Issue link: https://maltatoday.uberflip.com/i/1539305
OVER the last decade, the local retail phar- macy business has witnessed a significant shift. We have seen the takeover of inde- pendent pharmacies by Maltese companies that also function as pharmaceutical im- porters, wholesalers, and parallel importers. Currently, more than 60% of pharmacies are owned by these companies, which now control multiple steps in the retail pharma- ceutical supply chain. This business practice is called vertical integration, which brings about predictable ethical risks that the pa- tients and customers need to recognise, and the medical authority needs to manage actively. This new reality raises a signifi- cant 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 med- ical professionals' judgements and actions regarding the primary interests of their pa- tients 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 finan- cial 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 manage- ment encourages pharmacists to recom- mend and promote their imported prod- ucts. The company may incentivise this behaviour through monetary rewards or by fostering a workforce culture that pri- oritises profit maximisation. Recommendation bias can also mani- fest in how products are displayed, as the company insists on placing their imported items in prime shelf positions. These com- pany's coercive actions may induce the pharmacists to compromise their clinical decision-making, potentially undermining the best interests of patients and custom- ers. Often, the pharmacist is the final deci- sion-maker regarding which products to stock and dispense in the pharmacy. Com- pany managers often pressure the pharma- cist to stock products that do not compete with their imported goods. Additionally, these managers may insist that only prod- ucts 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' ac- cess to better options and promotes an- ti-competitive behaviour. Furthermore, these risks are accentuated when com- pany managers evaluate pharmacists on sales performance. This could distort the pharmacist's professional judgement. Corporate incentives may lead phar- macists to over-dispense non-essential products that lack scientific based ev- idence 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 situa- tions where there are shortages of es- sential 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 phar- macist'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 instrumen- tation on their pharmacies' signage or websites. This will help ensure that pa- tients and customers are informed about potential conflicts of interest, allowing them to make more informed choices. Retail chain pharmacies: A threat to patients' primary interests? Anthony Raphael Gatt Pharmacist and holder of MAs in bioethics and business ethics 10 maltatoday | WEDNESDAY • 10 SEPTEMBER 2025 OPINION 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.