What are the ethical implications of health care providers selling retail products from their offices and recommending said products to patients or clients?This is a touchy subject, meaning there are some strong feelings under the surface, but it is becoming more vital that we keep this discussion out in the open. I have worked in many different integrative health offices in my time: acupuncture, chiropractic, integrative MD and DO, ayurvedic, as well as in health food stores. I’ve seen the owners and practitioners handle this issue in a variety of ways. On one end of the spectrum there are the minimalists who keep a small inventory and recommend only the absolutely essential.On the other end, I’ve worked with integrative doctors whose patients rarely left without eight to 10 supplements in hand. In this case, the “natural pharmacy” retail in the practitioner’s office is a major part of overall income.
There are three main arguments here:
• First is the opinion that we serve our patients better by providing access to nutraceuticals in office. From the patient’s perspective, there is convenience and availability, consistency in quality, accuracy in purchasing the correct product, and trust in and loyalty to the provider. For the practitioner, there is also the aspect of convenience and availability of product, the ability to monitor quality, the accuracy of getting the right product to the patient, the accountability to monitor success, and the ability to receive a somewhat passive income that helps with the bottom line.
• Second is the possibility that a practitioner is in a position of power over the patient, and may be tempted to use this dynamic to further financial gains. This topic has been under debate in the American Medical Association (AMA) for years, and they have not been able to resolve the issue to the satisfaction of all the different medical specialties. Some physicians find this to be absolutely ethically wrong and are dead set against retail sales. Apparently, the AMA advises its physicians who want to keep supplements on hand for patients to provide Them either for free, or at their own cost at most. I have never seen this to be the case.Any physicians who do this, please speak up now and set an example for all of us!
• Third is the argument that this debate should be considered differently for conventional physicians than it is for natural or integrative practitioners.Most people who are patients of a chiropractor, acupuncturist, nutritionist, naturopathic doctor, homeopathic doctor, ayurvedic doctor or herbalist expect that their practitioner will carry certain products for retail sale. The more traditional medical fields that are based upon thousands of years of historical practice include the providing of medicine as part of the practice. These practitioners often operate on a small scale, and retailing the medicines they recommend helps them overcome the practitioner’s conundrum: the financial constraint that a provider can only see a certain number of people per day, a number much fewer for natural practitioners than for physicians.
A Long-Running Debate
Physicians who are not trained to be integrative and holistic may be the ones who are at the center of this debate. The global pharmaceutical market is predicted to reach $1.6 trillion by 20161, while the global herbal supplement market is slated for $107 billion by 2017. 2 Physicians cannot legally tap in to the treasure trove that is the pharmaceutical market. The nutraceuticals market, though a smaller pie, is up for grabs, and is counting on endorsement and sales by health care practitioners to drive the market increase.
In March 2010, the Nutrition Business Journal published a survey of 600 medical doctors, naturopathic physicians, chiropractors, nutritionists and other practitioners, which found that 76 percent sell supplements in their offices. There was no breakdown to show how many were Mds or Dos, but it showed that 75 percent of surveyed health care providers are profiting from the $30 some billion a year industry in the U.S. Back in 2001, Kyle Bliffert, director of sales and marketing at Metabolic Maintenance, stated that the company would receive resistance from doctors about actually selling out of their offices. Still, at that time, 11 years ago, 25 percent of their wholesale business was made up of Mds.3
Some physicians argue that to keep up with their patients’ knowledge, and to prevent Them from doing themselves harm by self-diagnosing and self-treating, they have found it almost necessary to start carrying certain products to impose quality control.They figure patients will buy something anyway, so why not from their doctor who can monitor quality and progress? Many feel it almost lessens their liability because they are more aware and more in control of all substances going into their patients’ bodies.4
Patients and consumers also chimed in, many of them adamant in their belief that a doctor should not retail nutraceuticals. Some have felt pressured by a physician to buy something expensive and not proven. Still, there are those who have purchased something they needed from their doctor at a far lower cost than they could have elsewhere and were appreciative.5
A real concern is that most conventionally trained doctors are not trained for nutrition, herbs, nutraceuticals or integrative medicine in general.What should be the educational requirement for a physician to recommend and retail nutraceuticals? This issue may actually be a question of scope of practice and the ethics intrinsic to that concept.
Integrative physicians, naturopaths, nutritionists, acupuncturists, herbalists, ayurvedic physicians and homeopaths are all trained to provide some form of “natural” medicine to their patients or clients. It is expected. This medicine, whatever the form, is meant to be determined and applied in a holistic manner, requiring that we take into account a patient’s social, spiritual, emotional and physical background to provide treatment.The term “holistic” comes from holism, the idea that natural systems (physical, biological, chemical, social, economic, mental, linguistic, etc.) and their properties, should be viewed as wholes, not as collections of parts.This often includes the view that systems somehow function as wholes and that their functioning cannot be fully understood solely in terms of their component parts.
In the linear Western model of medicine, if a patient’s results show X, then they need Y to make it better. In the holistic model we consider much more than the patient’s symptoms and lab results before we recommend treatment or medicine. This inspires us to find the common denominator, amongst all of the factors in the definition above, and prioritize our recommendations Accordingly. In doing so, we are less likely to overwhelm a patient with treatment protocols, and more likely to see compliance with the products we do recommend because the patient perceives that the protocol is possible to accomplish, and hopefully affordable.
In short, our first responsibility is to the patient. “I will use those dietary regimens which will benefit my patients according to my greatest ability and judgement, and I will do no harm or injustice to them.”6 Every practitioner is involved in a power dynamic with their patients, and conventional and integrative physicians are at the pinnacle. It is within each and every one of us that we must find our ethic that keeps us from the temptation to use our power over our patients and their trust in us to our own financial gain. Our prosperity should not be proportional to our salesmanship, but rather to our skill in helping our patients get better on their road to recovery.
1 www.reportbuyer.com/pharma_healthcare/country_ reports_pharmaceutical/outlook_pharmaceuticals_ worldwide.html.
2 www.nutraceuticalsworld.com/contents/ view_breaking-news/2012-03-07/global-herbal-supplement- market-to-reach-107-billion-by-2017/).
3 www.nutraceuticalsworld.com/issues/ 2001-04/view_features/the-health-practitioner-market- is-there-a-doctor-i/.
4 www.acpinternist.org/archives/1999/01/ retail.htm.
6 From the translation of the Hippocratic Oath by Michael North, National Library of Medicine 2002
©Copyright 2012, By Amber Lynn Vitse