The sale of non-prescription health products is ubiquitous, meeting a significant consumer demand [1, 2]. Natural health products, such as vitamins, minerals, herbal remedies, homeopathic and traditional medicines, nutritional supplements, and products such as cosmeceuticals, rehabilitation and fitness aids can be found online, in major retail chains, mall kiosks and in the offices of health professionals. A recent report estimated the total retail sales of natural health products in Canada to be worth $2.5 billion dollars in 2005, growing to an estimated $2.75 billion by 2010 [1]. Distributors identified healthcare practitioners as among their top three current and future most important distribution channels [1]. The regulation of and evidence base for many of these products are uneven or non-existent, leaving consumers to fend for themselves in a "buyer beware" market [3–5].

The roles and responsibilities of health professionals regarding the sale of non-prescription health products are unclear [5–7]. Should health professionals be marketing health goods to their patients? If so, to what standards should they adhere? Should there be any limits placed upon this practice? How are such sales monitored by professional bodies?

Research considering the sale of health products by health professional is limited. There have been a few studies that have explored the practice among dermatologists [7, 8], dentists [9] and most recently chiropractors [6, 10]. Together, these studies suggest product retailing by health professionals is prevalent. Proponents believe that it affords control over product quality, that it is a service patients appreciate, and that treatment compliance is enhanced [11]. Opponents argue that product sales are undertaken for profit, thus presenting a conflict of interest compromising the therapeutic relationship and professional integrity [12–14].

Considering chiropractic specifically, studies have suggested that the majority of practitioners (54-89%) sell a range of products [6, 10, 15]. Chiropractic trade reports and publications suggest product sales are a major revenue source, improving practice profitability for chiropractors [16–18].

Relative to other disciplines, the public trust in the healing professions is high [19]. Such trust is dependent upon practioners upholding their duties to act in their patients' best interests and is central to the effectiveness of the patient-practitioner relationship. Professional practice is guided in part by codes of ethics and conduct. As the health product market place continues to grow, so too will the potential for ethical conflicts faced by practitioners choosing to retail health products. Little is known about chiropractors' individual considerations of this practice

This study reports on the qualitative findings of a previous [10] survey where chiropractors had the opportunity to comment on the sale of health products. Guidance offered by the Alberta Chiropractic Association and College and the Canadian Chiropractic College are considered.

A random sample of 518 chiropractors (of 929 total population) in the province of Alberta, Canada received an initial survey package with a follow-up package sent out three weeks later., The four-page survey contained 34 fixed-choice questions about chiropractors opinions and practices surrounding health product sales. Subjects were invited to provide written comments about the sale of health products by chiropractors. Subjects were assured their data would be de-identified. The confidentiality of study responses was preserved by replacing respondents' names with codes and be reporting all findings in aggregate. This study received ethics approval from the Conjoint Health Research Ethics Board at the University of Calgary.

Two hundred sixty five chiropractors (51.2%) completed and returned the survey. Respondents were mostly men (N = 207; 78.1%) and had been in practice for a median of 12 years (IQR 8-20 years). Most were in multidisciplinary group practices (N = 204; 77.3%) and most (N = 208; 78.5%) were satisfied with their number of weekly patient contact hours. The majority (N = 247; 95.0%) believed that chiropractors should sell health products and 89.4% (N = 236) currently sold health products from their practices. The quantitative survey results are presented elsewhere [10]. This paper reports on the analysis of the volunteered, qualitative comments.

The written comments of 107 respondents were transcribed, yielding approximately 30 pages of double-spaced typed text. The text was entered into the Ethnograph (qualitative analytic) software [20]. The first author (SP) reviewed, coded and summarized the textual data using qualitative description. Qualitative description is a low-inference interpretation that focuses on describing "the facts [21]". codes and summary was reviewed against the raw data by the two other authors (JG, GM). No discrepancies in interpretation occurred.

The following themes emerged.

Chiropractors who responded to this survey did not uniformly support or condemn the practice of health product sale and, consistent with this engaged in product sales to varying extents. While a few chiropractors were implacably opposed to health product sales, most accepted the practice under various conditions and with varying degrees of comfort. Some clearly embraced the practice. Consistent with arguments in the literature, those engaged in the health product sales believed it was a convenience for patients and part of their role and responsibility as health care providers. Those who offered comments recognizing potential harms spoke of the practice as compromising professional integrity and described strategies to minimize negative effects.

Conflict of interest relates to a set of conditions or a situation such that professional judgment about a primary interest may be unduly influenced by a secondary interest [22]. Conflict of interest in selling health products from within a professional practice occurs if the potential sale of a product causes practitioners to deviate from their professional obligations to their patients in anticipation of economic gain. Assuming products are safe and efficacious, selling them is ethically neutral. Selling products primarily for profit rather than for patient necessity violates the practitioner's fiduciary duty to act in patient's best interests as their own interests prevail [12]

Recommended strategies to address conflict of interest involve taking steps to avoid or prevent the set of conditions provoking it [22]. Indeed, a few respondents stated that they did not engage in product sales or minimized the conflict by maintaining no/low profit margins.

Others emphasized that purchases were made voluntarily by patients, arguing that they had no influence over the patient's actions, a disingenuous claim at best in view of the nature of the therapeutic relationship and its inherent power imbalance. Patients may feel that purchases are necessary in order to maintain a positive relationship with the practitioner or to receive future care. Little research has investigated this area however one small study of patient opinion indicated that patients reason for purchasing products from practitioners was their trust in the practitioner [8]. Anecdotal reports suggest that such purchases may leave patients feeling exploited by practitioners [23]. While subtle influence may be pervasive, more worrisome is the allegation of aggressive sales strategies used by some of the respondents' colleagues.

Conflict of interest rules are a means of acknowledging that such problems may arise and offering guidance for individuals in managing these circumstances. Conflict of interest involving health product sales is recognized within the Canadian Chiropractic Association's (CCA) national code of ethics and conduct of chiropractors and also within Alberta College and Association of Chiropractors (ACAC), both of which permit health products sales provided certain conditions are met. The relevant section from the CCA's Code of Ethics and Conduct (Article 21) states:

It is not unethical to dispense items providing; it does not create a conflict of interest, they serve the best interests of the patient, clinical value has been demonstrated, and the item is available at a fair market price [24].

The Alberta College and Association of Chiropractors Code of Ethics provides the following guidelines:

A chiropractor who sells or markets professional products to their patients must:

The guidance offered by these codes is limited. Neither provides a clear definition of, or restriction on, the types of products chiropractors may choose to sell, leaving the interpretation and resulting choice up to individual practitioners. At a minimum, products should be related to the practitioner's area of expertise. However, there is debate within the profession as to where the boundaries of this expertise lie, as illustrated by the comments provided for this study.

Both the provincial and national codes stop short of requiring that a scientific evidence base exist for products sold from offices, recommending instead that subjective review is sufficient. Although some respondents cited reviews of scientific evidence, others referenced manufacturer's data or simply stated they promoted things they used/liked or knew worked. The widely recognized lack of scientific evidence and uneven regulatory oversight for many health products [26–28], mean that reliance on an individual practitioner's opinion or preference may leave consumers further at risk. Others have proposed that members of their profession establish a board of peers charged with the review of evidence and approval of products for in-office dispensing based on established criteria [14].

The Canadian Code makes reference to product cost, arguably the issue at the centre of the potential conflict of interest. The standard recommended is "fair market price" which may be interpreted as what the market or, more accurately, consumers will bear, and is inconsistent with no profit-taking or cost-recovery transactions, leaving room for financial exploitation. While many respondents spoke of products retailing at cost, variation in product pricing was clear leaving consumers with inconsistency in practice standards. The provincial code is silent with respect to product pricing.

Product sales in chiropractic appear well-established both provincially and nationally in Canada. As noted by some respondents, ethics and integrity are individual attributes. While this may be true, the actions of individual practitioners may affect public perception of the profession as a whole. To facilitate the integrity of professional judgment and to protect patient best interests, clearly articulated standards and consistency in practice are paramount.

The comments provided by the respondents suggest that existing guidelines may not be sufficiently detailed or stringent to adequately guide practice, or possibly that practitioners are simply not aware of these standards. It does not appear as though the profession has monitoring mechanism in place to assess compliance and enforce standards although several respondents suggested this would be a worthwhile undertaking on the part of the governing body. It would be worthwhile to systematically investigate how often complaints are received in this area by the provincial colleges or national association, and to determine whether disciplinary action has been taken.

Future research gathering data from a national sample of practitioners and examining patient perspectives will further inform the profession.