Earlier this year I wrote a post (along with fellow Sciblogger Grant) concerning the sale of homeopathic remedies in pharmacies. Monday night saw the release of England’s Science and Technology Committee’s “Evidence Check 2″ report on Homeopathy (also ably covered by Grant). One of the issues covered by the report is that of pharmacy responsibilities regarding sale of these remedies. Essentially the report recommended that sales continue but with adequate disclaimers stating that there is no scientific evidence that homeopathic products work beyond the placebo effect.
I see this as a compromise between commercial freedom to sell safe, though not necessarily effective, products and patient informed consent. It’s reasonable even if I disagree that it is ideal. Regardless, I thought it was a good excuse to look once again at our own pharmacies and see how the selling of scientifically unsupported remedies aligns with their professional responsibilities.
Enquiring into this area I was directed to the Pharmacy Council Code of Ethics for pharmacists. The Pharmacy Council seems to fill the function of professional association and regulatory body for pharmacists their functions including:
prescribe the qualifications required for scopes of practice within the profession, and, for that purpose, to accredit and monitor educational institutions and degrees, courses of studies, or programmes
consider the cases of health practitioners who may be unable to perform the functions required for the practice of the profession
Perusing the Code of Ethics (which may be found Here) I found a number of sections that I feel should preclude pharmacists from selling homeopathic remedies in good conscience. In order to try and represent the spirit of the code as accurately as possible I have included here both the relevant over-arching Principles that pharmacists should strive for as well as the Specific Obligations that I feel make my point (any emphases are mine).
The first principle is one of patient autonomy:
Principle 1: Autonomy
The pharmacist shall promote patient
self-determination, respecting the
patient’s right to understandable
information, privacy, and confidentiality
1.4 Professional services
Where the patient is seeking or receiving, from the
pharmacist or from other personnel for whom he or
she has responsibility, any professional service or
intervention, the pharmacist must ensure that the
patient is provided with credible, understandable
information about reasonably expected results,
outcomes or effects of the service or intervention, any
risks of receiving the service or intervention, and any
insufficiency of evidence about the efficacy of the
service or intervention, to allow the patient to make
an informed choice.
This to my reading implies that should pharmacists sell homeopathic remedies they are obligated to inform the patient of the lack of scientific underpinnings for the use of the remedy. One of the objections I have run into regarding the sale of these remedies in pharmacies is that they are commercial enterprises and are within their rights to sell products regardless of their medicinal value. This is partially true but these remedies are specifically sold to treat symptoms, not as entertainment, confection or cosmetic. The Code has several entries covering this aspect the first of which is:
1.5 Independent information
The pharmacist must ensure that their advice is
independent of personal commercial considerations.
Does this not imply that the sale of unscientific medicines should not be undertaken simply because it make financial sense? We will return to this point later.
The next Principle covers patient needs:
Principle 2: Beneficence
The pharmacist shall optimise medicines
related health outcomes for the patient
according to their concerns, needs,
cultural values and beliefs
2.2 Quality use of medicines
The pharmacist must provide scientifically-based,
unbiased medicines information to healthcare
providers, patients and the community in order to
optimise medicines related health outcomes.
My reading of this point leads me to understand that any information provided regarding pharmacy products must have scientific backing and moreover must not be biased by the pharmacist’s own views. Any such information regarding homeopathy must therefore be negative.
But, what if the pharmacist is not asked for this information? After all, I do not usually go in asking for a lecture if I already think I know what I need. I think the next obligation covers this instance:
2.8 Involvement in sale of medicines and other
The pharmacist must be involved and intervene in the
sale of any medicine, complementary therapy, herbal
remedy or other healthcare product whenever this is
necessary to ensure a reasonable standard of
Scientifically speaking homeopathy should not be considered to encompass a “reasonable standard of pharmaceutical care”.
The next Principle of relevance concerns fairness:
Principle 4: Justice
The pharmacist shall practise fairly and
justly and promote family, whanau and
4.4 Commercial interests not to override good
The pharmacist must ensure that commercial interests
are not permitted either to override the independent
exercise of their own professional judgement on
behalf of a patient or to compromise the standard of
care provided by them or to affect their cooperation
with other healthcare providers.
Once again the issue of financial gain over patient care is addressed with commercial interests coming off second best when the standard of care is concerned.
The next Principle is one I feel is of especial importance when the reputation of pharmacists in the wider community is considered and their self representation in the media is a factor (remember, they’re the health professional you see most often). This is trustworthiness, pharmacists are seen as, and promote themselves as, first and foremost medical professionals not business interests. The sale of homeopathic medicines is antithetical to this position and undermines their credibility in this regard, in direct contraction to the Code of Ethics as follows:
Principle 7: Trustworthiness
The pharmacist shall act in a manner
that promotes public trust in the
knowledge and ability of pharmacists
and enhances the reputation of the
7.7 Non-medical goods and services
The pharmacist must not purchase or sell from a
pharmacy any product or service which may be
detrimental to the good standing of the profession or bring the profession into disrepute.
If the sale of scientifically worthless remedies such as homeopthy does not do this I don’t know what would, perhaps offering Therapeutic Touch?
Finally the Principle of dignity undermines the pharmacist’s sale of unsupported medicines:
Principle 8: Dignity
The pharmacist shall provide
information about professional services,
medicines and healthcare products in a
dignified manner without making
exaggerated or unsubstantiated claims
8.4 Medicines not ordinary articles of
A pharmacist must only participate in promotional
methods that do not encourage the public to equate
medicines with ordinary articles of commerce.
If the previous examples of why remedies should not be sold with the sole purpose of earning money for the pharmacist this should put that argument to rest. The sale of medicines (which many people consider homeopathy to be) should not be equated with ordinary articles of commerce. This puts the lie to arguing that these remedies are simply another commodity to be bought and sold like chewing gum regardless of therapeutic value.
8.8 Evidence of efficacy
The pharmacist must only promote to a potential
purchaser that any medicine, complementary therapy,
herbal remedy or other healthcare product associated
with the maintenance of health is efficacious when
there is credible evidence of efficacy.
This last obligation explicitly refers to promotion of a therapy to a patient by the pharmacist which I don’t think any reputable pharmacist would do for homeopathy but arguably the presence of the product in the store constitutes an implicit promotion of it to potential customers. This point goes back to the principle of trustworthiness, the public trusts the pharmacist to stock efficacious products. To include unscientific therapies among their wares undermines and betrays this trust. Perhaps I am naive to think so but I think the Pharmacy Council’s own Code of Ethics backs me up when I say that we should hold pharmacists to a higher standard than your average shop owner.