Barbara's and Cindy's thoughts on the possibility of conflict of interest
when LCs provide pumps in hospitals have real meaning for me! I really
pondered this one when I started out, and still do.  Back in 1990 there were
no pumps available at all, except those little glass horrors with the red
bulbs that can't be cleaned.  So I imported just a few pumps with great
difficulty and would lend them out and get them back, at no charge.  About
four years ago our foreign exchange situation eased sufficiently for
companies to begin importing a wide variety of hand and little electric
pumps (of various degrees of quality/effectiveness) that are now available
for sale in pharmacies and one or two wholesale outlets. But there are no
rental stations at all.

To solve what I feel is the real ethical dilemma of saying to a needy
mom/baby couple, "Yes a pump would be helpful and I will sell it to you", I
offer the pump which IMHO is the most efficient, the easiest to clean, and
the least expensive (in the hospital, at home or in my office because the
need is usually *immediate*) in three ways - so that the mother can choose
which option will best suit her needs - (1) I lend the pump free of any
charge for two weeks (2) at the end of the two weeks I levy a daily hire
charge (to avoid pump sitting in mom's cupboard for three months gathering
dust), or (3) she can buy the pump at my price (more than the wholesalers,
but less than the pharmacies). In practice the large majority of mothers
exercise option (1) and then during the two free weeks they let me know that
the pump is so useful, or will be so useful in the future, that they
exercise option (3) whereupon I add the cost to the bill.

So in this way I hope I have got around the first dilemma of selling a
product to a captive market.  But there remain several other ethical
considerations: (1) the possibility that by offering a free product I am
promoting the use of pumps. To get around this I always teach manual
expression of breastmilk so that mom can choose which method of draining
breasts or providing EBM she prefers.  (2) I know (although the consumer
doesn't) that the single importer of my preferred pumps brings them in in
batches and there can be no pumps available anywhere for up to 3 months, so
I have to stockpile them and am not always anxious that they be sold. There
is the dilemma that it would be safer for each mother to use a brand-new
pump, rather than a used one.  I clean and sterilize to the best of my
ability, but what if ...? (3) Because I do not want to be seen as just a
retailer of pumps I will not just provide a pump without a consultation.
Perhaps this could be seen as "conditional selling".  If a caller "just
wants a pump" I direct him/her to a pharmacy/wholesaler, but I suspect that
often I am the only source available and the rush on my pumps will reflect
this.

This can go round and round in circles. I see pumps as a temporary tool to
maintain breastmilk production in certain individual situations where
breastfeeding cannot take place, and I observe that the more successful this
is the more likely the mom is, eventually, to be able to breastfeed her
baby.  Ideally, each mother's medical insurers would pay for her to receive
a brand new pump and there would be an independent mobile pump provider who
could deliver it within two minutes of her emergency call.  Until that
happens perhaps we could keep talking about these conflicts of interest.

Pamela Morrison IBCLC, Zimbabwe
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