Occasionally, pharmacists invite me to give a lecture about alternative medicine. The aspect I am always keen to debate with them is the issue of retail pharmacists selling medicines which are unproven or even disproven. The last time I was invited, I asked them how many might, when working as retail pharmacists, sell products such as flower remedies, homeopathic medicines, detox therapies, aromatherapy oils, etc. About half of them had the courage to admit that they would do this. I fear, however, that in reality this figure is probably closer to 100 per cent.
The question why pharmacists might offer unproven or disproven medicines to their customers has puzzled me for many years. It is intriguing not least because the ethical codes of pharmacists across the world quite clearly prohibit such activity. So, what are the possible motivations for pharmacists to sell bogus medicines?
One possible reason would be that they are convinced of their efficacy. However, talking to pharmacists, I do not get the impression that many of them believe in homeopathy or other bogus therapies. During their training, they are taught the scientific facts which clearly do not support the notion of efficacy.
If some pharmacists are nevertheless convinced otherwise, they are obviously not well informed and would thus find themselves in conflict with their moral, ethical and legal duty to practice according to the current best evidence. On reflection, therefore, strong positive belief is probably not a prominent reason for pharmacists to sell bogus medicines.
Another common argument is the notion that, because patients want to buy alternative medicines, pharmacists must offer them. When considering it, the tension between the ethical duties of a healthcare professional and the commercial pressures of a shopkeeper becomes painfully obvious.
For a shopkeeper, it is perfectly all right to offer all products that customers want. For a heathcare professional, however, this is not necessarily the case. The ethical codes of pharmacists make it perfectly clear that the sale of unproven or disproven products masquerading as medicines is not ethical. Therefore, the above notion may well be what pharmacists feel, but it is nevertheless not a valid reason for selling bogus medicines. Ethical imperatives must always override commercial self-interest.
Another argument holds that, if patients were unable to buy alternative medicines such as homeopathic remedies to treat self-limiting conditions which do not really require treatment at all, they would only find ways of obtaining more harmful and costlier prescription drugs. The notion here is that it might be better to sell harmless, cheap placebos in order to avoid the side effects of real but non-indicated medicines.
It looks plausible at first sight. At closer scrutiny, however, this argument does not hold water: if no (drug) treatment is indicated, responsible healthcare professionals have a duty to explain this fact to their patients. In medicine, a smaller evil cannot easily be justified by avoiding a bigger one; on the contrary, we should always thrive for the optimal course of action — and if this means reassuring patients that no medical treatment is needed, so be it.
An all too obvious reason for pharmacists to sell bogus medicines is, of course, the undeniable fact that they earn money by doing so. There clearly is a conflict of interest here, whether pharmacists want to admit it or not. And mostly they do try to deny that such a conflict exists, or they play down this reason for their decision to sell bogus medicines.
Pharmacists working in large chain pharmacies like Boots often claim that they have no influence whatsoever over the range of products on sale in their pharmacy. This perception might well be true. But equally true is the fact that no healthcare professional can be forced to do things which violate their code of ethics. If institutions like Boots insist on selling bogus medicines, it is up to individual pharmacists and their professional organisations to change this situation. They need to protest against such unethical malpractice and eventually refuse to comply. In my view, this argument is therefore far from convincing and certainly does not provide an excuse that can be used in the long term.
Yet another potential reason for selling bogus medicines in pharmacies seems a little more far-fetched. Some pharmacists claim they feel that stocking such products provides them with an opportunity for talking to patients and informing them about the evidence related to the remedy they were about to buy. This might dissuade them from purchasing it and could persuade them to buy something that is effective instead. In this case, the pharmacist would merely offer the bogus medicine in order to advise customers against using it. This strategy might well be an ethical way out of the dilemma; however, I doubt that it is common practice with many pharmacists today.
Nonetheless, we should keep in mind, of course, that there are many shades of grey between the black and the white of the two extreme attitudes towards bogus medicines. There is clearly a difference whether pharmacists actively encourage their customers to buy bogus treatments, or whether they merely stock such products and, where possible, offer responsible, evidence-based advice to people who are tempted to buy them.
In the end, it is up to the pharmacists’ professional organisations to provide guidance to their members in this complex and often difficult situation. The Pharmaceutical Society of Australia, for instance, does not support the sale of bogus medicines in pharmacies: ‘Our position is that pharmacists must use their professional judgement to prevent the supply of products with evidence of no effect.’
This surely is good news for all who stand up for evidence-based medicine and for the best interests of patients. It came only a few months after the Chief Scientist of the UK Royal Pharmaceutical Society, Professor Jayne Lawrence, outlined a similar vision: ‘The public have a right to expect pharmacists and other health professionals to be open and honest about the effectiveness and limitations of treatments. Surely it is now the time for pharmacists to cast homeopathy from the shelves and focus on scientifically based treatments backed by clear clinical evidence.’
These are clear and courageous words indeed. Let’s hope they are now followed by decisive action.
Edzard Ernst, emeritus professor at the University of Exeter, is the author of A Scientist in Wonderland and the awardee of the John Maddox Prize 2015 for standing up for science. He blogs at edzardernst.com.