By Edzard Ernst
We tend to trust pharmacists and are likely to assume that, if they sell this or that product, it must work. This attitude is, however, somewhat naïve and not necessarily correct. Alongside powerful drugs, most pharmacists also sell pure placebos masquerading as medicine – take, for instance, homeopathic preparations or Bach Flower remedies.
Most homeopathic remedies are so highly diluted that they contain not a single molecule of the ingredient printed on the label; in order to contain a single molecule of the declared substance, a “C30” pill [the dilution frequently sold by Boots] would need to have a diameter similar to the distance between the sun and the earth. This makes homeopathy very hard to swallow! About 200 clinical trials are available which tested whether homeopathic remedies have clinical effects beyond placebo. Collectively these data fail to provide good evidence in favour of homeopathy http://www.ncbi.nlm.nih.gov/pubmed/12492603.
Similarly, Bach Flower remedies have no basis in science. Like homeopathic preparations, they contain no active ingredients and, crucially, the clinical evidence is squarely negative http://www.ncbi.nlm.nih.gov/pubmed/20734279. In other words, they are pure and expensive placebos.
Why then are such remedies sold in virtually every pharmacy in the UK and abroad? Are pharmacists content to be shopkeepers, mainly out to make a profit, or are they healthcare professionals who adhere to certain ethical standards? Comments by a spokesman of the leading UK pharmacy chain, Boots, such as “we aim to offer the products we know our customers want”, seem to indicate that, regrettably, the former interests have won the upper hand [Bennett P.Are pharmacists shopkeepers out to make a profit? Pharm J 2010; 22]
But how can this be? Do pharmacists not have codes of ethics to which they are duty-bound? Yes, they do; in fact, even though they vary from country to country, these codes leave little room for manoeuvre instructing pharmacists in no uncertain terms to provide all the relevant information about the products they sell, to tell the truth as well as to act professionally and conscientiously. And such clear orders do not just apply to the sale of conventional drugs. When selling homeopathic or other alternative remedies, a pharmacist’s role is fundamentally the same.
Considering these facts, what choices do pharmacists have, if they elect to – or, if they are employed in chain pharmacies, have to – sell homeopathic or other disproven treatments? They could, of course, inform their customers honestly that these remedies are nothing more than placebos. This would probably deter all but a few from the purchase which hardly seems in the interest of the pharmacists or their employer. Alternatively, pharmacists might keep quiet about the evidence thinking “if the client wants it, she should have it”. This stance is prevalent today but, as it fails to provide the relevant information about the product in question, it clearly violates the pharmacists’ very own ethical code and standards. The only other option would be to stop selling disproven treatments altogether. It is not hard to imagine that this possibility might be unattractive; for some pharmacists, it would just mean earning less money, however, to the many UK pharmacists who are employed by large co-operations, such as Boots, it would mean taking a stand against co-operate policy and perhaps even losing their job in the course of doing so.
What is the solution to this conundrum? I do not pretend to know it, but I feel that pharmacists ought to find it sooner rather than later. As this profession is hoping to take on more responsibility in clinical care, their attitude towards selling disproven remedies should be clarified. Are they shopkeepers or healthcare professionals? Are corporate interests more important than professional ethics? These are not merely questions of professionalism, ethics and honesty but, more importantly, they are questions of patient welfare and public health.