Thank you for inviting the Society for Science Based Healthcare to provide feedback on the draft of your revised Code of Ethics. The Society for Science Based Healthcare is an advocacy organisation dedicated to protecting the right for people to make informed decisions about their healthcare. We are particularly concerned with situations where people are misled about their healthcare options.

In our submission on the initial 2015 proposal to alter the Pharmacy Council’s Safe Effective Pharmacy Practice Code of Ethics 2011, we suggested changes that centred around patients’ rights to make informed decisions about their healthcare.

We are happy to see that the draft revised code includes several sections with the same focus. This is reflected both in principles 1g and 2d, and in various parts of the Pharmacy Council Complementary and Alternative Medicines – Statement and Protocol for Pharmacists, particularly part 17.

We would like to reiterate the point we made in our 2015 submission, that a code of ethics which is not enforced may as well not exist. Both the Pharmacy Council and pharmacists should be able to look at any section of an effective code of ethics and be able to clearly see how compliance with that section could be recognised, and how it could be enforced.

Further than that, we think it is appropriate to consider an ideal situation and how the revised code of ethics could help to reach it.

The sale of ineffective health products in pharmacies does not benefit patients’ health, but can cause harm financially, to their health literacy, and also to their health by delaying effective treatment. Making ineffective health products available in a pharmacy also risks giving the public a false perception that these products are effective. In order to justify these products being offered for sale, the harm must be offset by some other benefit that requires them to be available in pharmacies.

When patients seek ineffective health products in a pharmacy, there is an opportunity for pharmacists to help them make an informed choice about how to best address their health issues. The size of this benefit depends on the demand for the product – if more patients are seeking it, then pharmacists are able to do more good by helping these patients make informed choices.

As pharmacists continue to provide patients with evidence-based advice, we would expect the demand for ineffective health products to drop. At some point, this demand will be low enough that making an ineffective health product available in a pharmacy will do more harm than good. From this point, it would be unethical for a pharmacy to stock such a product.

If pharmacies do stock ineffective health products, it should only be with a view to advise patients against them until, due to a drop in demand caused by pharmacists’ advice, it is no longer beneficial to stock them. Similarly, any code of ethics that allows the sale of ineffective health products from trusted health professionals such as pharmacists should only be enacted as a temporary measure, until a code prohibiting their sale can be effectively implemented.

This view is somewhat reflected in part 17.7 of the CAM guidelines, but we believe a wider interpretation is necessary to improve the pharmacy industry’s relationship with CAM to a point where patients are no longer harmed.

If the Pharmacy Council does not believe that pharmacists can be trusted to act in this manner, then they should not permit pharmacists to sell these products.

Given historical and current behaviours we have observed from some pharmacists in New Zealand, we lack the confidence that ineffective health products will only be sold in pharmacies within the context of advising customers not to purchase them. Particularly considering the innate conflict of interest involved when the same person is both promoting and dispensing health products, we think an ideal code of ethics would prohibit the sale in pharmacies of health products that are not supported by credible evidence of efficacy.

1. Can you think of any ethical values for the pharmacy profession that appear to be omitted from the revised code?

Availability of ineffective health products

As we discussed in our 2015 submission, it is important for pharmacists to weigh up the potential risks and benefits when choosing to purchase health products that are not supported by credible scientific evidence.

On one hand, having these products available in a pharmacy can bring the people who are seeking them to a place where they can receive appropriate advice from a pharmacist, instead of seeking it elsewhere and running a greater risk of being misinformed.

However, on the other hand, having these products available in pharmacies legitimises them, and the sale of ineffective health products may bring the pharmacy profession into disrepute.

The revised code addresses the issue of bringing the profession into disrepute under principle 7e, and principle 1 (particularly 1g) requires that pharmacists consider the health and wellbeing of the patient foremost in their decision-making. However, principle 1g lays out this responsibility only in the context of recommending or selling a product to a patient, and it is not clear that it should still apply when choosing which products to make available in a pharmacy.

We understand that the Pharmacy Council may not be willing to tell pharmacists which products they can and cannot sell. In light of this, we believe an aspirational statement should appear in the revised code reminding pharmacists that their responsibility to consider the health and wellbeing of their patients over anything else also applies when they are deciding which products to make available for sale.

The potential harms of stocking ineffective products in pharmacies were outlined in the recently released interim report from the Australian government on their Review of Pharmacy Remuneration and Regulation. Though they made these points in the specific context of homeopathic products, they apply equally to other health products not supported by credible evidence of efficacy:

“There are unacceptable risks where community pharmacies are allowed to sell homeopathic products.”

“In particular, the Panel notes that the supply of homeopathic products through pharmacies is not benign but, rather, risks creating a perception of reliability and efficacy in the mind of the consumer based on the status of the pharmacy as a healthcare provider. This may encourage patients to choose a homeopathic product over a conventional medicine with robust evidence of efficacy, which creates a risk of harm to the patient’s health.”

Relationship with CAM-based healthcare practitioners

It is not an uncommon practice for pharmacists to employ an in-house naturopath, or similar, to provide patients with information on CAM products. For example, Westgate Pharmacy and Unichem Meadowlands Pharmacy employ in-store naturopaths.

As it is also common practice among naturopaths to promote ineffective health products, such as homeopathic products, and to provide unsubstantiated and misleading health advice, we are concerned that this practice is likely to harm pharmacy patients and undermine their right to make informed healthcare decisions.

Principle 5f of the revised code makes it clear that a pharmacist is responsible for the actions of staff under their supervision, and principles 4c, 6a, and others clarify the responsibility of pharmacists (and, we presume, their staff) to maintain a contemporary knowledge of evidence-based practice sufficient to provide patients with only accurate information.

Further, principle 7g requires pharmacists to raise concerns or take appropriate steps if the actions of others may compromise patient care.

We think these principles, as aspirational statements, should address the issue of pharmacy staff such as in-store naturopaths providing misleading health advice. However, we are concerned that they will not be adequately enforced or adhered to by those pharmacists who employ these CAM practitioners. This will be particularly difficult if there is no auditing or active monitoring conducted by the Pharmacy Council.

We have similar concerns regarding potential referrals to CAM practitioners, whether they work in a pharmacy or elsewhere.

What are the Pharmacy Council’s expectations regarding the degree of supervision of these alternative healthcare practitioners, when they are employed in a pharmacy? We feel that either a clarification on this point or a relevant guideline would be useful for ensuring that pharmacists who employ naturopaths or similar practitioners will adhere to these sections of the revised code.

Health literacy

Though the code rightly tells pharmacists to put their duty to the patient foremost (e.g. principles 1a and 4j), there is no mention of the role of pharmacists in improving and protecting health literacy.

The closest the code comes to this is in principle 3c, but this appears to be more passive as the public health initiatives it refers to will presumably come from government rather than pharmacists.

However, pharmacists have an important role to play here as trusted healthcare professionals. One good example of how pharmacists make a difference in this area is around helping patients understand the facts around vaccinations – an area where there is a lot of misinformation.

An example of a plan for a pharmacy-led public health literacy project in this area is laid out in 2017 Future Pharmacist of the Year award winner Sonja Bimler’s essay A role for pharmacy in improving childhood vaccination rates through communication based intervention with parents.

The Roy Morgan Image of Professions Survey 2016 found, out of 30 professions, pharmacists were rated second highest in terms of ethics and honesty, at the same rate as doctors. Patients trust the advice they receive from pharmacists and, for better or worse, this advice contributes to their level of health literacy.

With this trust comes a responsibility for pharmacists to play an active role in improving and protecting health literacy. We believe this responsibility should be enshrined in the revised code’s principles, perhaps alongside principle 3c. Potential wording might be:

“cc. contributes to and protects public health literacy.”

2. Considering the explanation of the term “patient” and equivalent terms in the key terms:
a. Do you think think the term “patient” is the best word to use, most of the time, to express the relationship that exits [sic] between the pharmacist and the person they are directly or indirectly caring for or providing health care information to?

Yes. We think it is appropriate as it keeps the focus on a pharmacist’s duty of care, rather than terms like “consumer” or “client” which can imply a more profit-based motivation.

On the topic of terms used, we feel it is inappropriate to use the term “therapeutic products” in a way that includes products with no evidence of any therapeutic benefit. More appropriate terminology might be “health products”, which we think more clearly conveys an intent rather than any implication of effect.

b. Are there any specific clauses where you can think of a 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?

Yes, we think it is clear that when CAM products have demonstrated benefits for patients and have minimal risks, and the patient is making an informed choice, the Pharmacy Council does not oppose their sale.

However, as explained in the rest of our submission (see Enforcement concerns), we have some concerns that the revised code may also be permissive of the sale of CAM where these conditions are not all met.

We are also concerned that merely not opposing the sale of products without demonstrated benefits is not enough to protect patients. Rather, the Pharmacy Council should publish a statement that they are opposed to the sale of health products that do not have demonstrated benefits for patients.

This would reflect the positions of the Pharmaceutical Society of Australia and the Royal Australian College of General Practitioners, which have both published position statements opposing the sale of homeopathic products due to the lack of credible evidence of efficacy:

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

“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.”

4. Are there any other comments you would like the Council to consider?

Enforcement concerns

We are aware of multiple New Zealand pharmacies currently operating in ways that we do not think are consistent with either the revised code of ethics or the existing Safe Effective Pharmacy Practice Code of Ethics 2011. We do not expect that this behaviour is likely to change when the revised code comes into effect, particularly as principle 1g and part 12 of the CAM guidelines require only that a pharmacist be satisfied that the products they are selling are appropriate.

This wording requires only that a pharmacist convince themselves that a product is appropriate, rather than having it measured against an external robust evidential standard.

The code attempts to address this in principle 6a, by requiring that pharmacists maintain contemporary knowledge of evidence-based practice. However, the only direct requirements for which products can be promoted and sold in a pharmacy in the revised code is that a pharmacist is satisfied that they are appropriate and that they are convinced the health and wellbeing of the patient was the primary consideration (4h).

Though these principles may work well as aspirational standards, we believe their nature does not permit them to be enforced effectively and so they will not be sufficient to protect patients.

Principle 4c provides an appropriate external standard that information provided by a pharmacist is accurate, truthful, relevant, and not misleading. We believe that a similar standard should be applied regarding the promotion and sale of health products, rather than requiring only that a pharmacist be satisfied that a product is appropriate.

Without this, differences in understandings of what standard should be required before a pharmacist should be satisfied that a health product is appropriate could lead to the continued promotion and sale of ineffective health products in pharmacies.

Also, in order to ensure that the revised code of ethics fills its role of patient protection, we believe it will be necessary to have a robust and clear complaints process to address cases of repeat or continued non-compliance. When we met with the Pharmacy Council prior to this consultation, it was indicated that enforcement of the code would typically take the form of industry-wide guidance notes. However, we do not expect this will be sufficient to gain compliance across the industry, and a pathway for dealing with exceptions will be necessary for patient protection.

Advertising and online storefronts

The revised code contains appropriate requirements around ensuring patients are able to make informed decisions, such as principles 4c and 4d, and parts 14, 17.5, and 17.6 of the CAM guidelines. However, it is unclear how these are to be applied in some circumstances where information is conveyed to patients through advertising. This is particularly relevant in the case of online storefronts, where patients can purchase health products without any interaction with pharmacy staff.

As the code itself is intended to be principle-based, and accompanied by guidelines that go into more detail and can be updated as the industry continues to change, we feel it would be appropriate for the code to be accompanied by guidance on how these rules are applied to advertising and to online storefronts.

It should be made clear that pharmacists are responsible for all advertising they use, even if they didn’t produce the advertisement, and this should include in-store displays provided by a product’s manufacturer.

In the particular case of online advertising, we are aware of multiple NZ pharmacies who currently operate online storefronts where health products are promoted and sold using inaccurate, incomplete, and misleading information. This scenario can be particularly challenging, as there is typically no opportunity for a pharmacist to consult with the patient before a product is promoted or sold to them.

We think it would be appropriate for principles and guidelines as mentioned above to also apply in the case of online storefronts. Though many advertisements are necessarily small and will not be able to convey sufficient information to make an informed choice, it should not be possible for patients to purchase health products from a pharmacy online without being provided with this level of detail.

We believe that rule 14 of the CAM guidelines in particular should be applied in the case of all advertising material, regardless of medium. Otherwise we expect this information would likely be relegated to a footnote with little prominence that would commonly be missed by patients purchasing products online.

It should also be considered that promoting a health product through advertising is a form of recommendation, and so part 17 of the CAM guidelines should be abided by wherever possible in this context. As advertising is typically a one-way interaction, some of these requirements cannot reasonably be met, but parts 17.4, 17.5, and especially 17.6, should be considered when advertising CAM products.

There is also a worrying trend in the more general advertising of health products such as CAMs for certain ambiguous wording to be used in order to avoid falling afoul of existing regulations. Terms such as “winter ills and chills” and “immune system support” are commonly used because more specific claims would not stand up to scrutiny. We recommend it should be made clear to pharmacists that this practice would be inconsistent with sections 17.3 and 17.6 of the CAM guidelines, as it is not an appropriate way to discuss a product’s therapeutic benefits with a patient, and also risks misrepresenting the product.

We believe it would be appropriate to include a requirement for pharmacists to abide by the Advertising Standards Authority’s rules with regard to all advertising content they produce or display. The ASA is typically the first place that complaints regarding misleading advertising are directed, but the ASA has no power to enforce their decisions. Though non-compliance with the ASA’s rulings is relatively rare, a requirement from the Pharmacy Council for pharmacists to abide by their rules would provide a defence against noncompliance with their rulings from pharmacists, and would align with similar rules already employed by other healthcare regulatory bodies in New Zealand

Public confidence and disrepute

We are concerned about the disparity in opinion that will surely exist regarding principle 7e around what actions may or may not qualify as bringing the profession into disrepute or impairing the public’s confidence in the pharmacy profession.

As we have already mentioned, in Availability of ineffective health products, the interim report from the Australian government on their Review of Pharmacy Remuneration and Regulation, it is noted that:

“In particular, the Panel notes that the supply of homeopathic products through pharmacies is not benign but, rather, risks creating a perception of reliability and efficacy in the mind of the consumer based on the status of the pharmacy as a healthcare provider. This may encourage patients to choose a homeopathic product over a conventional medicine with robust evidence of efficacy, which creates a risk of harm to the patient’s health.”

We feel this may also apply to other behaviours we have mentioned, such as the availability of pseudoscientific diagnostic services and in-store naturopaths offering consultations in pharmacies. But those pharmacists who engage in this behaviour already are unlikely to see it as bringing the profession into disrepute or impairing the public’s confidence.

On what basis would the Pharmacy Council consider a complaint on this basis? Or is it intended solely as an aspirational statement, with no potential for enforcement?

CAM-specific guidelines

General applicability

The Pharmacy Council Complementary and Alternative Medicines – Statement and Protocol for Pharmacists document contains many appropriate standards and expectations, but in all but a few cases these are equally applicable to health products that fall outside the scope of “Complementary and Alternative Medicines”.

Though some of these statements do apply specifically to health products that are not supported by credible evidence of efficacy (e.g. 17.3 and 17.7) in most cases they apply equally well in a more general context. For example, we would expect pharmacists to not misrepresent information or opinion (17.6) when discussing an evidence-based health product.

Though this may not be intended, the inclusion of these statements in a separate guideline that applies specifically to complementary and alternative medicines carries with it an implication that they do not necessarily apply in other circumstances. It may be the intention that these statements are covered by the code of ethics itself, or that other similar guideline documents will be published setting these standards in the context of evidence-based health products, but currently this is not clear.

Part 13

Part 13 of the CAM guidelines refers to “treatments/products that have no current evidence of proven efficacy”. While part 13.1 is a suitable requirement in this case, we think that “no current evidence of proven efficacy” is too restrictive a requirement. In cases where there is an abundance of research on a health product, and the body of evidence clearly shows it is ineffective, there might still be low quality evidence of efficacy. Part 13.1 should still apply in these cases, in line with part 14’s “when scientific support for treatment is lacking”.

We also think it would be appropriate to refer to services as well as “treatments/products” in this section, so it would also encompass such things as diagnostic services. One example is the pseudoscientific “live blood analysis” diagnostic service that has been offered in some NZ pharmacies.

Our suggestion for alternative wording is:

“13. When supplying or providing information about treatments, products, or services that are not supported by robust evidence of proven efficacy pharmacists are expected to:”

Parts 16 and 17

It is not currently clear whether the requirements laid out in parts 16 and 17 of this document also apply in cases where patients actively request supplies of these products and, more importantly, whether they apply in cases where pharmacists promote these products without being prompted by the patient, such as when cross-selling. Is that what is meant by the wording “or a CM/NHP is recommended” in the heading above part 16?

It is not an uncommon practice for these products to be cross-sold in pharmacies, when a patient has come for a different reason such as filling a prescription. We think it would be appropriate for the requirements in parts 16 and 17 to apply in these circumstances, but the current wording of the document does not make it clear if this is the case.

Part 18

Regarding part 18 of the guidelines, we feel it would be appropriate to add a part 18.2 that says pharmacists should also make efforts to meet the requirements laid out in parts 16 and 17. Though they may not be requirements in those cases, and considering the note in part 18 that “not all patients will wish to engage in a conversation when purchasing a familiar self-selected CM/NHP”, we think the requirements laid out in parts 16 and 17 should still be considered best practice and be adhered to whenever possible.

We would like to reiterate our thanks to the Pharmacy Council to involving us in this process, and actively seeking our feedback. We hope this submission will be useful, and look forward to seeing the final outcome of the review.


Mark Hanna
Chair, Society for Science Based Healthcare

Submission on the Pharmacy Council’s draft revised Code of Ethics
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