The tension between the “business of pharmacy” and the professional responsibilities of pharmacists, as health care professionals, has always been present in retail (“community”) pharmacy practice. For much of the past several decades, pharmacies have generally been owned by pharmacists, elevating pharmacy ethics and professional responsibilities to the level of the owner. But the era of the independent pharmacist-owner-operated pharmacy is disappearing, and the era of the massive pharmacy chain is upon us. In the United States, CVS and Walgreens command 50% of the retail pharmacy business in major cities. In Canada, Shoppers Drug Mart has been purchased by the grocery giant Loblaw, and the Rexall chain has been purchased by American giant McKesson. And in the United Kingdom, retail pharmacy chain Boots has about 25% of pharmacy market share.
With this retail consolidation, are we seeing a decline in the autonomy of the front-line pharmacist? A scathing series of articles in The Guardian is raising questions about whether pharmacy giant Boots is putting a drive for profits ahead of safe and appropriate pharmacy care. And pharmacists are speaking up. Continue reading
Very excited to announce that a paper I collaborated on with Dr. Chris MacDonald has now been published in the peer-reviewed journal Bioethics, as part of a series on complementary and alternative medicine. It’s also open access (for now):
Is it ethical to market complementary and alternative medicines? Complementary and alternative medicines (CAM) are medical products and services outside the mainstream of medical practice. But they are not just medicines (or supposed medicines) offered and provided for the prevention and treatment of illness. They are also products and services – things offered for sale in the marketplace. Most discussion of the ethics of CAM has focused on bioethical issues – issues having to do with therapeutic value, and the relationship between patients and those purveyors of CAM. This article aims instead to consider CAM from the perspective of commercial ethics. That is, we consider the ethics not of prescribing or administering CAM (activities most closely associated with health professionals) but the ethics of selling CAM.
The full paper is here.
Macdonald, C. and Gavura, S. (2016), Alternative Medicine and the Ethics Of Commerce. Bioethics, 30: 77–84. doi: 10.1111/bioe.12226
Can you spot the sugar pills among the medicine?
Retail pharmacies have a sugar pill problem. Homeopathic “remedies” look like conventional medicine when they’re stocked on pharmacy shelves, like the photo above. But unlike conventional medicine, homeopathic products don’t contain any “medicine” at all. They are effectively and sometimes literally sugar pills – placebos. Not surprisingly, there is convincing evidence to show that homeopathy is useless as a medical treatment, and fundamentally incompatible with a scientific understanding of medicine, biochemistry and even physics. Questions have been raised worldwide about the ethics of pharmacists and pharmacies selling homeopathy to consumers who may not realize what they’re buying. This practice, which appears to be growing, is attracting sharp criticism from other health professions. So why do pharmacies sell them? And will the pharmacy profession change? Continue reading
Jimmy Wales, the cofounder of Wikipedia, was given some bad advice by a pharmacy:
Last week I was in a pharmacy (chemist) in London just around the corner from my apartment there. I had a sore throat and cough and wanted to buy some soothing cough drops. I did, buying a brand that contains benzocaine. These work.
The clerk tried to sell me something else, Oscillococcinum. He said that this is a French homeopathic remedy, which told me all that I need to know: homeopathy is a proven fraud. But he went on to give some “scientific” details – if I took Oscillococcinum it would disrupt the DNA of the virus before it could make me ill.
Well, that kind of lie is what makes me ill.
I hope it wasn’t a pharmacist, because if they gave that kind of advice, they should lose their licence to practice. Wales continues:
Oscillococcinum is a complete hoax product. The method of production is to take an extract of duck liver and heart and dilute it in a 1:100 ratio with water, and to do that dilution over and over, 200 times. Wikipedia, in the article I linked up above, eloquently explains what this means: “Mathematically, in order to have a reasonable chance to obtain one molecule of the original extract, the patient would have to consume an amount of the remedy roughly 10^321 times the number of atoms in the observable universe.”
When people are told that Oscillococcinum can disrupt the DNA of the flu, they may very well choose not to have a flu vaccine.
What I want to know is this: why is this legal? Or, if it is not legal, then what can be done about it? I’m quite sure that the clerk himself had no direct financial interest in defrauding me, and likely didn’t even know he was doing it.
He’s absolutely right. There is no convincing evidence that Oscilliococcinum is anything more than a placebo. The final product is simple lactose and sucrose. Wales finishes with an appeal and is inviting comments:
Who should I talk to about this in order to encourage the creation of a campaign to stop this? This is not my primary area of interest and so I am not the right person to lead it myself. But I would like to help.
Do pharmacies care that they’re selling sugar pills and calling them medicine? Judging by this sign I spotted at a local pharmacy, I don’t think so.
Placebos as Medicine: The Ethics of Homeopathy
Dilutions of Grandeur: It’s World Homeopathy Awareness Week
The consequences of legitimizing nonsense
Do pharmacy regulators “get” homeopathy?
Smarties: As effective as homeopathy
For a blog established to examine the role of science in pharmacy practice, I’ve given a disproportionate amount of attention to homeopathy. Which is frustrating, because homeopathy is not something that pharmacists, or the pharmacy profession, should even need to discuss. Unlike herbal remedies, and some supplements, there isn’t even any science to discuss. As pseudoscience goes, homeopathy is the worst of the worst – it is a belief system, nothing more. If homeopathy actually worked as claimed, it would mean that all we know about biology, biochemistry, pharmacology, and toxicology was wrong. Not a little wrong, but completely wrong. Which would then mean that all we know about science-based medicine is wrong.
In short, homeopathy is an elaborate placebo system, based on the idea that “like cures like” (which is simply a form of magical thinking) involving successive dilutions of products in water, like Berlin Wall, “Mobile Phone (900mHz)“, and even the light reflecting off Saturn. These substances are believed to have medicinal effects, and the dilutions are believed to increase, not decrease, the potency of the final product. But the dilutions in homeopathy are so great you’re not even getting any Berlin Wall. Think of putting one drop of a substance into a container of water. Only that container is 131 light-years in diameter. That’s the “30C” dilution. Homeopaths believe that the water molecules retains a “memory” of the original substance (while conveniently forgetting all the other products it has come in contact with.) The final remedy is diluted so so completely that most products on store shelves don’t contain a single molecule of the ingredient listed on the label. After all that dilution, the water is dripped on tablets of sucrose and lactose: They are, as a final product, sugar pills. Chemically indistinguishable, and as medicinal as a box of Smarties.
Not surprisingly, a review of clinical trials, when you control for biases, confirms what grade-school numeracy and scientific literacy would suggest – homeopathic products are no more effective than a comparable placebo. Yet frustratingly, regulators in Canada and in other countries have given legitimacy to homeopathy by registering both the medication and their purveyors – risking the perception that homeopathy may in fact offer medicinal value. And whether it’s due to ignorance of homeopathy, or indifference to the unfounded ideas of “alternative” health, legitimate health professionals continue to give a pass to homeopathy, taking a “What’s the harm” attitude. Yet harms can result: Continue reading
Imagine your pharmacy features a blood pressure measurement device. It has never worked correctly. Sometimes it give incorrect high results, suggesting hypertension. In other patients it misses hypertension completely. You’ve been advised by hypertension experts that this particular model isn’t accurate and shouldn’t be offered to consumers. Despite this, you continue to promote it to your patients, and you use the test results to recommend supplements to treat conditions that may or may not not exist.
Does this meet the professional standards expected for pharmacists? From an ethical perspective, does it respect patient autonomy? My sense is that consumers, ethicists, regulators, and other health professionals would say “no”. Pharmacists have an ethical and professional responsibility to base advice on the best scientific evidence – in this case, to ensure that a service being offered is reliable, accurate, and relevant for making health decisions.
That’s why I’m surprised to see Canadian and American pharmacies are now selling IgG food intolerance tests. Because if you agree that knowingly offering faulty blood pressure measurement tests is unacceptable, you should have just as much concern about food intolerance blood tests. These tests have been available for some time in the United Kingdom. Now they’re in North America. Rexall, the Canadian pharmacy chain, recently started selling the “Hemocode” test which is purported to test for 250 food intolerances: Continue reading
For those interested, I recently spoke with Karen Stollznow for the Point of Inquiry podcast. What is Point of Inquiry?
Point of Inquiry is the premier podcast of the Center for Inquiry, drawing on CFI’s relationship with the leading minds of the day including Nobel Prize-winning scientists, public intellectuals, social critics and thinkers, and renowned entertainers. Each episode combines incisive interviews, features and commentary focusing on CFI’s issues: religion, human values and the borderlands of science.
This discussion focused on the role of the pharmacist and the need for science-based pharmacy practice. We touched on a lot of issues including the changing role of the pharmacist, the ethical responsibilities of pharmacists when it comes to products like homeopathy, what compounding pharmacies do, what generic drugs are, what an expiry date means, what pharmacists think about vitamins and other supplements, and more. You can listen to the podcast here.