Homeopathy: To sell or not to sell? Pharmacists weigh in

Homeopathy is nonreturnable

Homeopathy is a popular topic here at Science-Based Pharmacy. I’ve blogged before on the ethics of the provision of these products, and argued pharmacists have an ethical responsibility not to sell, promote, or encourage the sale or use of homeopathy. It’s a question that has been put to pharmacists before. So I was I was interested to see the UK pharmacy publication Chemist and Druggist recently asked their readers about the ethics of the sale of homeopathy, setting up the scenario as follows:

You are working as a locum in a busy high street pharmacy. A customer comes in and asks about “non-drug” treatments for hayfever. The customer says she “doesn’t trust” pharmacy products and asks if you have any homeopathic remedies. The store does stock a range of homeopathic treatments, but you know they are not considered medicines by the RPS. What should you do?

I was hoping to see a discussion from pharmacists on how they’d approach a description of the products (most don’t contain a single molecule of the listed ingredient) and their efficacy (no effects beyond that of placebo) with some science-based (and perhaps non-drug) measures for allergy management. Here are some of the supportive responses:

As a pharmacist and a qualified homeopath, with experience in both conventional and natural medicine, I would be happy to recommend homeopathic remedies for hayfever.

Unfortunately, we need to realise it is not what we believe that matters, but in order that patients can have confidence in us, we need to listen to them rather than preach. There are occasions where it might be appropriate to pompously proclaim how clever we are and how important science is, but hayfever is unlikely to be one of them.

I don’t really want to fight with you guys over whether or not homeopathy works. But the evidence (facultyofhomeopathy.org/ research/rcts_in_homeopathy) is much more positive than most of you are saying. Please look for yourself and make your decision. Or if you take the Wikipedia conclusion, good luck to you sir.I personally believe that a pharmacist should apply all the things we normally expect with regards to safety and suitability and take patient choice into consideration – not just our own expectation of efficacy.

I realise that often we push what we think the patient should have rather than accept their views. I think dismissing homeopathy etc out of personal disdain is wrong. Remember that most of our little army of OTC products have less evidence than homeopathy in their use, and they still please patients, make us money and help the odd cold out there to boot. Please don’t be one of the holier than thou, I know everything, you’ll take what I tell you to, pharmacists as there are too many of you out there!

The comments were not all in favor: Some argued against their provision and sale:

If you’re attempting to make a case for the efficacy of homeopathy, it would probably be advisable to link to other sources. For example, the Cochrane Collaboration is the ‘gold standard’ organisation for the provision of information about the effectiveness of healthcare. It has published a raft of systematic reviews examining homeopathy, none of which have suggested that it is more effective than placebo.

I do not dismiss homeopathy out of “personal disdain”. I dismiss it because it’s implausible bunkum without a shred of evidence to support its use.

I must say, I find your reply troubling in a couple of aspects. The first of these is the suggestion that adopting an evidence-based approach to the recommendation of treatment(s) for hayfever is “preaching”. The second is the assertion that adopting an evidence-based approach would lead a pharmacist to pomposity and condescension. Patient beliefs and patient choice are obviously important and should be respected, but to recommend overly-expensive sugar pills at the expense of effective treatments is in my humble opinion unethical, in certain circumstances dangerous and also damaging to the professional reputation of pharmacists.

Interestingly, Edzard Ernst was asked to comment on the pharmacists’ responses[PDF], which I’ll quote in its entirety:

A C30 potency of a homeopathic remedy is so dilute that a pill would need to have roughly the diameter of the distance between the Earth and the Sun (1.48 x 10^11 metres) to contain a single molecule of active substance. The totality of the around 200 clinical trials of homeopathy fails to show that homeopathic remedies differ from placebos. Thus homeopathy is biologically implausible and clinically disproven. According to the General Pharmaceutical Council’s (GPhC) standards of conduct, ethics and performance, UK pharmacists must “be honest and trustworthy”. In particular, they “must explain the options available to patients and the public, including the risks and benefits, to help them make informed decisions [and] make sure the information [they] give is impartial, relevant and up to date”.
This leaves UK pharmacists essentially only two choices. They can sell homeopathic products and violate their own ethical standards, or they comply with their ethical code by being honest and providing the relevant information to their customers. The latter would mean telling them that the remedy contains no active material and has no effects. In this case, very few customers would buy the product.

The code makes it clear that patients’ safety is paramount. Selling products that are not demonstrably effective gives them undue credence. This can seriously jeopardise patients’ safety. Consumers will think that, as these products are for sale in pharmacies, they are evidence-based. Thus they may use them for treating serious conditions which obviously would do harm.

In conclusion, the sale in pharmacies of homeopathic remedies – and other alternative treatments that are unproven or disproven – is unethical. The GPhC’s standards of conduct could hardly be clearer when stating that “your conduct will be judged against the standards and failure to comply could put your registration at risk”.

The response from the legal and ethical lead of the Royal Pharmaceutical Society was less specific, and did not rule out their sale:

We would advise pharmacists who are approached by customers enquiring about homeopathic preparations to take the opportunity to talk to the patient about their health issues to establish any underlying problems which may need referral, and to assist patients in making an informed decision by providing necessary and relevant information, particularly regarding the lack of clinical evidence to support the efficacy of the homeopathic preparation. We would also recommend that homeopathic preparations are only sold if they are being used for a minor or self-limiting condition, and never to treat or prevent a serious condition. Naturally the pharmacist should only supply a product where they are satisfied that it is safe and a preparation that has been sourced from a reputable supplier. For this specific scenario it would be worth exploring the reasons behind the customer’s aversion to ‘drug’ treatments to discuss why there is a ‘distrust’ of conventional medicines.

The pharmacy sale of homeopathy, particularly when products are place beside real medications on pharmacy shelves, abuses the trust placed in the pharmacy profession, a sentiment perfectly reflected in a recent XKCD comic:

I just noticed CVS has started stocking homeopathic pills on the same shelves with–and labeled similarly to–their actual medicine. Telling someone who trusts you that you’re giving them medicine, when you know you’re not, because you want their money, isn’t just lying–it’s like an example you’d make up if you had to illustrate for a child why lying is wrong.

Emphasis added.