Tag: Pharmacy Council

New rules for pharmacists

New rules for pharmacists

The Pharmacy Council has (finally) published their new Code of Ethics 2018.

I’ve written several times on the ongoing saga of the Pharmacy Council’s Code of Ethics. In late 2014 we put together a complaint at the Society for Science Based Healthcare arguing that their Code of Ethics 2011 had been violated by an Auckland pharmacy, in which a salesperson had recommended and sold a homeopathic product to someone who didn’t realise they were buying quackery.

Following this complaint, the Pharmacy Council decided they would not enforce the rule in their Code of Ethics at the time that prohibited pharmacies from purchasing or supplying any health product that was not backed by “credible evidence of efficacy”.

This led to two protracted consultation processes, first about that specific part of the code and then about rewriting the code entirely. I worked on the Society for Science Based Healthcare’s submissions during each consultation period, and we met with the Pharmacy Council twice to discuss the topic.

The consultation processes also saw well-voiced support for strong patient protection rules coming from the New Zealand Medical Council and the Pharmaceutical Society (who represent professional pharmacists). Whereas the Pharmacy Guild (who represent pharmacy owners) was in favour of the more relaxed rules that had been suggested. For more detail on this, you can read my submissions roundup from 2015.

The Code of Ethics 2018 will come into force on the 12th of March 2018. It’s principle-driven, and accompanied by a number of guidelines that go into more detail on what’s expected of pharmacists in various areas. One of these guidelines is the Pharmacy Council Complementary and Alternative Medicines – Statement and Protocol for Pharmacists.

Unlike the Code of Ethics 2011, the new rules don’t prohibit pharmacists from selling quackery. While this is unfortunate, it’s seemed clear from the outset that the Pharmacy Council had no intention to keep this rule given they aren’t prepared to enforce it. Instead, there has been an increased focus on ensuring patients are given the opportunity to make an informed choice.

I’m feeling cautiously optimistic about the change. Though ideally pharmacists shouldn’t be lending their credibility to ineffective health products, if pharmacists must be allowed to sell quackery then I think the next best approach to regulation is to protect patients’ rights to make an informed decision.

On the face of it, I think the new rules seem good. But enforcement has been a concern in the past and parts of the previous code were widely disregarded. Come the 12th of March, I plan to have a look for pharmacists who aren’t complying with the new rules and lodge complaints to see how they are treated, and if the behaviour is corrected. Unfortunately, there are a few pharmacies in New Zealand that have a history of promoting quackery, including by selling ineffective health products online, which seems like a good place to start.

I’d recommend you read the rules for yourself if you’re interested, but here’s my summary of what I think are the most important new patient protection rules regarding informed consent:

[Principle 1H: A pharmacist] Before recommending, supplying or promoting a medicine, complementary and/or alternative medicine or other healthcare product or service, considers available evidence, and only supplies a product when satisfied that it is appropriate, and the person understands how to use it correctly and safely.

[Principle 4C: A pharmacist] Provides accurate, truthful, relevant, and independent information in an appropriate form that is not misleading to patients, the public and/or other healthcare professionals.

[Principle 4H: A pharmacist] Ensures that when providing any medicine, complementary and alternative medicine, or other healthcare product or service, that the health and wellbeing of the patient or consumer is the primary consideration, and that the benefit of use outweighs the risk.

[Principle 4I: A pharmacist] Does not engage in advertising, promotion or supply of goods or services that could include misleading or unsubstantiated claims, and/ or undermine public trust in the profession.

[Principle 6A: A pharmacist] Maintains contemporary knowledge of evidence-based practice.

Where it makes sense, all of these principles are effectively extended to non-pharmacist salespeople who work in pharmacies via Principle 5G:

[A pharmacist] Is responsible for actions of staff under their supervision.

Looking at the associated guideline on “complementary and alternative medicines”, the requirements in parts 14 and 15 seem like they will be particularly important for protecting patients from quackery in pharmacies:

14. When supplying products or information about treatments/products/services that have no current evidence of proven efficacy pharmacists are expected to:

a. ensure that patients are informed about the degree to which treatments or products have been evaluated, and

b. the degree of certainty and predictability that exists about their efficacy and safety

15. Pharmacists must advise patients when scientific support for treatment is lacking.

Part 18 of the guidelines also includes the following requirements:

e. provide sufficient information regarding the CM/NHP [Complementary Medicine/Natural Health Product] to allow patients to make informed choices

f. not misrepresent information or opinion. Patients must be made aware of the likely effectiveness of a given therapy according to recognised peer-reviewed medical publications, in spite of your personal beliefs

g. provide the patient with a timeframe for accessing conventional medicine if their condition is unresolved or there is no improvement

Time will tell if these rules really do enhance patient protection in the pharmacy industry, which has a long-standing problem with promoting quackery on the side.

From the 12th of March onwards, if you see behaviour that you think is non-compliant with the code feel free to let me know about it. I can be contacted via email at mark@honestuniverse.com.

Pharmacy ethics: Have your say

Pharmacy ethics: Have your say

The Pharmacy Council has opened consultations on a proposed new code of ethics. Following an initial consultation in 2015 where they’d proposed changing one part of the existing code, the council has since decided the whole code could do with a review.

The Pharmacy Council is the regulatory body for pharmacists in New Zealand, set up by the Health Practitioners Competence Assurance Act 2003. As well as overseeing the registration of pharmacists, they are also responsible under Section 118(i) of the Act for setting standards of ethical conduct to be observed by pharmacists.

I met with the Pharmacy Council just prior to the new consultation being opened, as part of my volunteer work with the Society for Science Based Healthcare. They told us that the revised code is intended to be more principle-driven, with associated guidelines that will be able to be updated more easily so as to keep pace with the evolution of the healthcare industry and with new legislation.

As well as these principles, the proposal also includes a draft of the Pharmacy Council Complementary and Alternative Medicines Statement and Protocol for Pharmacists as one of its appendices, and the council is also seeking feedback on this part of their proposal. Here are the consultation questions they’ve put forward, though they note that these are only intended as a guide and submissions can comment on any part of the proposal:

  1. Can you think of any ethical values for the pharmacy profession that appear to be omitted from the revised code?
  2. Considering the explanation of the term “patient” and equivalent terms in the key terms (key terms):

    1. Do you think the term “patient” is the best word to use, most of the time, to express the relationship that exits between the pharmacist and the person they are directly or indirectly caring for or providing health care information to?
    2. Are there any specific clauses where you can think of different term that could be more appropriate?
  3. Considering the new clauses that relate to the sale of complementary and alternative medicines (CAM, clauses 1g, 4h and 4hh): Do you find it clear that the Council is not opposed to the sale of CAM when they have demonstrated benefits for patients, have minimal risks, and the patient is making an informed choice?
  4. Are there any other comments you would like the Council to consider?

In the Society for Science Based Healthcare’s 2015 submission, we stressed the importance of a code of ethics that would effectively protect patients. The context of the original proposed change was a complaint we laid in 2014 regarding an Auckland pharmacy promoting and selling a homeopathic product, in which the Pharmacy Council determined it could not enforce its existing code of ethics:

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.

Our submission will view the draft revised code in this light, looking at it in terms of how effectively we could expect it to prevent patients from being misled in pharmacies.

If this is important to you too, I hope you’ll consider making a submission. As the consultation document notes, submissions can be sent via email to enquiries@pharmacycouncil.org.nz, and (at the time this article was published) submissions will close at 5pm on Friday 18 August 2017.

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).

Ethical Pharmacy Practice 5: Looking for Leadership

Pharmacy
Pharmacy by russellstreet on Flickr CC BY-SA 2.0

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

YOU MUST:

Only purchase, supply or promote any medicine, complementary therapy, herbal remedy or other healthcare product where there is no reason to doubt its quality or safety and when there is credible evidence of efficacy.

Safe Effective Pharmacy Practice Code of Ethics Section 6.9

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

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

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

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

The Society for Science Based Healthcare

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

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

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

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

Complementary and Alternative Medicines — Best Practice Guidance for Pharmacists

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

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

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

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

Pharmacy Council July 2015 Newsletter

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

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

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

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

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

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

Pharmacy Awards | Best Complementary Healthcare Campaign

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

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

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

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

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

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

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

Pharmacists support patient choice with homeopathy – Pharmacy Today

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

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

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

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

I just noticed CVS has started stocking homeopathic pills on the same shelves with–and labeled similarly to–their actual medicine. Telling someone who trusts you that you’re giving them medicine, when you know you’re not, because you want their money, isn’t just lying–it’s like an example you’d make up if you had to illustrate for a child why lying is wrong.

Randall Munroe – xkcd: Alternative Literature

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

Ethical Pharmacy Practice 4: Paving the Way

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

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

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

Statement on Homeopathy – National Health and Medical Research Council (Australia)

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

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

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

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

Position statement: homeopathy – Royal Australian College of General Practitioners

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

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

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

Doctors Told to Stop Prescribing Homeopathic Products – Radio NZ

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

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

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

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

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

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

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

Pharmacist bins ‘crap’ homeopathic products – The West Australian

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

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

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

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

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

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

YOU MUST:… Only purchase, supply or promote any medicine, complementary therapy, herbal remedy or other healthcare product where there is no reason to doubt its quality or safety and when there is credible evidence of efficacy

Safe Effective Pharmacy Practice Code of Ethics – Pharmacy Council of New Zealand

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

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

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

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

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

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

Pharmacists Support Patient Choice with Homeopathy – Pharmacy Today

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

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

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

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

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

Dr Stephen Child, Doctors Told to Stop Prescribing Homeopathic Products – Radio NZ

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

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

Green Cross Health

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

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

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

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

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

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

Homeopathy discredited again on both sides of the Tasman – Pharmacy Today

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

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

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

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

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

Ethical Pharmacy Practice 3: Running Out of Excuses

Ethical pharmacy practice is something I have written about before. If you’ve read those posts, please bear with me as I cover some familiar background.

In New Zealand, we are lucky enough to have an industry code of ethics for pharmacists, published by the Pharmacy Council of New Zealand, which holds pharmacists to high ethical standards. This code of ethics is the Safe Effective Pharmacy Practice Code of Ethics. One of the most important parts of this code of ethics is section 6.9, which states:

[PHARMACISTS] MUST:… Only purchase, supply or promote any medicine, complementary therapy, herbal remedy or other healthcare product where there is no reason to doubt its quality or safety and when there is credible evidence of efficacy.

Pharmacy Council’s Safe Effective Pharmacy Practice Code of Ethics Section 6.9

The Pharmacy Council of New Zealand isn’t a voluntary member organisation like the Pharmacy Guild or the Pharmaceutical Society. Instead the council is established as part of the Health Practitioners Competence Assurance Act 2003. Their roles are set out in this act and include:

  • Registering pharmacists
  • Reviewing and maintaining the competence of pharmacists
  • Setting standards of clinical competence, cultural competence, and ethical conduct for pharmacists

Which means that the Safe Effective Pharmacy Practice Code of Ethics is not a voluntary code of ethics. It is published by the body whose legal duty it is to set the standards of ethical conduct for pharmacists. Yet all over New Zealand, many pharmacists ignore it.

Walk into any New Zealand pharmacy. Chances are that you will find a section where they advertise and sell a range of homeopathic products. To anyone familiar with the evidence for homeopathy, it will come as no surprise when I tell you that there is no credible evidence of efficacy for any homeopathic product. Therefore, it seems to me, New Zealand pharmacists have an ethical obligation not to promote or sell them.

Yesterday, the Australian National Health and Medical Research Council (NHMRC) issued their final statement on homeopathy, following an incredibly extensive and rigorous review of the literature. They looked at over 1,800 scientific papers, and found that 225 met their criteria for methodological rigour, sample size, and placebo control. Their main finding was:

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

NHMRC Statement: Statement on Homeopathy

As I said, this conclusion does not come as a surprise. This research is the latest in a long line of reviews of the evidence for homeopathy that drew essentially the same finding:

  • A 2002 systematic review of systematic reviews of homeopathy published in the British Journal of Clinical Pharmacology concluded that:

    the hypothesis that any given homeopathic remedy leads to clinical effects that are relevantly different from placebo or superior to other control interventions for any medical condition, is not supported by evidence from systematic reviews. Until more compelling results are available, homeopathy cannot be viewed as an evidence-based form of therapy.

    A systematic review of systematic reviews of homeopathy

  • A 2010 systematic review of systematic reviews of homeopathy published in the Medical Journal of Australia concluded:

    The findings of currently available Cochrane reviews of studies of homeopathy do not show that homeopathic medicines have effects beyond placebo.

    Homeopathy: what does the “best” evidence tell us?

  • A 2010 report from the UK House of Commons concluded:

    homeopathy is a placebo treatment.

    Evidence Check 2: Homeopathy

  • In 2013, the NHMRC published a report based on their research that found:

    There is a paucity of good-quality studies of sufficient size that examine the effectiveness of homeopathy as a treatment for any clinical condition in humans. The available evidence is not compelling and fails to demonstrate that homeopathy is an effective treatment for any of the reported clinical conditions in humans.

    Effectiveness of Homeopathy for Clinical Conditions: Evaluation of the Evidence

I could go on, but I hope by now you get the idea.

New Zealand pharmacists need to respond to the NHMRC’s research. And if they mean to practice responsibly and ethically, that response should be to immediately stop all promotion and sale of homeopathic products. The ethical standard to which they should be held is clear, and it is not consistent with promoting or supplying homeopathic products.

Last year, I complained to the Advertising Standards Authority under the auspices of the Society for Science Based Healthcare about a homeopathic product for preventing jet lag (No-Jet-Lag) that was advertised in Parnell Pharmacy. The pharmacy responded by removing the advertisement, and agreeing to stop selling the product if it was found that the claims were not supported by credible evidence, and my complaint was upheld. Unsurprisingly, my complaint was upheld when the ASA decided claims such as “it really works” were not supported by credible evidence. However, despite Parnell Pharmacy’s example, many New Zealand pharmacies still sell this exact product.

The NHMRC’s report represents the same finding, but on a larger scale. New Zealand pharmacists who promote and sell homeopathic products should follow the responsible example of Parnell Pharmacy, and remove homeopathic products from their shelves.

Ethical Pharmacy Practice 2: Time for a Spring Clean

In July, I wrote an article on Ethical Pharmacy Practice and Homeopathic No-Jet-Lag. In it, I described the importance of the role pharmacies play in the healthcare system, and their ethical obligation not to mislead consumers or promote ineffective healthcare products. In particular, I described an advertisement I saw in an Auckland pharmacy for a homeopathic product called “No-Jet-Lag”, and the complaint I submitted to the Advertising Standards Authority about it via the Society for Science Based Healthcare. There’s also a write up of this decision and the 2 others released at the same time on the Society’s website: Pharmacy to Remove Homeopathic Product Following Complaint

On the 9th of October, the ASA released their decision to the public. They ruled to uphold my complaint, which means the advertisement has to be removed. More importantly, in response to my complaint the pharmacy made a promise to remove the product from sale if the complaint was upheld. Here’s what they said:

We believe that the manufacturer, Miers Laboratories ought to respond to the substantive complaint that it’s [sic] representations fail to comply with the Therapeutic Products Advertsing [sic] Code.

We believe that the product is sold in many pharmacies in New Zealand and it is somewhat arbitrary that our pharmacy is the subject of the complaint.

We are interested in the outcome of the complaint and can indicate that if the Authority upholds the complaint we will remove the product from sale. In the meantime, the product has been removed from the counter and placed on a less prominent position.

I agree with their first two points. While I think pharmacies shouldn’t promote or sell healthcare products without a sound understanding of the evidence behind them and the claims made about them, I also think it’s reasonable to expect the manufacturer (who also produced the advertising in this case) to substantiate the claims. Moving the display to a less prominent position in the meantime seems like a reasonable compromise as well, although of course I’d prefer it if the product were never stocked in the first place.

I also agree with them that their inclusion in this complaint is somewhat arbitrary. For that reason I am not going to specify in this article which pharmacy it was. If you really must know then you can read the full decision on the ASA’s website. As they said, many New Zealand pharmacies sell this product and I think this complaint applies to all of them.

I also think this pharmacy’s promise to remove the product from sale in the event that this complaint is upheld, as it now has been, is the appropriate response. I think that every single New Zealand pharmacy that stocks No-Jet-Lag should follow suit. There are a lot of them. The website for this product even claims on its New Zealand Retail Outlets page that “Most chemists nationwide” stock it.

As I mentioned in my original post on this topic, and in my complaint, New Zealand pharmacists are bound by the Pharmacy Council’s Safe Effective Pharmacy Practice Code of Ethics 2011. Perhaps the most important part of this industry code of ethics, at least in my mind, is section 6.9:

YOU MUST:

Only purchase, supply or promote any medicine, complementary therapy, herbal remedy or other healthcare product where there is no reason to doubt its quality or safety and when there is credible evidence of efficacy.

This is a very fine standard to adhere to, and I would hope that all businesses to which it could possibly apply would adhere to it as well, although realistically I know that’s not the case.

In response to the complaint, Miers Laboratories submitted a few studies to the ASA. They were pretty laughable though when you look at the sample size:

In all our research we base our work on previous studies, the first study for jet lag used 5 people, then it was 10 and at the time the accepted worldwide minimum was 12 for clinical trialOur [sic] bigger study used 19 people.

So basically “most of our studies didn’t even meet the very low minimum accepted size, and even the largest one was tiny”. Very impressive, Miers Laboratories.

The 19 person study they mention is also promoted on their website, and I pre-emptively discussed it in my complaint. It seems the Advertising Standards Complaints Board essentially agreed with my criticisms:

The majority of the Complaints Board said the statement “It really works” was an absolute therapeutic claim and, as such, required a high level of support. However, it noted the trial population in the pilot study was small, the methodology was not robust and the results had not been published or peer reviewed. The Complaints Board also noted the study was an in-house trial conducted by the Advertiser rather than independent research.

Given the weaknesses in the study, the majority of the Complaints Board said the Advertiser had not satisfactorily substantiated the claim the product “really works” and, as such, the Complaints Board said the advertisement had the potential to mislead consumers. Consequently, the Complaints Board said the advertisement did not observe a high standard of social responsibility required of advertisements of this type. Therefore, the majority of the Complaints Board ruled the advertisement was in breach of Principles 2 and 3 of the Therapeutic Products Advertising Code.

For context, Principle 2 of the Therapeutic Products Advertising Code states that:

Advertisements must be truthful, balanced and not misleading. Claims must be valid and have been substantiated.

And Principle 3 states that:

Advertisements must observe a high standard of social responsibility.

This is basically exactly the result I was hoping for, which is great. However, I was a little concerned by one part of the decision:

A minority of the Complaints Board disagreed [that the advertisement was in breach of Principles 2 and 3 of the Therapeutic Products Advertising Code]. It acknowledged the study sent by the Advertiser to support its claims. While it noted the issues with the study, the minority of the Complaints Board was of the view the product was not harmful and said the consequences of the product not working were not significant or serious for the consumer.

I’d expect anyone who has ever paid money for a pill to prevent jet lag would disagree with this, although it is obviously a lot more serious than something like a cancer treatment that doesn’t work. More importantly, although I do agree that it’s important to consider the severity of what happens if the product doesn’t work, I hope that the ASA will not give a free pass to misleading therapeutic advertising simply because it’s for a condition that they deem insignificant.

Now that this complaint has been upheld, the pharmacy in question has promised to remove No-Jet-Lag from sale. I hope this is the start of a spring clean for all New Zealand pharmacies that stock this product. They should follow this responsible example and take the opportunity to examine other products they have for sale – especially homeopathic products – to ensure that they are abiding by their ethical duty not to promote or supply healthcare products for which there is no credible evidence of efficacy.

You can help. Next time you see a homeopathic product in a pharmacy, ask them what the evidence for it is. If you see this particular product, ask them if they’re aware that the Advertising Standards Authority upheld a complaint against it on the basis that the evidence for it just isn’t good enough.

EDIT 2014/10/12

It’s great to see that several media outlets have picked up this story:

Ethical Pharmacy Practice and Homeopathic NO-JET-LAG

Pharmacies are an integral part of the healthcare industry. They provide a valuable decoupling between the doctor you see for an examination and potentially a prescription, and the institution that stands to profit from the medicine you pay for. Without this separation, there’s the potential for a conflict of interest where the physician examining you would profit more from giving you a prescription than they would from telling you that you’re fine and sending you on your way.

I’m not trying to imply that bias has been entirely removed from the healthcare industry, but having independent pharmacies fill prescriptions from doctors does help. You unfortunately don’t generally see this sort of separation of interests in the alternative healthcare industry, where practitioners who claim to know the secret true cause of your “dis-ease” or “lack of wellness” (blocked chi, misaligned chakras, vertebral subluxation complexes etc.) also just so happen to also offer the solution; for a price, of course.

This association between pharmacies and doctors leads pharmacies to be respected and trusted institutions. After all, we expect the person behind the counter – the pharmacist – to not only be able to dispense the correct amount of the correct drug we’ve been prescribed, but also to have a sufficient understanding of how it works so they can advise us on such things as precautions we should take. “Do I need to take this with food?”, “Will this make me drowsy?”, and so on. However, pharmacies also need to be profitable to work as a business, which is why you’ll also be able to find all sorts of non-prescription products for sale such as cosmetics and non-prescription medication. Because of their involvement with the healthcare industry and respected status, it’s important that these other products sold in pharmacies also be reliable, and they should not be stocked without good reason. Essentially, pharmacies should be held to a relatively high ethical standard.

In New Zealand, there is a crown entity known as the Pharmacy Council that is established by the Health Practitioners Competence Assurance Act 2003. The Pharmacy Council is responsible for duties such as registering pharmacists and setting standards of conduct, although in cases where pharmacists require disciplining that is carried out by another crown entity also established by the Health Practitioners Competence Assurance Act: the Health Practitioners Disciplinary Tribunal. In order to ensure that pharmacists are held to an appropriate ethical standard, the Pharmacy Council has developed a Safe Effective Pharmacy Code of Ethics, published in 2011, which is publicly available on their website.

In my opinion, this Code of Ethics is an admirable document, and I’m encouraged by the idea that New Zealand pharmacists might be held to such an appropriate ethical standard. For example, it defines its principles to be the following:

AS A PHARMACIST YOU MUST:

  1. Make the health and well-being of the patient your first priority.
  2. Promote patient self-determination, respect patients’ rights, autonomy and freedom of choice.
  3. Use your professional judgment in the interests of the patients and the public and promote family, whānau and community health.
  4. Show respect for others and exercise your duties with professionalism.
  5. Actively seek and apply contemporary pharmacy knowledge and skills to ensure a high standard of professional competence.
  6. Act in a manner that promotes public trust and confidence in pharmacists and enhances the reputation of the profession.
  7. Practise in a manner that does not compromise your professional independence, judgement or integrity, or that of other pharmacists.

The Code of Ethics goes on to expand on each of its principles in seven sections. I encourage you to read through the document, as it’s interesting to come to a better understanding of the ethical standards to which New Zealand pharmacists should be held. For example, part 2.4 regards the patient’s right to informed consent:

YOU MUST… Explain the options available to patients and the public, to help them make informed decisions. Make sure the information you give them is impartial, relevant, up-to-date and independent of personal commercial considerations.

The section of this Code of Ethics which I found most interesting, as well as most encouraging, is section 6.9 (emphasis mine):

YOU MUST… Only purchase, supply or promote any medicine, complementary therapy, herbal remedy or other healthcare product where there is no reason to doubt its quality or safety and when there is credible evidence of efficacy.

Although it is written here in this code, most people who use a pharmacy in their day to day lives aren’t aware of it. Instead, it is more like an unspoken assumption: if it’s sold in a pharmacy, then surely it’s legitimate, reliable, and effective. And of course, this should be the case – if there is no credible evidence of efficacy then an ethical institution should neither promote nor supply it. The Pharmacy Council has also published Advertising Guidelines, and its General Principle 7 reiterates this point (emphasis mine):

Any medicine, complementary therapy, herbal remedy or other healthcare product associated with the maintenance of health must have credible evidence of efficacy and safety (Code of Ethics 2011: 6.9). Health claims for complementary therapies or herbal remedies must be able to be substantiated and must not breach the Medicines Act with regard to therapeutic purpose.

Unfortunately, it appears many New Zealand pharmacists do not abide by these rules. I was unfortunate enough recently to discover an instore display in an Auckland pharmacy for a product called “NO-JET-LAG”. While I was in the pharmacy, I took a photograph of this display with my phone:

NO-JET-LAG

As you can see, this display makes some strong and explicit claims regarding the effect of the product:

TRY NO-JET-LAG
It Really Works

Effective

Homeopathic Jet Lag Prevention

Hang on a minute… “Homeopathic”… That sounds familiar. I wonder what exactly is in these pills? Luckily, there’s a website listing their ingredients:

The five homeopathic remedies listed below are the active ingredients in No-Jet-Lag.

Arnica Montana 30C (Leopard’s Bane), Bellis Perennis 30C (Daisy), Chamomilla 30C (Wild Chamomile), Ipecacuanha 30C (Ipecac), Lycopodium 30C (Clubmoss)

If you’ve read my post on homeopathic dilutions, you may recall that “30C” means the ingredient has been diluted by 1/100 30 times. That is a mind bogglingly large dilution. If you were to end up with just one single molecule of the original ingredient at the end of that, you’d have to start with 1060 molecules of it.

That’s a hard number to visualise though, and it’s hard to think of things in numbers of molecules, so let’s compare it to something more familiar. The Earth is made up of roughly 1050 atoms, so the amount of ingredient we’d have to start with would be roughly 10,000,000,000 (yes, that’s ten billion) times bigger than the planet. Even the Sun only has around 1057 atoms in it: still 1,000 times fewer than the number we’d need. Needless to say, after the dilution is done there is absolutely no amount of any of these ingredients remaining in any “NO-JET-LAG” pills.

Knowing this, it seems rather implausible that they’d be effective for anything at all, let alone specifically preventing jet lag, but all the same it’s best to look at the evidence. The manufacturer’s website has a Scientific Test page. Now, given that I have spent some time writing up a complaint to the Advertising Standards Authority because I don’t think this evidence even comes close to being enough to substantiate the claims made about these products, I don’t particularly want to write out the same arguments all over again. So I am going to make this complaint public. While the first section specifically regards the instore display I saw in Parnell Pharmacy on the 2nd of July, the other sections are about the evidence regarding “NO-JET-LAG” and the ethical implications of my complaint, and these sections apply to all of the many New Zealand pharmacies that promote and supply this product.

This complaint should be read with the following in mind: Assuming I am correct regarding the evidence for this product, I think the appropriate response of pharmacies stocking it would be to immediately remove it from their stock, and to apologise to the customers they have failed to protect. The Code of Ethics for an industry is the absolute minimum acceptable level of ethical behaviour, and it appears for all the world that many New Zealand pharmacies haven’t even been doing that.

(Note that the original complaint was in plain text but I’ve edited it to add appropriate formatting here)

An instore advertisement for “NO-JET-LAG” in Parnell Pharmacy contains misleading therapeutic claims, in violation of the Therapeutic Products Advertising Code Principle 2. Because these claims are misleading, the advertisement also fails to observe the high standard of social responsibility required of it by the Therapeutic Products Advertising Code Principle 3.

The advertisement contained the following text (also see image attached):

TRY NO-JET-LAG
It Really Works

NO-JET-LAG
Homeopathic Jet Lag Prevention
Natural | Effective | No Side Effects or Drug Interactions

The Perfect Travel Companion

The product packaging, also visible from the front in the attached image, displayed this text:

The Perfect Travel Companion

NO-JET-LAG
Long Haul, for flights longer than 7 hours
Homeopathic Jet Lag Prevention

The strong and absolute therapeutic claims “Homeopathic Jet Lag Prevention”, “Effective”, and “It Really Works” require robust substantiation. Although it may not fall within the ASA’s jurisdiction, it is important to consider the advertisement within therapeutic context implied by its placement on the front desk of a pharmacy and by the prominently displayed name of the product “NO-JET-LAG”.

As far as I can tell, the only substantiation offered by the manufacturer is a small (n=19) pilot study that does not appear to have been published in a peer-reviewed scientific journal. This pilot study can be found on the manufacturer’s website: http://www.jetlag.co.nz/jet-lag6.html

Although it is not stated in the study, the POMS scale on which subjects rated their level of “fatigue-inertia” (the only measured end point reported to have statistically significant differences between control and experimental groups) is measured on a scale from 0-28. In this context, the mean difference between control and experimental groups of 3.84 is less impressive than in the context of a smaller scale that seems a sensible conclusion from reading the study, given that the y-axis of the bar chart only goes from 0-12. The non-significant measure of “vigor-activity” is similarly displayed on a chart with a y-axis from 0-22, whereas the actual scale is from 0-32.

Also, the POMS scale includes 6 measurements, yet there is no mention in the study of having corrected their statistical analysis for multiple measurements. Assuming that no adjustment for this was made, as none is mentioned in the study, this means that although one of the 6 measurements purportedly reached statistical significance it is fairly likely to have been a false positive. From random chance alone, the chance that 1 out of 6 measurements would reach this level of statistical significance is approximately 1/4 (26.5%). A relatively conservative method of correction, the Šidák correction, would alter the required p-value for statistical significance in this case to 0.0085. However, the measurement’s p-value of 0.026 doesn’t even come close to crossing below this threshold and would therefore not normally be considered statistically significant.

The study also brings the effectiveness of its participant blinding measures into question with the following statements:

When asked if they knew whether they had taken the remedy or the placebo, they said that at the time of arrival in Germany the whole party all felt very tired but most were already fairly sure which treatment they had taken.

On the outward journey, of the 19 taking part 13 (68%) correctly guessed whether they had taken the placebo or No-Jet-Lag. Of the others, three did not know and three incorrectly assigned themselves to the wrong group.

On the return journey, two were incorrect, three did not know and 14 (74%) correctly guessed.

Also, one of the study’s authors was the Director of Research at Miers Laboratories, the manufacturer of this product. It is not clear how much influence the manufacturer had over the study design or operation, or to what extent it may have been funded by them.

So, as far as I’ve been able to find, the only evidence that could be used to support the very strong claims made on this advertisement is a small unpublished non-independent pilot study with questionable blinding that does not appear to have reached the threshold for statistical significance. In short, the claims do not appear to have been adequately substantiated, and should therefore be considered to violate the Therapeutic Products Advertising Code Principle 2.

Although it falls outside of the ASA’s jurisdiction, I feel it would be appropriate to briefly discuss the Pharmacy Council’s Safe Effective Pharmacy Practice Code of Ethics 2011. Section 6.9 of this industry code of ethics states that:

YOU MUST… Only purchase, supply or promote any medicine, complementary therapy, herbal remedy or other healthcare product where there is no reason to doubt its quality or safety and when there is credible evidence of efficacy.

I sincerely hope that the manufacturer of this product has high quality rigorous scientific evidence that substantiates the claims made about this product hidden away somewhere and that, despite the fact that the only evidence they publicise on their website is the tiny low quality pilot study I discussed above, they have shared this evidence with every single one of the many New Zealand pharmacies who stock their product. If not, and things really are as they seem, then this would be an appallingly widespread violation of perhaps the most important part of the Pharmacy Council’s Code of Ethics.