Retail chain pharmacies: A threat to patients’ primary interests? | Anthony Raphael Gatt

Anthony Raphael Gatt is a pharmacist and holder of MAs in bioethics and business ethics

Over the last decade, the local retail pharmacy business has witnessed a significant shift. We have seen the takeover of independent pharmacies by Maltese companies that also function as pharmaceutical importers, wholesalers, and parallel importers.

Currently, more than 60% of pharmacies are owned by these companies, which now control multiple steps in the retail pharmaceutical supply chain. This business practice is called vertical integration, which brings about predictable ethical risks that the patients and customers need to recognise, and the medical authority needs to manage actively. This new reality raises a significant question: Are patients and customers receiving the best professional advice from pharmacists considering these changes?

A conflict of interest is defined as a set of circumstances that create a risk that medical professionals’ judgements and actions regarding the primary interests of their patients are unduly influenced by a secondary interest of financial profits. The primary interests include the patient’s right to have the pharmacists prioritise their well-being above all other secondary interests. The secondary interests primarily involve financial gain.

Recommendation bias

A significant ethical risk category that may be occurring in these chain pharmacies is recommendation bias. This risk is highly likely to occur as the company’s management encourages pharmacists to recommend and promote their imported products. The company may incentivise this behaviour through monetary rewards or by fostering a workforce culture that prioritises profit maximisation.

Recommendation bias can also manifest in how products are displayed, as the company insists on placing their imported items in prime shelf positions. These company’s coercive actions may induce the pharmacists to compromise their clinical decision-making, potentially undermining the best interests of patients and customers.

Often, the pharmacist is the final decision-maker regarding which products to stock and dispense in the pharmacy. Company managers often pressure the pharmacist to stock products that do not compete with their imported goods. Additionally, these managers may insist that only products with high profit margins should be stocked and displayed on the pharmacy shelves.

Such decisions, many times, do not align with the patients’ best interests. Such behaviour limits the patients’ access to better options and promotes anti-competitive behaviour. Furthermore, these risks are accentuated when company managers evaluate pharmacists on sales performance. This could distort the pharmacist’s professional judgement. Corporate incentives may lead pharmacists to over-dispense non-essential products that lack scientific based evidence or to prefer specific brands over more affordable generics.

In certain Maltese villages, only chain pharmacies operate, which may limit the local elderly population’s access to product choice and undermines their autonomy. Additionally, these chain pharmacies hold sensitive health data. If the company markets products, there may be the temptation to leverage this data for targeting promotions, raising concerns regarding confidentiality and consent norms. Furthermore, in situations where there are shortages of essential medicines, a vertically integrated importer might prioritise stocking these items in its own outlets, which could negatively impact the continuity of care in other areas.

All these conflicts of interest arising from this new reality may erode the pharmacist’s fiduciary ethos and public trust. This issue is highlighted across European governance literature, which emphasises the need for greater public transparency. Vertical integrated companies should disclose their imported pharmaceuticals, medical devices, and medical instrumentation on their pharmacies’ signage or websites. This will help ensure that patients and customers are informed about potential conflicts of interest, allowing them to make more informed choices.