Misleading claims common among chiropractors

Misleading claims common among chiropractors

Most New Zealand chiropractors make misleading claims.

Through my role as the chair of the Society for Science Based Healthcare, I see a lot of misleading health claims in advertisements. Many of them are pretty clearly bogus; I’ve seen claims that drinking “harmonized water” is as good as sunscreen and that bacteria make your cells each lose a positive electron.

But not all misleading claims are obvious. Many might sound plausible, especially if you don’t know much about the therapy or if they come from someone in a position of authority. This, I think, is where they can be the most dangerous. Luckily we have rules in place to prevent this, but the complaint-based systems we rely on require cooperation from advertisers. When the rules are widely ignored, we simply aren’t protected.

In 2015 my colleague at the Society for Science Based Healthcare Mark Honeychurch and I gathered data on how common misleading claims from chiropractors are in New Zealand. We systematically searched through the first 30 pages of results of an anonymous Google search for “Chiropractor New Zealand”. For all 137 websites we found for New Zealand chiropractic clinics, we recorded the presence or absence of claims that chiropractic manipulation can help with ADHD, allergies, asthma, bed wetting, colic, or ear infections. We also looked for health testimonials used as a marketing tool.

We picked that list of conditions based on the results of successful complaints to the Advertising Standards Authority, and on our failure to find credible evidence to support the claims when searching the scientific literature ourselves. We included health testimonials in our search because they can be both very convincing and highly misleading. We have legislation prohibiting them in medical advertisements, and for good reason.

Today, our results have been published in a letter to the editor at the New Zealand Medical Journal: Chronic misleading online advertising by chiropractors

Claim Quantity Proportion
ADHD 34 25%
Allergies 48 35%
Asthma 54 39%
Bed Wetting 43 31%
Colic 59 43%
Ear Infections 55 40%
Any condition 74 54%
Testimonials 48 35%
Any condition or testimonials 96 70%
Total 137 100%

Unfortunately, we weren’t surprised to find that such a high proportion of New Zealand chiropractors who advertise online make unsubstantiated claims about what they can treat. Similar research has found as high as 95% of English chiropractor websites make unsubstantiated claims.

This problem is also widespread in Australia, where the Chiropractic Board of Australia recently published a Statement on advertising addressing this problem along with several others:

Claims suggesting that manual therapy for spinal problems can assist with general wellness and/or benefit a variety of paediatric syndromes and organic conditions are not supported by satisfactory evidence. This includes claims relating to developmental and behavioural disorders, ADHD, autistic spectrum disorders, asthma, infantile colic, bedwetting, ear infections and digestive problems.

Statement on advertising | Chiropractic Board of Australia

We have a Chiropractic Board here in New Zealand as well, which was set up to regulate chiropractors under the Health Practitioners Competence Assurance Act. They have their own Advertising Policy:

All advertising must… be presented in a manner that is accurate, balanced, and not misleading

A chiropractor shall not advertise any material which relates to the chiropractor’s qualifications, practices, treatment or the premises where they practice chiropractic if the material… uses testimonials whether from patients or any other person

Advertising Policy | New Zealand Chiropractic Board

Even if we didn’t have these rules laid out in an explicit “this is for chiropractors” format, we also have the Fair Trading Act and the Advertising Standards Authority’s codes of practice both requiring that claims made in advertisements must be substantiated, and the Medicines Act prohibiting health testimonials in advertisements.

How the regulation is enforced currently is not working. Our findings make that abundantly clear. If we’re going to solve this problem, the Chiropractic Board needs to take a more active role.

The New Zealand Chiropractors’ Association’s response to our findings has been that they are “not really current now”, and “the issues had been addressed recently, and the numbers would be much different now”. However, when Mark Honeychurch re-checked all 137 sites this morning for the claims we were looking for he found that only 15 (11%) had changed in this respect. Eight of those sites had removed claims (four of them had disappeared entirely), whereas seven had claims we didn’t observe last year. The problem is not solved yet.

Here’s what I want to see the New Zealand Chiropractic Board do about this:

  1. Publish a public statement on advertising, like the Chiropractic Board of Australia did, making it abundantly clear that this behaviour is not acceptable.
  2. Take an active role in maintaining compliance, by seeking out and contacting chiropractors that are making unsubstantiated and misleading claims. We are willing to share the data we collected with the Chiropractic Board to assist this effort.
  3. Sanction any chiropractors who might continue to make misleading claims after being told to stop. It is not appropriate for a registered healthcare professional to mislead their patients – any who continue to do so simply should not be trusted to hold that position of authority.

Perhaps just as importantly, I want to see New Zealand chiropractors themselves clean up their act. Those chiropractors who already ensure that they don’t engage in this behaviour should lead the charge for change within the industry – from my vantage point it sure looks like it could use some leadership on this.

Are You an Organ Donor?

Are You an Organ Donor?

Organ donation is important. When a person dies in a way that leaves them brain dead but their other organs still viable, such as an intracranial haemorrhage in an intensive care unit, their organs can be transplanted to save others’ lives in a way nothing else can. Only a few organs, kidneys for example, can be donated by live donors. But others, like lungs and hearts, can only be given posthumously.

This is something most of us will already know, but it’s something else entirely for it to have saved the life of someone you know. I want to start this article by telling you a story.

Poppy McKay is a family friend. She’s 24 years old, and she is probably alive today because of an organ donor who is sadly not.

She was diagnosed at birth with cystic fibrosis, an incurable genetic disease that primarily affects her lungs and digestive system. For her whole life, she’d been in and out of hospital, having to undergo daily treatment.

In early 2012, most of her treatment was stopped as it was no longer being effective. The only option left to her, she was told, was to be assessed for a lung transplant. She was put on the active list later that year. She spent her 21st birthday on the list, and by the end of the year could barely walk up the stairs at home. Her lungs were so weak she wasn’t even able to blow into the machine to measure their function.

But then the phone rang, and the transplant coordinator said she should go to the hospital immediately because they had a pair of lungs for her. After a long operation starting in the early hours in the morning, she came out of the operating theatre with a new pair of lungs.

Since the transplant, she progressed from breathing with help from a machine, to breathing on her own, to walking with a frame, and then without one. When I see her now, you could tell me she’d never been sick a day in her life and if I didn’t know better I might believe you.

Organ donations like this are very special. They can save the lives of multiple people, but only at the cost of another life. I think it says a lot about a person, and their family, when they allow this to be done.


Are you an organ donor? When I ask that question, do you think to check your driver licence? That’s the closest thing New Zealand has to recording a person’s status as an organ donor. When you apply for a driver licence, as part of the process you are asked this question:

Would you be willing to donate organs in the event of your death?

New Zealand Transport Agency | Organ and tissue donation

You can’t apply for a licence unless you tick either “Yes” or “No” in response to this. If you tick “Yes” then the word “DONOR” will be printed on your licence. Either way, you’ll very likely consider the question answered and not worry about it for most of the rest of your life, and you might feel justified in doing that. But you’d be wrong.

When I was applying for my licence a few years ago, I noticed this text on the NZTA website (the emphasis is mine):

Ticking the ‘Yes’ box on your driver licence form only means that you have indicated your wish to be identified as an organ and tissue donor. It does not automatically mean that your organs or tissues will be donated in the event of your death. In practice, your family will always be asked for their agreement to organ and tissue donation.

If your family knows what your wishes are in regard to donation, they will be more likely to follow them through in the event of your death. Having your wishes displayed on your driver licence is just one way of making them known to your family. You should also discuss your decision with them.

New Zealand Transport Agency | Organ and tissue donation

I emailed Organ Donation New Zealand about this in 2012, to ask if there was anything I could do that would guarantee that my wish to be an organ donor would be respected if I were ever in a situation where I was a potential organ donor. I was told that my family and friends would be asked about my wishes and if they would agree to consent. I emailed them again last week and they confirmed that this answer is still true today.

I’m lucky in that my family and I are on the same page about organ donation. Having spoken to them about it recently, I can be entirely confident that they would respect my wish to be an organ donor if they ever had to. I’m sure not everyone is in the same position, although until recently I could only speculate as to how common that would be.

Last week, Andy Tookey from the organ donation lobby group GiveLife released a press release in response to information released to him under the Official Information Act. Mr Tookey was kind enough to send me the documents released to him, and gave me permission to publish them here.

The document includes a copy of the most recent audit of potential donor deaths in New Zealand. One part of this document in particular was very interesting to me, and I’ve duplicated it here:

ICU deaths 1,123
Ventilated in ICU and died with severe brain damage 367 (33% of ICU deaths)
Of these 367
Discussed with Organ Donation New Zealand 35% (129)
Organ donation mentioned 43% (159)
Organ donation formally discussed 37% (135)
Of the 135 where organ donation was formally discussed
Families agreed to donate 39% (53)

It’s that last figure in particular which I find interesting. In all the cases where organ donation was formally discussed with the family of a potential organ donor in 2015, they only agreed to it 39% of the time. The reasons the families refused the remaining 61% of the time weren’t recorded, and I could imagine in some cases they might have known their loved one did not want to be an organ donor.

For comparison, I’ve seen several figures of the proportion of NZ driver licences with “DONOR” printed on them, which all centre at around 50%*. Given the discrepancy between this and the proportion of families that agreed, it seems likely at least some of the time the family would have acted against their loved one’s wishes and prevented them from being an organ donor.


To help make sense of all this I spoke to Associate Professor Colin Gavaghan, an expert in medical law and ethics at Otago University. I asked him about what the law says about how organ donation handles informed consent, what problems he sees with the current system, and what could change so someone could be assured that their wish to be an organ donor could be respected even if their family disagrees. Here’s what he told me:

The use of organs in NZ is covered by the Human Tissue Act 2008. The Act has a number of stated purposes, the first of which is to ensure that the collection of human tissue occurs only with proper recognition of, and respect for:

  • the autonomy and dignity of the donor;
  • the cultural and spiritual needs, values, and beliefs of the deceased’s immediate family;
  • the cultural, ethical, and spiritual implications of the collection or use of human tissue; and
  • the public good associated with collection or use of human tissue.

Straight away, the potential for conflict between some of those objectives becomes obvious. How are medical staff to balance the autonomous wishes of the deceased with the beliefs of their immediate family, if those are not aligned? How is the public good of organ donation to be balanced with the “cultural, ethical and spiritual” values of those who don’t agree with organ donation?

Luckily, the Act makes it clear that those objectives are not equally weighted. As the Ministry of Health point out “The Act makes informed consent the fundamental principle underpinning the lawful collection and use of human tissue from deceased people.” [http://www.health.govt.nz/our-work/regulation-health-and-disability-system/human-tissue-act/about-human-tissue-act]

What that means is that if you have documented your wishes before you die, those wishes should be the most important determinant of what happens after death. No other authority is needed.

That’s the theory, anyway. In reality, there are a few factors that make things a bit more complicated.

1. The Act doesn’t require doctors to take your organs. Your consent authorises the salvaging of your organs, but it doesn’t make it compulsory for anyone to do so. In some ways, this discretion seems sensible. We wouldn’t, I assume, want to force doctors to harvest organs that are likely to be unsuitable for transplant. There may also be cases where evidence arises that the deceased may have changed their mind after indicating their consent. More controversially, the MoH notes that ‘the immediate family may be distressed by a decision to proceed with donation.’ How much weight should be given to that is contentious, and I’ll come back to it in a minute.

2. By far the most common way for New Zealanders to record their wishes about organ donation is via their driving licenses. Both the Act and the MoH make it clear, however, that this won’t constitute “informed consent” for legal purposes.

I can see why this would be the case. Unlike the UK’s donor card, for instance, the NZ driving license doesn’t allow people to specify which organs they would be willing to donate. (I’ve never really understood what would motivate someone to agree to donate all of their organs, but not, say, their pancreas. But ultimately, it’s their choice.)

This is problematic for a couple of reasons. One is my suspicion that most people who fill out that part of the license actually do so believing they are giving legally valid consent. If so, that’s just bad in itself; if we value autonomy (as the Act claims to) then it seems generally wrong when people do things under false beliefs. But it might also be bad in that it discourages them from taking other steps that might actually be legally significant. Why bother if you think the info on your driving license is enough?

Even if people were to recognise that the driving license doesn’t amount to “informed consent”, it isn’t entirely obvious what they could do instead. Unlike the UK and Australia, NZ doesn’t have a register where people can record their wishes. The Act provides that one could be set up, but thus far, there has been no political will to establish one.

I’m not sure whether establishing a register would be worthwhile in terms of increasing the supply of donor organs. It’s possible that it would cost too much to set up and run, and divert too much money from more worthwhile initiatives. But there may be cheaper options available that could be almost as effective.

Although they were rendered largely redundant by the Register, I still have my UK Donor Card, a wallet-sized statement of willingness to donate my organs after I die. It contains simple tick boxes to indicate views regarding specific organs.

I can’t think of any reason why something similar couldn’t be distributed in NZ, and be so constructed as to contain enough information to constitute “informed consent”.

3. The Act makes it clear that, where valid consent is obtained from the deceased, no-one else should be able to override that. As the MoH says: “The framework does not allow others to legally veto an individual’s consent”.

In practice, however, we know that immediate family (and sometimes more distant family) are routinely asked to make the decision. Unfortunately, this doesn’t just happen in NZ, but in the UK as well. It happens even in situations where the relevant law has made it clear it isn’t required.

There can be good reasons to consult the family of the deceased. As the UK NHS explains, “In the event of your death, the person closest to you (usually your next of kin) will be asked to confirm that you hadn’t changed your mind before your death.” (http://www.nhs.uk/conditions/organ-donation/Pages/Donationprocess.aspx)

A lot can depend, though, on how the approach is made and the questions asked. There’s a difference between asking the family if the deceased changed their mind, and asking them for their own consent. In the UK, where it’s also worryingly common for families to override consent in this situations (500 recorded instances since 2010) various strategies are being tried out to reduce this phenomenon.

For instance, the relatives of the deceased can be provided with an information sheet, gently but clearly explaining that the deceased has consented to organ donation, and that this will be what happens unless they know of a good reason why it should not. This might not sound very different to what happens at the moment, but the hope is that it will make it clearer that it isn’t up to the family to decide what should happen, but rather, to inform the medical staff of any relevant information that they may not know.

What of the situation where the bereaved relatives are genuinely distraught at the prospect of the organs being taken? There’s no clear answer here, but my own view is that the wishes of the deceased, and the value of the potential donation, should still carry greater weight.

There are 3 reasons why I say this. First, we don’t give that sort of weight to family wishes in any other circumstances. If I refuse life-saving treatment, that refusal has to be honoured, regardless of how much my family might want me kept alive. Likewise, I can’t imagine any competent adult having their consent to treatment being invalidated on the basis that their family don’t wish them to have it.

We have, as a society, accepted the primacy of individual autonomy in just about every other medical situation. It isn’t clear why organ donation should be the exception.

Second, it isn’t clear to me that immediately bereaved people are generally in a state of mind to make properly reflective choices about such matters. Certainly, it doesn’t seem likely that they will make a better decision (in the sense of being a balanced one) than that made by the deceased themself when they set down their wishes in advance, presumably in the cold light of day.

Third – and this is important – if really we’re going to start down the road of overruling individual autonomy on the basis of the interests of other people, then let’s consider all of those interests – not only those of the immediate family, but those of the potential donor recipients. And their families. Of course, the medical staff who are seeking consent to take organs won’t have to face those people, and explain to them that – while a perfectly good organ was available – someone has just refused to let them have it.

To summarise, I’d favour 2 changes:

  1. A means should be made available for people to express their wishes about organ donation in a manner that will be regarded as legally valid consent. This could be via a register, or a donor card, or something else. This should replace the section of the driving license, which has substantial potential to be misleading with regard to its legal status.
  2. Where legally valid consent from the deceased is available, the practice of routinely seeking consent from what will frequently be traumatised, overwrought bereaved relatives should end. Instead, relatives should approached with a sensitive statement to the effect that the deceased has consented to their organs being taken, and that this is what will happen unless the relatives know of any specific reason why it should not. Of course, the possibility remains that certain families with very strong anti-donation views will lie about this, but it’s hard to imagine that being a common occurence.

Associate Professor Colin Gavaghan

I also asked Poppy, as someone who has personally been involved with organ donation, what her thoughts on this issue were:

I have an issue with people not being able to be in “control” of the last wish they could potentially have by, when unable to communicate with them, their families or loved ones can say no to organ donation.

A donor registry could be a good option. I haven’t done a lot of research around it but know it’s successful in some countries. If anything, it brings a hell of a lot more awareness, and even if we still had the same law as the driver’s license one, you would think seeing as a much more informed decision had been made to register themselves as donors, the families may not oppose it as often.

Having been in the position of needing a transplant, I obviously believe that everyone who can be a donor, should be a donor. Everyone who wants to be a donor, should be allowed to keep their wishes.

However, I have never been on the other side. Having to already deal with the fact a loved one is going to die, some people may find it too hard to then have their body “chopped” up and not be buried/cremated whole. I believe that if someone has expressed strongly enough their feelings of being a donor, their loved ones would want to honour it. More awareness needed?

My main advice for people who want to be organ donors and their families is to “have the conversation”. Make sure those who will be responsible to make the decision for you if you’re ever in that situation knows your wishes and how strongly you feel about it. Research success stories of organ donation/transplant and see how life changing it can be for up to 8 people per donor, not only life changing for them but for their families and friends.

Poppy McKay

The idea of a register is one that Andy Tookey from GiveLife has also been pushing for. In my opinion, it seems the current system is simply not robust enough. It fails to capture people without a driver licence, for example, and also isn’t enough to constitute informed consent. I don’t know if a register is the right way forward, but I do think it seems like a good suggestion and I hope it will at least be considered. There should be a way for people to be assured that their wishes regarding organ donation will be respected after they’ve died.


So, what should you take away from this article? If nothing else, remember this:

  • Your driver licence saying you’re an organ donor doesn’t mean you would be if you ever could be
  • In order for you to be an organ donor, it is important that your family understands your wishes, and that you’re on the same page. Talk to them about it.

I would also like to give my sincere thanks to Colin and Poppy for their contributions to this article. Thank you both!


* I’ve seen figures of 48.8%, 49%, and 52% over the past few days, but I haven’t found a primary source for any of them. I’ve asked NZTA for the information via the Official Information Act, but I expect it will take them a while to give it to me. Here’s a link to the OIA request on FYI.org.nz – Organ donor preference on driver licences

Fun with Light

Fun with Light

There are lots of cool science activities you can do at home with light.

Like I’ve done almost every year of my life, I spent my summer break at my family bach at Oakura. Last summer I wrote a post about a trip to the rocks and what could be found living there. This summer, on the relatively few sunny days we had, I had fun playing with light.

Here are three easy, fun, and cheap activities you can try yourself.

  1. Make a Telescope
  2. See Shadows Jump
  3. Wave at the International Space Station

Make a Telescope

The previous year, I made a simple telescope out of a $2 set of two magnifying glasses. Playing with trial and error and a piece of soft wood, I ended up with something that had a zoom of about 2x. However, because it only used two lenses the resulting image was inverted.

IMG_2683

IMG_2686

This summer, I came prepared with an extra set of magnifying glasses, making four in total. I raided the recycling bin and used some ginger beer bottles to hold them in place, facing an island in the bay. Then I moved them back and forth until the zoom and focus seemed as good as I could get it.

Once I had the placement right, I marked off the distances on a long piece of wood, then taped the magnifying glasses to it. What I ended up with wasn’t the strongest or most portable telescope in the world, but all it took to make was $4 and a fun afternoon.

20151228_160600

20151228_160808

20151228_16101820151228_190418


See Shadows Jump

My brother Jeremy is a concept artist for Weta Workshop, which has left him with a good understanding of light and colour. One evening up at the beach he started talking about some interesting things that shadows do.

Watching shadows of leaves dance on the ground, he wondered if they often form natural pinholes. When we had a partial solar eclipse in Auckland in 2012, my mum (who also has a great artistic understanding of light and colour) mentioned to me how the shadows in her garden looked strange when she went outside during the eclipse. This would have been due to the pinhole effect, and it’s why some of the recommended ways of viewing an eclipse are to make a pinhole in a piece of paper or use a colander.

You’ve probably seen diagrams showing the basics of how a pinhole camera works. Even without a lens, when light passes through a small hole it can project a sharp image on a surface opposite that hole. However, that image will be inverted (like in my first attempt at making a telescope).

Pinhole-camera

I often collect pāua shells from my trips to the rocks when I’m at the beach. A pāua shell has a row of holes along one side. When I held it a certain distance away from a wall, with the Sun low on the horizon, we found it made a row of pinholes. But because a projection of the Sun looks the same inverted as it does normally, in order to tell if the image really was inverted I moved a cardboard roll behind the pāua and watched at the holes “filled up” with shadow backwards – just as we’d expected.

But something else happened which I definitely didn’t expect. Watch this video we took to see the shadow of the pāua shell reach out to touch the cardboard roll’s shadow as they get close together:

If instead the pāua shell was held closer to the Sun and the cardboard roll was closer to the wall, then we found it would be the shadow of the cardboard roll that bulged out as they got close.

We immediately took to pen and paper to try to draw out diagrams that would explain how this worked. My initial idea was that we were seeing the area of intersection between the penumbras – the hazy edge of the shadows where the Sun was only partially obscured. But this wouldn’t explain why the bulge would change depending on which object was in front of the other.

Before too long, one of Jeremy’s ray diagrams seemed to explain what was happening. I’ve tried to reproduce them here (I hope you’re all suitably awed by my skills with MS Paint):

Shadow Single

This diagram shows a light source on the left casting a shadow from the object in the middle onto the surface on the right. It shows how a non-point light source such as the Sun produces a shadow with an umbra (where none of its light reaches) and a penumbra (where part of its light reaches). The darkest part of the shadow, the umbra, is the middle section between the lines on the right.

Now, what would happen if I insert another object partly between the light source and the first object?

Shadow Overlap

The new object blocks some of the light from reaching the original object. As this ray diagram shows with the red line – where the light is partially blocked – the result of inserting this second object is that the umbra of the first object’s shadow is extended toward the new object. This is the cause of the bulge you can see in the video above.

It turns out this shadow jumping effect is called the shadow blister effect. You can observe it easily for yourself on any sunny day.


Wave at the International Space Station

The sky at Oakura is lovely and dark, with the nearest city being nearly 50 km away. Before the Moon rose one night after Christmas a few of us went up a nearby hill to stare up at the night sky.

With a clear dark sky, you can see the band of the Milky Way galaxy arc across the sky like a pale cloud, as well as the fuzzy blobs that are the Large Magellanic Cloud and Small Magellanic Cloud. These are dwarf galaxies which orbit the Milky Way.

We also saw many meteors, and a surprisingly high number of satellites. From Earth satellites look just like stars, except they move steadily across the sky in a straight line. Usually they appear quite dim, but there is one satellite in particular which can shine brighter than any star in the sky, and even brighter than any of the planets. That is the largest artificial satellite of them all: the International Space Station (ISS).

International_Space_Station_after_undocking_of_STS-132

The ISS orbits the Earth about once every 90 minutes, and although it doesn’t pass over New Zealand each time it does fly over us more often than you might think. But we can’t always see it in the sky; the conditions have to be right first.

Before we can see the ISS the sky needs to be dark enough for it to stand out. Also, it needs to be in the right position for sunlight to reflect down at us off its massive arrays of solar panels. This means that you’ll only be able to see it in the hours after sunset and before sunrise.

It generally takes 1-6 minutes for the ISS to pass visibly overhead. This will usually end with it appearing to fade into darkness as it stops reflecting sunlight back at us – you won’t see it set over the horizon like you would with the Sun or Moon.

NASA has a great online service, which you can subscribe to and get email alerts, that can tell you when and where to look to spot the ISS. It’s called Spot The Station. It lets you enter a city, and will tell you when the next few ISS sightings will be as well as how long they will last, and how it will travel across the sky.

ISS sightings often come in clusters – there will be sightings around a similar time in the morning or evening for several days in a row, followed by a period of no sightings. If you’re extra lucky, you might get to see it twice in one evening as it comes back round an hour and a half later.


I’d be remiss if I didn’t also mention that you can rent our bach if you ever want to see Oakura with your own eyes.

It’s Detox Season

It’s Detox Season

Summer is detox season, but beware misleading health advice.

Every summer, we are bombarded with advertisements, editorials, and advertorials chastising us for all the toxins we have poisoned ourself with by indulging in fruit mince pies and Christmas ham. But it’s okay, we are told, for there is a solution to this toxic overload. And that solution is…

The detox

Sound advice and playing to our holiday guilt gets a foot in the door. Eat your greens, shed those Christmas kilos, make a New Year’s resolution to avoid toxins. They may even appeal to the rationalist in us: your kidneys and liver are your detox organs, but they need support to do their job optimally.

Next comes the sale. They just so happen to know the perfect thing you can do to detox. Their dietary supplement, their green juice, their herbal tea. This is the secret to ridding your body of toxins, we are told.

But these products, so often forgotten by March, rarely stand up to closer inspection. No evidence (although perhaps some testimonials) are offered in support, specific toxins are rarely mentioned, and claims about what the products can do are often restricted to vague claims such as “support your body’s natural detoxification process”. Such ambiguity is necessary to avoid being held accountable for specific claims.

In practice, the current regulations allow for claims like “supports your body’s natural detoxification process” to be made without supporting evidence. If a product is said to “support” something that happens already in a healthy person, and there’s no evidence it has harmful side effects, the regulators will tend to steer clear of it.

This hasn’t stopped action being taken against detox claims. In the past two years, there have been 12 complaints against detox ads laid with the Advertising Standards Authority. In every single case, the advertisement was found to be misleading.

So who can we trust? In the case of advertisements and advertorials it’s clear that the company behind them has something to gain from us buying their products. Conflicts of interest are important, and in those contexts they are clear. But can we trust other sources of information to be accurate and free from this bias?


If conflicts of interest are hidden from us, we can be misled. A well-informed society depends heavily on the press, and it’s in our best interest for mainstream media to report without having undeclared conflicts of interest. One of the Press Council’s principles describes why conflicts of interest are an important consideration for the press:

To fulfil their proper watchdog role, publications must be independent and free of obligations to their news sources. They should avoid any situations that might compromise such independence.

The New Zealand Herald recently published a column giving health advice about detoxing from an expert, but didn’t adequately declare the author’s conflict of interest. In truth, the columnist makes a living from the sale of the exact products they were promoting in the article, but you wouldn’t know unless you did some digging.

The column was published on Sunday November 29, just before the start of detox season. It was headlined “Detoxing: What you need to know” and clearly marked as the opinion of Sandra Clair:

Sandra Clair detox opinion headline

Sandra is described briefly before and after the article:

Sandra is a medical herbalist, medical anthropologist, and columnist for the NZ Herald.

Sandra Clair is the founder of Artemis (artemis.co.nz) offering New Zealanders a premium range of traditional plant medicine products. She is one of New Zealand’s most highly qualified health professionals in her field, as a Swiss trained medical herbalist and a medical anthropologist (M.A.). Sandra is currently completing a PhD in health science at the University of Canterbury in collaboration with the Chair for Natural Medicine of the University of Zürich, Switzerland.

She’s clearly framed as an expert in the field she’s writing about, rather than someone with a conflict of interest. So it certainly wouldn’t surprise me if someone reading her article about everything they “need to know” about detoxing would take her advice seriously. But let’s take a closer look at the advice she gives.

The article starts off giving some sound advice, appealing to the sceptic in us that knows “quick fix” health products are often too good to be true:

At this time of year, detox diets and miracle products spring up like brightly coloured daisies. Many of them promise quick weight loss and eternal youth at the drop of a hat, or a pill.

It is easy to get swayed by enticing marketing when trying to find an approach to rejuvenate or drop those annoying extra kilos.

However, most of these products and fad diets are neither successful nor sustainable, and their harsh, artificial composition can strip the body of essential nutrients resulting in a worse state of health.

So far, I’d been nodding along to her article. She’s got her foot in the door, and it’s not too long before she moves on to the sale. According to Ms Clair, the secret to detoxing is drinking two types of herbal tea, and making this a lifestyle change instead of something you do for just a brief duration:

In more serious health issues it is advisable to follow a targeted cleansing regime for a minimum of eight weeks, as this is the minimum time it takes for the liver to restore and cleanse deeper layers. By the end of that time most people find it easy to incorporate better choices into their daily lives for long-term health.

The easiest way to support your body’s daily detoxification is to take a medicinal tea with bitter liver herbs before breakfast. Liquid plant medicine is perfect for detoxification since water has additional flushing benefits over and above the therapeutic ingredients of the tea.

Follow this with a kidney cleansing medicinal tea mid-morning to complete the flush by removing the released water-soluble toxins. Golden rod, horsetail, birch leaves, nettle and raspberry are traditionally used to improve kidney function and help clear the body of water-soluble metabolic wastes and toxins, excess sodium, uric acid and inflammatory by-products. I call this combination your daily ‘internal shower’.

At first glance this just looks like advice from an expert in the field, not a marketing pitch for specific products. But not all is as it seems.

As mentioned in Ms Clair’s bio, she is the founder of Artemis Natural Healthcare. And it just so happens that Artemis sells a “Liver Detox Tea” and a “Kidney Cleanse Tea”. The wording in her article seems like it could easily have been tailored specifically to match the marketing for these teas, listing their ingredients and using terms such as “kidney cleansing medicinal tea” and “medicinal tea with bitter liver herbs”.

Surprise surprise, if you search for either of those phrases from the article on Google in a New Zealand context, the first results are for Artemis’ products:

Google Liver Detox Tea

Google Kidney Cleanse Tea


I found about these products when the December catalogue for Health 2000, which is New Zealand’s natural health retailer and has been in trouble in the past for misleading claims about toxins, was released on the Wednesday after the Herald article. It advertises Artemis’ “Liver Detox Tea”, which prompted me to check further and led to me finding out about their “Kidney Cleanse Tea” through their website.

Health 2000 Artemis Liver Detox Tea

I sent a message to the New Zealand Herald’s online editors the day after I found this out, to express my concern about this conflict of interest and about the misleading content of the article. It’s been over a week now, and disappointingly I’ve had no response from them. You can read my message at the bottom of this article.

The morning after I sent that message, the New Zealand Herald was distributed along with a copy of the Health 2000 December catalogue. The same catalogue advertising one of the products Ms Clair was surreptitiously promoting in her Herald column only days earlier.

As far as I’m aware the New Zealand Herald has yet to acknowledge the full extent of this conflict of interest, but I hope that hearing about this will make you think twice before trusting detox advice. Without taking the time to look behind the curtain, it can be hard to tell if someone stands to gain financially from the advice they’re giving.

As always, if you think a health claim might not be all it claims to be, the best approach is to ask for evidence. If all you’re given is anecdotes, it’s probably not trustworthy. In the case of detox advice, asking for specifics on which toxins they’re talking about can also be a good approach.


It seems appropriate for me to state here that I have no conflicts of interest to declare. All I’ll gain if you take my advice to be sceptical of misleading detox claims is peace of mind.


Here is the letter I sent to the New Zealand Herald’s online editors:

Earlier this week I read an opinion piece published on your website by Sandra Clair, entitled “Detoxing: What you need to know” (http://www.nzherald.co.nz/lifestyle/news/article.cfm?c_id=6&objectid=11552384)

I’m concerned that the article contains misleading content and that her substantial conflict of interest is not made adequately clear to readers.

As noted at the bottom of the article, the author is the founder of Artemis, a for-profit business that sells herbal healthcare products. One of the products this company sells, advertised in the latest Health 2000 catalogue which was released this week, is “Liver Detox Tea”. You can see it advertised on page 22 of the catalogue online here: http://www.health2000.co.nz/december-2015_1268

In Ms Clair’s article, she says:

“The easiest way to support your body’s daily detoxification is to take a medicinal tea with bitter liver herbs before breakfast. Liquid plant medicine is perfect for detoxification since water has additional flushing benefits over and above the therapeutic ingredients of the tea.”

This very closely echoes the marketing for her business’ “Liver Detox Tea” product.

Artemis also sells a “Kidney Cleanse Tea” to “Flush those toxins away”. According to the Artemis website it contains Birch leaves, Golden Rod, Horsetail, Nettle, and Raspberry leaf. In her article, Ms Clair also says:

“Follow this with a kidney cleansing medicinal tea mid-morning to complete the flush by removing the released water-soluble toxins. Golden rod, horsetail, birch leaves, nettle and raspberry are traditionally used to improve kidney function and help clear the body of water-soluble metabolic wastes and toxins, excess sodium, uric acid and inflammatory by-products. I call this combination your daily ‘internal shower’.”

This too very closely echoes the marketing for her business’ “Kidney Cleanse Tea” product.

It seems fairly unlikely that the timing of her article and the increased marketing of “detox” tea products by her business are a coincidence. It is absolutely in the interest of your readers to be made aware of her conflict of interest involving these products, and it does not seem to me like this has been done adequately.

Furthermore, I’m concerned that much of the information presented in her column is likely to be misleading. It is absolutely true, as she says in the opening paragraphs, that “detoxification” is the role of your kidneys and liver. However, the article is written in such a way as to imply, without any supporting evidence as far as I am aware, that products like the “Liver Detox Tea” and “Kidney Cleanse Tea” sold by her company are able to provide health benefits such as “improved immune system” and “better circulatory and lymphatic function”.

I’m also concerned that the article advises readers to “Reduce pharmaceutical drug intake”. As the conflict of interest statement refers to Ms Clair as “one of New Zealand’s most highly qualified health professionals in her field”, I am concerned that this advice might be taken seriously by some readers and as reliable health advice, and result in some degree of harm.

I think we are all aware that summer is the time of year where businesses in the “natural health” industry most strongly market “detox” products. As the chair of the Society for Science Based Healthcare, I see a significant amount of misleading advertising for these products, particularly at this time of year.

Over the past two years, 12 advertisements about detox products have been complained about to the Advertising Standards Authority, and in every one of those cases the advertisement was found to be misleading. Many more of these advertisements will surely have been similarly misleading, but will not have attracted formal complaints.

I understand that opinion pieces such as this may not be bound by the same requirements for accuracy and balance as non-editorial content, but I hope that you nevertheless do care about and understand the importance of the accuracy of content presented as expert health advice.

I hope you will discuss these matters with Ms Clair, and ensure that her conflict of interest is stated much more clearly if you publish future articles from her.

Here’s the follow-up message I sent the next morning:

Further to my message last night regarding your columnist Sandra Clair’s conflict of interest, this morning I see that the New Zealand Herald was distributed with the December Health 2000 catalogue.

This is the catalogue that I raised as a concern due to the fact that it advertises Ms Clair’s “Liver Detox Tea” product.

The fact that the New Zealand Herald is distributing marketing for one of the products lauded in a Herald article makes it all the more important that the nature of this conflict of interest is made clear to readers.

I hope you will treat this matter seriously.

Pharmacists Don’t Want to Sell Unproven Products

Pharmacists Don’t Want to Sell Unproven Products

The Pharmaceutical Society doesn’t think pharmacists should be able to sell healthcare products with no evidence of efficacy.

Last week I wrote about the Pharmacy Council’s proposal to change their Code of Ethics, and summarised the submissions that I was aware of. One important organisation that was missing from that roundup is the Pharmaceutical Society.

The Pharmaceutical Society is a professional association representing New Zealand pharmacists. Given their important position in the pharmacy industry, I think their submission might arguably be the most important. Earlier this week I spoke with Bob Buckham, Chief Pharmacist Advisor at the Pharmaceutical Society, about their submission on the Pharmacy Council’s proposal.

The Pharmaceutical Society does not support the proposed change. Coming from the perspective of pharmacists, their submission also raised two important points around this issue:

  • Pharmacists need clarity: what behaviour is consistent with the Code of Ethics, and what is not?
  • The Code of Ethics is important and cannot be ignored. The Pharmacy Council must be willing to provide guidance and to enforce the code.

The reason why the Pharmaceutical Society does not support this change is similar to the reasons given by other organisations, in that it would implement a double standard:

The Society does not support the proposed supplementary wording in obligation 6.9 as the split wording in the two parts separates the therapy terms “medicine or herbal remedy” in 6.9a from “complementary therapy or other healthcare product” in 6.9b. The result is that the subsequent obligation attached to those therapies does not apply to the other.

To clarify further, “credible evidence of efficacy” is only required when supplying or promoting a “medicine or herbal remedy” (Obligation 6.9a) and “no reason to doubt… quality or safety and when sufficient information about the product can be provided” only applies to “any complementary therapy or other healthcare product.

The Society considers that the obligations of “credible evidence of efficacy” and no reason “to doubt… quality or safety” should apply to the supply or promotion of all therapies and products – ie. any medicine, herbal remedy AND any complementary therapy or other healthcare product.

Submission to the Pharmacy Council of New Zealand (Pharmaceutical Society of New Zealand)

Like other submissions, the Pharmaceutical Society does support the addition of a new clause about providing sufficient information for patients to make informed choices. However, they also made a similar suggestion to one in the Society for Science Based Healthcare’s submission in that the wording of this clause should be strengthened:

The Society also considers that “sufficient information about the product” must be provided in order for purchasers to make an informed choice with respect to efficacy of that product and the risks and benefits of that against other treatment options.

Submission to the Pharmacy Council of New Zealand (Pharmaceutical Society of New Zealand)

Aside from their comments on the new proposed wording, the Pharmaceutical Society raised concerns about the application of this section of the Code of Ethics. Part of their submission focussed on pharmacists’ responsibility to comply with the Code of Ethics:

Pharmacists must comply with the Code of Ethics
The Council have stated that it is not the purpose of the Code, or the Council, to endorse or prohibit the supply of any particularly complementary and/or alternative medicine, product, or practice. However, as the responsible authority for pharmacy under the Health Practitioners Competence Assurance Act 2003, standards of ethical conduct set by the Council must be observed by pharmacists. Indeed, in the Code of Ethics the Council requires that pharmacists must comply with “all the implied requirements of ethical practice” within the Code.

The Medicines Regulations 1984 (in Schedule 2 related to applications for a licence to operate a pharmacy) also refers to how pharmacists being employed or engaged in duties in a pharmacy are

not requested or required to act in a way that is inconsistent with the applicable professional or ethical standards of the pharmacy practice

Therefore, the obligations within the Code of Ethics must be interpreted clearly so that pharmacists have a clear understanding of what is considered ethical practice, but also so that the Council can investigate and act upon breaches of the Code.

Submission to the Pharmacy Council of New Zealand (Pharmaceutical Society of New Zealand)

This call for clarity has been a common theme among submissions. Both the NZ Skeptics’ submission and Dr Ben Albert’s submission called for guidelines on product categories that should not be sold in pharmacies due to a lack of evidence. Also, when the Society for Science Based Healthcare complained to the Pharmacy Council last year, one of the recommendations made was to for the Pharmacy Council provide guidance on this issue:

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. 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.

NaturoPharm Wartoff Complaint (Society for Science Based Healthcare)

If it’s unclear where the line is drawn with regard to “credible evidence of efficacy”, it makes it more difficult for pharmacists to practice ethically. The Pharmaceutical Society’s submission raises questions about where this line might be drawn regarding alternative healthcare products, and talks about how the Code will be applied in practice:

Definition and interpretation of obligations
The wording of the proposed obligations 6.9a and 6.9b make reference to “credible evidence of efficacy” and “quality and safety”. Therefore, if presented with a complaint against a pharmacist claimed to be in breach of the obligations within the Code of Ethics, the Council is expected to determine what is “credible evidence of efficacy” and/or “quality or safety”.

The Society recognises that the application of a principles-based Code of Ethics to individual scenarios or circumstances is open to interpretation and challenge. Such scenarios are often not “black and white”, but “shades of grey” where a group of peers may have differing opinions to the acceptability or otherwise of a particular practice. It is expected that such “shades of grey” will always exist in pharmacy practice, as indeed it does in medicine and other areas of professional practice. However where a particular practice is determined to be unethical or unacceptably, this must be made clear. This is a difficulty faced when considering the evidence and use of complementary treatments against regulated medicines.

Submission to the Pharmacy Council of New Zealand (Pharmaceutical Society of New Zealand)

The submission goes on to compare “natural” or herbal healthcare products with homeopathic products, in terms of plausibility:

Complementary/alternative medicine: natural/herbal remedies
The Society recognises the history of pharmaceuticals, and indeed of the pharmacy profession, where the first “medicines” were derived from natural products. Many of these have been purified, refined and further manipulated in the development of modern day pharmaceutics. Much of modern pharmaceutical research continues to analyse the therapeutic potential of compounds found naturally occurring substances derived from flora and fauna. We recognise how the levels of evidence of the therapeutic benefits (or otherwise) of natural products can vary markedly, but understand the science behind their potential mechanisms of action has the same pharmacological basis and pharmaceuticals.

Homeopathy
We note the Council’s own ‘Complementary and alternative medicines – best practice guidance for pharmacists’ document makes reference to the Natural Health and Supplementary Products Bill which states:

currently there is no accepted scientific evidence for the effectiveness of homeopathy and therefore that health benefit claims should not be made for homeopathic products

This aligns with further documents and statements issued internationally, including the Australian National Health and Medical Research Council (NHMRC)(1), the Cochrane Library and others have noted homeopathic products show no effects beyond placebo. A large number of government committees, professional pharmacy and medical organisations internationally have issued statements reinforcing this lack of effectiveness of homeopathy in treating health conditions. The Pharmaceutical Society of New Zealand does not at this time have a position statement on complementary medicines or homeopathy.

Homeopathy is not herbalism, and homeopathic science is not consistent with currently accepted medical and pharmacological science. Some pharmacists, and indeed other health professions, have argued for the role of homeopathy as a valid form of treatment to meed patient demand, while acknowledging any “benefit” is achieved through a placebo effect, while not necessarily agreeing with the purported science behind homeopathic practice.

The question for the Council must then be whether it is considered ethical practice for pharmacists to charge a fee for products for which there is no accepted scientific evidence for effectiveness; OR for which they acknowledge a lack of evidence yet sell for the purposes of providing a placebo effect.

(1) National Health and Medical Research Council of Australia (NHMRC). NHMRC Information Paper: Evidence on the effectiveness of homeopathy for treating health conditions [Internet]. Canberra: National Health and Medical Research Council; 2015. Available from: https://www.nhmrc.gov.au/guidelines-publications/cam02

Submission to the Pharmacy Council of New Zealand (Pharmaceutical Society of New Zealand)

The Pharmaceutical Society also noted something that was raised in a few other submissions; when pharmacies sell ineffective products they lend them the credibility of their profession, which can inadvertently lead to patients being misled about their efficacy.

While we again note that the Council have expressed that it’s not their purpose or the purpose of the Code of Ethics to “endorse any particular complementary or alternative medicine or practice”, in setting the requirements for pharmacists to conform with obligation 6.9 (or 6.9a and 6.9b), the Council must determine whether the practice of homeopathy is consistent with the Code. Particularly when having homeopathic products available alongside pharmaceutical medicines, or indeed herbal/complementary medicines with their varied levels of evidence, potentially implies clinical benefit by association and provision through a respected and regulated health professional.

Submission to the Pharmacy Council of New Zealand (Pharmaceutical Society of New Zealand)

I’ve not yet been made aware of any other submissions that have been made to the Pharmacy Council, but I imagine a number of individuals at least will have made submissions that have not been publicised. As it stands though, the Pharmacy Council’s proposal seems to have strong opposition from all sides, with the only significant support I have seen so far coming from the Pharmacy Guild, who represent only those pharmacists who own their own pharmacies.

It seems no group other than pharmacy owners wants to keep the status quo of pharmacies selling ineffective products without consequences.

Pharmacy Council’s Code of Ethics Proposal: Submissions Roundup

Pharmacy Council’s Code of Ethics Proposal: Submissions Roundup

The Pharmacy Council has proposed a change to their code of ethics, here’s everything you need to know.

EDIT 22/10/2015: When this article was published it didn’t include details of the Pharmaceutical Society’s submission. Since then, I have spoken with their Chief Pharmacist Advisor, Bob Buckham, about their submission. For more details, see my article summarising it: Pharmacists Don’t Want to Sell Unproven Products

The Pharmacy Council is the statutory body responsible for setting standards of conduct and competence of pharmacists in New Zealand. They have a code of ethics, the Safe Effective Pharmacy Practice Code of Ethics 2011, which currently includes a section that requires pharmacists must:

6.9
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 2011 (Pharmacy Council)

In August, the Pharmacy Council proposed to change this section of the code of ethics. The first part of the proposed change is to remove the requirement for complementary therapies and other healthcare products to be supported by credible evidence of efficacy before they can be promoted or supplied in a pharmacy. The other part is to add a requirement that purchasers must be given enough information about these products to make an informed choice:

6.9a
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.
6.9b
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.

Proposed supplementary wording to clause 6.9 of the Code of Ethics 2011 (Pharmacy Council)

As part of this proposal, the Pharmacy Council called for submissions from stakeholders. In my last article on this topic, I discussed the submission from the Society for Science Based Healthcare, of which I am a co-founder. Although the extended deadline for submissions passed last Friday, various other groups have made their views on this proposal clear and made their own submissions.


The Society for Science Based Healthcare

The Society for Science Based Healthcare is a group of consumer advocates, scientists, and medical professionals. I am one of its co-founders. The submission from the Society for Science Based Healthcare proposed a modified version of the new wording:

6.9a
Only supply any medicine or herbal remedy where there is credible evidence of efficacy.
6.9b
Only promote any complementary therapy or other healthcare product where there is credible evidence of efficacy.
6.9c
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, when there is not credible evidence to suggest that the product lacks efficacy.
6.9d
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.

Pharmacy Council Code of Ethics Proposal (Society for Science Based Healthcare)

After lodging a complaint last year with the Pharmacy Council regarding an incident in which a patient was misled by an Auckland pharmacy that recommended and sold them a homeopathic product, both the Pharmacy Council and the Health and Disability Commissioner refused to enforce the code by telling the pharmacy not to promote or sell the homeopathic product, despite the fact that it was not supported by any credible evidence of efficacy.

In principle, the society would oppose the change. However, having have found that the existing section of the code is disregarded rather than enforced, the society decided it was best to try to turn the code into something the Pharmacy Council might be willing to enforce that could still offer protection to patients.

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.

Pharmacy Council Code of Ethics Proposal (Society for Science Based Healthcare)

This view that the current code of ethics is commonly disregarded has been shared among many of the other submissions that have been made public, and appears to be supported by a statement made by the Pharmacy Council chairman Dr Andrew Bary in a recent article on Stuff.co.nz:

But Pharmacy Council chairman Dr Andrew Bary said the rules as they stood were “unworkable” and many pharmacists, including himself, were already selling complementary medicines, even if they didn’t believe their claims.

Doctors and pharmacists clash over complimentary medicines (Stuff.co.nz)

The Society for Science Based Healthcare’s submission also argued that there are both potential risks and potential benefits to these products being sold in pharmacies. The proposed new wording is intended to provide the best risk/benefit profile for patients.

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.

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. For all intents and purposes, supplying a product in a pharmacy is also a form of promotion.

Pharmacy Council Code of Ethics Proposal (Society for Science Based Healthcare)

When it was submitted this submission had a list of 36 supporters, 24 of whom are healthcare professionals or PhD scientists


The NZ Skeptics

The NZ Skeptics’ submission opposed the change. It also proposed that the Pharmacy Council maintain a list of products or product categories that are not supported by credible evidence of efficacy, to make it easier for pharmacists to determine which products could or could not be sold in pharmacies. The motivation for this recommendation is similar to one made in the Society for Science Based Healthcare’s complaint last year:

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. 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.

NaturoPharm Wartoff Complaint (Society for Science Based Healthcare)

To inform their submission, the NZ Skeptics conducted a “secret shopper” exercise with their members to discover what actually happens when consumers talked to pharmacy staff about homeopathy.

We found that around half of the pharmacies visited had staff that were willing to promote or supply homeopathic products without adequately explaining the current lack of evidence.

It seems that some pharmacies did not stock homeopathy, but a significant number of others did have homeopathic products on their shelves and in most of these pharmacies staff were willing to offer homeopathy as a viable treatment, with no information offered about a lack of efficacy.

With the code being an important patient protection mechanism, we’re disappointed to see it so readily disregarded.

Submission to the Pharmacy Council’s 2015 Code of Ethics Consultation (NZ Skeptics)

The NZ Skeptics have made these reports available on their website: Pharmacy Homeopathy Reports. As well as this, they conducted a non-exhaustive search for New Zealand pharmacies promoting homeopathic products online, and made the results of this available too: Pharmacies Promoting Homeopathy.

One argument that is used to support pharmacies selling products with no credible evidence of efficacy is that, if pharmacists were prevented from selling these products, then patients’ freedom of choice would be infringed. This argument has been made, for example, by Pharmacy Council chairman Dr Andrew Bary when he was interviewed on Radio New Zealand about this proposed change:

You know, I think we need to respect the wish of the consumer from time to time, so you know, individuals have their own cultural and traditional beliefs around certain alternative and complementary therapies… So I think that the key thing is that we are setting out that we think pharmacists should be informed about the efficacy of the evidence for each individual product when they are promoting and making recommendations to people. But at the same time, we need to put the person at the centre, the consumer, and respect their wishes and desires.

Pharmacy Council moves to change code of ethics over homeopathy (Radio New Zealand)

The argument has also been put forth by pharmacists that sell these products in their pharmacies:

“Many patients believe homeopathy has been of benefit and they should be given the freedom to choose it if they want, [Lincoln Mall Pharmacy owner pharmacist Caleb Townsend] says.”

Pharmacists support patient choice with homeopathy (Pharmacy Today)

It may be worth noting that Lincoln Mall Pharmacy is one of the ones on the NZ Skeptics’ list of pharmacies promoting homeopathy online, and the Pharmacy Today article notes they have “qualified homeopaths onsite”. An Advertising Standards Authority complaint laid by Society for Science Based Healthcare member Simon Clark was settled in June when the pharmacy opted to remove claims that homeopathic products can “treat a wide range of illnesses and concerns” from an online listing.


Ben Albert et al.

Dr Ben Albert is a paediatric endocrinologist who researched fish oil for his PhD, which made headlines earlier this year after his research was published in the Nature journal Scientific Reports. Along with five other doctors, he has written a submission to the Pharmacy Council opposing the change.

Despite coming from a group of individuals rather than a professional society, the submission boasts the impressive support of 180 medical doctors, predominantly senior consultants, representing all medical specialties. It also has the support of the NZ Society of Paediatric Surgeons and the NZ Resident Doctors Association, which represents over 90% of the resident medical officer workforce in New Zealand. Its authors are:

  1. Dr Benjamin B. Albert FRACP, Paediatric Endocrinologist and Clinical Research Fellow. Liggins Institute, University of Auckland.
  2. Professor Wayne S. Cutfield MD FRACP. Professor of Paediatric Endocrinology, and Director of A Better Start National Science Challenge, Liggins Institute, University of Auckland. Past president, Australasian Paediatric Endocrinology Group. Past president, Asia Pacific Paediatric Endocrine Society.
  3. Professor Paul L. Hofman FRACP. Professor of Paediatric Endocrinology, Director of the Maurice and Nessie Paykel Clinical Research Unit, Liggins Institute, University of Auckland. President Asia Pacific Endocrine Society. Past president Australasian Paediatric Endocrinology Group.
  4. Professor Alistair J. Gunn PhD FRACP. Professor of Physiology and Paediatrics, and Head of Department of Physiology, University of Auckland. Paediatric Endocrinologist.
  5. Associate Professor Timothy Kenealy PhD FRANZCGP, Professor of Integrated Care, University of Auckland. General Practitioner.
  6. Dr Olivia J. Albert FANZCA. Anaesthetist, Royal Hospital for Women, Sydney, Australia.

The specific recommendations made in their submission are:

  • Reject the proposed change, or reinsert the requirement for “credible evidence of efficacy” in to clause 6.9b. We suggest this wording.

    • where there is no credible evidence to suggest a specific complementary and/or alternative medicine/product is effective, or the proposed effect of the product is scientifically implausible pharmacists should not promote or recommend its use
  • Current ethical standards should be enforced
  • Treatments and products that do not have “credible evidence of efficacy” such as homeopathic remedies, ear candles and magnet based therapies should be listed by the PCNZ, with the intention that they are not sold in pharmacies.

Submission to the Pharmacy Council of New Zealand (Ben Albert et al.)

The last recommendation echoes that of the NZ Skeptics, aiming to simplify things for pharmacists by providing a list of products or product categories which clearly are not supported by credible evidence of efficacy.

The rationale for their opposition to the change is laid out clearly and concisely in the submission:

The suggested change is in opposition to the general principles of the code, and the expectations of the public and other members of the multidisciplinary science based healthcare team.

This change would make it permissible within the ethical code for pharmacists to promote and sell products that are unproven and even scientifically implausible. We believe that this is harmful and wrong.

the current code should be enforced, not amended.

Submission to the Pharmacy Council of New Zealand (Ben Albert et al.)

They raise another counterargument to the “freedom of choice” argument, noting that pharmacists should be wary of their conflict of interest between advising against patients purchasing products that aren’t supported by evidence and selling more products to generate more profit for the pharmacy:

pharmacists (like many health providers) have a conflict of interest when they sell and give advice about health products from which they make profit. There is evidence that financial pressures do impact the clinical decisions of pharmacists1. One of the reasons that a code of ethics is important is because it provides guidance where the interests of pharmacists and patients differ.

1 Chaar B, Brien Ja, Krass I. Professional ethics in pharmacy: the Australian experience. International Journal of Pharmacy Practice. 2005;13(3):195-204

Submission to the Pharmacy Council of New Zealand (Ben Albert et al.)

They also raise the issue that products sold in pharmacies are likely to be seen as effective by the public, which can lead to harm when they are sold in pharmacies:

Many patients will assume that the pharmacist endorses the health products sold in the pharmacy as scientifically supported. But many pharmacists sell products that are known to be ineffective, such as homeopathic remedies3 or potentially harmful, such as ear candles4. Selling such products conflicts with the principles of the current code5 as it reduces patient autonomy. The patient that wrongly assumes that a health product is scientifically supported is ill-prepared to make an informed decision.

3 Ernst E. A systematic review of systematic reviews of homeopathy. Br J Clin Pharmacol. 2002;54(6):577-82.
4 Seely DR, Quigley SM, Langman AW. Ear Candles-Efficacy and Safety. The Laryngoscope. 1996;106(10):1226-9.
5 Zealand PCoN. Code of ethics 2011: Pharmacy Council of New Zealand; 2011 [cited 1015 17 September]. Available from: http://www.pharmacycouncil.org.nz/cms_show_download.php?id=200.

Submission to the Pharmacy Council of New Zealand (Ben Albert et al.)

Although this submission has not been made public, it shares much in common with a letter to the editor from the same authors that was published today in the New Zealand Medical Journal.

I spoke with Dr Albert to ask what motivated him to take action on the Pharmacy Council’s proposal, here’s what he had to say:

For years it has bothered and surprised me that products that are entirely implausible such as magnets and homeopathic remedies, and harmful products such as ear candles are sold in pharmacies. When scientifically trained and trusted health professionals promote and sell such treatments they betray the trust of the public who will quite reasonably assume such products are endorsed by the pharmacist and supported by scientific evidence. The current PCNZ code of ethics indicates that it is unethical and unprofessional for pharmacists to sell these products. The right course of action is to stop selling them. To instead change the code to redefine ethical behaviour appears cynical and makes the sale of unsupported or harmful treatments no less wrong.

Dr Ben Albert


The New Zealand Medical Association

The New Zealand Medical Association is New Zealand’s largest medical organisation, representing over 5,500 medical professionals. The New Zealand Medical Association’s submission strongly opposes the change. They echo the views of other submissions that in the face of widespread behaviour at odds with the current code, the way forward should be change behaviour to match the code rather than to relax the code to permit existing behaviour:

The NZMA is strongly opposed to the above proposed change

We do not believe that pharmacists should be selling ‘treatments’ that are known to be ineffective or lack evidence of effectiveness. We contend that doing so is unethical. While this practice may be happening under the present Code, we believe that the PCNZ should be seeking ways to enforce the Code rather than amend it to accommodate this practice.

Submission to the Pharmacy Council of New Zealand (New Zealand Medical Association)

The NZMA acknowledged the trust placed in pharmacists by the public, and how this affects the way in which products sold in pharmacies are perceived:

It is our view that allowing pharmacists to sell ineffective therapies or products is contrary to the profession’s own aspirations, including of trustworthiness and professionalism. More broadly, it undermines the social contract between the public and the profession. The pharmacist is trusted by patients and other members of the health care team precisely because of their scientific training. The sale of products by pharmacists that knowingly do not work is inconsistent with the high trust health care professional the public expects and the profession requests.

Submission to the Pharmacy Council of New Zealand (New Zealand Medical Association)

The NZMA also deals with the “freedom of choice” argument in a similar way to the other submissions:

We understand that patient autonomy and freedom of choice are being advanced as the rationale for the proposed rewording to the Code. We believe these are spurious arguments on which to remove the requirement for “credible evidence of efficacy” for pharmacists to sell complementary therapies or other healthcare products. Freedom of choice should not transcend the health and well-being of the patient. Furthermore, such products are already available to people to purchase at other outlets, such as health food shops and supermarkets.

Submission to the Pharmacy Council of New Zealand (New Zealand Medical Association)

The NZMA raised some new concerns, regarding the potential impacts of the proposed change:

The proposal is of all the more concern given the current lack of regulation of complementary therapies in New Zealand.

We are also concerned at the impact of the proposal on equity. Patients that are least likely to consult a doctor could end up being even more likely to purchase costly ‘healthcare’ products from their pharmacy that do not work.

The proposal also undermines the wider health sector’s efforts to improve health literacy.

Submission to the Pharmacy Council of New Zealand (New Zealand Medical Association)

The NZMA’s final recommendation is for the requirement for credible evidence of efficacy to be kept and enforced, and until it is enforced for the newly proposed requirement for supplying sufficient information to make an informed choice to bridge the gap:

Ideally, we would like to see pharmacists end the sale of complementary therapies or other healthcare products for which there is no credible evidence of efficacy (ie, meet their obligations under the existing Code). Until such time, we would suggest the addition of a subclause to 6.9 which addresses the need to provide sufficient information for herbal remedy, complementary therapy or other healthcare product. Accordingly, we proposed the following wording:

6.9
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.
6.9a
When supplying a herbal remedy, complementary therapy or other healthcare product, sufficient information about the product must be provided in order for the purchaser to make an informed choice with regard to efficacy of the product and the risks and benefits of all available treatment options.

Submission to the Pharmacy Council of New Zealand (New Zealand Medical Association)


The Pharmacy Guild

The Pharmacy Guild represents pharmacy owners in New Zealand. The Pharmacy Guild’s submission supports the Pharmacy Council’s proposed change:

We support the Council’s intentions of the proposed changes to clause 6.9 of the Code of Ethics 2011 (the Code).

Consultation on the proposed wording to clause 6.9 of the Code of Ethics 2011 (Pharmacy Guild)

The primary motivation for this support seems to be a combination of the “freedom of choice” argument I described above, and the potential for benefit described in the Society for Science Based Healthcare’s submission:

We believe that if pharmacists were prevented from selling natural products then patients wanting these products would continue to source them from somewhere. We consider that it is far safer for consumers to approach pharmacists for advice and that they purchase supplies of complementary medicines from a pharmacy rather than over the internet for instance, where the quality and safety of a product cannot always be guaranteed.

Consultation on the proposed wording to clause 6.9 of the Code of Ethics 2011 (Pharmacy Guild)


As well as these submissions, I have been made aware of a few more, mainly submitted by individuals. Of those I am aware of, such as Edward Linney’s submission, they are predominantly opposed to the change for many of the reasons described in these submissions. I am aware of one instance of an ex-pharmacist who supports that change who is now a practising homeopath and, scarily, was previously employed by the Pharmacy Council as their Professional Standards Advisor even while they were practising as a homeopath. However I don’t know if they have made a submission.

I’m also aware that the Pharmaceutical Society has made a submission. Whereas the Pharmacy Council regulates pharmacists, the Pharmacy Guild and Pharmaceutical Society are membership organisations; the Guild represents pharmacy owners and the Society represents pharmacists in general. Although I have tried to get in touch with them, I haven’t seen the Pharmaceutical Society’s submission and can’t provide comment. I will update this article if that changes.

However, I am aware that the Pharmaceutical Society has close ties to the New Zealand Medical Association, even to the point where they have a joint agreement for members to abide by both organisations’ codes of ethics. So I expect that if they have made a submission it may be along similar lines to the NZMA’s submission.

If anyone knows of any more information that I’ve missed in this article, please leave a comment below.

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:

6.9
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:

6.9a
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.
6.9b
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 sbh@sbh.nz. 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:

6.9a
Only supply any medicine or herbal remedy where there is credible evidence of efficacy.
6.9b
Only promote any complementary therapy or other healthcare product where there is credible evidence of efficacy.
6.9c
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.
6.9d
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 sbh@sbh.nz. 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).