Ethical issues in traditional herbal medical practice in Nigeria

There is increased use and popularity of herbal medicine in Nigeria in recent times. Scholars from different fields have attributed this recent upsurge to economic issues, high cost of modern medical care, loss of confidence in synthetic drugs, resistant of diseases to some modern drugs and easy accessibility of herbal medicines and its practitioners, amongst others. According to the World Health Organization (WHO), a large portion of the world’s population patronize s traditional herbal medicines. However, there is perceived neglect of the core principles of health care ethics by the practitioners and marketers of traditional herbal medicine in Nigeria. This is worrisome. In this connection, this paper argues that Nigerians will benefit immensely from traditional herbal medicine if its practitioners and marketers observe and respect these core principles of health care which includes the principles of beneficence, non-maleficence, autonomy, informed consent, justice, and truthfulness. This study is purely qualitative and adopts a textual critical analytic method.


INTRODUCTION
The growth of Bioethics was championed by James F. Childress and Thomas Beauchamp, who were the first Americans to publish a book on Bioethics (Pereira-Sáez, 2016). The text formed the foundation of Bioethics. The four core principles of Bio-Medical ethics namely the principle of beneficence, non-maleficence, autonomy, and justice, were contained in their book titled Principles of Biomedical Ethics. These four principles are also known as "Principlism." The idea was that these core principles must be observed for ethical medical care. This work will evaluate these principles concerning traditional herbal medical practice in Nigeria. This research will examine how each of these principles is being violated in traditional herbal medical practice in Nigeria.
In conventional medical practice, ethical guidelines are already put in place to enable physicians and all health caregivers to adhere strictly to but in herbal medical practice, ethical principles are not considered as necessary. These principles are important because they act as the moral compass that guides and directs the actions of the practitioners, marketers and all those involved in the practice. In medical practice, both conventional and traditional herbal these principles of health care ethics are indispensable. These principles are inseparable from medical practice. The danger is that once these principles are neglected, human cruelty, exploitation, abuses, dehumanization, and all sorts of unethical acts sets. Many of the present-day traditional herbal medicine practitioners and their marketers misinform the public through spurious claims. There is no doubt that such an act is motivated by self-interest and sharp business mentality and that automatically violates the principles of truthfulness. Some of them circumvent drug approval procedures and this implies that they are putting their interest above that of the public which violates the principles of beneficence and nonmaleficence. Furthermore, the information they give is usually insufficient and when people consent based on such insufficient information such consent is invalid and this violates the principles of informed consent. When the practitioners circumvent drug approval procedures, adulterate herbal preparations and make spurious claims, they are not just to the consumers and this violates the principle of justice. It is therefore evident that these principles are violated in traditional herbal medical practice in Nigeria and this is worrisome because the benefits of traditional herbal medicine will not be achieved when these core principles are being violated daily.

THE ETHICAL ISSUES IN TRADITIONAL HERBAL MEDICAL PRACTICE IN NIGERIA 2.1 The Principle of Beneficence
This concept is widely used in medical practice though it has received several interpretations over time. Broadly speaking it means "doing good, the active promotion of good, kindness and charity" (Beauchamp, 1984). From a traditional perspective, acts of beneficence arise from obligation. In medical ethics, beneficence is a moral principle which demands that physicians or health caregivers provide good benefits like good health, prevent and avoid harm to patients to the best of their ability. This principle protects an individual to minimize harm and maximize benefits. According to Mawere (2012) "beneficence as a principle of medical ethics asserts an obligation (on the part of the physician) to help others (patients) further their importance and legitimate interest and abstain from injuring them in any way, that is psychologically, morally or physically." Beneficence also holds that in health care, the interest of the patient takes precedence over that of the physician or health caregiver. Its central concern is that the physician has an obligation towards the good of the patient, keeping the patients from harm, injury, or injustice. The emphasis in healthcare is the patient's best interest and not that of the physician. The principle of beneficence is essential for health caregivers to carefully analyze, evaluate and promote those acts that bring benefits to patients and the general public. Beneficence is a "prima facie" principle. In this principle, the healthcare giver or the physician has the obligation not to harm the patient either physically or morally. The interest of the patient overrides that of the physician. The welfare of the patient is a vital factor. It advocates no harm and seeks the good of the individuals, which is the goal of medicine.
It has been observed that some of the practitioners and marketers make spurious claims in a bid to sell their herbal products. They mislead the public through false claims. Such claims are seen when they propagate one herbal medicine as having the capacity of curing about 10 or more unrelated diseases. This problem of spurious claims observed in traditional herbal medical practice is a violation of the principle of beneficence, which is an important principle in healthcare. This principle says, "always do good." It is a concept that is widely used and interpreted in several ways in medical ethics. It is a principle that protects an individual to minimize harm and maximize benefits. Most important to this work is that the principle of beneficence holds that "a practitioner should act in the best interest of the patient. "Salusa egroti suprema lex" (Asira & Ogar, 2009). It is this view of beneficence that is apt to this work and which I will use to argue that spurious claims in traditional herbal medical practice in Nigeria are against this important principle in health care ethics. The problem of making bogus or exaggerated claims has become a challenge in practice. It is important to state here that, in as much as they have brought out what they produced in their micro level to the macro society they must be subject to this principle.
Therefore, the interest of the patient must take precedence over their own according to this principle. However, this observation that some of the traditional herbal medicine practitioners and marketers make spurious claims can be interpreted as being motivated by a sharp business mentality which implies they are putting their interest over and above that of the patients/consumers. It is said that extraordinary claims require extraordinary evidence and facts; some of them make extraordinary claims without extraordinary evidence. Imagine an herbal practitioner or a marketer holding one bottled herbal preparation and mentioning about ten diseases that particular medicine can cure. Such a claim is an extraordinary and spurious claim as that is misleading and dishonesty and such an act can only be motivated by selfinterest. Such a practitioner is putting his interest which is a monetary gain over that of the patients. The interest of the patient is to get cured through such medication and such interest must take precedence over that of the practitioner. When a traditional herbal medicine practitioner or his marketer makes spurious claims he is not doing any good to the patient preferably through those claims put his interest above that of the patient and this is a violation of the principle of beneficence in health care ethics "This is because positive consequences are likely to flow in direct proportion to the extent that adherence to truth is held as central principle amongst all agents involved in healthcare and negative consequences are likely to flow from the converse" (Ernst & Smith, 2018). To put the interest of the patient above that of the herbal medicine practitioner and their marketers must stop making spurious claims. When a practitioner does this, he is putting the interest of the consumer above his but when he goes contrary to this, he is putting his interest above that of the patient which contradicts the principle of beneficence.
Furthermore, when a traditional herbal medicine practitioner puts his interest above that of the patient by making spurious claims, he is violating this principle. In this connection, whenever a traditional herbal medicine practitioner makes spurious claims without substantial scientific or verifiable evidence, he is acting from self-interest and in this sense, he puts his interest above that of the patient/consumer. He is just using another, a vulnerable person as a means to an end and such an act is ethically reprehensible. Recent activities of making spurious claims by some traditional herbal medicine practitioner and their marketers show lack of respect for human dignity is exploitation and unethical and such violates the principle of beneficence in health care as this work has established.

The Principle of Non-Maleficence
This ethical principle in its Latin origin states "primum non nocere" (first do no harm) which is traced to the Hippocratic Oath, which medical practitioners take as a code for their profession. This principle forbids harming others. The physician or a caregiver must not intentionally, negligibly or carelessly harm another. It also forbids harm that can come up either by commission or omission. Non-Maleficence is a reminder that the primary concern in medical care or treatment is to avoid harm. The principle of beneficence and non-maleficence are similar, both state that one must act in a way that provides benefit for another and at the time, protects the person from harm. In this principle, a health caregiver must target eliminating all negative effects and simultaneously work towards the welfare of the patient. When a health caregiver neglects to control some aspects of his work that have harmful consequences on others then the person is going contrary to the principle of non-maleficence. Traditional principles of medical ethics say that "the physician must evaluate whether any particular treatment or procedure is clinically indicated and whether the procedure will provide a benefit or undue burden to the patient" (Lawrence, 2007).
Traditional herbal medicines are found at every nook and cranny of our markets and streets. What is worrisome is that many of those herbal medicines did not undergo drug approval procedures. They have no registration details showing that they have been screened. It has been observed that some of the practitioners boycott this procedure. The issue of marketing traditional herbal medicine that has not been clinically approved by the appropriate body by some traditional herbal practitioners is against the principle of non-maleficence in health care ethics. This principle holds that it is a positive moral duty of a practitioner to ensure that his/her treatment is based upon sound scientific evidence. It could be read today as "respect a patients' dignity".
The first Nigeria Patients' Bill of Rights of 2018 is designed to ensure that patients have high-quality healthcare in a way that recognizes their needs and rights. The Bill emphasized that patients have the right to be treated with respect. Some of the traditional herbal medicine practitioners do not take the rights and dignity of consumers as a serious issue. The streets are flooded with all sorts of herbal preparation though some are of good quality and approved many are concoctions and not clinically approved. We met a traditional herbal medicine vendor in Owerri in Douglas road marketing his products; we approached him to buy herbal medicine. After the thorough check, we discovered that it has no (National Agency for Food, Drug Administration and Control) NAFDAC number and in our curiosity, we asked how come this medicine has no NAFDAC registration no he told me that it has been done but they are yet to put the number on the packet. How can one believe such statement? When we inquired the more, he opened an envelope and showed us a letter from NAFDAC which we do not know how authentic it is, but claims that it covers everything he is selling. It will not be out of place to notice that some are even using fake NAFDAC numbers to market their products. We also interacted with another why some of them do not like going through drug approval procedures, he avers that such processes reduce the efficacy of their medicine and that after all those procedures the power in the medicine will no longer be there. Ekeanyanwu (2011) reported his experience from a certain traditional Herbal practitioner who argued that "the mystical aura surrounding herbs will be destroyed by extraction and standardization." Another practitioner said he does not need to do that because he has been using this medicine for years and it has been working so for him there is no need going through drug approval procedures. He also added that Nigerians are corrupt that if he takes it there now, they will take his medicine from him, go and market it and he will lose his profit. However, a good number of them we encountered during this study emphasized the importance of subjecting their herbal preparation through drug approval procedures for safety purposes. You can even see the NAFDAC number on the products and documents to confirm their claims, such an act is highly commendable. The view of this work is that circumventing drug approval procedures is not in tandem with the principle of non-maleficence. The principle of non-maleficence states "first do no harm" "primum non nocere". This principle forbids harming patients either by omission or commission. Ekeanyanwu also added that "one feature of healthcare does no harm, which means assuring that whatever is being taken by humans for medicinal purposes is safe "(2011: 91). Non-maleficence reminds us that the primary concern of a medical practitioner in treating the sick is to avoid harm. Lawrence (2018) holds that "the physician must evaluate whether any particular treatment or procedure is clinically indicated and whether the procedure will provide a benefit or undue burden to the patient." This implies that the patient is the center of all treatment and should not be harmed through negligence, intentionally or unintentionally. The implication is that any herbal medicine practitioner who circumvents drug approval procedures is guilty of medical neglect irrespective of his motives. Bringing it down to the activities of some traditional herbal medicine practitioners in Nigeria who market herbal medicines that were not clinically approved is acting against this principle. It has been established that much harm has been caused by the consumption of traditional unapproved herbal medicine. There have been cases of kidney and liver damage and other serious health complications as a result of such traditional herbal medicine thereby causing harm to unsuspecting sick people. Ekeanyanwu (2011) agrees to this that "Herbal medicine, however natural can cause serious illnesses from allergy to liver or kidney malfunction to cancer and even death. Asira and Ogar (2009) contributing to this argued that …is partly because enthusiastic practitioners are prone to using treatments that they believe will do good, without first having evaluated them adequately to ensure they do no (or only acceptable levels of) harm. Much harm has been done to patients as a result. It is not only more important to do no harm than to do good, but it is also important to know how likely it is that your treatment will harm a patient.
When a traditional herbal medicine practitioner markets unapproved herbal preparation he puts people's lives at risk and even harm them. However, some of the practitioners are of the view that since the medicine has been used for years there will be no need for such rigorous procedures, but we want to remind them that there could not be immediate harm but it does not rule out the possibility of long term effects and harm. It is only when a drug goes through the clinical drug approval procedures that its efficacy, effects, risks, and benefits can be ascertained and precautions are taken. Research has shown that some of the medicinal herbs can be contaminated by pollution, are toxic above the recommended level and even poor manufacturing processes can contaminate herbal preparations and put people's lives at risk and harm them. This work argues that if a traditional herbal medicine practitioner wishes to bring what he is doing at his small micro village to the macro (larger society) he must go through the rigorous of drug approval procedures otherwise he will be harming people without knowing it. Especially if he wishes to commercialize it there is a need for proper clinical testing, documentation, and approval by the appropriate bodies for human safety. Anything short of this is ethically unacceptable. It does not matter how good his intention is what is imperative is that he failed to do what ought to be done. It is therefore important that the traditional herbal medicine practitioner does not just rely on millennial or generational beliefs only but clinical investigations because of the complexity of human physiology. The antiquity of an herbal remedy might simply show that the medicine originated from a time when even the most basic knowledge about human anatomy, physiology, pathology were not available. Therefore, a generational belief is no longer sufficient to ascertain the quality and safety of traditional herbal medicine hence the importance of drug testing and approval becomes indispensable.

The Principle of Informed Consent
Informed consent is another important principle to be considered. In medical and health care ethics, we advocate for not just consent but informed consent. Informed means that a person is fully informed and he understood the potential benefits and risks of his choice of treatment. It is the cornerstone of medical ethics. Gillon (1986) defined it as "a voluntary, uncoerced decision, made by a sufficiently competent or autonomous person based on adequate information and deliberation to accept rather than reject some proposed course of action"). Also, Faden and Beauchamp (1994) have it the "informed consent is an autonomous action by "a patient that authorizes a professional" to initiate a medical plan for the patient informed consent is given if a patient or subject with (i) substantial understanding and (2) in the substantial absence of control by others (3) intentionally (4) authorizes a professional". The implication of this is that for consent to be informed the information must be comprehensive. The comprehensive nature of the information involves the risk and benefits, whether a particular treatment or medicine has been certified or still undergoing experimentation and other relevant information that would make a person accept or reject the treatment or medicine. Ernst and Smith (2018) add that "informed consent requires that the patient must understand why a particular treatment is being offered. In turn, this requires that the patient receives a valid explanation of the disorder, which must also be accurately explained to the patient." In conventional medicine, such explanations are usually done. This means that consent given based on insufficient information is not informed consent. An important question here is how much information is required to ensure that a person is genuinely consenting to a treatment? Answering this question, Ross (2013) opines that "every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive. This implies that there are two important criteria, the circumstances of the consumer and for informed decision to be made there must an evaluation of what any reasonable person in that circumstance may wish to know. Therefore, one cannot be expected to make a reasoned decision when he does not have full relevant facts. One needs to know the benefits and risks (side effects) of a remedy. This is important for a patient to give informed consent or make an informed choice. Another important criterion for informed consent is competence. People categorized as incompetent include children, mentally deranged, terminally ill and drunk.
The third criterion is voluntariness. This means that the action must be voluntary, free from coercion or external influence. The question now is how the activity of some traditional herbal medicine practitioners undermines the principle of informed consent? It has been observed that some of these traditional herbal medicine practitioners and their marketers do not give sufficient or detailed information to consumers. It will be important to note that in the Patients' Bill of Rights launched by the Vice-President Prof. Yemi Osinbajo on July 31, 2018, the right to relevant information and fair treatment of patients are among the rights emphasized by the document. Some of the herbal practitioners often do not even reveal the ingredients of their herbal preparation. We once asked an herbal medicine practitioner in Calabar the content of his herbal medicine and in reply, he said that what he is being asked can be compared to asking a warrior to expose his fighting tactics. He only said the medicine is made up of roots and herbs. Moreover, he added their usual slogan; they are "natural and safe." So, for them, they have given complete information. However, we argue that such information is insufficient and misleading because they have said nothing about its risk, benefit ratio and potential side effects. They see side effects only from the negative point of view forgetting that even so many conventional medicines have side effects and they are written down in black and white on a particular drug. For instance, the regular antibiotics we use to treat infection in conventional medicine have some side effects and they have stipulated warning consumers on the dangers of prolonged use.
Some herbal practitioners shy away from stating the potential side effects of their herbal remedy may be either because they circumvented drug testing procedures or they just do not want to lose their customers. In this connection, De Smet at al (1997) says that "the quality of consumer information about the product is as important as the finished herbal product. Warnings on the packet or label will help to reduce the risk of inappropriate uses and adverse reactions." The first source of information about any herbal remedy should be found on the label. However, unfortunately, what is on the label sometimes does not reflect the content of the product. Further, Kunle et al (2011) observed that "It has been found that herbal remedy labels often cannot be trusted to reveal what is in the container. Studies of herbal products have shown that consumers have less than a 50% chance of getting what is listed on the label and published analyses of herbal supplements have found significant differences between what is listed on the label and what is in the bottle. All these are a show of insufficient information from herbal practitioners. However, if they circumvent the drug approval procedure their action is culpable and if they do not know, they cannot also be exonerated because they failed to do what they ought to have done. Even in the legal sector ignorant of the law is not an excuse. The principle of informed consent stipulates that a practitioner should give full information on the benefit and risk and allow the patient to decide. When you hide the risk from a patient and he consent, his consent is defective and not informed and such action of a practitioner is ethically objectionable. From this perspective, one can also argue that there is exploitation going on the practice in Nigeria.
Everyone offering health care services ranging from professional physician to the traditional herbal practitioner is under a moral duty to be truthful. Looking into the criterion of competence we argue that some of these sick persons are desperate to get the cure and, in such desperation, maybe after several attempts in many hospitals but no cure yet. In such a situation, their mental stability is distorted. Some of them and their family members have been mentally and psychologically exhausted. Yemi Osinbajo during his launching of "Patients' Bill of Rights" argued that "needing medical attention is many times the most vulnerable or weakest point for both patients, and many times family. It necessarily connotes desperation, and a combination of these leads to significant impairment in decision making and exposure to abuse and exploitation" (cited in Adeyemo, 2019). However, we do not intend to say that they are incompetent or argue that they are not responsible for their actions because they are still free to reject it, but we bear in mind that some of them have been mentally and psychologically exhausted by sickness. Here this principle is sometimes challenged by the principle of autonomy which says a patient has the right to go for any medication of his choice. This is true if he has sufficient and comprehensive information but when this is absent autonomy is not undermined. They are desperate and as such have become vulnerable to exploitation. Their acceptance was influenced by insufficient information. This leads us to the third criterion voluntariness. The spurious claims and the natural and safe slogan are strong influences on their decisions. These practitioners use their usual slogan "it is natural and safe," "it has no side effects like Oyibo (conventional) medicine" and "it cleanses your system from all bacteria and virus". Some of these claims are attractive and it goes a long way in influencing the consumers to consent. The view of this study is that their consent is no longer voluntary because some forces are compelling them to consent. Consent is voluntary when all the benefits and side effects are spelled out and the person consents. When consent is not freely given the action is not voluntary. We, therefore, argue that some of these traditional herbal medicine practitioners give insufficient information and becloud people with spurious claims. Such attitudes or action is ethically reprehensible and undermines the principle of informed consent in medical and health care ethics.

The Principle of Justice
Another point of concern is the principle of justice in medical ethics. Justice is an important political and moral concept (Ogar & Akpan, 2016). Justice is giving one what he deserves or his due. It involves lawfulness and fairness, equitable distribution of goods and services. In medical ethics, this principle requires respecting the rights and dignity of each person. Among those rights are right to life and to proper and adequate treatment in times of ill health. It implies that the practitioner must be fair and just to the patient, respect his dignity as a person and give him access to proper and adequate health care. This view is contained in the 2018 "Patients' Bill of Right" that patients have the right to quality care. Everyone deserves a minimum standard of healthcare as a human being. The big question is, to what extent is the principle of justice respected in traditional herbal medical practice in Nigeria? Just as we argued earlier that some of them circumvent drug approval procedures after preparing their herbal remedy. Although some of them have argued that this is because their remedy has stood the test of time. They claim that they inherited the practice from their great grandparents and people have been taking their medicines for years without any problem. Some others complain of a lack of funds to embark on this. However, what some of these herbal practitioners fail to understand is the fact that standing the test of time does not guaranty its safety. We had a lot of things and theories that stood the test of time but recently modern science has debunked such notions. For instance, in the field of astrology, the Copernican revolution is a good analogy. It was generally accepted that the earth was at the center of the universe and that the sun and all other planets revolve around it. This stood the test of time until Copernicus scientifically argued and proved that it is the sun that is at the center of the universe and all the planets revolve around it.
Therefore, it is not the sun that revolves around rather it is a man that moves around the sun. Copernicus scientifically challenged and debunked the view that stood the test of time. Also, the history of medicine is full of medicines that had stood the test of time but was later abounded once scientific result shows they are no longer effective or safe. For instance, the popular anti-malaria drug chloroquine was used for years until it was banned in 2005 when it was discovered that its treatment failures were high. Although NAFDAC allowed it for treatment of other diseases like arthritis or intestinal infection, but not for malaria because of its failure rate. World Health Organization (WHO) approved its ban when its therapeutic efficacy showed just 35% efficacy against the 95% standard efficacy. You will discover you hardly see chloroquine been recommended in hospitals for treatment of malaria rather artemether has taken over the market. This is an indication that the number of years does not guaranty efficacy and safety. Efficacy and safety can only be ascertained by scientific testing by drug approval bodies. Some of these preparations have long term effects that the practitioners will not know unless the preparation goes through clinical screening. Even some of the medicinal leaves and roots can be contaminated by pollution, toxic above the recommended level or can be contaminated at the processing point all these can only be ascertained through clinical testing by drug approval bodies. The point is that any traditional herbal medicine practitioner who intends to market his herbal remedy to the public market for public consumption without submitting it for clinical screening and approval is being unjust to the consumers. In a similar case, it has also been observed that some of these herbal preparations are hawked under sun and rain, in wheelbarrows and car boots.
We once encountered an herbal medicine practitioner advertising his herbal remedy under a harsh weather condition, in fact, the sun was so much that day that we had to use a handkerchief to cover our heads. The bottled herbal remedy was kept under the hot sun. We do understand that drugs require a certain room temperature to remain effective and safe. Some need to be stored in a room temperature of below 30c in a dry place and away from sunlight. On this Erhun et al says that "The medicines are often left under the sun in such conditions that could facilitate the deterioration of the active (2001) revealed that on that case, it is reasonable to argue that keeping them under such weather conditions can render them ineffective and dangerous to human health and in few occasions cause death. Actions as these shows lack of respect for people's life, dignity and right to adequate healthcare. Such action is unethical and a concomitant violation of the principle of justice in medical and health care ethics. The practitioner is not being just to the consumers. This is because when a traditional herbal medicine practitioner acts in this manner he is putting his interest above that of the patient and his action can be said to be based on self-interest. Although he can claim that his product is for the good of the patient and that is why he went in search and production of an herbal remedy but that is not enough. Having a personal interest in one's actions may not be said to be completely bad for we all have our interest in so many things we do but it cannot be morally praiseworthy. In this connection, the traditional herbal medicine practitioner who circumvents drug approval procedures has failed in his obligation, he is unjust to the consumers and his action is morally unacceptable. He is dutybound to submit his traditional herbal medicine for clinical scrutiny and approval, failing to do what he ought to do means he is being unjust to the consumers.
In another direction circumventing drug approval procedures is antithetical to medical practice. It is against the practice of health care ethics. The dictum of medicine is "never kill, always care". In circumventing drug approval procedures, some herbal medicine practitioners have harmed consumers even without being aware of this. This is paramount because it is possible to have up to five to ten different herbs ingredients in one herbal preparation. Hence the need for proper clinical analysis from the cultivation of medicinal plants and harvesting to clinical application. Some traditional herbal medicine practitioners prefer to remain in the epistemic dark ages and argue that the best evidence of clinical effectiveness is in traditional knowledge and individual observation by the practitioner. Relying on traditional knowledge for efficacy and safety can no longer be adequate due to different genetic factors and physiological differences. Ernst and Smith (2018) confirm that "medical researches do not usually rely upon isolated studies of individuals. Instead, most studies involve a group of subjects, with data from all the subjects aggregated to show general features." Some instances of negative effects and death have also been recorded as a result of over-reliance on traditional knowledge and belief and this work argues that it is a dangerous setback into the dark ages. Our duty in the 21st century is to test what we inherited from tradition to determine the good to be adopted and the bad to be abandoned. A traditional herbal practitioner who fails to adopt this is working against the standard. When one goes out from the recommended standard then his actions are not motivated by goodwill. This is because if he has goodwill, he will follow the recommended standard and observe the drug approval procedures before marketing such herbal remedy.

Principle of Truthfulness and Autonomy
Truthfulness is a complete disclosure of all relevant information. To be truthful is an ethical and legal duty. Honesty is an important factor for patients and consumers of herbal medicine this is because when people are ill, they become vulnerable and burdened with so many questions that require truthful answers. When the truth is lost all is lost because truth-telling is an ethical obligation. Lying undermines the principle of autonomy. Autonomy in medicine requires that the patient must have the capacity to consider any issue independently, deliberate a course of action and put that into action. It is the ability to decide freely independent of control or influence of others and with a sufficient level of understanding to make an informed choice. For a person to make an informed decision he requires nothing but truthful information. The physician or practitioner needs to educate the patients to enable them to understand the situation properly. It involves presenting all treatment options, explaining the risk, after effects, ensuring that they understand the risks and procedures and agree to all the procedures before taking the treatment. Autonomy, information, and respect go hand in glove. It further involves the patient's right to accept or reject any medicine or treatment. Lying is a breach of the right of autonomy of a person and contradicts patient-centered care. Immanuel Kant once said that everyone deserves the truth even when it hurts. For him lying harms, a person and truth-telling is a duty.
Making spurious claims as a way of marketing traditional herbal medicine for whatever reason is dishonesty. Truthtelling protects the consumer, practitioner, and marketer. Using spurious or any marketing gimmick tantamount to deceit and dishonesty, and it is motivated by sharp business mentality to obtain money from vulnerable consumers. False information is deceit and deceiving consumers is ethically unacceptable. Such an act is condemned in medical ethics. Kant in his second categorical imperative warned that we shall never treat humanity whether in our personal or in the person of another as a means but always as an end. When a traditional herbal medicine practitioner or vendor gives false information to convince consumers he is using them to his end. He is taking undue advantage of the vulnerable to obtain money for himself which is his end. Human life must not be sacrificed for financial considerations; an act that mainly aims at a profit is shortsighted. Making spurious claims and circumventing drug approval procedures will lead to a lack of trust in our traditional herbal medicine. The efficacy of traditional herbal medicine in treating diseases cannot be denied but my worry is the issue of adulteration and poor regulation. So many concoctions are sold in the market in the name of traditional herbal medicine.
A lot of adulterated herbal remedies are scattered on the streets and this is worrisome. The level of regulation is too poor and so many people have made themselves traditional herbal medicine practitioners. The level at which is going now if nothing is done people will lose confidence in traditional herbal medicine due to the influx of adulterated and unapproved herbal remedies in the market. The implication is that it will now become difficult to differentiate the real from the fake, the safe from the unsafe and the natural from the concoction. There is no doubt that so many of them are doing good work in terms of exploiting medicinal plants and observing drug approval procedures but when some circumvent this procedure, they end up jeopardizing the good work going on in the field of alternative medicine. Furthermore, they end up marketing ineffective and unsafe herbal remedies that are dangerous to human health and such cannot but lead to distrust in the efficacy of traditional herbal medicine. People have a lot of trust and confidence in the therapeutic effect of our natural herbs and roots in treating diseases and they do so with much respect. In this direction, the practitioners have full control over the patient, and this should not warrant neglect of their obligation and ethics of health care. This is essential to avoid the loss of our indigenous medicine and its therapeutic benefits.
Finally, if nothing is done to control and regulate the recent activities of some traditional herbal medicine practitioners it will lead to a slippery slope. Slippery slope in this sense means that if traditional herbal medicine remains unregulated or poorly regulated the presence of concoctions will be high in the market more than what are experiencing now in the name of natural/herbal medicine. Abuses will become inevitable, and the herbal medicine market will become chaotic with all sorts of concoctions. Proper clinical evaluation of some of these herbal remedies reveals that the risk outweighs the benefits. If the drug and health regulatory agencies are not proactive in monitoring and regulating the influx of traditional herbal medicine abuses will surely set in and the implication is that human life will be at risk and everyone is a potential victim. Prof. Yemi Osibanjo during the launching of the "Patient's Bill of Rights" in Abuja shared this view when he affirmed that we need to ensure that people's rights in the healthcare sector are respected and protected "because no one in our country is insulated or immunized from needing medical services" (premiumtimesng.com). My argument is that if traditional herbal medicine must provide effective and safe natural medicine for its consumers there is a need for clinical screening, approval and adequate regulation as it is done in conventional medicine and in countries like India and China. This will strengthen the efficacy and trust we have in traditional herbal medicine and the entire humanity will benefit immensely from it.

CONCLUSION
It has become imperative for our traditional herbal medicine practitioners and their marketers to realize that neglecting the basic principles of health care is like destroying the foundation of the practice. These principles are violated daily by the practitioners and the marketers and one cannot be indifferent to this ugly trend. Once the foundation is destroyed or neglected, human cruelty, abuses, all sorts of human exploitation, and unethical practices become imminent. In moments of ill health, our humanity must be respected and respecting our humanity involves respecting these core principles of health care ethics. When these principles are neglected our humanity is threatened. It further undermines the trust and confidence people have in our traditional herbal medicine. This is a clarion call for all because protecting human life is a collective project.