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Retail pharmacy is giving itself a credibility problem. While pharmacists are highly trusted health professionals, there are increasing questions about the products sold in pharmacies. Many of the non-prescription products that you can find aren’t backed by good evidence. And the number of dubious products seems to be growing. Homeopathy is an extreme example. Homeopathic “remedies” look like conventional medicine, but unlike actual medicine, homeopathic products don’t contain any active ingredients. They are effectively and sometimes literally sugar pills: placebos that are marketed to treat health concerns. Not surprisingly, there is zero convincing evidence to show that homeopathy has any value in medicine. Homeopathy is fundamentally incompatible with the current scientific understanding of the medicine, biochemistry, and even the basic physics that form the foundation of a pharmacist’s knowledge base about medicines. There is no medicinal benefit to homeopathy. Yet despite the obvious ethical issues of selling sugar pills to patients who may be led to believe these products may be beneficial, the profession of pharmacy hasn’t acted, or even seriously asked itself if selling these products is appropriate. And homeopathy has moved quickly from a fringe product to one that you can find in most retail pharmacies. Here’s a picture from a local pharmacy near me. Imagine you’re in a rush, searching for a cough and cold product. How easily can you identify the homeopathy?

Why do pharmacies sell snake oil?

A few weeks ago Steven Novella wrote a thoughtful post about pharmacist ethics and responsibilities. Building on editorials from Edzard Ernst and myself, he made an appeal to the professionalism of pharmacists to prioritize patient interests and good medicine over retail interests. In Steve’s opinion, which I share, it is up to pharmacists themselves to lead this change. Pharmacy is a self-governing profession in most regions of the world, which means that it can define the terms of its practice. And there is nothing to stop the profession of pharmacy from rejecting homeopathy; Steve wrote:

For pharmacists there is also a very simple and clear course of action that they can take. Just stop selling health care products that have no evidence of efficacy or evidence of lack of efficacy. Stop selling products that don’t work, can’t work, or are unproven to work. This means a refusal to sell any homeopathic product. If you work for a large corporate pharmacy chain, that still does not obligate you to violate your professional ethics, and you should express your position up the corporate chain. If pharmacists as a profession refused to sell homeopathy, big pharmacy chains would have no choice but to drop the products. Failure to take such a stand is interpreted by the public as endorsement. Most people believe that pharmacists would not be selling homeopathic products alongside actual drugs if they were nothing but snake oil. Failure to oppose the sale of snake oil is implicit acceptance.in

Yet, to date, I’m not aware of any pharmacy organization or regulator seriously considering this issue. Pharmacies profit from selling products like homeopathy, but there’s been no discussion within the profession about whether this is ethical or even appropriate. Increasingly, questions are being raised outside the profession about the professionalism of pharmacists and what pharmacies sell. There’s an excellent video from the Australian consumer affairs show The Checkout that looks at this issue from the patient’s perspective:

Do pharmacists recognize the problem?

While many pharmacists know that homeopathy is nonsense and are frustrated with the profession’s inertia, some of the resistance to change may be coming from pharmacists themselves. From the Canadian pharmacy trade magazine Pharmacy Practice , I found a remarkable statistic:

CAM

However, it is not plausible to excuse vendors for selling a product that does not work simply because they have either not taken the time and effort to investigate whether their product works, or turned a blind eye to the evidence that is available to them. There is, after all, such a thing as willful ignorance. While the credulous seller of (for example) homeopathy may not be guilty of knowingly selling something that does not work, he or she is guilty of having culpably low epistemic standards. Such a person does not sell knowingly, but he or she does arguably sell recklessly.

Starting the sentence with “just” signals how little emphasis the profession seems to place on the use of good evidence. If one in five pharmacists doesn’t understand that homeopathy is pseudoscience and has no medicinal benefit, then the profession has a serious knowledge gap, because the evidence is unambiguous . (Also notably, 50% believe homeopathy to be a placebo but believe they may have a place in therapy.) Data like this suggests that pharmacists may not have fully thought through the ethical implications of selling complementary and alternative medicine. In a recent paper published in the peer-reviewed journal Bioethics , Professor Chris MacDonald and I argue that sellingfails to not only meet the ethical standards of health professionals, it violates all three ethical principles of commercial transactions . Ignorance of the evidence isn’t acceptable, particularly for a health professional and especially for a pharmacist. We noted:

While I have yet to see any responses to our paper in print, it was interesting to see a column posted at Canadian Healthcare Network (registration may be required) by pharmacist Jeannie Collins Beaudin. She endorses homeopathy, sells it in her pharmacy, and argues for its use in pharmacy practice. She writes:

What is it about homeopathy that has enabled it to survive over 200 years of usage, in spite of having what current studies insist is no greater effect than placebo? Is it simply that the placebo, or essentially our own immune system, is that effective when given a little encouragement? I have to say that my overall experience in using these medications with clients has been surprisingly positive. I was first introduced to the medication system in the mid-nineties when we had just opened a new pharmacy. My husband, who is also my business partner (and a non-pharmacist), had noticed the rising interest in natural remedies and, in spite of my hesitation, insisted that we should stock homeopathy as well as herbal medicines. As a pharmacist, I had a hard time getting my head around the way homeopathy was prepared, and the Latin names and different preparations were confusing to me, but I agreed to give it a try. Of course, we didn’t have the meta-analysis studies that we have today, which would likely have convinced me to do otherwise. Initially, my role was simply to provide the specific medications that clients came in looking for, or I would consult homeopathy texts to help clients determine which medication would specifically be recommended for them when someone asked. Although I didn’t have an overwhelmingly large number of clients and didn’t specifically track their responses, it seemed that I received far more positive feedback than negative.

and later

Knowing how homeopathic medications are prepared, I had difficulty understanding how it possibly could work. There is a parallel with vaccines, where the agent that causes the problem is basically destroyed and then made into a solution that then stimulates the immune system to do the action we desire. This seemed to be the only plausible explanation for how homeopathy could work, but why would a more dilute solution give a stronger effect rather than a weaker one? Confounding my understanding was the existence (although rare) of the “exacerbation reaction,” which is reported in the literature and was experienced by one of my clients who tried an allergy product. How could a substance that is diluted beyond Avogadro’s number (leaving it unlikely to contain even a single molecule of the original substance) cause her allergic symptoms to strongly intensify only minutes after taking a homeopathic medicine? Homeopathic medications are used around the world far more commonly than they are in North America. England even has homeopathic hospitals, according to a pharmacy student who had done a rotation in such a hospital. Another student from India told me that homeopathic medicines were routinely used at home. One of my best clients was a veterinarian who regularly used homeopathic medications with his animal patients—if the action of homeopathy relies only the placebo response, how could they work in an animal? Are we missing something? Could it be that standard testing methods cannot be used for homeopathy due to its individualization? Do we need to, perhaps, include the ability of the immune system to respond in our attempts to prove or disprove this system? More questions than answers…

Colllins doesn’t describe any struggle ethically with selling homeopathy. She seems to place greater value on anecdote over published and more systematic evidence. And she doesn’t discuss one of the most critical issues and challenges that homeopathy (and CAM more generally) presents: Homeopathy challenges patient autonomy. In order for placebos to “work”, patients must believe something that is untrue. Ethical codes for the pharmacy profession can vary, but any I have seen make it clear that the patient’s interests are central to the pharmacist’s role, and that pharmacists must provide evidence-based information to support informed decision making. As MacDonald and I discuss is our paper, selling sugar pills, without an adequate explanation that these products contain no medicine, and have been evaluated and are not effective, may mean patients are making decisions without being fully informed. Failing to provide complete disclosure is effectively a form of medical paternalism. Homeopathy illustrates, with perhaps the most clarity, why selling unproven or ineffective treatments is incompatible with ethical pharmacy practice. Mark Crislip summed it up nicely:

This is the paradox of alternative medicine; by understanding, we render the treatment ineffective. Yet by concealing medical knowledge, we return to a dangerous, medieval-like approach to healthcare. It is for this reason why alternative medicine is flawed. As tempting as it might be to embrace placebo-based treatments, the ethical standards we would have to sacrifice are infinitely more valuable.

I’m not convinced the profession will change on its own, so I’m cautiously optimistic about a new review of pharmacy in Australia. Change may be coming, and it may be forced on the profession:

From The Australian (may be firewalled):

Pharmacists have a conflict of interest in selling unproven drugs and therapies to supplement their incomes from dispensing medicines, an independent review has been told.

and

Apart from perennial issues of fees, business models and location rules, the paper questions the very nature of what pharmacists do, and what they charge, and asks should they be put to better use. “It was put to the panel that community pharmacists face conflicts of interest between their role as retailers and as healthcare professionals,” says the paper, noting pharmacists can sell over-the-counter, complementary therapies and other retail ­products. “The panel has heard that some consumers are concerned that pharmacists may compromise on the level of professional advice provided to patients on the quality use of medicines and feel financial pressure to ‘up-sell’ to consumers, for example by recommending medicines or products that may not be necessary for the patient. It was also claimed that many complementary products do not have evidence-based health benefits and as such, the sale of these products in a pharmacy setting may misinform consumers of their effectiveness and undermine the professional integrity of community pharmacists.”

To be clear, the review, which will be conducted by the Department of Health, goes well beyond the sale of “complementary” product and promises to thoroughly examine the organization and practice of retail pharmacy (may be firewalled), including examining the entire distribution and funding model for medicines. If done well, this could prompt an overdue consideration of the responsibilities retail pharmacists hold as key members of health care systems. But it may threaten cherished ideas that pharmacists hold about their dual role as a retailer and health professional. The specific questions the review is asking (see page 47) highlight the important issues that the profession at large needs to discuss, before decisions are made (and imposed) on pharmacists:

Does the availability and promotion of vitamins and complementary medicines in community pharmacies influence consumer buying habits?

Should complementary products be available at a community pharmacy, or does this create a conflict of interest for pharmacists and undermine health care?

Do consumers appreciate the convenience of having the availability of vitamins and complementary medicines in one location? Do consumers benefit from the advice (if any) provided by pharmacists when selling complementary medicines?

Does the ‘retail environment’ within which community pharmacy operates detract from health care objectives?

Conclusion: Ethical practice means prioritizing patients over retailing

The tension between the “business of pharmacy” and the professional responsibilities of pharmacists, as health care professionals, has always been present in retail pharmacy practice. Owing to the close linkage with retail aspects of medicine (like the sales of over-the-counter drugs), there’s a much more obvious relationship between the provision of health care and the need to derive revenue from consumer purchases. This may explain why homeopathy has made such inroads into retail pharmacies. But the growing shelf space devoted to dubious products is raising broader questions about the role of pharmacists as partners in health care systems. Pharmacists are trusted health professionals. That trust has been earned. If the profession doesn’t take steps to maintain that trust, then change may be forced upon it.