Saturday 12 March 2011

Quack Medication and Professional Ethics

I believe that the multi-billion pound\dollar alt-med "movement" is a real problem that is a shame on our society. Apart from the areas where it accidentally leverages placebo effects it does nothing positive at best, can be hugely destructive at worst and relies on fantasy and a denial of reality as fundamental principle.

As an example, the overwhelming medical research* out there indicates that Homeopathy does not, and cannot, deliver positive medical outcomes. I’m picking on them as an example but like the rest it’s a hugely profitable business based on fantasy. Fortunately, unlike some others (many herbal teas can be toxic in large doses for example), there is also zero risk of direct negative medical outcomes. The opportunity cost, however, can be fatal for those ill-informed enough to put their entire trust in it which is not a trivial consequence. As a business it’s about selling little bottles of water and sugar pills where the raw material costs of the ingredients are effectively zero. All real costs are for packaging, marketing and distribution alone. Even better they can make “stronger” products (ie more expensive ones) by (further) diluting the ingredients. Imagine how you could rake in the cash in any other business if you could persuade your customers to pay you twice as much for half the product. From a purely business perspective, that really is magic, but it needs a lot of effective marketing to convince people to pay for something that does nothing. Most of that marketing comes from effective placements in Pharmacies, because we’re all conditioned to trust our Pharmacists’ professional medical judgements.

That it exists at all may be an insult to rationality, but at some level if people want to be duped then I can’t fault a smart business for chasing that market. However a large part of its continued success stems from the fact that the public perception of its validity is massively inflated by the fact that Pharmacists appear to a casual consumer to consider them as perfectly valid medications.Now I know that many will argue that they are (usually) displayed and labelled in a way that separates them from real medications but I cannot understand how they can fail to acknowledge how weak that argument actually is.

From my perspective the fact that Pharmacists dole out Homeopathic and other “alt-med” quack cures would be like an Electrician who would happily wire up your house with wiring made from wool wrapped in paper. We don’t get duped by wool and paper pseudo-electricians of course but that’s because any fool can demonstrate that some wool wrapped in paper wont power your kettle. With medical issues we need trustworthy medical professionals to tell us whether some possible treatment will do what we need it to do. Proving medical outcomes is hard, requires expertise, and defending the rigour required by those processes in the face of the overwhelming force of the profitability of the quack medication industry is hard. Given the trust we put in Pharmacists I feel that they should be obliged to act ethically in this regard, and they don’t.

Before I go on I probably should also say that I don’t particularly trust the Pharmaceutical Industry as a whole, the companies that make all our (legal) drugs that is. It’s got its own problems, some of them immense, but for the most part their business is to make stuff that has genuine medical effects. For all the corruption that there may be there, they are accountable to rationality at some level and their products are subject to extensive scrutiny with regard to their benefits and harms. They are also profit-seeking scumbags in many cases, but they actually do deliver reality based medications that have transformed the medical outcomes of virtually everyone on the planet. They are subject to license (in most places) and have to act accordingly. 

In Ireland we have a tightly controlled consumer pharmaceutical trade. I cannot buy more than a handful of paracetamol pills at a time (for well intentioned medical reasons), codeine based OTC painkillers are now only available after talking to a Pharmacist (again arguably a valid requirement that helps limit potential abuses), and pretty much any genuine medication has to be purchased through a regulated pharmacy. We give Pharmacies this monopoly because they are rigorously regulated as professionals and that provides benefits to us because they control the distribution of many beneficial but genuinely dangerous drugs.

The downside is that, as with any other monopoly scenario, we pay many times more for common drugs here than we otherwise would. If I recall correctly from my last trip to the US I could buy many common drugs (ibuprofen, aspirin, paracetamol, famatodine) easily in bulk at costs up to 40x lower than here. And if I can buy a couple of thousand ibuprofen pills in the US for the cost of a packet of 24 here then, frankly, the bloody pharmacists should be doing that for us instead and making it obvious to us when we are about to spend €5 on a couple of Neurofen that they could give us 100 generics for €1, or whatever. And by all means be careful about selling 1000 Paracetamol to anyone stupid\depressed enough to try and down them all in one go but don’t use that as a shotgun excuse to extort 95% profit margins from the 99% of the population who aren’t going to do that.

But all of that is a minor business ethics faux pas compared to the medical ethics catastrophe that is their willingness to collaborate with the various quack pseudo medication scams out there. The sight of magic cures sold by Pharmacies and presented as if they were on a par with real medication is a shocking example of profit trumping medical ethics. How on earth can anyone trust a pharmacist's ability to provide competent advice on taking medication when they also sell magic magnetic bracelets, water potions, Flower Power pills and Mr Fruity's Frightfully Useful Unguent. They might as well have displays for Ollivander's Magic Wands, quantum dream catchers, holographic pixie dust, compressed unicorn karma, blue moon crystals and other trans-dimensional snake oils sitting by the till under a sign that says "Guaranteed Cures for all your Ailments".

Frankly in doing this they whoring out their professional reputation in order to delude the vulnerable and make a quick buck. I really find that despicable. I’m sure their businesses are complex, and making a profit is relatively hard overall so in their defence I’d actually be happy enough to let them charge me 40x the cost for a few painkillers if I knew that cost also made their business viable enough that I would then trust their medical judgement when it came to the stuff they sell. But right now there is no way that I can, and I don’t see how anyone could.

As a possible compromise perhaps Pharmacists should be obliged to treat alt-med products in the same way that they deal with codeine based products: Hide them behind the counter and interview all potential customers. After all the purpose with the Codeine rule is to protect people from their own stupidity, so if they took the time to have a chat with anyone looking for magic water pills so as to explain what they actually contained, the real benefits\risks attached and then form a judgement as to whether the sale was going to be helpful to the customer before allowing it, then they could ethically continue to sell them.


* You know the extensive actually scientific stuff with proper controls**, statistical analysis, peer review and openness about methodology.

** For placebo effects***, age cohorts, other drugs, blah blah.

***Now if Homeopathy was to rebrand themselves as “Placebopathy” and drop the magic water-bashing of minute trace dilutions imparting some mystical quantum molecular memory mumbo jumbo then we’d be getting somewhere.

No comments: