A N AUDIT OF HEALTH PRODUCTS ADVERTISED FOR SALE ON

CHIROPRACTIC W E B SITES IN CANADA AND CONSIDERATION

OF THESE PRACTICES IN THE CONTEXT OF CANADIAN
CHIROPRACTIC CODES OF ETHICS AND CONDUCT
Stacey A. Page, PhD,"''' and Jaroslaw P. Grod,

ABSTRACT

Objective: This study describes the extent to whieh chiropractors with Web sites practicing in Canada advertise health
products for sale and considers this practice in the context of chiropractic codes of ethics and conduct.
Methods: Chiropractic Web sites in Canada were identified using a public online business directory (Canada 411).
The Web sites were searched, and an inventory of the health products for sale was taken. The influences of type of
practice and province of practice on the sale of health product were assessed. Textual comments about health product
marketing were summarized. National and provincial codes of ethics were reviewed, and the content on health product
advertising was summarized.
Results: Two hundred eighty-seven Web sites were reviewed. Just more than half of the Web sites contained information
on health products for sale (n = 158, 54%). Orthotics were advertised most often (n = 136 practices, 47%), followed
by vitamins/nutritional supplements (n = 53, 18%), pillows and supports (n = 40, 14%), and exercise/rehabilitation
products (n = 20, 7%). Chiropractors in solo or group chiropractic practices were less likely to advertise health products
than those in multidisciplinary practice (P < .001), whereas chiropractors in BC were less likely to advertise nutritional
supplements {P < .01). Provincial codes of ethics and conduct varied in their guidelines regarding health product sales.
Conclusions: Variations in codes of ethics and in the proportions of practitioners advertising health products for
sales across the country suggest that opinions may be divided on the acceptability of health product sales. Such practices
raise questions and considerations for the chiropractic profession. (J Manipulative Physiol Ther 2009;32:485-492)
Key Indexing Terms: Chiropractic; Professional Ethics; Codes of Ethics; Marketing

he chiropractic professioti in Canada is facing a

number of challenges. Data from Ontario have
shown that despite continued growth in the number
of chiropractic graduates, the use rates for chiropractic are
remaining relatively stable. ' Recent years have seen reduced
insurance coverage in some provinces for chiropractic care.

" Senior Research Associate Office of Medical Bioethics, Heritage

Medical Research Building, Faculty of Medicine, University of
Calgary, Calgary, Alberta.
"' Adjunct Assistant Professor, Department of Community Health
Sciences, Faculty of Medicine, University of Calgary, Calgary,
Alberta.
'^ Professor and Director, Continuing Education, Canadian
Memorial Chiropractic College, Toronto, Ontario, Canada M2H 3JI.
Submit requests for reprints to: Stacey A. Page, PhD, Senior
Research Associate Office of Medical Bioethics, RM 93, HMRB,
Adjunct Assistant Professor, Department of Community Health
Sciences, Faculty of Medicine, University of Calgary, 3330 Hospital
Drive NW, Calgary, AB. T2N-4N1 (e-mail: sapage@ucalgary.ca).
Paper submitted November 12, 2008; in revised form April 9,
2009; accepted April 27, 2009.
0l61-4754/$36.00
Copyright 2009 by National University of Health Sciences.
doi:10.1016/j.jmpt2009.06.010

limiting access for consumers.'^'^ The numbers of other

complementary and alternative practitioners stich as massage
therapists and acupuncturists are increasing, competing for
market share with chiropractors.'' These factors may
contribute to a reduced patient-to-chiropractor ratio, which
in turn may lead to reduced income for practitioners. It
has been reported that chiropractors are retailing a range
of health care products,'*"^ possibly as another means of
generating revenue.
Data from a recent audit of chiropractic Web sites in
Alberta suggest that the marketing of health products and
services by chiropractors is common. Almost two thirds
(65%) of the 56 chiropractic Web sites surveyed indicated
that the practices offered health products for sale. Orthotics
were the products most often sold, followed by pillows and
supports, and then vitamins/natural supplements.^
The sale of health products by chiropractors is guided by
the codes of ethics of either provincial or national
professional associations. At the time this study was
undertaken, there are some variations across the country,
with the code followed by practitioners in British Columbia
being most restrictive, specifically prohibiting the sale of
nutritional supplements, vitamins, and minerals.^
485

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Audit of Health Products

The retailing of health products is an important issue that

warrants consideration when defining the professional
conduct boundaries of health care practitioners These actions
may be considered by some as being at odds with the
professionals' ethical obligations to act in patients' best
interests and avoid actions that may cause conflict of
interest.^'' Although the recommendation of health products
should be based on a clinical value that addresses a patient's
needs, a financial interest in the sale of that product might
influence the practitioner's behavior, and the patient's best
interest has the potential of being compromised. Little is
known about the current practices of retailing health
products by chiropractors in Canada.
The purpose of this study is to provide a preliminary
description of the extent to which Canadian chiropractors
are selling and marketing health products as evidenced by
advertisements or offers on Web sites. This study also
describes and discusses the guidelines offered by Canadian
national and provincial chiropractic codes of ethics and
conduct relating to health product sales and advertising.

METHODS

Consistent with the Tricouncil Policy Statement, this

study did not require ethics review [Section I.A., Article
1.1 (c)].'" Chiropractic Web sites in Canada were identified
using a publicly available business directory, Canada 411.
This online directory provides contact information (name,
address, phone numbers) for chiropractors offering services
in the country. Chiropractors with Web sites can choose to
have their URLs listed in this directory for an additional fee.
In 2009, the Canadian Chiropractic Association stated
there were 7000 licensed chiropractors in Canada."
Searching for "chiropractor" in the Canada 411 directory in
June of 2007 yielded 8401 listings, suggesting most
chiropractors were represented. These online listings were
reviewed to find practices with Web sites. Once identifled,
the Web addresses were recorded and the Web sites were
audited. All health products and services offered through the
practice were recorded on a standard inventory form. The
results were summarized descriptively using proportions.
The association between the type of practice and the
advertising of health products and the province of practice
(British Columbia vs other) on sale of health products was
evaluated using the j ^ statistic. Comments made about the
products available for sale were also recorded and summarized using content analysis.
The Canadian Chiropractic Association (CCA) is a
national voluntary organization that represents Canada's
licensed chiropractors. Approximately 87% (N = 6100) of
the approximately 7000 chiropractors in Canada are
members. The national code of ethics and conduct of the
CCA, available online from the CCA's Web site, was
reviewed, and its content relating to the sale of health
products was summarized. Six provincial associations have

Table I. Health products sales on chiropractic Web sites in Canada

Province
BC
AB
SK
MB
ON
QB
NFLD
NS
PEI
NB
Total

Chiropractic Web
sites identified
45
30
9
152
34
1
14
2
287

Selling health
products at clinic
33 (73%)
20 (67%)
3 (33%)
88 (58%)
3 (9%)
0
7 (50%)
1 (50%)
155 (54%)

Link to a
product site
15
7
4
79
4
0
4
1
114(40%)

BC, British Columbia; AB, Alberta; SK, Saskatchewan; MB. Manitoba;

ON, Ontario; QB, Quebec; NFLD, Newfoundland; NS, Nova Scotia;
NB, New Brunswick; PEI, Prince Edward Island.

developed their own codes of ethics and conduct (British

Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Nova
Scotia), and these are also available on their Web sites. The
Code of Ethics of Chiropractors in Quebec is found within
the Chiropractic Act (RSQ, c. C-26, S. 87) available online.
The provincial codes were reviewed, and their content on the
sale of health products was summarized.

RESULTS

From the 8401 listings for chiropractors, 225 were

nonchiropractic, leaving 8176 chiropractic listings. From
these listings, 929 Web addresses were found. Upon review,
637 were nonchiropractic, duplicates, or inaccessible, leaving
292 unique active Web addresses for audit. No Web sites were
found using Canada 411 for either Saskatchewan or
Manitoba. For these 2 provinces, we searched the Yellow
Page print directories for the 2 larger cities in each province
(Saskatoon and Regina, and Brandon and Winnipeg,
respectively). Nine Web addresses were found for Manitoba,
whereas none were found for Saskatchewan, resulting in a
total of 301 Websites.
Three sites represented multiple, franchised clinics. It
was not impossible to determine who owned and operated
these clinics, nor was it possible to identify the practitioners
or products by clinic site. Therefore, these sites were
excluded, reducing the number of practice sites reviewed to
298. Two sites were resource or product sites for
practitioners, not consumers, and these were also dropped,
reducing the number of chiropractic sites to 296. Eleven
sites comprised clinics that were clearly owned by other
health professionals (eg, massage therapists, physiotherapists, naturopaths) and were dropped, leaving 285 Web
sites. In contrast, 2 Web addresses reported on 2 clinics
each, and it was possible to code practitioners and products
by site. The final tally of clinics reviewed was 287. The
number of clinic Web sites identified for each province is
shown in Table 1.

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Audit of Health Products

Table 2. Health products advertised for sale through chiropractic

practices

Table 3. Links to health product sales sites

Link to product site

Sold through practice

n (%)
Product
Orthotics
Pillows
Supports, braces
Exercise/rehabilitation equipmetit
Topical creams (tnassage oil, atialgesics)
Hot/cold packs
Other health products
Nutritional supplements including:
Vitamins and minerals, herbal
Supplements, hormonal
Supplements, digestive enzyrnes
Homeopathic supplements
Miscellaneous products for sale
Brand name/custom footwear
Skin care products
Backpacks
Other: cardiopulmonary resuscitation barriers.
transcutaneous electric nerve stimulator
machines, books, chairs, energy drinks, infant
carriers, sleep aids, therapeutic videos,
magnets, ozone generator, Huida Clark
A 6 parasite zapper, air purifiers, allergy
products, parasite cleansing kit, mattress pads

135 (47%)
40(14%)
27 (9%)
20 (7%)
18 (6%)
14 (5%)

53 (18%)

n (%)
Product
Orthotics
Pillows
Supports, braces
Exercise/rehabilitation equipment
Topical creatTis (massage oil, analgesics)
Hot/cold packs
Other health products
Nutritional supplements including: vitamins
and minerals, herbal supplements, hormonal
supplements, digestive enzyrnes

41 (14%)
12(4.0%)
7 (2%)
6 (2%)
11 (4%)
1 (0.3%)

26 (9%)

Homeopathic supplements

4 (2%)

10 (3%)

Amazon

4(1%)

34 (12%)
11 (4%)
4 ( 1 %)
3 (1%)

Miscellaneous: clothing, diapers, workout

DVDs, sport drinks water bottles, hypnosis
workshops, mattresses, biopro
electromagnetic fields protection

Linked by <2 clinics

Sold by <2 clinics

Practice Descriptions
A total of 485 chiropractors were affiliated with the Web
sites surveyed. Most chiropractors were male (n = 325,
67%). Most chiropractic clinics were multidiscipiinary (n =
179, 63%), whereas some were solo practices (n = 70, 24%)
and some were group chiropractic practices (n = 37, 13%). A
range of other health practitioners was affiliated with the
multidiscipiinary clinics. The most common practitioners
were massage therapists (n = 172 clinics); naturopaths (n =
43 clinics); physiotherapists (n = 27 clinics); athletic
therapists, including kinesiologists, exercise/rehabilitation
practitioners, personal trainers, and fitness professionals (n =
20 clinics); and dieticians/nutritionists (n = 16 clinics).
Health Product Advertising and Selling
Practices were considered to be selling health products
directly to the consumer if they made a clear statement to that
effect (eg, "orthotics that are produced through our office,"
"feature product offered at clinic name"). Sites sometimes
had only a "product" section where links to vendor sites could
be accessed (eg, "click on any of the links to get more
infomiation on these products"). In the latter cases, we made
the assumption that the practices were not directly selling the
products but providing the links to other vendors. Similarly,
one clinic was identified as providing orthotics. However,

this service was clearly contracted out to a certified pedorthist

who was available to clinic patients once every 2 weeks. We
concluded that the practice itself was not selling this product.
Slightly more than half of the clinics advertised that they
sold health products (n = 155, 54%). Nine Web sites (3%)
offered online product sales, whereas 4 (1%) had online
product pages under development. One hundred fourteen
(40%) Web sites had links to product sites. These results are
displayed by province in Table 1.
The range of health products sold is shown in Table 2. As
would be anticipated, most ofthe items for sale were directly
related to the practice of chiropractic, that is, products that
potentially affected the musculoskeletal system (eg, orthotics,
braces, pillows). A variety of other products was offered for
sale less frequently. Most often, these were supplements
(vitamins, nutritional supplements, herbal remedies). Homeopathic products were also offered on occasion. Miscellaneous
items advertised by 34 clinics included brand name and
custom footwear, and skin care products. Less common items
included backpacks, infant carriers, ozone generators, transcutaneous electric nerve stimulator machines, sleep aids, and
water purifiers. In addition to selling directly through the
practices, a number of chiropractic Web sites provided links to
product sites (Table 3). Linked sites either sold products
directly or provided information about how to find a supplier.
Multidiscipiinary practices were more likely to have
products advertised for sale than were solo or group
chiropractic practices (/^ = 37.6, P < .001).
The codes of ethics and conduct followed by the British
Columbia College of Chiropractors, Canada, at the time this
study was undertaken, was most restrictive regarding the
sale and dispensing of supplements. For this reason, we

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compared the prevalence of health product advertised for

sale by chiropractors with Weh sites in British Columbia
compared with those in the remaining provinces and found
that, although those in British Columbia were more likely to
engage in health product sales generally {y!' = 8.0; P =
.005), they were less likely to sell nutritional supplements
2

Comments Accompanying Product Advertising

Most comments about products for sale involved an
endorsement or recommendation. Product endorsements
varied in intensity and were most often made about nutritional
supplements. Some described their products as simply "recommended," whereas others offered evaluation of products using
phrases such as "award winning," "highest quality pharmaceutical grade," and "finest supplements available today" in
their descriptions. One offered a personal endorsement stating
that clinic members had "personally used every product on this
page and have recommended them to our families."
To a lesser extent, comments focused on the effectiveness of
products. For example, general claims such as "I recommend
them because they get the best results" were made. Less often,
specific health claims were made (eg, "our products address
health concerns such as ...," "natural solutions to the most
common conditions," and "absolutely miraculous for..."). One
product descriptor indicated that ''named product could
replace prescription medications such as naproxen." Effectiveness was hacked up by reference to clinical or scientific
research on a couple of sites. On one site, links to joumal
publications about a few products (ie, multivitamins, glucosamine, and coenzyme QIO) were available. In contrast, one
site offered a disclaimer indicating that the information
provided with the product was for educational purposes only
and that no medical or curative claims were implied.
A few sites commented on product safety (eg, "all Chinese
herbs available at named chiropractic centre are manufactured to high quality North American standards and are very
safe"). Others pointed out the need for patient monitoring of
product use (eg, "caution should be taken ... self-prescribing
or self-dosing is not in a patient's best interest").
Occasionally, statements centered on the value and
affordability of products. Some Web sites offered assistance
with product access for patients, indicating that if desired
products were not seen on the Web sites, the patient could
request that the practitioners order them.
A few sites indicated the products they sold were only
available through a health practitioner's office. One Web site
clearly stated it did not offer supplements for sale because
these could be readily obtained at local stores and pharmacies.
Health Product Sales, Chiropractic Codes of Ethio and Conduct, and
Federal Guidelines
The CCA's Code of Ethics and Conduct contains a general
statement that conduct in the profession of chiropractic should

Joumal of Manipulative and Physiological Therapeutics

July/August 2009

be above reproach and will take no physical, mental, social, or

financial advantage of a patient. The Code of Conduct expands
upon this, stating the dispensing of health products is
permissible, with certain provisions.'^ These provisions
include that dispensing such items does not create a conflict
of interest, they serve the best interests ofthe patient, clinical
value has been shown, and the items are available at fair market
price. Moreover, the code states that the chiropractor will
recommend only treatment considered essential for the wellbeing of the patient. Product endorsements are permitted
provided such endorsements reflect favorably upon the
profession and that CCA's policies are upheld.
Some provincial bodies have adopted the CCA's Code of
Ethics and Conduct (Newfoundland, New Brunswick, Prince
Edward Island), whereas others have developed unique
provincial codes (Alberta, British Columbia, Saskatchewan,
Manitoba, Ontario, Quebec, Nova Scotia). The codes of these
latter provinces all contain statements similar to that of the
CCA, prohibiting the professional ft-om taking advantage of
patients, financial or otherwise, and limiting chiropractors to
the provision of treatment believed necessary for the wellbeing of the patient.
The Nova Scotia College of Chiropractors Code of Ethics
and Conduct contains the same statement as the CCA with
respect to its position on the retailing of health products.'''
The remaining 6 provinces vary in the extent to which they
permit the sale of health products. The Code of Conduct of
the British Columbia College of Chiropractors was most
restrictive, specifically prohibiting the sale or dispensing of
vitamins or food supplements, drugs, or homopathies and
also prohibiting chiropractors from receiving any financial
remuneration or other benefit coming from the supply or
distribution of vitamins or food supplements. This code also
prohibited chiropractors from engaging in any product or
service endorsement, unless it related directly to the practice
of chiropractic and limited the links that chiropractors could
have on their Web sites. Where the chiropractor shared office
space with another health practitioner who sold or dispensed
these products, the code stated this activity must be carried
out solely by the other health practitioner and further stated
that no vitamins, food supplements, drugs, or homopathies
may be displayed or sold in any office space or common area
occupied by the chiropractor.'
Since the time this study was undertaken, the College of
Chiropractors of British Columbia (formerly the British
Columbia College of Chiroprators) has revised its Professional
Conduct Handbook.''* The revised code of conduct lifts
previous restrictions imposed on chiropractors regarding health
product sales. Notably, chiropractors do not appear to be
prohibited from selling, or from being associated through their
practices with the sale of, vitamins or food supplements.
Although the current professional conduct handbook does not
directly address product sales and endorsements as the previous
code of conduct did, it does indicate the chiropractors may
"recommend" nutritional supplements for specified conditions.

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The Ontario Chiropractic Association does not prohibit the

sale of products. However, it clearly defines conflict of interest
and acknowledges that the sale of any product to a patient is a
potential conflict of interest. The Ontario Chiropractic
Association lays out clear ethical guidelines to help practitioners avoid a conflict of interest. These include that the
chiropractor should not receive financial benefit from a third
party in retum for the sale of products to a patient, and that
the markup on products should have a reasonable relationship
to the expenses associated with supplying the product.
Members are cautioned to avoid engaging in commercial
activities that could improperly influence their professional
judgment. Product endorsements are not mentioned,'^
In contrast, the Code of Ethics of the College of
Chiropractors of Ontario, Canada, the province's governing
body, does not directly address health product sales. It does
state that chiropractors should avoid both flnancial conflict
of interest and the provision of unnecessary care,'*
Although the code of ethics of the Alberta College and
Association of Chiropractors does not prohibit the sale of
health products, it does have a section on product marketing
in the chiropractic office in which a number of conditions are
placed on this practice. These include that chiropractors
ensure they do not exploit the trust in the therapeutic
relationship, not misrepresent or exaggerate the value of
products, have evaluated that the therapeutic value is rational,
and make available information necessary for patients to
make an informed choice, including the availability of the
product elsewhere, ' '
The Code of Professional Ethics of the Chiropractor's
Association of Saskatchewan does not directly address the
retailing of health products. It does, however, state that
chiropractors shall avoid the advocacy of any product when
they are identified as members ofthe chiropractic profession, ' ^
The Manitoba Chiropractors' Association Code of Ethics
makes a general statement about not taking financial
advantage of patients and another statement about protecting
professional reputation by avoiding all situations that could
lead to a conflict of interest as defined in the Conflict of
Interest Policy'^ Although product sales per se are not
addressed within this policy, conflict of interest is clearly
defined. The policy also outlines procedures to be followed
when a conflict of interest arises; however, these apply more
to a single event rather than to an ongoing pattern of practice,
such as product retailing.
Finally, the Code of Ethics of Chiropractors in Quebec
clearly states that the chiropractor must subordinate his
personal interest to that of his patient. The Quebec code is
consistent with others, stating the chiropractor should avoid
any situation that would put him in a conflict of interest, and
it describes such a conflict as arising when, in respect of a
given act, the chiropractor finds direct or indirect, real or
possible, personal advantage therein. Like the Code of the
Manitoba Chiropractors' Association, this code does direct
the chiropractor to advise his patient of this situation once

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Audit of Health Products

recognized, but again, this does not seem applicable to an

ongoing pattern of practice,^"
Federal Guidance and Advertising of Health Products
For chiropractors, the practice of selling health products is
addressed by their provincial and national codes of ethics.
Advertising of health products is also overseen by Health
Canada, Advertising as defined under the Food and Drugs Act,
the Food and Drug Regulations, and the Natural Health
Products Regulations refers to "any representation by any
means whatever for the purpose of promoting directly or
indirectly the sale or disposal of any food, drug, cosmetic or
device," Health Canada provides guidance on direct-toconsumer advertising of health products including natural
health products and nonprescription drugs. Only those
products (including drugs, natural health products, medical
devices, vaccines, and biologic products) that have been
authorized for sale by the Health Products and Food Branch
may be advertised. Health products authorized for sale are
readily identified by an 8-digit identification number preceded
by a specific acronym (DIN, NPN, DIN-HM), Specific provisions limit the type and extent of advertising. For example.
Health Canada does not permit the use of superlative
terminology to exaggerate therapeutic properties of a product
(eg, "amazing formula"), it does not permit products to be
described as safe or free of adverse effects, and it prohibits the
advertisement of health products as treatments, preventions,
or cures for a number of specific diseases and conditions,^'
These guidelines have been developed to minimize the
health risk factors to Canadians while maximizing safety and
to promote conditions that enable Canadians to make healthy
informed choices, Noncompliance with these guidelines
could result in uninformed decision making, threatening the
well-being of the consumer.

DISCUSSION

This study explored the extent to which Canadian

chiropractic Web sites identified using the Canada 411
Business Directory advertised products for sale. Our findings
show that just more than half of the chiropractors with Web
sites were offering health products for sale. Most health
products related directly to promotion of musculoskeletai
health and included orthotics, pillows, braces, and exercise
equipment. Nutritional supplements were offered to a lesser
extent and were more often advertised by those in a
multidisciplinary practice setting. Practitioners in the province
with the most restrictive guideline on the sale of nutritional
supplements (British Columbia) were less likely to advertise
these products.
The codes of ethics and conduct of the national and
provincial chiropractic associations were generally permissive
ofthe practice of selling health products, with the exception of
British Columbia, Conditions placed on the sale of these

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products included that they pose no conflict of interest, they

serve the best interest of the patient, they have clinical value,
and they be made available at fair market.
Conflict of Interest, Patient Best Interests, and Fair Market Price
The potential problem with office dispensing by health
professionals is the conflict it may create between the role of
the health practitioner as a professional performing in the best
interest of the patient and the role of the health practitioner as a
business person. The practice of retailing is viewed by some
health professionals as undermining professionalism.^'^^'^''
Health professionals have a fiduciary duty to act in their
patients' best interests. Implicit within the healing professions
is the commitment to serve the interests of patients; effacement of self-interest is the ethical ideal.^'' A potential conflict
of interest exists when practitioners proflt from selling health
products to their patients. Some of the chiropractic codes of
ethics described above take this into account, recommending
that products be sold at "fair market price" (CCA) or that
product markup be reasonable in relation to expenses incurred
(Ontario); however, these parameters are variable and subject
to individual interpretation. This conflict may be magnifled if
the demand for the product does not come from the patient and
the patient only purchases the product because of the
chiropractor's recotnmendation or endorsement.
Smith^^ suggests that conflict of interest represents a set of
conditions rather than a behavior. That is, although the selling
of health products may not be deliberately intended to take
advantage of patients, the very fact that such products are for
sale in the office may influence practitioners' behaviors in
ways they are potentially unaware of. For example, a
practitioner may be drawn into discussions of products that
are unrelated to the patient's reason for seeking care simply
because the patient has seen the product in the office. In turn,
patients may feel compelled to purchase products because of
the practitioner's endorsement.
In addition, chiropractors arc confronted with business
advertisements, such as "Retail product sales at point of service
improve chiropractic clinic revenues and patient loyalty,"^* and
trade publications suggesting practitioners can increase their
incomes through the sale of nutritional or other products.'^'
Such advertisements may mask the potential ethical conflict
created by health product sales by making such sales appear the
norm and, therefore, acceptable within the profession.
The intentions of the practitioners, markups on the
products, and the motivations of the patients could not be
assessed from the methods used in the present study. These
are important areas of inquiry for future research.
Clinical Value
In addition to the commitment of service to others,
professionalism assumes possession of a specialized body of
knowledge. Although chiropractors are recognized as
neuromusculoskeletal specialists, some have suggested that

the expertise of some chiropractors does not necessarily

extend to other areas of health, such as nutrition, which rnay
make it difficult for these practitioners to recommend
treatments essential for the well-being of their patients.^'^"'
Moreover, it has been suggested that some chiropractors may
lack the expertise required to critically evaluate the evidence
on product safety and efficacy; therefore, decisions may not
be grounded in science or clinical efficacy.'"''^ This is
particularly important in the area of nutritional supplements,
where claims of benefit lack scientific validity and research
is frequently criticized for its lack of rigor (eg, references 36
to 38). The average consumer is at an even greater
information disadvantage and may assume that, because
some chiropractors are selling such products, the products
have shown safety and efficacy.
Other Professions and Perspectives
Chiropractors are not the only group of health professionals who have ventured into the health product marketplace. Others, such as dentists and dermatologists, have gone
there too.^'^'''' Members of some other professions have
described the benefits of selling products to their patients.
Dentists who engaged in product retailing did not believe that
this behavior harmed the professional image of dentistry and
strongly agreed that retailing offered convenience to their
patients. Moreover, dentists were likely to view retailing of
products as ethical if the product was backed by clinical
research.^^ Dermatologists identified trust and convenience
as the most common reasons patients purchased nonprescription products from them. For their part, the patients
listed physician knowledge and trust most frequently. 22
Limitations
The sampling strategy used in this study captured a very
restricted proportion of ehiropractic practices. The sample is
limited because not all chiropractors list their Web sites with
the online directory. In addition, chiropractors who do not
have Web sites might also sell health care products. Bias within
this sampling strategy may have arisen because chiropractors
with advertised Web sites may be more aggressive marketers
and may, therefore, be more likely to advertise products. As
well, advertisement of a product on a Web site may not
correlate with sales of the product. For these reasons, the
estimate of chiropraetors who engage in the advertising of
health products should be interpreted with caution. Future
research should use representative samples of practitioners to
allow chiropraetors to provide their opinions of and practices
around health product retailing and to examine practitioner
knowledge of their codes of conduct and ethics.

CONCLUSION

Chiropractors are responsible for good practice, achieved

in part by complying with professional standards and

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Volume 32. Nutnber 6

regulatory mandates. The review of national and provincial

codes of ethics and conduct showed that the practice of
health product sales is generally permitted with the exception
of the restrictions in place in British Columbia at the time of
the audit. The differences are evidenced in the detail the
codes contain. Where there is less specificity, practitioners
are permitted a greater degree of subjectivity in their
interpretation and, therefore, application of these standards.
This may result in an uneven standard of practice both across
and within provinces and is illustrated in part by the range
health product advertising found in this study. The results of
this Web site audit have raised the. possibility that some
practitioners may not be aware of, or adhering to, their
professional guidelines regarding health product advertising
and sales, nor aware of the Health Canada guidelines
regarding advertising and health products.
The challenge before chiropractic is to decide if the act
of advertising and selling health products inevitably
conflicts with its code of ethics and its professional role.
Once this is determined, the profession can move toward
consistent standards of practice across the country,
complemented by appropriate guidelines and monitoring
of professional conduct.

Practical Applications
Chiropractors' professional conduct is governed in
part by their professional codes of ethics.
Canadian chiropractic codes of ethics vary in
their position on the sale of health products by
chiropractors.
The sale of health products by chiropractors may be
in conflict with their professional code of ethics.

ACKNOWLEDGMENT

The authors acknowledge Dr Michael King for his initial

review of the manuscript.

FUNDING SOURCES A N D POTENTIAL CONFLICTS

OF INTEREST

Funding for this project was granted by the Canadian

Memorial Chiropractic College. The authors have no
conflicts of interest.

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