Ethical Pharmacy Practice 6: An Opportunity for Change

Ethical Pharmacy Practice 6: An Opportunity for Change

I’ve written a lot about ethical pharmacy practice in New Zealand, advocating for New Zealand pharmacists to choose not to promote or sell healthcare products that aren’t supported by credible evidence of efficacy. I’ve also complained in the past about misleading advertising of ineffective healthcare products in pharmacies. I strongly believe that we should be able to feel confident going into a pharmacy that we will get evidence-based advice on purchasing effective healthcare products, and not be misled.

The Pharmacy Council is responsible under the Health Practitioners Competence Assurance Act for setting standards of ethical conduct for pharmacists in New Zealand. Section 6.9 of their current Safe Effective Pharmacy Practice Code of Ethics 2011 states 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.

The Pharmacy Council is currently proposing to change this section of their code of ethics to the following wording, prior to the entire code being reviewed in 2016:

Only supply or promote any medicine or herbal remedy where there is no reason to doubt its quality or safety and when there is credible evidence of efficacy.
Only supply any complementary therapy or other healthcare product where there is no reason to doubt its quality or safety and when sufficient information about the product can be provided in order for the purchaser to make an informed choice with regard to the risks and benefits of all the available treatment options.

I have referred to section 6.9 of that code of ethics many times, as I feel it is a great standard which should offer a significant degree of consumer protection. However, despite there being ample evidence that homeopathic products are ineffective, most New Zealand pharmacies continue to sell them. I have heard many stories of people encountering misinformation about homeopathy in New Zealand pharmacies that sell it. The section of the code of ethics that is meant to protect consumers against this simply has not been enforced.

Even when the Society for Science Based Healthcare lodged a formal complaint directly to the Pharmacy Council about an instance where someone was recommended and sold a homeopathic product in a pharmacy (but didn’t realise it was homeopathic until they got home), both the Pharmacy Council and the Health and Disability Commissioner (who had the complaint forwarded to them from the Pharmacy Council) refused to enforce it. Neither of them were willing to tell pharmacies that they could not sell any specific product.

So although I really do like the old wording, I think this change could be an opportunity to turn the code of ethics into something that really can help consumers. As part of the proposed change, the Pharmacy Council is calling for submissions on it, so I see this as an opportunity to make things better.

At the Society for Science Based Healthcare, we have prepared a proposal to submit before the deadline of 5pm on the 1st of October 2015. I’ve included this proposal below for you to read, and you can also find it on our site: Pharmacy Council Code of Ethics Proposal

If you agree with our submission and would like to support it, please leave a comment below or get in touch. You can contact the Society for Science Based Healthcare via email at We will be sending this submission to the Pharmacy Council on Wednesday the 30th of September Thursday the 8th of October (the Pharmacy Council extended their deadline).

Of course, you can also send in your own submission on this proposal. Details on how to do this can be found in the Pharmacy Council’s proposal document.

Last year the Society for Science Based Healthcare submitted a formal complaint to the Pharmacy Council regarding an Auckland pharmacy that had misled a consumer by promoting a homeopathic product as effective, then selling it to them. Although the council did write to the pharmacy, to our knowledge it did not consider whether or not the Safe Effective Pharmacy Practice Code of Ethics 2011 section 6.9 had been breached as alleged in the complaint. The council forwarded the complaint to the office of the Health and Disability Commissioner, but both organisations were unwilling or unable to enforce it as this would involve telling a pharmacy which products they can or cannot sell. Neither the Pharmacy Council nor the Health and Disability Commissioner seems willing to enforce a code of ethics when this would involve telling pharmacists which products they can or can’t stock.

The Pharmacy Council’s proposal document notes that the Council “has a duty to protect the public”. A code of ethics which is not enforced may as well not exist. We feel the addition of a new section requiring that sufficient information can be provided to consumers in order for them to make an informed choice regarding whether or not to purchase a complementary therapy is in line with what consumers could reasonably expect. We hope that complaints about potential breaches of this standard would be considered by the Pharmacy Council or another body, so that it can offer some measure of consumer protection.

However, we think the wording could be improved by changing “when sufficient information about the product can be provided” to “when sufficient information about the product is provided”.

It is currently widespread practice for New Zealand pharmacies to supply and promote healthcare products which are not supported by credible evidence of efficacy, such as homeopathic products. This is despite several prominent healthcare organisations, including the Royal Australian College of General Practitioners (RACGP) and the New Zealand Medical Association (NZMA), speaking out against these products being prescribed or promoted by healthcare practitioners. Most recently, the Pharmaceutical Society of Australia (PSA) published a statement on the 10th of September that:

PSA does not support the sale of homeopathy products in pharmacy.

When it comes to pharmacies stocking healthcare products that are not supported by credible evidence of efficacy, or for which there is credible evidence that they are not effective such as in the case of homeopathic products, it is important to weigh up the potential risks and benefits.

On the one hand, if these products are available in a pharmacy consumers will be more likely to visit a pharmacy to purchase them.. This can put them in a position where a pharmacist is able to provide them with evidence-based advice, so they can make an informed decision on purchasing the best product for whatever problem they are experiencing. If the product were not available in a pharmacy, they may instead seek it from a source which would not provide them with this information, or which may misinform them.

However, there are certain circumstances in which any potential for this benefit can be lost completely:

  1. If consumers are sent away from pharmacies when they ask about these products. We are aware, for example, of numerous instances of people being recommended by pharmacy employees that they should instead go to a dedicated natural health product store for information on homeopathic products.
  2. If pharmacists create an environment in which consumers are likely to be misled, for example by employing a homeopath to give non evidence-based advice to their customers.
  3. If a pharmacy sells these products online, in which case they can be purchased without any opportunity for a pharmacist to provide enough information for consumers to make an informed decision.

On the other hand, when a product is available in pharmacies it is likely to lead consumers to believe that it is an effective, evidence-based product. This is often used as a selling point by products which are not supported by evidence. For example, the homeopathic product No-Jet-Lag advertises itself as being available at “Most chemists nationwide“. In this way, pharmacists stocking products without credible evidence of efficacy can also contribute to an increase in consumer demand for them. Supplying a product in a pharmacy is effectively also a form of promotion.

Although some benefit can be gained from pharmacists stocking products that are not backed by credible evidence of efficacy, in order for consumers to make an informed choice about purchasing these products it is important that they be made aware of this lack of evidence. It should be an ethical requirement that pharmacists will not promote any healthcare product where there is not credible evidence of efficacy.

The Pharmacy Council’s consultation document for this proposed change says that:

In instances where there is credible evidence to suggest a specific complementary and/or alternative medicine/product lacks efficacy, pharmacists should not promote or recommend its use

We agree with this, but feel it has not been clearly conveyed in the proposed new wording for section 6.9. We feel it would be useful for this to be included more clearly.

We also feel that the important distinction between healthcare products is not whether they are considered a complementary therapy, herbal remedy, or medicine, but whether or not they are supported by credible evidence of efficacy. However, we recognise that medicines and herbal remedies typically have greater risk than other healthcare products, so it may be more suitable to have more stringent requirements for when pharmacists may supply them.

With this in mind, we propose the following wording:

Only supply any medicine or herbal remedy where there is credible evidence of efficacy.
Only promote any complementary therapy or other healthcare product where there is credible evidence of efficacy.
Only supply or promote any medicine, herbal remedy, complementary therapy or other healthcare product where there is no reason to doubt its quality or safety and when there is not credible evidence to suggest that the product lacks efficacy.
Provide sufficient information about any medicine, herbal remedy, complementary therapy or other healthcare product product in order for the purchaser to make an informed choice with regard to the risks and benefits of all the available treatment options.

Finally, we feel that certain words could benefit from guidance on their definitions. In our 2014 complaint we raised with the Pharmacy Council that the meaning of “credible evidence” was not clear but were informed it was not their role to clarify this. However we feel it would be useful for an organisation such as the Pharmaceutical Society to publish guidance notes on this after the code has been updated.

We also feel that the meaning of “promote” should be clarified in the same way so it is clear where exactly the line is drawn. For example, we feel it is currently unclear which of the following activities might be considered promotion for the purpose of this code:

  • Advertising the availability of a healthcare product at a pharmacy
  • Featuring a product on a pharmacy’s website
  • Including an advertisement for the product on a pharmacy’s website on a page from which it can be purchased

If you agree with our submission and would like to support it, please leave a comment below or get in touch. You can contact the Society for Science Based Healthcare via email at We will be sending this submission to the Pharmacy Council on Wednesday the 30th of September Thursday the 8th of October (the Pharmacy Council extended their deadline).

Ethical Pharmacy Practice 5: Looking for Leadership

Pharmacy by russellstreet on Flickr CC BY-SA 2.0

In New Zealand, the Pharmacy Council is legally responsible under section 118(i) of the Health Practitioners Competence Assurance Act 2003 for setting standards of ethical conduct for New Zealand pharmacists. As part of this, they’ve written a Safe Effective Pharmacy Practice Code of Ethics, which requires that:


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.

Safe Effective Pharmacy Practice Code of Ethics Section 6.9

Last November, a case was brought to our attention at the Society for Science Based Healthcare of a salesperson in an Auckland pharmacy recommending and selling a homeopathic product to someone who didn’t realise until they’d bought the product and taken it home that it was homeopathic and that there is no credible evidence of its efficacy. The society wrote a formal letter of complaint to the Pharmacy Council about this, alleging that it was a clear violation of this section of their code of ethics.

As part of this complaint, we made a series of recommendations:

As a result of this complaint, we want pharmacists to have the opportunity to do the right thing and fulfill their ethical obligations. In order to achieve this, we suggest that the Pharmacy Council consider the following courses of action:

  1. Advise [the pharmacy] of their ethical obligation not to purchase, supply, or promote any healthcare product where there is not credible evidence of efficacy.
  2. Recommend that [the pharmacy] review their stock, starting with [the homeopathic products we found in their store], to ensure that they meet this ethical obligation. If they are not currently aware of credible evidence of efficacy for these products, they should request it from the manufacturer and, if they are not supplied with credible evidence of efficacy within a certain specified timeframe (we recommend 10 working days) to remove the products from sale.
  3. Recommend that [the pharmacy] undertake training of their staff to ensure that no one is giving unfounded healthcare advice to customers.
  4. Relay these recommendations to other New Zealand pharmacies so that they are also given the chance to ensure that they meet this ethical obligation.
  5. To assist pharmacies in evaluating whether or not a healthcare product is supported by credible evidence of efficacy, the Pharmacy Council should develop and publish guidelines regarding what constitutes credible evidence of efficacy. This need not be a strict requirement so much as a useful guide that pharmacists can use to establish a consistent minimum standard of evidence.

The Society for Science Based Healthcare

The Pharmacy Council said that creating a guideline for standards of evidence was not their role, although they suggested that it may be appropriate for the Pharmacy Guild or the Pharmaceutical Society to create such a guideline and forwarded the letter of complaint on to these organisations. To my knowledge, neither of them has created any such guideline.

The Pharmacy Council also wrote to the pharmacy in question. When I visited it some months later I found the same homeopathic products were still for sale, although they had at least been moved behind the counter.

I don’t know if that particular pharmacy still actively promotes and tries to sell these products, but on Twitter the other night I was told of another case where a sales assistant at a New Zealand pharmacy tried to sell a homeopathic product while clearly lacking any useful knowledge about homeopathy:

In response to the Society for Science Based Healthcare’s complaint, the Pharmacy Council also offered to remind pharmacists of their obligations with respect to selling any alternative medicines in their next newsletter. Last week, 9 months after having received our complaint, they finally published this newsletter. Here’s what they said:

Complementary and Alternative Medicines — Best Practice Guidance for Pharmacists

As medicines experts, pharmacists have built their reputation on providing accurate, unbiased information on the use, safety and effectiveness of all medicines, including complementary and alternative medicines. Pharmacists must be familiar with the latest information on the medications they supply to their patients, and seek independent information to maintain an objective viewpoint so they can help individuals make informed choices (Competence Standard O1.2.4).

Homeopathy in particular has had much attention over recent times, specifically regarding its plausibility and efficacy. Nonetheless, many people, including some healthcare professionals, continue to use or practise homeopathic medicine and advocate its safety and efficacy.

It is not Council’s purpose to endorse any particular complementary or alternative medicine or practice; however, Council believes it is necessary for pharmacists to have a basic knowledge of complementary and alternative medicines to engage with and advise patients appropriately.

This approach also ensures pharmacists can meet their duty of care to patients and the profession. Pharmacists should be able to counsel patients about complementary and alternative medicines’ general use, the current evidence and any safety issues, including their use with other medications.

Pharmacy Council July 2015 Newsletter

Although I’m glad to finally see a statement from the Pharmacy Council about homeopathy, I am disappointed at the weakness of this statement. Especially in contrast with their clear and strong code of ethics that requires pharmacists only sell healthcare products with credible evidence of efficacy – something that is clearly not the case for homeopathy.

However, I’m aware that the Pharmacy Council’s role is restricted to the responsibilities set out in the Health Practitioners Competence Assurance Act. So perhaps it would be better to expect professional organisations representing pharmacists to speak out against this. We have recently seen this to be the case with organisations of other healthcare professionals, such as the New Zealand Medical Association whose chair recently agreed on national radio that homeopathy is “just rubbish”.

In New Zealand there are two professional organisations (that I’m aware of) that represent pharmacists: the Pharmacy Guild and the Pharmaceutical Society. They are not so limited in position by the law as the Pharmacy Council, so I would hope to see stronger positions supporting science based healthcare from them.

Over the weekend, the annual Pharmacy Awards were held, hosted by both the trade magazine Pharmacy Today and by the Pharmacy Guild. Surely, at an event like this we should expect to see a celebration of outstanding examples of pharmacies providing quality healthcare services, right? For the most part, I hope, that may have been the case, but I was rather disheartened to see one award that flies in the face of this goal.

The official description for the Best Complementary Healthcare Campaign award is (with my emphasis added):

To win this award you need to have come up with a complementary health promotion or ongoing programme that has contributed to improved retail result, in areas such as, vitamins, supplements, sports nutrition or homeopathy.

Pharmacy Awards | Best Complementary Healthcare Campaign

I was shocked and dismayed to see this. Pharmacists should win awards for providing an excellent healthcare service. Not for selling more fake medicine.

Of the previous winners listed, one is Auckland pharmacist Martin Harris. I’ve written about him briefly before in another article about homeopathy being sold in New Zealand pharmacies, quoting him from a Pharmacy Today article in which he defended the practice:

Auckland pharmacist Martin Harris says there is good evidence for homeopathy in the field of quantum physics.

“There’s no placebo-controlled, double-blind randomised controlled trials using one remedy and one result because homeopathy doesn’t work that way, it works on energy,” Mr Harris says.

Conventional medicines have been proven to have side effects and contraindications, but pharmacies still sell them, he says.

Mr Harris, who specialises in nutrition medicine, admits he is no expert when it comes to homeopathy, and his Massey pharmacy sells only a few homoepathy products.

But he would be very disappointed if he was not allowed to sell the products as an option, he says.

Pharmacists support patient choice with homeopathy – Pharmacy Today

Mr Harris last won the “Best Complementary Healthcare Campaign” award in 2012, but perhaps you could hope the pharmacist community has since stopped celebrating such massively misguided interpretations of the evidence (and ethics) surrounding homeopathy. Unfortunately, this does not seem to be the case, as Mr Harris took home the Supreme Award at this year’s Pharmacy Awards despite selling homeopathic products in his pharmacy and appearing to be proud of it.

The pharmacist community makes no secret of the fact that it wants to play a larger role in New Zealand’s healthcare system, calling for changes such as allowing pharmacists to dispense contraceptive pills without a prescription and and provide a substitute for a GP’s services in some circumstances. From my position as an external onlooker, it does seem like there is a certain degree of pharmacists wanting to extend their practice and doctors trying to defend their turf, although I also think both sides have good arguments to make. So long as any changes primarily act to serve the healthcare needs of the public, I’m happy.

However, running a successful pharmacy is a balancing act between running a profitable retail store and providing a reliable healthcare service. Pharmacies can do a great job at improving access to essential healthcare services such as vaccinations and smoking cessation, but on the other hand many of them also boost their profits by selling healthcare products that do nothing aside from emptying your wallet. A recent opinion piece in Pharmacy Today that acknowledged this balance recommended upselling Vitamin C when customers asked about cold/flu products. While this would surely increase the pharmacy’s profits, the best available evidence doesn’t show that Vitamin C supplementation can help with the common cold or influenza.

There is a clear need for leadership within the pharmacist community regarding putting customers’ healthcare needs before profits. We trust pharmacies to provide us with reliable healthcare products and advice, but so long as they keep fake medicine on their shelves I’m not convinced they deserve this trust. To quote the hover text of this relevant xkcd strip:

I just noticed CVS has started stocking homeopathic pills on the same shelves with–and labeled similarly to–their actual medicine. 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.

Randall Munroe – xkcd: Alternative Literature

I believe pharmacists generally do care about providing the best health outcomes for their customers. What I want to see is more pharmacists putting patients before profits, following in the footsteps of Australian pharmacist Grant McGill by choosing to remove homeopathic products from their shelves.

Pluto and Charon Up Close

I was born in June 1989. Just 2 months after that, the Voyager 2 spacecraft flew past Neptune on its way out of our solar system and for the first time ever we saw real close up pictures of the solar system’s outermost giant planet.

Of course, I was too young to remember this, but it means that as I’ve been growing up I’ve been able to see amazing and beautiful photos of the 8 planets of our solar system. Pluto is no longer classified as a planet, but nonetheless it has been conspicuously missing from this set for my whole life.

That is, until this week. After travelling for 9 1/2 years, the New Horizons spacecraft finally flew past the only remaining “classic planet” that we had not yet explored. We are seeing real close up pictures of a new world, one that we’ve never seen like this before. And it’s glorious:

Pluto in glorious colour | Image by NASA

This image is made by compositing the high resolution black and white image taken from LORRI (LOng Range Reconnaissance Imager) and colour imagery taken from Ralph (New Horizons’ colour imager). It was sent back to Earth by New Horizons prior to its exciting flyby of Pluto on Tuesday night (closest approach was 11:50 pm Tuesday 2015/07/14, New Zealand time), having been taken 16 hours ahead of time.

It sent back data ahead of time because during the 24 hour flyby New Horizons was busy collecting data. All of its instrumentation is built into the body of the spacecraft, so in order to point them the whole spacecraft needs to rotate. This means that in order to talk to Earth it has to look away from Pluto, so we had to wait in patient agony while it was collecting data.

After the flyby, New Horizons sent a packet of telemetry data back to Earth, containing information about how its systems were doing. The flyby was the most dangerous part of the mission; travelling at about 14 kilometres per second, an impact with even a tiny piece of debris could absolutely destroy the spacecraft and near Pluto is the most likely place to encounter such debris. Since New Horizons was travelling into the unknown, no one could guarantee this wouldn’t happen, although NASA was confident that the chance of such a collision was very low.

The “Phone Home” signal reached Earth at 12:52:37 pm on Wednesday 2015/07/15 (New Zealand time), telling us that everything went perfectly. New Horizons survived the flyby! The next stage of the mission is to send down all the data it collected, but getting data back from Pluto is hard. Even at the speed of light signals take over 4 hours to cross the distance, and the transfer rate varies from just 1 kb/s to a whopping 4 kb/s. It’ll take around 16 months to get all the data from the flyby down to Earth.

This morning (7am Thursday 2015/07/16 New Zealand time) NASA held a press conference in which they released some new images, including a high resolution image of Pluto’s largest moon Charon:

Pluto’s largest moon Charon | Photo by NASA

There’s a lot of interesting stuff going on here, for example that little notch you can see in the upper right is a canyon that’s 6-10 kilometres deep. So deep that you’re looking through it to the space behind Charon. The dark polar region at the top, which has been informally named “Mordor”, is also interesting. The fact that impact craters allow lighter material to peek through makes it seem as though the dark material on the surface is just thin layer. Apparently one possible cause of this could be some form of atmospheric transfer from Pluto.

At the press conference, NASA also released a much higher resolution of an area in the “heart” region of Pluto. The heart has been named Tombaugh Regio after Clyde Tombaugh, who discovered Pluto in 1930. Although he died in 1997, New Horizons carried some of his ashes on board to honour his request for his ashes to be taken to space. Here’s the image:

Zoomed in on Tombaugh Regio, Pluto (rotated 90 degrees counterclockwise) | Photo by NASA
Zoomed in on Tombaugh Regio, Pluto (rotated 90 degrees counterclockwise) | Photo by NASA

This is a very interesting image. The first thing you might notice is the mountains. These are about 3.5 kilometres tall, and almost certainly made of water ice. Also, there are no impact craters in this photo. That’s strange, really strange. It means that Pluto’s surface is new, probably less than 100 million years old.

Pluto is the first icy world we’ve seen that isn’t also the moon of a gas giant. Icy moons like Saturn’s moon Enceladus get stretched and heated by the tidal forces placed on them due to their close proximity to much more massive bodies. Tidal forces are caused by a gradient in the strength of gravity – parts of a body closer to a source of gravity experience a stronger force than those further away, and when this gradient is strong (which happens when you’re nearby a much larger body) the tidal forces are greater. The Moon’s tidal influence on Earth drives our oceanic tides, and the extreme tidal forces you’d experience crossing the event horizon of a black hole are what would turn you into a space noodle.

But Pluto isn’t near any other large bodies that could exert this sort of tidal force on it. Charon is around half its size, but Pluto and Charon are both tidally locked to one another, meaning the same parts always face each other, so the tidal forces never change. There must be some other process driving geological activity on Pluto, and we don’t know what that is yet.

There’s a lot more interesting stuff coming out of the New Horizons mission, and of course much more to come now that we’re getting data back. I recommend you follow Emily Lakdawalla’s blog at the Planetary Society for up to date and accurate information. Her latest article is a great overview of what we learned at this morning’s NASA press conference.

This isn’t the end for New Horizons, even after the 16 month period of sending all its data down it’s going to continue into the outer region of the solar system known as the Kuiper belt, and hopefully visit one or two more icy worlds.

For now, though, we have finally completed our reconnaissance of the solar system. This is the end of the beginning.

Ethical Pharmacy Practice 4: Paving the Way

This year has not been a good year for homeopathy. There have been many blows to the industry in the form of more research finding it ineffective, position statements from organisations of health practitioners discouraging its use, and successful complaints to regulatory authorities. And this trend shows no signs of abating.

In March, the Australian National Health and Medical Research Council (NHMRC) published their Statement on Homeopathy, following a rigorous review of the evidence encompassing over 50 systematic reviews. The conclusion was clear:

there are no health conditions for which there is reliable evidence that homeopathy is effective.

Statement on HomeopathyNational Health and Medical Research Council (Australia)

Most organisations of medical professionals have codes of ethics that make it clear prescribing or selling treatments which are not supported by evidence is unethical. Putting two and two together, these ethical standards and the clear findings of the NHMRC have prompted the Royal Australian College of General Practitioners (RACGP) to publish a position statement on homeopathy:

The RACGP supports the use of evidence-based medicine, in which current research information is used as the basis for clinical decision-making.

In light of strong evidence to confirm that homeopathy has no effect beyond that of placebo as a treatment for various clinical conditions, the position of the RACGP is:

  1. Medical practitioners should not practice homeopathy, refer patients to homeopathic practitioners, or recommend homeopathic products to their patients.
  2. Pharmacists should not sell, recommend, or support the use of homeopathic products.
  3. Homeopathic alternatives should not be used in place of conventional immunisation.
  4. Private health insurers should not supply rebates for or otherwise support homeopathic services or products

Position statement: homeopathyRoyal Australian College of General Practitioners

Following this, in an interview with Radio New Zealand the chair of the New Zealand Medical Association (NZMA), Dr Stephen Child, made the NZMA’s position clear:

Susie Ferguson: So Australian doctors being told not to be prescribing this, and they should come off the shelves as well so people couldn’t even buy them over the counter. Would you support that happening here?

Dr Stephen Child: Well yes, it’s an ineffective treatment. It’s basically giving a glass of water or a sugar pill to patients, and I think you would consider that unethical if I gave you a sugar pill and charged you eighty dollars for that.

Doctors Told to Stop Prescribing Homeopathic ProductsRadio NZ

Homeopathy has never been supported by evidence, but the recent findings from the NHMRC have strengthened the scientific consensus and allowed many organisations to take a stronger stance against it.

When there is also a clear ethical mandate not to promote or provide healthcare that is not supported by evidence, all it takes to put two and two together is a little courage.

Now, Kingsley Village Pharmacy in Australia is paving the way, stating that their “Homeopathic products [are] going in the bin”:

The owner of Kingsley Village Pharmacy, pharmacist Grant McGill, has explained why he made this decision:

I’ve never promoted or recommended these products but I’ve accepted them passively and I felt a bit hypocritical having them on the shelves.

I operate a bit differently to corporate chains and believe a pharmacy should be professional rather than a place selling a lot of cosmetics.

If someone comes in with sleep problems, I will look at what is known to help and address things like sleep hygiene issues, rather than recommending flower essences.

Pharmacist bins ‘crap’ homeopathic productsThe West Australian

When the Twitter account for the pharmacy was asked if they thought their customers would notice or care about the change, they said:

A tweet from Grant McGill echoed the same sentiment as the reason for this change:

Through the Society for Science Based Healthcare, I have called previously for New Zealand pharmacists to stop selling homeopathic products.

When I had an complaint upheld against an Auckland Pharmacy for a misleading display stand for the homeopathic product No-Jet-Lag, that pharmacy promised to remove the product from sale and I hoped that New Zealand pharmacists would follow their example.

But it isn’t feasible for me to complain about each and every homeopathic product sold in a New Zealand pharmacy (although that hasn’t stopped me complaining about some). New Zealand pharmacists need to follow Kingsley Village Pharmacy’s example and remove the products not because complaints have been upheld, but because there’s no evidence they work so it’s clearly the ethical thing to do.

The Pharmacy Council of New Zealand is the body legally responsible under the Health Practitioners Competence Assurance Act for setting standards of ethical conduct to be observed by pharmacists on this side of the Tasman. To this end, they have published a Safe Effective Pharmacy Practice Code of Ethics. Section 6.9 of this code is very clear when it comes to pharmacists’ ethical responsibilities surrounding evidence-based healthcare:

YOU 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

Safe Effective Pharmacy Practice Code of EthicsPharmacy Council of New Zealand

Despite this, as mentioned in the Radio New Zealand interview with Dr Stephen Child from the NZMA, “In New Zealand, many pharmacies stock a range of homeopathic treatments”. When New Zealand pharmacists have been challenged on this point, their defences have ranged from bizarre misunderstandings of the evidence (e.g. “Auckland pharmacist Martin Harris says there is good evidence for homeopathy in the field of quantum physics”) to arguments that patient choice overrides their ethical responsibility:

But homeopathy is part of a holistic approach to healthcare, according to Auckland pharmacist Caleb Townsend, whose Lincoln Mall Pharmacy has qualified homeopaths onsite.

There is not one system that suits all people, Mr Townsend says in an email.

“Homeopathy is seen at this pharmacy as complementary to conventional medicine, in much the same way as acupuncture, vitamins and herbs are.”

Many patients believe homeopathy has been of benefit and they should be given the freedom to choose it if they want, he says.

“We have not yet become a society where cultural beliefs are legislated out of existence.”

Pharmacists Support Patient Choice with HomeopathyPharmacy Today

Dr Child provided a response to this line of argument in his interview:

Well, again as I say they argue that it’s mainly free trade basically, or a free market, so if people are willing to pay the money, and they think it works, then what are they doing that’s wrong?

And my problem with that argument though is to say that if they are telling the patient that it works then they are misleading in their advertising and even the Consumer Guarantee Act that it’s not allowed to mislead the consumer.

Second of all there’s an imbalance of a relationship when you come in to see a health practitioner and you’re the patient.

And thirdly when you’re suffering and you’re unwell you’re possibly not in a position to make an informed, balanced decision as a consumer. So I’m not even sure the free market argument would suggest that it would be legitimate practice.

Dr Stephen Child, Doctors Told to Stop Prescribing Homeopathic ProductsRadio NZ

The Society for Science Based Healthcare has also been in touch with Green Cross Health, an umbrella organisation that owns brands such as Unichem and Life Pharmacy and represents over 300 New Zealand pharmacies, to ask if they have a commitment to uphold section 6.9 of the Pharmacy Council’s code of ethics. Despite following up multiple times, the closest thing to a direct answer Green Cross Health has given to this question is:

While we support best practice we are also supportive of consumer choice.

Green Cross Health

The remaining defence of this practice is that pharmacists do more than provide healthcare, they also have to run a business. Following his Radio NZ interview, Dr Child alluded to this in an article from Pharmacy Today following his Radio NZ interview:

“Medically, it’s unethical to provide a treatment that’s not proven,” Dr Child says.

However, he has stopped short of telling pharmacies not to sell homeopathic products.

“It’s not really appropriate, I believe, for the medical profession to tell pharmacies how to run their business and how to act.”

Pharmacies have a difficult balance between providing healthcare and running a business, Dr Child says.

“It must be very difficult because they are a business as well.”

Homeopathy discredited again on both sides of the TasmanPharmacy Today

There is a range of behaviours among New Zealand pharmacies when it comes to promotion of homeopathy. Some few pharmacists refuse to sell the products at all, whereas many stock them but might not actively promote or recommend them. On the extreme end of this ethical scale, there are pharmacies like Lincoln Mall Pharmacy in Auckland, which promotes “homeopathic consultations” from homeopaths within the pharmacy, and Simillimum Pharmacy in Wellington, which describes itself as a “homeopathic pharmacy”.

The fact that there are some pharmacists who operate without relying on profits from selling homeopathic products indicates that it is entirely possible. Those pharmacists who passively sell them likely don’t rely on the profits made from those products as the difference between financial success and failure, so I’d hope they wouldn’t use higher profits as a justification for breaching their ethical obligations.

If any pharmacy has got to the level where their business would fail financially were it not for homeopathic products and services that they sell, then their business practices would blatantly violate their ethical responsibilities. I should think the risk of financial failure in a case like this should certainly not be an acceptable excuse for such unethical conduct.

Kingsley Village Pharmacy in Australia has set a great example for all pharmacists, having the courage to take a stand on ethics and stop selling homeopathic products. New Zealand pharmacists who currently have them on their shelves should follow in these footsteps.

To borrow Grant McGill’s words, pharmacists need to stand up for patient outcomes.

Natural Curiosity: Stretching Reflections 2

After my earlier post on this topic, I talked to a few people about why they thought these stretching reflections happened. There were a few different ideas, and when I talked to my brother about it he pointed out something in one of the images on my last post that was inconsistent with my explanation.

Sun Reflection | Photo by oboejoe92 on Flickr CC BY-NC 2.0
Sun Reflection | Photo by oboejoe92 on Flickr CC BY-NC 2.0

My hypothesis would have predicted that reflections would stretch down, but not up. However, looking more carefully at this image, the reflection of the Sun is clearly both stretching down and stretching up to the horizon. So it can’t be explained just by the surface appearing to be rougher as it gets closer to the observer.

However, in that discussion we came up with a new hypothesis. As I said in my last post, if we imagine a rough surface as being made up of a lot of small flat mirrors at random angles, some of them will be at the correct angle to reflect light toward you so you’ll see a reflection in those places. The new hypothesis was that the angle required for this would be less extreme above and below the reflection than to the side of it.

In order to test this, I needed 3 things:

  1. A light source
  2. A flat reflective surface
  3. A wedge
  4. A flat surface to rest it all on

Luckily, these things were all readily at hand. For a light source, I used a nearby lamp. My phone’s screen made a good flat reflective surface. I used the alarm remote for my car as the wedge, and rested everything on the floor. I’m sure you could find similar objects to reproduce this experiment for yourself.

First, I lined up the lamp, my phone, and myself so that I could see the lamp’s reflection in the centre of my phone’s screen when it was sitting flat on the floor. Then, using my makeshift wedge I tiled the screen of my phone away from me, then moved the tilted reflective surface towards me until the lamps’ reflection was in the middle of the screen.

I then repeated this for the other directions – away from me, to the left, and to the right. Because my phone isn’t square, I also rotated it so it was landscape when I moved it towards me and away from me, but portrait when moving it left and right. That made it easier to judge when the reflection was in the centre of its screen.

What I found was that I had to move the phone a lot further toward me or away from me than I had to move it left or right in order to see the reflection again. I think this explains, at least in part, why reflections on rough surfaces appear to be stretched towards you.

We can get a rough approximation of the outline of a reflection on a rough surface by assuming it has a maximum roughness, i.e. the maximum angle at which one of those little mirrors that make up its rough surface could be tilted. Then, the approximate outline of the reflection would be along the curve where a mirror at that maximum angle, facing in the right direction, would reflect light toward you.

On a perfectly flat surface, this maximum angle is 0. So the shape of the reflection is exactly as you’d expect, undistorted.

However, as the maximum roughness of the surface increases, the outline moves out from the undistorted reflection. And the reflection doesn’t just get larger, it gets stretched towards you. It’s because the angle required to reflect it at you is less within that outline that reflections on rough surfaces appear to be stretched.

I’ve written a small JavaScript simulation to show this effect. Unfortunately WordPress doesn’t let me embed it in this post, but you can have a play with it by clicking on the image below:

Stretching reflection simulation
Stretching reflection simulation

If you’re interested, you can also take a look at the source on GitHub.

The simulation works by sending out rays from the observer to hit different parts of a horizontal reflective surface. When a ray hits the surface, the simulation calculates the angle that would be required at that point to cause the simulation’s light source (displayed as a red dot) to be reflected there. Places where there would be a reflection are shaded according to the required angle, with brighter yellow areas being flatter, and areas where there would be no reflection are black. The simulation also draws a reflected red dot to show where the reflection would be on a very flat surface.

There are a few numbers you can configure to see how the shape of the shadow changes under various scenarios:

Light source distance
The distance “into the screen” that the light source (the red dot) is from you.
Light source height
How much higher than you the light source is. You’ll want to make sure it’s higher than the reflector.
Reflector height
How much lower (using negative numbers) the reflective surface is than you. The simulation doesn’t look above horizontal for reflections, so this won’t work with positive numbers.
Maximum angle
The maximum amount of roughness the reflective surface can have. Higher numbers are rougher, lower numbers are flatter.
Step size
How far apart the rays are, in degrees. The default setting is 0.1 degrees. Larger step sizes will make the simulation run faster, but it will be less precise.

The simulation shows how reflections can be stretched vertically in this way, depending on the roughness of the reflecting surface and the relative positions of the observer and the light source. If you make the light source very far away and near the horizon, you’ll see that the reflection can stretch all the way up to the horizon just like the Sun’s reflection in that picture.

However, there’s still a decent amount of horizontal spreading so I don’t think this entirely explains the stretched reflections. Yesterday, I saw this beautiful photo on Twitter, taken by Ian Griffin of a sunset in Otago:

In this photo, there is pretty much no horizontal stretching. This can be seen in the black lines in the reflection caused by trees blocking the Sun’s light – if the reflection were stretching sideways then these would be blurred and wouldn’t have such a uniform thickness.

There could be a few things helping in this case. Because this particular example is taken with water being the reflective surface, and the observer was standing at the shore, the waves are mostly perpendicular to the line of sight. That would help minimise horizontal scattering.

It can’t be just that, though, because the same stretching is seen on rough surfaces where the roughness has no direction, such as wet roads:

Wet road reflections | Photo by Thomas Hawk on Flickr CC BY-NC 2.0
Wet road reflections | Photo by Thomas Hawk on Flickr CC BY-NC 2.0

I think the rest of this could possibly be explained by surfaces that reflect the light straight towards you from under the light source appearing larger, because they’re angled towards you. Surfaces to either side of the reflection could also reflect the light towards you, but perspective would cause them to be foreshortened and therefore contribute less to the overall picture.

What do you think?

Natural Curiosity: Stretching Reflections

Auckland reflection at night | Photo by 111 Emergency on Flickr CC BY 2.0
Auckland reflection at night | Photo by 111 Emergency on Flickr CC BY 2.0

On a rough reflective surface like the ocean or a dark wet road, reflections from bright lights like city lights, car brake lights, or the Moon appear stretched vertically. Why is this?

When a surface is perfectly flat, like a regular mirror, the image we see in the reflection isn’t distorted at all. Even if we put a mirror flat on the ground, we wouldn’t see a vertically stretched reflection like this.

Neither the road nor the ocean are perfectly flat though. Their surfaces are rough, and this rough surface scatters light when it’s reflected. If we imagine that each piece of the surface was a little flat mirror, with each piece facing in a random direction, some of these would be at the right angle to reflect light from a source (like the Sun) directly into our eyes, and most would not. We’d only see a reflection in those pieces that are at the correct angle to reflect the light into our eyes.

The further these little mirrors are from the area where we’d see the reflection in a flat mirror, the more extreme an angle they will need in order to still reflect the light at us. If every one of these little surfaces was really really tiny, what we’d expect to see is a blurry reflection. The smaller the pieces get, the less blurry the reflection would get.

We can actually see this in effect when we compare pictures of the Sun reflected off the ocean. When you’re quite near the ocean, all the different reflecting surfaces are relatively large so the reflection is quite blurry and broken (especially if there are lots of waves):

Sun Reflection | Photo by oboejoe92 on Flickr CC BY-NC 2.0
Sun Reflection | Photo by oboejoe92 on Flickr CC BY-NC 2.0

In comparison, if we look at a reflection of the Sun on the ocean that was taken from space, all the waves and ripples that distort the reflection are far too tiny to see, and as a result the reflection is quite clear and crisp:

Sun reflection from space | Photo from NASA
Sun reflection from space | Photo from NASA

Another difference that’s quite apparent between these photos is the vertical stretching that I’ve been wondering about. From up close, it’s very stretched. From a distance? Not so much. This gives me a thought, one that actually hadn’t occurred to me until I got to this point in writing this post and saw those images one after another:

What if it’s important that there’s a significant relative distance between the closest and furthest parts of the surface that are reflecting the light source?

From a long way away, these distances appear quite small. For example, if I’m 1 km away from a surface, then a 1 m distance between two points on that surface is really quite small. If I’m only a metre away myself though, then that’s a very significant distance.

As we just saw, reflections on non-flat surfaces are more blurry when they’re closer to you, so what if this vertical stretching is actually just the reflection getting more blurry towards the bottom, because that part of the road or ocean is closer? As it’s more blurry, this would let the edge of the reflection creep out further, and could look like stretching.

If I’m right, then I should be able to see the same type of stretching if I look at a reflection on a vertical surface, except the stretching would be horizontal in that case. I should also be able to replicate the same stretching effect if I can get a reflecting surface that is smooth on top and gets rougher towards the bottom, and look at a reflection of a light in it like I would a normal mirror (i.e. with the reflecting surface vertical and the light source behind me).

Let me know what you think of this idea in the comments, and if you have any ideas of your own for why we see these stretched reflections. Any ideas about how I could try to disprove my idea would be welcome too! In the meantime, I’ll try to do these experiments, and see if I can find an expert to talk to about this question.

I’ve written more on this topic in another article: Natural Curiosity: Stretching Reflections 2

Natural Curiosity

Blue Sky | Photo by Mohammed Tawsif Salam - CC BY-SA 3.0
Blue Sky | Photo by Mohammed Tawsif Salam – CC BY-SA 3.0

On the second Wednesday of every month, there’s a great Twitter chat on science communication in New Zealand: #SciCommNZ

Unfortunately I’m always busy on Wednesday evenings while this is going on, but I’ve tried to participate as much as I can by joining in late and reading through each discussion. The questions that have been asked have made me think about the things I write about on this blog, and some of the things I’d like to write about:

After having these thoughts churn around in my head for a few weeks, I’ve come up with something I’d like to try.

There are a lot of “everyday science” questions that I see asked and answered fairly often. Common examples include “why is the sky blue?” (which is not quite as simple as you might think) and “how do rainbows work?”. I really like these questions, but I feel sometimes like they’ve all been done many times already.

Of course, they haven’t all been done many times already. But I do feel like I see the same “everyday science” questions over and over again. I think they’re great and really interesting the first time you encounter them, so I want more.

As a remedy to this, and as an attempt to do something different and (hopefully) interesting with my science communication, I’m going to start asking some of my own everyday science questions. This might be a bit grandiose, but I’m calling this little project of mine Natural Curiousity

The format may change as I get into it, but the way I see this happening is to take every question in two parts:

First, I’ll write a post framing the question and some of my own thoughts (as a non-scientist) on what the potential answers might be, and what some problems with those potential answers might be. I want to try to do this without any Googling, but I might try a few homemade experiments. My hope would be that posts like these could get some interesting discussion going, but I guess we’ll see.

After that, I’d like to talk with someone who is an expert in a relevant topic and get their thoughts on the question, both on the potential answers brought up in the first post and on what they think the answer probably is and why. This isn’t something I’ve done before, so I hope I’ll be able to find some experts who’ll be happy to find some time to talk to me about this.

If you have any everyday science questions that you’ve been wondering about, let me know in the comments. I’ll update this post with links to posts using this format as I publish them.

  1. Stretching Reflections
  2. Stretching Reflections 2