Wednesday, February 24, 2010

New Zealand Pharmacy Ethics in Relation to Homeopathy in the Wake of Homeopathy Report

Earlier this year I wrote a post (along with fellow Sciblogger Grant) concerning the sale of homeopathic remedies in pharmacies. Monday night saw the release of England’s Science and Technology Committee’s “Evidence Check 2″ report on Homeopathy (also ably covered by Grant). One of the issues covered by the report is that of pharmacy responsibilities regarding sale of these remedies. Essentially the report recommended that sales continue but with adequate disclaimers stating that there is no scientific evidence that homeopathic products work beyond the placebo effect.

I see this as a compromise between commercial freedom to sell safe, though not necessarily effective, products and patient informed consent. It’s reasonable even if I disagree that it is ideal. Regardless, I thought it was a good excuse to look once again at our own pharmacies and see how the selling of scientifically unsupported remedies aligns with their professional responsibilities.

Enquiring into this area I was directed to the Pharmacy Council Code of Ethics for pharmacists. The Pharmacy Council seems to fill the function of professional association and regulatory body for pharmacists their functions including:

prescribe the qualifications required for scopes of practice within the profession, and, for that purpose, to accredit and monitor educational institutions and degrees, courses of studies, or programmes

and

consider the cases of health practitioners who may be unable to perform the functions required for the practice of the profession

Perusing the Code of Ethics (which may be found Here) I found a number of sections that I feel should preclude pharmacists from selling homeopathic remedies in good conscience. In order to try and represent the spirit of the code as accurately as possible I have included here both the relevant over-arching Principles that pharmacists should strive for as well as the Specific Obligations that I feel make my point (any emphases are mine).

The first principle is one of patient autonomy:

Principle 1: Autonomy

The pharmacist shall promote patient

self-determination, respecting the

patient’s right to understandable

information, privacy, and confidentiality

1.4 Professional services

Where the patient is seeking or receiving, from the

pharmacist or from other personnel for whom he or

she has responsibility, any professional service or

intervention, the pharmacist must ensure that the

patient is provided with credible, understandable

information about reasonably expected results,

outcomes or effects of the service or intervention, any

risks of receiving the service or intervention, and any

insufficiency of evidence about the efficacy of the

service or intervention, to allow the patient to make

an informed choice.

This to my reading implies that should pharmacists sell homeopathic remedies they are obligated to inform the patient of the lack of scientific underpinnings for the use of the remedy. One of the objections I have run into regarding the sale of these remedies in pharmacies is that they are commercial enterprises and are within their rights to sell products regardless of their medicinal value. This is partially true but these remedies are specifically sold to treat symptoms, not as entertainment, confection or cosmetic. The Code has several entries covering this aspect the first of which is:

1.5 Independent information

The pharmacist must ensure that their advice is

independent of personal commercial considerations.

Does this not imply that the sale of unscientific medicines should not be undertaken simply because it make financial sense? We will return to this point later.

The next Principle covers patient needs:

Principle 2: Beneficence

The pharmacist shall optimise medicines

related health outcomes for the patient

according to their concerns, needs,

cultural values and beliefs

2.2 Quality use of medicines

The pharmacist must provide scientifically-based,

unbiased medicines information to healthcare

providers, patients and the community in order to

optimise medicines related health outcomes.

My reading of this point leads me to understand that any information provided regarding pharmacy products must have scientific backing and moreover must not be biased by the pharmacist’s own views. Any such information regarding homeopathy must therefore be negative.

But, what if the pharmacist is not asked for this information? After all, I do not usually go in asking for a lecture if I already think I know what I need. I think the next obligation covers this instance:

2.8 Involvement in sale of medicines and other

therapies

The pharmacist must be involved and intervene in the

sale of any medicine, complementary therapy, herbal

remedy or other healthcare product whenever this is

necessary to ensure a reasonable standard of

pharmaceutical care.

Scientifically speaking homeopathy should not be considered to encompass a “reasonable standard of pharmaceutical care”.

The next Principle of relevance concerns fairness:

Principle 4: Justice

The pharmacist shall practise fairly and

justly and promote family, whanau and

community health

4.4 Commercial interests not to override good

practice

The pharmacist must ensure that commercial interests

are not permitted either to override the independent

exercise of their own professional judgement on

behalf of a patient or to compromise the standard of

care provided by them or to affect their cooperation

with other healthcare providers.

Once again the issue of financial gain over patient care is addressed with commercial interests coming off second best when the standard of care is concerned.

The next Principle is one I feel is of especial importance when the reputation of pharmacists in the wider community is considered and their self representation in the media is a factor (remember, they’re the health professional you see most often). This is trustworthiness, pharmacists are seen as, and promote themselves as, first and foremost medical professionals not business interests. The sale of homeopathic medicines is antithetical to this position and undermines their credibility in this regard, in direct contraction to the Code of Ethics as follows:

Principle 7: Trustworthiness

The pharmacist shall act in a manner

that promotes public trust in the

knowledge and ability of pharmacists

and enhances the reputation of the

profession

7.7 Non-medical goods and services

The pharmacist must not purchase or sell from a

pharmacy any product or service which may be

detrimental to the good standing of the profession or bring the profession into disrepute.

If the sale of scientifically worthless remedies such as homeopthy does not do this I don’t know what would, perhaps offering Therapeutic Touch?

Finally the Principle of dignity undermines the pharmacist’s sale of unsupported medicines:

Principle 8: Dignity

The pharmacist shall provide

information about professional services,

medicines and healthcare products in a

dignified manner without making

exaggerated or unsubstantiated claims

8.4 Medicines not ordinary articles of

commerce

A pharmacist must only participate in promotional

methods that do not encourage the public to equate

medicines with ordinary articles of commerce.

If the previous examples of why remedies should not be sold with the sole purpose of earning money for the pharmacist this should put that argument to rest. The sale of medicines (which many people consider homeopathy to be) should not be equated with ordinary articles of commerce. This puts the lie to arguing that these remedies are simply another commodity to be bought and sold like chewing gum regardless of therapeutic value.

8.8 Evidence of efficacy

The pharmacist must only promote to a potential

purchaser that any medicine, complementary therapy,

herbal remedy or other healthcare product associated

with the maintenance of health is efficacious when

there is credible evidence of efficacy.

This last obligation explicitly refers to promotion of a therapy to a patient by the pharmacist which I don’t think any reputable pharmacist would do for homeopathy but arguably the presence of the product in the store constitutes an implicit promotion of it to potential customers. This point goes back to the principle of trustworthiness, the public trusts the pharmacist to stock efficacious products. To include unscientific therapies among their wares undermines and betrays this trust. Perhaps I am naive to think so but I think the Pharmacy Council’s own Code of Ethics backs me up when I say that we should hold pharmacists to a higher standard than your average shop owner.

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