Are pharmacists just shopkeepers?

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.

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0 Responses to Are pharmacists just shopkeepers?

  1. JDM says:

    Pharmacies are two shops in one. In front of the heavily-regulated professional is the shop floor. This stocks all the unregulated crap local people expect to be able to buy: shampoo, perfumes, witches’ potions and the completely ineffective cough mixture that you probably have at home and swear by. The one that is sugar and cherry flavouring with a pinch of bitter placebo thrown in.

    Behind the pharmacist is the stuff you can’t just grab and buy. That’s the proper shop. Where the methadone is quite carefully dispensed. Where drug doses are confirmed with the GP who prescribed them to prevent an accidental death. A good deal of the stuff protected here is probably rubbish therapeutically too, it should be noted.

    You wouldn’t *not* buy a petrol station’s petrol because their forecourt flowers are rubbish, would you? Really? They’re crap flowers, but they suit someone’s purposes. They wouldn’t be on sale otherwise.

    Perhaps you could try talking to your local pharmacist about their business model, rather than blithely criticising them?

  2. edzard ernst says:

    I did talk to pharmacists, employed some in my team and often gave lectures for them.Also, i was not talking of a business model, I was alluding to ethics {not a county in SW England, you know!}

  3. CSH says:

    I don’t believe that this is an ethical problem in the slightest. Many people WANT to try homeopathic or herbal remedies first. I have never seen a pharmacist in practice recommend any of these products, however. Often, in fact I would say at least 98% of the time, a pharmacist does explain to the patient that those types of products don’t really work. So long as the pharmacist gives a professional opinion and doesn’t put a patient at risk by allowing him/her to buy a homeopathic product, I see no ethical dilemma.

  4. houston, tx says:

    From the USA here. As a Pharmacist, I have no say in what gets stocked outside the pharmacy counters. That is all for pure profit. Ask any pharmacist worth his salt, we are taught about homeopathic remedies and how not to believe any of what they say until they have gone through actual clinical trials and hopefully been FDA approved – in that case they wouldn’t be considered homeopathic remedies anyways. I never steer my patients down that path if I can help it. Obviously some pharmacists might just want to make a sale so they will tell the patient to go ahead and try it but most pharmacists I know let the patient know the good and the bad so they can make an informed decision. Who am I to tell a dying cancer patient that they shouldn’t take homeopathic meds even though they have just been through radiation, chemo, and surgery only to find out that their cancer has still metastasized. Your article brings up some decent points about how homeopathic meds aren’t regulated but don’t generalize pharmacists to be ‘shopkeepers’.

  5. Nadja says:

    You lost me at “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”. Have you any idea what you’re talking about? A concentration is a concentration–it does not imply a volume (and “the distance between the sun and the earth” is a distance, not a volume) unless the amount of solute has been stated. I suspect that you don’t know what you’re talking about.

    Also, pharmacists are highly trained and we can definitely trust many of them. Don’t judge them by what is in front of the counter–their kingdom is behind the counter, where they are mixing your medications and double-checking drug interactions. Maybe if you ask nicely, your pharmacist will explain to you what a C30 dilution is.

  6. Nadja says:

    I have returned with some math. Assuming that a C30 dilution means 1 molecule of solute per (10^60) molecules solvent, and assuming that the “pill” is a sphere, the radius of the “pill” is about 48,000,000,000 meters, or about 1/3 of the distance between the sun and the moon (150,000,000,000 meters). It is correct to say that it is extremely unlikely that the C30 pills contain anything other than water (homeopathy says that you don’t actually need the contaminant because its presence and character is ‘imprinted’ on water molecules…).

    I stand by what I said though: “pharmacists are highly trained and we can definitely trust many of them. Don’t judge them by what is in front of the counter–their kingdom is behind the counter, where they are mixing your medications and double-checking drug interactions.”

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