Ethical and professional issues in the practice of complementary medicine in retail pharmacies.
Subject: Alternative medicine (Health aspects)
Alternative medicine (Management)
Alternative medicine (Analysis)
Alternative medicine specialists (Practice)
Alternative medicine specialists (Analysis)
Pharmacy (Management)
Author: Mendel, Joy
Pub Date: 03/22/2007
Publication: Name: Australian Journal of Medical Herbalism Publisher: National Herbalists Association of Australia Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2007 National Herbalists Association of Australia ISSN: 1033-8330
Issue: Date: Spring, 2007 Source Volume: 19 Source Issue: 1
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Geographic: Geographic Scope: Australia Geographic Code: 8AUST Australia
Accession Number: 174818455
Full Text: Herbalists, naturopaths and other practitioners of complementary medicine (CM professionals) are becoming an increasingly visible phenomenon. This paper aims to provoke thought in the areas of ethics and professional practice in the multidisciplinary health care milieu of the typical retail pharmacy. Complementary medicine (CM) practice in community pharmacy is presented as potentially beneficial for both clients and CM professionals but also one that portends potential conflict in ethical, philosophical and professional areas. The juxtaposition of CM and pharmacy practice raises the potential for inter-professional ethical issues, not only for CM professionals and pharmacists, but for other professionals such as doctors, who particularly in regional and rural areas, may be important pharmacy stakeholders. Some of these issues may be based around differences in the philosophical positions of mainstream and CM medicine. Acknowledgement of CM practice in pharmacies also prompts consideration of big-picture intra-professional issues, particularly around the sociocultural positioning of the CM professions. Throughout the discussion reference is made to areas of health care ethics, including client confidentiality, professional and client autonomy, distributive justice and informed consent.

Introduction

Increasingly, qualified herbalists, naturopaths and other practitioners of complementary medicine (CM professionals) are practicing in retail pharmacies. This phenomenon raises the need for a consideration of the associated inter and intra professional issues. A CM professional working in a pharmacy often does so as an employee. As retail pharmacies in Australia cannot be owned by individuals other than pharmacists, the CM professional with employee status will ultimately be working for a pharmacist. Pharmacists are bound by a code of ethics that qualifies, among other issues, the nature of their interactions with other professionals. Similarly the CM professional's affiliation with a professional body such as the National Herbalists Association of Australia, carries the responsibility to abide by the code of ethics formulated and supported by the particular CM fraternity to which he or she belongs. While pharmacists may offer some health care advice to their clients, especially in regard to minor complaints and commonly available over the counter medicines, referral of the client to a doctor for more complex diagnosis and treatment has been the cultural norm.

Some CM therapists such as naturopaths are trained as primary health care practitioners. As such CM professionals are not essentially restricted by the same set of professional and ethical considerations that may be present in a doctor/pharmacist relationship. This paper seeks to bring into focus ethical and professional issues that may arise with the professional practice of CM in pharmacies. General workplace concerns, treatment paradigm differences, who benefits and professional issues related to CM practice in pharmacies will be discussed in the process.

Complementary medicine in pharmacies

Although no statistics currently exist as to the numbers of CM professionals practicing in pharmacies, it would be fair to say that the phenomenon is increasing. A recent reading of the employment pages of a major city newspaper showed five employment opportunities for CM practitioners in pharmacies in the Brisbane area (Courier Mail 2005). The reasons for the rise in CM practice in pharmacies are almost certainly reflective of the documented trend towards the use of CM in Western countries (McLennan 1996, Eisenberg 1993, 1998).

The practice of CM in pharmacies is undoubtedly the pragmatic reflection of a natural marriage, due simply to the fact that pharmacies are major retailers of CMs. In the past many people purchasing CMs in a pharmacy may have done so with no, or minimal advice from pharmacy staff about the products they have purchased. While some pharmacists and pharmacy staff members have self-educated around CM, traditional sources of information about CM use have been of variable quality. A major source of training for example, has been through sales representatives and training programs presented by CM wholesalers. There are obvious dangers in relying heavily on such sources of information, not least of which is the potential for a bias toward the particular brand the trainer represents. Omission of information that may favour a competitor's product is also commonplace. Further such presentations may contain a less than optimal presentation of material about disease processes, comorbidities and safety issues.

Although quality printed materials aimed at education of pharmacists and pharmacy staff have been scarce until recent times, the situation has improved with the publication of journals about CM aimed specifically at providing information to the pharmacy industry in Australia, and the now regular inclusion of articles about CM in pharmacy trade journals and trade information leaflets.

A recent proliferation in the number of courses offered in CM from a number of sources (Buswell 2004, National Training Information Service 2005) may also be offering an effective remedy to the previous lack of quality information about CM for pharmacists and their staff. CM wholesaler Blackmores, the Journal of Complementary Medicine, and Australian Journal of Medical Herbalism have offered summaries of potential interactions between pharmaceuticals and CMs. These are presented as ready reference guides (Blackmores 2002, Braun 2004a,b,c, Kendon 2005 onwards).

Revision of training courses for pharmacy assistants has resulted in a component of the National Training Framework competencies for community Pharmacy focusing on appropriate presentation and sale of CMs. The guidelines for the competencies indicate that pharmacy assistants should be able to offer generalised advice about CMs to the public, obtain a level of competency in recommending appropriate CMs to individual clients and safety issues associated with CM such as medication interactions and contraindications. A pharmacy assistant is also required to know the limits of his or her competency and to refer to a professional staff member as appropriate (National Training Information Service 2005).

While the education programs discussed in the preceding paragraphs have helped pharmacists and pharmacy staff to bridge the information gap about the CMs sold in their pharmacies, some pharmacists have preferred to employ CM professionals to fulfil this role. A CM professional working in a retail pharmacy may undertake a variety of activities. These include, but may not be limited to giving advice about the efficacy and safety of CMs to pharmacists and pharmacy clients, sale of CMs, professional consultations and the provision of staff training in CM. In some pharmacies CM professionals work as independent entities and hire a consulting room from a pharmacist from which they work as independent practitioners. Often the CM professional will use a space in a pharmacy but the pharmacist retains all profits from sales of CM arising from professional consultations. In many instances however, the CM professional is employed on a salaried basis working under similar conditions to other pharmacy staff (Williams 2003). This raises its own set of professional issues on a number of fronts that will be taken up later in this paper.

Benefits of CM practice in retail pharmacies

It is important to present a balanced perspective in a critique of CM practice in retail pharmacies by presenting the very real benefits of the practice for clients and practitioners themselves. CM professionals in pharmacies are able, for example, to provide advice about over the counter CMs to large numbers of people. This undoubtedly has the potential to somewhat limit the number of adverse events associated with the use of CM. In terms of public education, the importance of this role cannot be underestimated as many freely available CMs have been associated with risks in terms of the possibility of their interaction with pharmaceuticals. Further, many over the counter CMs are contraindicated with pregnancy, breastfeeding and a range of health conditions.

Having a person knowledgeable about CM on the staff of a pharmacy has the potential to lead to clients receiving a more complete package of health information. Pharmacy clients, through interacting with a CM professional, may become more aware of treatment options that CM offers or ways of managing symptoms of conventional treatment through the use of CM. While this would occur in the private practice of CM professionals outside of pharmacies, in the pharmacy setting greater numbers of clients can feasibly access information.

The accessibility of CM in terms of the ethics of distributive justice is arguably enhanced in a pharmacy setting. To some clients the fact that CMs are conveniently offered for sale within a retail pharmacy may add to their likelihood of using them. A decision to use a CM may also be impacted by the trust many individuals place in their pharmacist, the CM professional working under the pharmacy umbrella or the pharmacist's recommendation to an onsite CM professional.

The phenomenon of CM in pharmacies also arguably creates a situation of easier access for a broader socioeconomic group. In a sense CM in pharmacies breaks down, at least to some degree, the economic barrier that may have prevented those with less disposable income from accessing it. CM has in the past been associated with the middle class. Indeed as studies have shown the majority of CM users are white, educated professionals (Eisenberg 1993, Elder 1997, Astin 1998). Non professional clients may be able to budget for medicines but find costly professional fees outside of their reach.

The benefits of CM practice in a retail pharmacy do not accrue solely to clients. CM professionals may also benefit, especially early in their careers, from a stint in a pharmacy. Practicing in a pharmacy offers the possibility for a recent graduate to benefit from a learning experience in which further knowledge can be obtained about the use of prescription and over the counter pharmaceutical medicines, drug side effects and drug interactions. The graduate will also be exposed to a wide range of health issues, encountering clients with simple complaints such as stings and scratches, through to those with complex health conditions including those managed through orthodox polypharmacy.

In effect working in a pharmacy can be approached as a style of internship in health care, something that is lacking in the current career paths of many CM professionals. Working as a member of a multi-disciplinary team may also benefit a recent graduate. Pharmacy staff, as members of a team, learn to interact effectively with diverse business stakeholders including professionals, CM salespeople and clients. This can only provide an enhanced education in industry knowledge and life skills. Further, as mentioned, there is often an opportunity for CM professionals to engage in the education of pharmacy staff and in doing so, add further skills to his or her repertoire.

An obvious benefit, especially for a recent graduate, is that pharmacy practice provides a CM professional with income. How many people working in CM have forgone income for ideals at some point of their professional lives? While this may be admirable it may bring with it associated financial and relationship stresses. On this point there is a need to recognise that the introduction of CM education into universities carries with it a fiduciary responsibility towards students. To act in the best interests of the student equates in part to positively directing him or her towards the employment opportunities that are immediately available upon graduation. As many graduates may not be in a financial position to immediately enter private practice, working in a pharmacy can be viewed as a worthwhile interim opportunity. There is also a need to consider that many women study naturopathy. Women may benefit from part time employment within pharmacies that enables them to supplement another income or to provide the flexibility they may desire to raise children or pursue other interests.

Philosophical issues--holistic health care and the biomedical treatment model

A pharmacy represents the main point at which health care consumers purchase pharmaceutical treatments prescribed by doctors, or access the range of over the counter medicines including CMs. Because of the fundamental role of a pharmacy, pharmacists may tend to view their businesses as a component of the mainstream health care system and acquiesce without argument to a biomedical treatment model. Further a pharmacist may think of CM as simply an increasingly lucrative addition to his or her product mix or as simple, adjunctive treatments to those prescribed by doctors. Although a number of pharmacists have possibly not considered that there may be a philosophical conflict between biomedicine and CM, many CM professionals will be aware of the fundamental philosophical divide in treatment models.

Biomedicine, the underpinning model of mainstream medicine, is characterised by a reliance on a reductionist approach; a tendency to reduce phenomena to their constituent parts and favour symptom focused treatment (Birch 1988). By contrast holistic health care, the oft cited framework of preference for CM practice, is not reductionist, tending in the determination of many authors to recognise the interconnectedness of phenomena. Well (1983) and Dunne & Watkins (1997) for example, in descriptions reminiscent of the philosophical position of monism, describe the individual as consisting of all of the factors that make up and surround him or her. While the contextual component of human existence is not a feature of all descriptions of holistic health care, the human being is at least viewed as interconnected on physical, psychoemotional and spiritual planes. Further the origin of physical symptoms is not inherently confined to the physical realm. Rather symptoms are often considered to be an outward manifestation of disturbances on other planes.

A further issue that may arise in terms of conflicting treatment models has been described by Davies (1997) who posits that mainstream health care's reliance on pharmaceutical prescribing reflects a culture of medical practice and uses the term 'pharmacodoxy' as a descriptor. In practice drugs are often supplied to deal with patient symptoms, doctor and pharmacist becoming intrinsically linked together by their respective roles in the pharmacodoxy. In a sense pharmaceutical prescribing and supply is frequently characteristic of a reductionist approach to health care. A pharmacist who does not question the use of pharmaceuticals as alleviators of symptoms, may expect that a CM professional will or should act in a similar way, using CMs to treat illness symptomatically.

Due to the differences in the philosophical underpinnings of mainstream medicine described above, there is likely to be an intrinsic conflict between the approach to practice taken by pharmacists and CM practitioners. From this difference, personal ethical dilemmas on the part of CM professionals may arise, particularly where practice in a pharmacy precludes the full expression of a holistic health care model. What is of fundamental importance is that philosophically, the positions of mainstream medicine and holistic health care are contradictory. Although it has been argued that there is a place for a multi paradigm approach to health care that involves selection of treatment paradigm based on context (Engbretson 1997), others have argued that the paradigm differences between holism and reductionism cannot be bridged:

"Holism cannot sit comfortably with reductionism, which seeks to attribute reality to the smallest constituent of the world. The paradigm of deterministic science that informs biomedicine views the world as random, atomised and mechanistic, this is irreconcilable with holism" (Fricker 1992).

Fricker's position could however be contested by the notion that the person who adopts a fully holistic perspective with monist informants may view reductionism as encompassed by and therefore a part of the whole.

Where a CM professional does not accept this latter stance, he or she may have a genuine disagreement about the approach a doctor or pharmacist takes towards treatment. Within a retail pharmacy context, particularly as an employee, the CM practitioner, except through educating the pharmacist and his or her staff, may be able to do little about this. The biomedical treatment model is firmly entrenched within the culture of pharmacy with whole professions practicing it and members of the community supporting in monetary terms and as patrons. In the case of individual clients, a CM practitioner may feel it appropriate to lead individual clients away from a belief in pharmaceuticals as the most desirable treatment option for their particular circumstances. On the basis of the codes of ethics of the CM professions such as that of the National Herbalists Association of Australia, a CM professional would need to be very careful about how he or she approached this type of interaction as respect is to be shown for the practice of other professionals (National Herbalists Association of Australia 2003).

Allowing a client a greater knowledge of health options and complementary treatments is however, ethical. This is especially the case in terms of client autonomy, an ethical precept that supports the adequate disclosure of treatment options to clients, allowing them to make more informed choices. Providing information about CMs will not intrinsically lead a client to break compliance with a pharmaceutical prescription which may indeed be an ethical issue. On the contrary disclosing information about CM may lead to additional benefits for clients in terms of their health, client and CM professional discussions with doctors about treatment options and a more complete achievement of informed consent to treatment. If education about the difference in approach between mainstream and CM practice occurs, this also arguably increases the basis for client autonomy.

Of further interest to CM professionals is that in a retail pharmacy setting he or she is potentially open to being pressured to break with his or her philosophical perspective to provide symptomatic treatment. Arguably this style of practice would almost certainly occur to varying degrees in over the counter style, brief consultations where a person seeks CM to deal with a specific health issue or symptom. A client for example, may request a probiotic to assist with gut symptoms after taking an antibiotic. Instances such as this in which the client requests the quickest possible way to resolve symptoms are commonplace in pharmacies. He or she however may have no desire to understand the CM professional's viewpoint on whether the antibiotic was necessary in the first instance or whether a compromised immune system should be supported by ongoing therapy.

Such an approach in reality is typical of the way in which many pharmacy assistants and pharmacists frame the use of CMs in discussions with clients. Note that the pharmaceutical prescription that has led to the gut disturbance in the first instance is rarely questioned, although the presenting symptoms are widely known to be associated with antibiotic use. The client, in a sense, is led into accepting a reductionist approach to treatment by every piece of advice he or she is given from doctor through pharmacist to pharmacy assistant. This may in part be due to pharmacy codes of ethics that provide a strong message that a pharmacist should not lead a client away from the treatment a doctor has prescribed (Pharmaceutical Society of Australia 2006).

The tendency of mainstream health professionals and their clients to support a biomedical treatment model may originate in a subtle favouring of deterministic science within the education system. Giddens (1992) has described a rhetoric within society that promotes reductionist science as prestigious and by implication something to be desired. He also notes the rise in the trend towards the use of alternative health care and argues that the competing 'expert' voices within the health profession milieu demand greater individual autonomy. The health professional in his thesis becomes a source of information. Of particular interest is Gidden's recognition of the complexity within the CM professions in terms of approaches to treatment and he promotes the informed individual as the ultimate arbiter of how to proceed. Thus the role of the CM professional becomes one of an information conduit, educating his or her client while recognising the increasing value being placed on individual autonomy. As health care ethics continue to move away from traditional positions that focus on beneficence (illustrated by the paternalistic axiom 'doctor knows best') towards a model of greater client autonomy, CM professionals may encounter freedom in realising that it is not them but their clients who will or will not ultimately effect a shift in their philosophical positions.

The employer/employee relationship and how this impacts the interaction between a pharmacist and the CM professional as employee is another area that demands some thought. It is possible that a CM professional employed by a pharmacist may feel pressured to shorten time spent in consultation or to give a quick comment on a client's health issues in a similar fashion to a pharmacist's practice of giving minor health advice. This may occur simply because the pharmacist thinks it an appropriate approach to health care within a pharmacy, pressure of time or economic considerations that are important to a pharmacist as business owner.

A CM professional who does not reflect the level of his or her training in practice may be acting negligently. Naturopaths for example, are trained to engage at least initially in long consultations that are multi-faceted and deeply exploratory in nature. In terms of legalities, professionals are obliged to act in ways that reflect the level of their training. In many instances it would be doubtful that a brief consultation would be commensurate with this standard.

Expectations of professional practice: inter professional concerns

Where CM professionals and pharmacists work together, questions may arise as to what constitutes professional appropriateness in such relationships. As mentioned, pharmacists are required to maintain satisfactory relationships with other health professionals:

"A pharmacist must respect the skills and expertise of other professionals and work cooperatively with them to optimise the health outcomes of their mutual clients" (Pharmaceutical Society of Australia 2006).

While this statement sets the tone for peer relationships between professionals associated with a pharmacy, there is still a potential for problems to arise in this area. One reason for this is that the CM professional working in a pharmacy is often trained as a primary health care practitioner. The clause also suggests that a pharmacist and CM professional should regard each other with peer respect and work together to the benefit of their clients. What is important in terms of inter professional relationships is how the respect that is demanded is expressed in practice. In a pharmacy it is likely that the employer will show respect by referring clients for consultations as appropriate and discussing a client's health needs with the CM practitioner after obtaining his or her consent. Ethical principles however, may come into conflict when issues arise regarding a third party professional such as a doctor. The Code of Professional Conduct for pharmacists states:

"... pharmacists shall refrain from making comment that may detract from the professional reputation of other health professionals" (Pharmaceutical Society of Australia 2006).

As mentioned, pharmacists carry a mandate within the mainstream health care culture to give limited health advice only. This factor may be important in a relationship between a CM professional and pharmacist in which the employer/employee relationship sets up an initial hierarchical structure that, codes of practice aside, has the potential to compromise the way in which the CM professional utilises and expresses his or her training as a primary health practitioner.

Hypothetically a problem may arise in the professional/peer relationship between the two where a CM practitioner employed by a pharmacist has a professional disagreement with another health care professional such as a doctor and the pharmacist expects the naturopath to bow to his or her demands or not to 'make waves' with the doctor. Bearing in mind that such differences of opinion are often features of peer relationships within professions and that CM professionals are both engaged in providing health care, it becomes even more necessary to acknowledge that this possibility may arise. Where a doctor is an important business stakeholder, as would be the case in many country towns, the pressure to bow to the needs of the business may be paramount in the employer' s mind.

A pharmacist in his or her role as a dispenser of medicines works in a chain of command situation with the prescribing doctor. A pharmacist often consults a doctor when a query arises around clarification of advice to a client on issues such as treatment choice or dosage. In such situations the pharmacist, as suggested by the Code of Professional Conduct, is ethically bound not to cause a patient to doubt the professional judgement of his or her doctor (Pharmaceutical Society of Australia 2006).

A CM professional's advice to a client, no matter how respectfully the doctor's opinions are approached, may feasibly result in a client questioning the medical opinion he or she has received. This could in a similar fashion to the points raised in the preceding paragraph, lead to the pharmacist/employer placing pressure on his or her CM professional employee to desist from important aspects of his or her professional practice. While the Code promotes inter professional liaison regarding clients, subject to confidentiality considerations and consent, it does not cover what to do when disagreements occur between pharmacy stakeholders regarding treatment, or clients elect an approach to treatment that one or more of the professionals involved may bitterly disagree with. In the latter case the problem could be philosophically solved by holding client autonomy as an ultimate principle. This however may do little to resolve the difficulties that may arise from inter professional disagreements.

In the circumstance of several professionals providing a client advice, it becomes important that each remain informed about all of the treatment options the client ultimately chooses. Client confidentiality is paramount in such situations. Inter professional conversations about individual clients should only occur with the consent of the client. If consent has not occurred the client's role becomes pivotal in regard to keeping all of his or her health practitioners informed about the treatments he or she is using. Doctors have a responsibility to ask questions about their patient's CM use through appropriate questioning. Likewise CM practitioners need to ensure that adequate case taking includes exploration of all aspects of their clients' health care regimes. The pivotal point is that without consent from the client to enter into discussions with other professionals such interactions cannot ethically occur.

Informed consent in the context of multi professional care--the case for a broader context?

Informed consent demands that a client be told about and understand the full range of treatment options available, their risks and benefits and the risks and benefits of the non treatment option. Further the way in which treatments are administered, potential side effects and the possible outcomes of treatment should be presented. Manipulation of information, bias and coercion of clients into particular courses of action are unacceptable (Beauchamp 2001).

The traditional context for informed consent is the doctor/patient relationship. As many CM professionals are trained as primary health practitioners, a case may exist for casting the process of achieving informed consent within a multi disciplinary health care framework that involves all of a client's health care practitioners. This approach carries the suggestions that where a doctor is uneducated about herbs for example, a herbalist may be better placed to provide information about them to clients. Further it acknowledges the autonomy and right of the client to determine who will be involved in his or her health care. It is also pragmatic in that it does not demand a doctor and CM professional be fully informed about the treatments the other is offering. Such a model of consent would of course need to be achieved with due regard for patient confidentiality and with a regard for the maintenance of beneficial peer relationships between the professionals involved.

Evidence based medicine and the CM in pharmacies

The current climate of evidence based health care has given rise to a culture of medical practice that promotes the use of treatments for which sufficient scientific evidence is available. While there is a requirement of evidence based practice that best evidence be considered judiciously with due regard for the art of clinical practice (Sackett 1996), a potential exists for treatments with a large amount of evidence to support their use to be considered more favourably than those with minimal science to back them.

In some instances uncertainty in relation to treatments that have not been studied using clinical trial or other scientific methodology and those that are unlikely for a variety of reasons to be the subjects of such research, may too quickly become allied in a mainstream professional's mind with a higher degree of risk than may in reality be appropriate.

While it is not the purpose of this paper to discuss the philosophical underpinnings of evidence based medicine, it is important to highlight some of the ethical difficulties that may arise in a health care landscape that has given it increasing credence.

Hirst & Ward (2000) describe the 'levels of evidence' approach to the classification of medical treatments. Level I and II evidence, also referred to as 'gold standard evidence' applies to those treatments that have been studied using randomised controlled trials. Critique of this grading system has come from many sources with some questioning the applicability of trial results to a broader population outside of the study group (Tonelli 2001, Stirrat 2004) and the potential for clinical experience to be relegated to the background (Stirrat 2004). It has been noted that many CMs are not amenable to study using the methodological techniques promoted by evidence based medicine (Eden 2001).

What is ethically important is that a culture of evidence based medicine may erode the position of CMs that have not been tested using scientific methodology. As Kerridge and Saul (2003) observe, the lack of scientific studies for some treatments has been deemed by some advocates of evidence based medicine as a lack of evidence of treatment efficacy. Bensoussan (1999) however makes the observation that scientific evidence of treatment efficacy may mean little to patients. He proposes an uncomplicated reason for the rise in the use of CM among the public: patients use CMs because they work. Once again it is important that treating professionals recognise that autonomy, reflected in client preference for particular therapies, is upheld in dealing with clients and that a lack of scientific evidence does not equate to a reason to disparage a therapy that has reportedly worked for some members of the community.

It is important that evidence based medicine be promoted within Sackett et al's (1996) promotion of the judicious use of evidence. In terms of the tendency of mainstream medicine to promote a pharmacodox treatment model after Daview (1997) there is perhaps an ethical requirement that all health care practitioners step back and consider the fact that the production of science is contextual, influenced as much by the economic goals of big pharma as the desire to rationalise the availability of health care treatment as treatment costs increase.

Territorialism in health care or a chance for integrative treatment

In the past an argument has existed within CM literature that doctors may have difficulty working with CM professionals. Traditionally it has been argued that issues of professional territorialism may underpin this resistance (Willis 1989, Wearing 1996). More recently it has been argued there are different reasons why doctors may show resistance toward CM. Some may be influenced by a presentation of CM in elite medical discourse that has tended to focus on its risks rather than its benefits (Lowenthal 1996, Komesaroff 1998, Angell 1998).

A pragmatic consideration is highlighted by the concern that patients do not always report their use of CM to their medical practitioners (Shenfield 1997). On the other hand studies have shown that a percentage of doctors is comfortable with the use of CM (Eisenberg 1998, Wearn 1998, White 1998, Perry 2000).

In the context of a retail pharmacy the relationship between CM professionals and doctors may be enhanced. This may occur in part because of the ability of a CM practitioner in such a context to interact more freely with doctors than working in private practice may permit. The pharmacist will often telephone a doctor to discuss issues around his or her prescription of medicines. Working under the umbrella of a pharmacy the CM professional has the opportunity to develop professional relationships with doctors in much the same way as the pharmacist, using the telephone to discuss, with due consideration for client confidentiality, how he or she is approaching treatment and how this may sit with the course/s of action the doctor has offered to the client.

The telephone also provides a fast way of quickly resolving a potentially risky situation, for example where the concomitant use of medications and herbs may be contraindicated in the case of a particular client. Such interactions have the potential to promote the position of professionalism of CM practitioners within the medical community, the loop being opened in the first instance by the positioning of the practitioner within a pharmacy.

Intra professional issues for the CM professions

Often a salaried CM professional working in a pharmacy is able to offer free advice about CM to the public. For this reason he or she may be able to attract substantially more clients than a professional in private practice. This may be viewed as problematic by CM professionals working in private practice who argue there is a potential for pharmacy based CM professionals to erode the client base, 'unfairly' gaining clients in a competitive marketplace. This argument fails to observe the fact that the practice of CM within pharmacies, in all likelihood, is increasing access to those who would not otherwise use CMs. A private practitioner for example is unlikely to consult with large numbers of clients at the lower end of the socioeconomic scale.

Salaried CM professionals in pharmacies may gain experience at a much faster rate than practitioners in private practice, simply because they have the potential to see more clients. Some may view this as unfair. It should be noted however that this disparity would be likely to occur in the absence of CM practice in pharmacies for a range of reasons from the geographical location of practice to hours worked.

Salaried naturopaths working in pharmacies currently earn between $25 and $45 per hour (Williams 2003). At the high end of the scale this salary is within a few dollars of an employed pharmacist. For a number of reasons comparing salaries between professionals may not be an appropriate way to set wage rates or enter into workplace negotiations with employers. Naturopaths arguably have a deeper training in health care than a pharmacist and the training focus is of a different nature to that of a pharmacist. While no figures are available on herbal medicine or other CM professions, anecdotal reports indicate that financial rewards may be even less lucrative.

Anyone involved with the CM professions will have heard the discussions about CM professionals being employed under retail shop assistant's wages. This is important from the perspective that wage rate may determine both status and the duties that one is expected to perform. Lower paid CM professionals may be expected to perform non CM related activities such as supplying over the counter pharmaceutical products, collecting scripts, selling perfume, make up and syringes and needles.

Acting as a sales assistant may impact on the social and professional positioning of CM and the presentation of the CM professional as a primary health care practitioner. Acceptance of low rates of pay could also be problematic in that CM professionals may become diminished in the eyes of employers and not viewed as independent professionals or treated with the peer respect deserved.

Conclusions and areas for future investigation

The preceding discussion has raised several issues around the practice of CM in retail pharmacies. Inter professional ethical issues that may arise between pharmacists, CM professionals and doctors have been iterated. The ways in which differing philosophical approaches to health care interface within a pharmacy is an important area for future research. This is not simply because the addition of a CM professional to the staff of a pharmacy immediately extends it beyond its traditional role but because the philosophical underpinnings of CM must be maintained and respected, even within mainstream health care settings.

The pharmacy has now become a place where clients can access health advice from, in many cases, a professional trained as a primary health care practitioner. This has the potential to create new patterns of health care in Australian society. It sets the stage for positive interactions between health care professions that in the past may have viewed each other with suspicion. It is important that the bodies representing CM professionals seize on the opportunity that pharmacy practice offers to improve the professional positioning of CM practitioners.

Professional bodies also carry a responsibility to create policy to guide the practice of CM in retail pharmacies. There is a need to offer some protection to CM professionals, especially in the current context of unregulated practice. Workplace exploitation of CM professionals is an ever present threat, particularly while CM professionals are not enrolled with registering bodies.

The current push towards the registration of CM professionals in Australia is aligned with some important goals. The CM professions will be better able to sustain ethically based professional and peer relationships when full professional status is achieved. Individual professions such as herbal

medicine and naturopathy will have a stronger platform from which to launch and promote ethically sustainable social and political agendas.

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Joy Mendel BHSc, BSocSc(Hons), BNat, MBA, MBioethics

joy.mendel@mater.org.au

Joy Mendel is a graduate of the schools of Natural and Complementary Medicine, Social and Workplace Development and the Graduate College of Management at Southern Cross University. She holds qualifications in health science from the University of New England and bioethics from Monash University. She is currently completing a PhD in the area of ethics and complementary medicine. Joy has practiced as a naturopath in pharmacy and private practice. She also has a background as a teacher of community pharmacy practice for TAFE NSW and is currently Hospital Ethicist for Mater Health Services, Brisbane.
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