence of efficacy, how often pharmacies have been found by the Pharmacy Council to be in breach of the code, and what action was taken in each case.
We would also like to see the Pharmacy Council introduce a way to effectively measure whether pharmacies are following the code of ethics – some method of proactively auditing the compliance of pharmacies. These checks would have to be incognito, to ensure that an accurate measure is taken of how pharmacies are promoting CAM to patients.
