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