Ethics and the WHO “International Code of Marketing of Breast-milk Substitutes”

In December last year many of you would have been aware of the concern expressed by individuals and organizations that the American Academy of Pediatrics (AAP) had contracted with Mead Johnson to provide AAP-branded materials as part of the formula manufacturer's maternity discharge pack. At the time the Academy of Breastfeeding Medicine (ABM) wrote to the President of the AAP and distributed a media release calling on the AAP to discontinue this relationship with the formula company concerned and to implement a formal policy prohibiting AAP participation in direct-to-consumer marketing of formula or formula company materials.

The issues surrounding relationships, commercial or not, with formula manufactures and other companies and organizations that do not comply with the World Health Organization (WHO) “International Code of Marketing of Breast-milk Substitutes” and its subsequent resolutions (the Code) have the potential to be quite complex. There are often differences of opinion regarding who is not Code compliant, how close a relationship could be, and whether any benefits of a relationship outweigh the negative impact of association with a non–code-compliant company.

To assist with many of these questions within ABM, we have developed a “Code and Policies for Interaction with Commercial and Non-profit Organizations” (Ethics Policy) (http://www.liebertpub.com/mcontent/files/ABMCodeofEthics.pdf). ABM has also adopted the “Code for Interacting with Companies,” developed by the Council of Medical Specialty Societies (http://www.liebertpub.com/mcontent/files/CMSS_Code_for_Interactions_with_Companies.pdf).

The underlying guiding principles of ABM's Ethics Policy include the WHO Code and a need to provide breastfeeding education and evidence-based protocols that have not been influenced by financial or philosophical concerns.

All organizations with which ABM has official relationships or that exhibit at ABM meetings must be compliant with the WHO Code, regardless of any perceived benefit to ABM's mission. If there is any uncertainty about WHO Code compliance, the Ethics Committee is the ABM's review body and has a procedure in place to investigate WHO Code compliance or otherwise of the particular company and organization in question. This investigation includes the compilation of information and materials from a variety of sources, including the company/organization concerned and breastfeeding advocate organizations. The Committee formulates conclusions and recommendations following the investigation that are forwarded to the ABM Board of Directors for review and endorsement. At times, these are difficult decisions to make, and not everyone may agree with the stand taken.

Sometimes it is not initially apparent that particular companies or organizations (including professional organizations) are WHO Code violator or have relationships with Code violators. In these situations it can be even more difficult to make decisions to cease negotiations or an ongoing relationship. However, ABM's intent is to only be officially associated with those who are WHO Code compliant.

The subject of conflicts of interest of speakers at conferences or meetings is also a vexed issue, especially if the conflicts relate to the WHO Code. Although there is no absolute prohibition on anyone speaking at an ABM meeting, speakers are required to reveal all conflicts of interest prior to the meeting. These conflicts are published in the meeting program and are acknowledged at the beginning of a speaker's presentation. Meeting participants are then able to consider the information presented in the context of any conflict the speaker acknowledges.

Of course, conflicts of interest do not only occur in the context of the WHO Code. Therefore, the ABM Ethics Policy also encompasses other groups such as pharmaceutical manufacturers, producers and distributors of products for breastfeeding mothers and infants, publishers and authors of breastfeeding materials, commercial milk banks and purveyors of human milk–derived products, the media, and not-for-profit educational, research, or service organizations. To develop an association with ABM, these groups must have either a positive or neutral relationship with breastfeeding, and their motivation must be in line with ABM's vision and mission.

Ethical issues will no doubt arise for ABM in the future, especially as we become more widely known for our expertise and influence. However, the principles outlined in the Ethics Policy will continue to guide our decisions regarding interactions with outside companies and organizations and enable us to give a consistent response to any challenges that we encounter.