Pharmacists selling CAM doesn’t wash

SCAN the shelves of your local pharmacy and chances are you’ll see a whole range of “natural” products on sale, promising everything from better digestion to a stronger immune system.

The ethics of health care professionals promoting products of, at best, doubtful efficacy have often been questioned, including by me.

Canadian pharmacist Scott Gavura has long argued his profession needs to take a more evidence-based approach, based in part on his own experience working in community pharmacy.

“If it was unorthodox, this store probably sold it,” he writes on the Science-Based Pharmacy blog. “Conventional drug products (the ones I was familiar with) were hidden off in a corner, and the store was otherwise crowded with herbal remedies, homeopathy, and different forms of detox kits and candida cleanses. All of this was unlike anything I’d ever seen or heard about in pharmacy school.”

Gavura can’t have been the only new pharmacy graduate ever to have been confronted by that reality, but he may be the first to suggest the selling of complementary and alternative medicine (CAM) violates, not just medical ethics, but even the “relatively permissive” principles of commercial ethics.

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In an article in Bioethics, he teams up with business ethicist Dr Chris MacDonald to make that case, starting off with the identification of some essential ethical principles that underlie commercial transactions.

Two of these are that the product has to work, and that the purchaser has to understand the product and be able to assess whether it will meet their needs (I’m going to call that second one informed consent).

So, a consumer buying a used car is entitled to expect that it is able to be driven. And they should not be misled into believing it can sprout wings to escape traffic jams.
 
The informed consent principle implies “a general demand for honesty on the part of sellers, and a refusal to profit from the ignorance of consumers”, Gavura and MacDonald write.

So how does the CAM industry fare when measured against these principles of commercial ethics?

It’s pretty much a total fail on the first one, since few CAM products are able to provide quality evidence of efficacy.

“Empirical testing confirms what a priori plausibility suggests: there is little convincing evidence that the overwhelming majority of CAM has any meaningful medicinal effects, and some CAM, like homeopathy, has no effects at all,” the authors write.

CAM practitioners are fond of blaming the poor performance of their treatments in trials on what they consider to be inappropriate methodologies: randomised controlled trials just don’t suit their kind of practice they often claim.

All right then, these authors say, tell us what you want to use instead? Give us another rigorous method of establishing efficacy, “something beyond intuition, tradition, and anecdote, something that goes some distance to overcoming the well-documented flaws to which personal documentation is subject”.

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It’s not always a question of intentional dishonesty, as the authors acknowledge. Some in the CAM industry clearly believe in the products they sell, but that doesn’t let them off the ethical hook.

“It is not plausible to excuse vendors for selling a product that does not work simply because they have either not taken the time and effort to investigate … or turned a blind eye to the evidence that is available to them,” the authors write. “There is, after all, such a thing as willful ignorance.”

The sellers of CAM also get a fail on the informed consent requirement, since most consumers have little capacity to assess the evidence base – or lack of it – for the treatments being spruiked to them.

“Consumers generally don’t know just how little reason there is to believe in the specific effects offered by purveyors of, for example, homeopathy,” the authors write. “Not only do they not know there’s no evidence that homeopathy works, they a) generally don’t have the expertise to evaluate the evidence, and they b) don’t realise that the claims of homeopathy are fundamentally at odds with basic biology and even physics.”

The selling of CAM is often defended with arguments about respect for the autonomy of the individual, each person’s right to make decisions about their own health.

But that really only holds water if the individual is fully informed before making his or her decision, something that would require manufacturers and retailers to clearly disclose the lack of evidence for the products they sell.

Imagine that: “I recommend this $29.99 potion to improve your energy levels and general sense of wellbeing. The laws of science tell us it can’t possibly do anything on a biological level, but you may experience a placebo effect that will make you feel better anyway.”

The used car salesmen would be proud.

Jane McCredie is a Sydney-based science and health writer.