Mart over this issue last year. He accused the chain of hypocrisy Ed.] In June 1989, the Ontario College of Pharmacists also adopted a policy against tobacco sales in drugstores. Like Toni, Jim Dunsdon, deputy registrar of the college, declines to commit himself on the ethical aspect of such sales. He says the college has no power to enforce its policy because tobacco is not legally defined as a drug and its sale has not been defined as unprofessional conduct. Dunsdon takes exception to action suggested by Physicians for a Smoke-Free Canada - that doctors direct patients to pharmacies that do not sell tobacco. He says it suggests there is a connection between selling tobacco and professional competence. However, he admits that the college has no alternative tactics in place to promote its policy. "Pharmacists are in a market economy", he says. Although the profit margin on tobacco is not high, it is seen as a "traffic builder" - it attracts customers who may buy something else when getting their cigarettes. David Sweanor, legal counsel for the Non-Smokers' Rights As-

sociation, maintains that it is both unethical and unprofessional for pharmacists to sell tobacco, "the only legal consumer product which kills when used exactly as intended". Pharmacies, he says, give tobacco an air of legitimacy, especially among young people. How can something sold by a health facility be that bad? Sweanor asserts that there is more to the profit aspect than meets the eye. Pharmacists, he claims, receive cash payments for the amount of shelf space devoted to cigarettes and for countertop displays. Thus, Sweanor argues that drugstores are putting profits ahead of ethical integrity. He would like to see pharmacists' governing bodies declare the sale of tobacco unprofessional conduct. Dr. James Walker, an Ottawa dermatologist active in Physicians for a Smoke-Free Canada - he was one of the first Canadian physicians to have a request printed on his prescription pads asking patients to take their prescriptions to drugstores that don't sell tobacco - regards the sale of tobacco by pharmacists as "totally inappropriate". He sees no ethical problem in directing patients to those who "have made the respon-

sible decision" not to sell tobacco. Indeed, he sees it as being in the interest of his patients. In his view, the sale of tobacco in a drugstore indicates a lack of professional judgement. He, too, would like to see pharmacists' governing bodies take a stronger line. The CMA has made its position clear. It wants to see pharmacists get out of the tobacco business and it is working with the CPA to achieve this. However, Doug Geekie, the CMA's director of communications and government relations, points to "the reality - cigarettes are a significant financial factor" in drugstore operations. He says the average pharmacy can turn the product around, from delivery to sale, in 10 days, but does not have to pay for it for 30 days. This means it is equivalent to an interest-free loan. As for the ethics of directing patients to pharmacies that don't sell tobacco, he sees no problem: "Damage to health far outweighs any such considerations." Toni says his association has chosen the route of "gentle, persistent and consistent pressure". It will be interesting to see how much effect this will have, and how soon.-

Seat-belt exemptions: "Just say No", experts tell MDs Patrick Sullivan says. Dr. Ronald Ailsby, who represents the Saskatchewan Medical Association (SMA) on the provincial safety council, says there is neither rhyme nor reason to the large number of exemptions being granted by many of his less-thancautious colieagues. "It is becoming fairly ridicuand fealous", he told a recent meeting of

octors must exercise more caution and common sense when asked to provide medical exemptions that free their patients from wearing seat belts, a Saskatchewan physician D

Patrick Sullivan is CMAJ news tures editor. 622

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the SMA's Representative Assembly, pointing to one case in which a seat belt was not being worn because of a 6-year-old hip fracture. Ailsby acknowledged that temporary exemptions may be warranted in "rare" cases, but said frivolous ones must be stopped. "Some doctors give them

"I'd simply say that there is general agreement that there are no medical conditions, including pregnancy, that call for routine exemption." -

Dr. Stephen Hart

because they want to keep the patient in the practice", he said. They are worried that if they don't the patient will simply skip down the street and get one from another physician. Another doctor said that in some cases physicians have no choice. "This woman is so big the belt won't even reach around her", he said of one patient, who has ignored his advice about dieting. "She fills the whole compartment. Can you get extensions for seat belts?" Some police have started taking a harder line on questionable exemptions. One person complained in the Ottawa Citizen recently that an Ottawa police officer had rejected his: "When I complained at the police station, the duty sergeant stated that the reason - phobia - was insufficient and that I must go to court", he wrote in a letter to the editor. Raynald Marchand, manager of traffic safety at the Canada Safety Council, said the many exemptions doctors grant undermine the entire traffic-safety campaign. "Here in Ottawa we have STEP [Selective Traffic Enforcement Program] and the police are finding that once they reach about an 88% compliance level people start handing them exemptions. It can be absurd - one guy had one 624

CAN MED ASSOC J 1990; 142 (6)

because he had his appendix out 6 years ago. "My message to the doctors is that you're not doing anyone a favour by giving out exemptions that people don't need. And if you do feel one is warranted, put a date on it saying that it is good for 6 weeks." Marchand said police morale is hurt when they try to enforce a law and find that physicians have provided a loophole that lets people break it. Dr. Stephen Hart of Fredericton, NB, a traffic safety expert and president-elect of the College of Family Physicians of Canada, said exemptions are a national problem. What should doctors do when asked for one? "I'd simply turn to page 43 in the CMA's Physicians' Guide to Driver Examination and say that there is general agreement that there are no medical conditions, including pregnancy, that call for routine exemption", he said. Hart said he knew of one case in which a woman with a seat-belt exemption was killed in an accident, while her husband, who was wearing a belt, lived. Dr. Orville Messenger, medical coordinator at the Canadian Medical Protective Association (CMPA), said the association has no official position on the issue, although it does respond to physi-

cians' requests for advice on individual cases. "What we do say is that unless there is a good reason for providing a slip the physician could be at [legal] risk in the event of an accident-related injury", he said. He also warned that when exemptions are granted, the reasons should be well documented because of the potential for lawsuits. The CMA's guide suggests that possible reasons for exemption include abnormal skeletal structure or seat-belt impingement of medical appliances such as pacemakers or colostomy bags. The CMA says "it is debatable" whether any psychologic conditions justify exemptions and physicians faced with requests made on those grounds "should keep in mind that the medical profession in Canada has declared itself unequivocally in favour of the use of restraint systems. Physicians have an obligation to support this view responsibly and should never recommend any exemption for claustrophobia unless the patient can support the request with firm evidence of a long-standing and disabling history of this condition". Doug Geekie, the CMA's director of communications and government relations, said he would be concerned "if my physician provided an exemption just because I asked for it. Maybe he would give me surgery because I asked for it, too". Ailsby said doctors should follow two rules: they should provide exemptions only when "it is absolutely medically indicated and then only on a temporary basis until the condition in question has healed". SMA delegates passed a resolution calling for Saskatchewan to eliminate permanent seat-belt exemptions, since no medical condition warrants one. They also want to see guidelines for temporary exemptions developed and alternative methods to protect drivers and passengers considered.-