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207 W. High St. P.O. Box 899 Jefferson City, MO 65102 Via e-mail: firstname.lastname@example.org Fax: 573-751-0774 Dear Attorney General Koster, Thank you in advance for your time. I am writing on behalf of People for the Ethical Treatment of Animals (PETA) and our more than 3 million members and supporters to file a complaint against St. Louis Children’s Hospital (SLCH), a business located at One Children's Place, St. Louis, MO 63110. We respectfully request that you take all necessary action to ensure that SLCH immediately halts and removes all deceptive and misleading advertisements from its Web site that are used to promote the sale of the training course described below that are in alleged violation of Missouri consumer protection laws including the Merchandising Practices Act, Mo. Ann. Stat. § 407.020 et seq. Missouri Law Prohibits Using Deception, Misrepresentation in Advertising SLCH published and maintains a Web site (located at www.stlouischildrens.org/health-care-professionals/education/pals-classoverview) in order to advertise and promote enrollment in its Pediatric Advanced Life Support (PALS) training course, which is offered in conjunction with Washington University in St. Louis (WUSTL) School of Medicine. Nurses, paramedics and physicians-in-training are charged $300.00 and physicians are charged $400.00 to attend SLCH’s PALS course.1 As detailed below, SLCH’s Web site contains a number of misleading and fraudulent claims about the superiority of its PALS course over other PALS courses based on its use of live cats for training exercises. We believe the statements outlined below are deceptive, misleading, and in possible violation of Mo. Ann. Stat. § 407.020(1), which states:
St. Louis Children’s Hospital, “Education: PALS Class Registration – August 1-2,” 2013, retrieved 29 Apr. 2013 <https://www.stlouischildrens.org/health-careprofessionals/education/pediatric-advanced-life-support-course-pals/pals-class-registr-2>.
“The act, use or employment by any person of any deception,2 fraud, false pretense, false promise, misrepresentation,3 unfair practice4 or the concealment, suppression, or omission of any material fact in connection with the sale or advertisement of any merchandise in trade or commerce or the solicitation of any funds for any charitable purpose, as defined in section 407.453, in or from the state of Missouri, is declared to be an unlawful practice.” In addition, Missouri law is clear “A seller shall not make a representation or statement of fact in an advertisement that is false or has the capacity to mislead prospective purchasers.” Mo. Code Regs. Ann. tit. 15, § 60-7.020(1). “Advertisement” is defined as “the attempt by publication, dissemination, solicitation, circulation, or any other means to induce, directly or indirectly, any person to enter into any obligation or acquire any title or interest in any merchandise.” Mo. Ann. Stat. § 407.010(1). “Merchandise” is defined as “any objects, wares, goods, commodities, intangibles, real estate or services.” Id. § 407.010(4). “Sale” is defined as “any sale, lease, offer for sale or lease, or attempt to sell or lease merchandise for cash or on credit.” Id. § 407.010(6). “Trade” or “commerce” is defined as “the advertising, offering for sale, sale, or distribution, or any combination thereof, of any services and any property, tangible or intangible, real, personal, or mixed, and any other article, commodity, or thing of value wherever situated. The terms “trade” and “commerce” include any trade or commerce directly or indirectly affecting the people of this state.” Id. § 407.010(7). SLCH’s Alleged Misrepresentations and Deceptive Statements On its Web site, SLCH advertises it training program by saying: “The people best qualified to practice advanced life-saving techniques on small children and infants are those who’ve had a well-rounded and comprehensive training course, where they’re exposed to multiple forms of instruction including the use of mannequins and live animals. Ultimately, our goal is to do what’s right for kids, and that means giving our physicians and caregivers every possible learning tool so they’re best prepared to save these tiny young lives.”5 It goes on to state, “Using mannequins isn’t as effective as using mannequins and a live animal. This is why the adjunct program is offered.”5 (Emphasis in original.) SLCH further “Deception is any method, act, use, practice, advertisement or solicitation that has the tendency or capacity to mislead, deceive or cheat, or that tends to create a false impression.” Mo. Code Regs. Ann. tit. 15, § 60-9.020. 3 “A misrepresentation is an assertion that is not in accord with the facts.” Mo. Code Regs. Ann. tit. 15, § 60-9.070. 4 An unfair practice is, in part, any practice which “[i]s unethical, oppressive or unscrupulous” and “[p]resents a risk of, or causes, substantial injury to consumers.” Mo. Code Regs. Ann. tit. 15, § 608.020
St. Louis Children’s Hospital, “Education: PALS Class Overview,” 2013, retrieved 29 Apr. 2013. <http://www.stlouischildrens.org/health-care-professionals/education/pals-class-overview>.
advertises its PALS training on its Web site by telling its consumers that, “[T]he USDA conducted a thorough assessment of the airway intubation program and facilities, and gave its full approval and support of the [SLCH PALS] program.”5 These claims are not only unfounded, but are also unfair, deceptive, and misleading to the general public, the people of Missouri, other institutions offering PALS training, and the consumers of such trainings. Evaluation of SLCH’s Advertising Statements Alleged Deceptive and Misleading Claims About Efficacy of Using Cats to Teach Human Intubation On its Web site advertising its PALS course, SLCH claims that those “exposed to multiple forms of instruction including the use of mannequins and live animals” are “best qualified to practice advanced life-saving techniques on small children and infants.”5 Further, it states, “Using mannequins [for intubation training] isn’t as effective as using mannequins and a live animal.” 5 These marketing statements about the educational benefits of intubating cats are baseless, and are contrary to medical best practices and the scientific evidence available on the subject. SLCH’s advertising statements listed above leads consumers to believe they will be less qualified to perform procedures on infants if they do not participate in the training exercises on cats. Contrary to the false impression created by SLCH, the available scientific evidence demonstrates exactly the opposite. To begin with, the American Heart Association (AHA)—which developed and sponsors the course in question at SLCH—has clearly stated, “We do not endorse or require the use of animals during the AHA-PALS training because of advances and availability of simulation mannequins. These mannequins provide the opportunity to practice all the necessary skills required for successful completion of an AHA PALS course.”6 It has also previously written, “The AHA does not endorse the use of live animals for PALS training. The use of lifelike training manikins for PALS courses is the standard accepted norm. … [T]he AHA recommends that any hands-on intubation training for the AHA PALS course be performed on lifelike human manikins.”7 The AHA’s position against animal use is based on the scientific evidence that using animals does not improve the intubation skills of trainees. A study published in the scientific journal Pediatric Emergency Care compared the pediatric intubation skills of medical care providers who had completed an initial training program on mannequins and then had either undergone additional training using mannequins or cats.8 The study found that those who did the additional mannequin training instead of using animals were “significantly more successful on the first attempt at intubation and overall,” and the study’s authors concluded that “training on mannequins allows for greater concentration by the trainee on technique. Without the urgency to place the tube, which is felt when practicing on animals or humans, the trainee is much more open to suggestions and
American Heart Association, E-mail to PETA, 18 Mar. 2013. American Heart Association, Letter to PETA, 3 Feb. 2009. 8 K. Adams et al., “Comparison of Intubation Skills Between Interfacility Transport Team Members, ” Pediatric Emergency Care (2000) 16: 5-8.
corrections.” This peer-reviewed published study fully debunks SLCH’s erroneous claim that, “Using mannequins isn’t as effective as using mannequins and a live animal.”5 Indeed, the opposite is true. Further, research published in the prestigious scientific journal Pediatrics found extremely poor intubation performance by pediatric residents following “practice in an animal laboratory”–specifically, intubation success rates were 50%, 55% and 62% for 1st, 2nd, and 3rd year pediatric residents respectively.9 In contrast, a study conducted by researchers at Stony Brook University and the University of Pittsburgh found that pediatric residents who practiced only on high-fidelity infant simulators and then performed intubation on live human babies achieved notably higher intubation success rates of 58%, 66% and 83% for 1st, 2nd, and 3rd year pediatric residents respectively. 10 Indeed, there is absolutely no evidence available to show that using animals is as effective, never mind more so, as training using only humanlike simulators. SLCH is the only one of the more than 1,000 PALS facilities in the nation that PETA knows of that still uses cats for intubation training. Similarly, more than 98 percent of the roughly 200 pediatric residency programs in the U.S.—which are specifically training physicians to treat babies—do not use any animals to teach intubation skills.11 Not only are SLCH’s misrepresentations about the superiority of cat intubation laboratories misleading to consumers, but they place the many other St. Louis-based PALS training facilities that do not use animals—including nearby Cardinal Glennon Children’s Hospital,12 St. Louis Community College,13 Mercy Children’s Hospital St. Louis and CPR St. Louis14—at an unfair competitive disadvantage because potential course customers viewing SLCH’s Web site are led to believe that they need to participate in a cat intubation training session in order to achieve competency in pediatric intubation skills and SLCH’s Web site does not mention the AHA’s position that animal laboratory exercises are not necessary to achieve competency in PALS skills. Alleged Misleading Claim Regarding Approval of Federal Authorities SLCH claims that the U.S. Department of Agriculture (USDA) “gave its full approval and support of the [SLCH PALS] program.”5 This marketing statement—intended to portray SLCH’s PALS training program as having the endorsement of the federal government for humane care of animals—is false and misleading to consumers because the USDA does not endorse or support any particular research or training methods that use animals or not. Indeed, the USDA’s function in this matter is limited to enforcement of the federal Animal Welfare Act and pursuing actions against facilities that violate this law and the associated regulations.
A. Falck et al., “Proficiency of Pediatric Residents in P erforming Neonatal Endotracheal Intubation,” Pediatrics (2003) 112.6(Pt1): 1242-7. 10 J. Arnold et al., “A Randomized Controlled Trial of Simulation in Neonatal Airway Management Skills: Improved Clinical Performance,” (2008) Presented at the 6th Annual Safar Symposium <http://www.wiser.pitt.edu/sites/wiser/safar08/arnold.asp>. 11 Physicians Committee for Responsible Medicine. Survey of Animal Use in Pediatrics Training. Available at: http://pcrm.org/research/edtraining/peds/survey-of-animal-use-pediatrics-training. 12 Cardinal Glennon Children’s Hospital. PACTS for Life/PALS. Available at: http://www.cardinalglennon.com/Pages/PACTS%20for%20Life-PALS.aspx 13 St. Louis Community College. CPR and First Aid: American Heart Association. Available at: http://www.stlcc.edu/Continuing-Education/Programs/Health/CPR-and-First-Aid.html. 14 CPR St. Louis. First Time PALS Certification Schedule. Available at: http://aclsstlouis.com/classes/pals-certificationschedule-1st-time/.
Request for Action We urge you to investigate SLCH’s advertisements to determine whether SLCH has violated Missouri law. If violations are found, we ask that you take swift and decisive action that includes acting to enjoin SLCH from committing further violations, ensuring that SLCH halts and removes all false and misleading advertising statements that are used to promote its PALS program from its Web site, and seek all appropriate penalties permissible by statute. You may contact me directly by telephone at 757-962-8325 or by e-mail at ShalinG@peta.org. Thank you for your consideration, and I look forward to your response. Sincerely,
Shalin G. Gala Laboratory Methods Specialist Laboratory Investigations Department cc: Jonathan Hensley Assistant Attorney General Jonathan.Hensley@ago.mo.gov