Part 2

1. Part 2 Code in practice

2. So…. • Medela is now classified as Code violator because of the way they started promoting and still promote feeding bottles • These are promoted for breast-milk feeding • Can this be considered also problematic ? undermines the best feeding method: direct breastfeeding • undermines a potentially better method for feeding breastmilk: cup-feeding (emphasized in all UNICEF/WHO materials)

3. Breastfeeding vs breastmilk feeding • Marketing of feeding bottles, i.e. promotion of these products contributes to the notion that breastfeeding and breastmilk feeding are the same thing. • What do you think? Has not the community of lactation consultants become too casual about promotion of breast milk pumping and thus breastmilk feeding?…some of its members do seem to think so. (Becker, G. (2007)

4. Difference between information and marketing • ILCA’s The WHO Code and You: By NO MARKETING is understood: "not plaster your walls and counters and websites with signs advertising the logos and brands of the products falling under the WHO Code." • However-not the usual understanding of marketing • The International Code: "Marketing means product promotion, distribution, selling, advertising, product public relations and information services" • No definition of "information" given. Spirit can be read from the detailed instructions under Article 4 Information and education.

5. IBCLC Code of Ethics • What may be more important in this context, is to remember that the IBCLC Code of Ethics requests that lactation consultants ensure: "that professional judgement is not influenced by any commercial considerations."(para 17) One cannot emphasize this sentence enough!

6. Marketing defined in the literature • Sergio Zyman, the Former Chief Marketing Officer of Coca Cola: "to fully understand what current day marketing is, one should not get lost at looking at its different tools, such as advertising, market-research, sponsorships etc. One should understand marketing by focusing on its end goal: selling! " • "Marketing is a strategic activity and discipline focused on the endgame of getting more consumers to buy your product more often so that your company makes more money." • The criticized Medela advertisement seems to prove this point.

7. Breast pumps, collection containers, and milk storage containers are not covered by the Code, so Medela was not in violation of the Code until it recently began marketing feeding bottles and artificial nipples to the public, ◄ using the concerns over Bisphenol A for promotion Advertisement from the American Baby magazine July 2008

8. marketing vs promotion or some other approach? • It may be more useful to distinguish between: • Giving unbiased information and • Being used – or giving the appearance of being involved with commercial actors – for commercial purposes. • quite some literature on: ► how masquerading marketing as information helps to influence health professionals and/or consumers ►what health professionals may need to do to not be influenced

9. Some examples of this writing • "The truth about drug companies: How they deceive us and what to do about it" (2004) byMarcia Angell, former editor in chief of the New England Journal of Medicine. • "Marketing breast pumps and breastfeeding equipment: Is it ethically any different to marketing infant formula, bottles and teats? " by Genevieve Becker, IBCLC, and her presentation at the ILCA Conference 3 years ago.

10. http://www.nofreelunch.org/aboutus.htm

11. A new Code needed? • Giving many examples of the concrete risks of too close relationships of lactation consultants with manufacturers of breast pumps and other breastfeeding equipment, Genevieve Becker launches the idea of having a Code of Marketing of Breastfeeding Substitutes. • This would shift the notion of displacing breastmilk to the notion of displacing breastfeeding.

12. Exploring conflicts of interest • The IBCLC Code of Ethics requests that the International Board Certified Lactation Consultant must "remain free of conflict of interest…." (Ethical principle No. 5). • The problem: a great majority of interaction with breast pump manufacturers do entail conflict of interest. It will be very difficult for lactation consultants and their associations to be completely "free" of conflicts of interest (selling/renting of the breast pumps…) • Analogy: Physicians/pharmacists

13. Thus need to better understand: • what a conflict of interest is • which ones have to be avoided at all cost • and which ones should be managed to ensure that they do not harm the interests of the baby and the child, nor undermine the trust in the lactation consultants' ability to give advice which is not biased by commercial motives

14. CoI Policy: help to act in the best interest of baby/mother when interacting with commercial actors • Conflict of interest laws in the field of health have been developed because: • a) health – and other – professionals constantly underestimate the way in which their professional judgement could be biased by their financial interest. • b) there are always actors which may try to use health and other professionals who enjoy public trust to serve their commercial interest.

15. A definition • Many exist - for this presentation: • "a conflict of interest is a set of conditions in which professional judgement concerning a primary interest….tends to be unduly influenced by a secondary interest… (Thompson 2005)

16. Primary and secondary interest • E.g. concerns for patient’s health, validity of research, or education of students … • primary interests are often defined in professional ethics codes. • Two overarching, age old, ethical principles in the medical professions: Beneficience: do good. "This principle refers to the moral obligation to act for the benefits of others" Nonmaleficience: "above all, do no harm"

17. Concretely for IBCLCs • the IBCLC Ethics Code: overarching Principles of Ethical Practice - the duty to "act in a manner that safeguards the interests of individual clients…" [IBCLC 2004] • Global Strategy "…responsibility for ensuring the fulfilment of the right of children to the highest attainable standard of health and the right of women to full and unbiased information, and adequate health care and nutrition….(§35) [WHO/UNICEF 2003]

18. Secondary interests • encompass the most varied kinds of financial interests and ties as well as personal and political interests, which risk to adversely affect the judgement of a professional. • Getting sponsorship or other form of incentive – payment for advertisement, recognition points for company–sponsored education event etc. from a breast pump manufacturer represent such secondary interests.

19. IBCLCE clearly aware • IBCLCE stresses its "determination to avoid any real or perceived conflict of interest" in the interest of the public IBCLCs serve, the lactation consultant profession, and society at large. (CERPs for educational programmes funded or sponsored by commercial entities, IBLCE 2009)

20. Conflict between primary and secondary • primary interest must always prevail! • Thompson sees two primary purposes of conflict-of-interest regulation in the medical field: • to ensure the integrity of professional judgment, and • to maintain confidence in professional judgment.

21. Secondary purpose of any conflict-of-interest regulation • ensure that the public sees no reason for distrust. It is usually referred to as avoidance of "appearance of conflicts of interest" or of "perceived conflicts of interest." • That is : to minimize conditions that would cause reasonable persons (patients, colleagues, and citizens) to believe that professional judgment has been improperly influenced… (Thompson 2005)

22. Identifying, assessing and managing financial conflicts of interests • The IBCLC Code Ethics says that The International Board Certified Lactation Consultant must "remain free of conflict of interest…." (Ethical principle No. 5.)

23. The debate in the LCs community • 1. That lactation consultants have to earn a living and the income may be also linked to renting/selling of breast pumps. • 2. That the associations could not survive if they did not have access to revenues from links with commercial actors, such sponsoring of conferences or permitting them to advertise their products in the conferences or the material of associations.

24. Steps to developing response to CoI • Step 1: identifying/listing the various types of CoI at individual and association's level • Step 2: assess their impact/what risks they pose: - Which financial interests might most adversely affect the Integrity of professional judgment of lactation consultants? - And which may most adversely affect Confidence in their professional judgment?

25. Steps to developing response to CoI • Step 3: How serious might be the consequences: to babies, to mothers, to confidence of the profession… • Step 4: distinguishing between unacceptable activities and relationships that should be prohibited and those that could be permitted and regulated/managed to minimize the risks.

26. Steps to developing response to Conflicts of Interest (CoI) • Step 5: Managing CoI coherently and effectively: ►developing a specific CoI policy which would delineate the unacceptable from the permissible and provide effective mechanisms for the regulation of the latter • Step 6: Broader- often political - measures e.g. Use CoI Policy and debate for advocacy: a tool to argue that you should be properly paid for your services, just like physicians, midwives etc.