MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Recently, I have been invited by the final year pharmacy students of the ‘SWISS FEDERAL INSTITUTE OF TECHNOLOGY ZURICH‘ to discuss alternative medicine with them. The aspect I was keen to debate was the issue of retail-pharmacists selling medicines which are unproven or even disproven. Using the example of homeopathic remedies, I asked them how many might, when working as retail-pharmacists, sell such products. About half of them admitted that they would do this. In real life, this figure is probably closer to 100%, and this discrepancy may well be a reflection of the idealism of the students, still largely untouched by the realities of retail-pharmacy.

In our discussions, we also explored the reasons why retail-pharmacists might offer unproven or disproven medicines like homeopathic remedies to their customers. The ethical codes of pharmacists across the world quite clearly prohibit this – but, during the discussions, we all realised that the moral high ground is not easily defended against the necessity of making a living. So, what are the possible motivations for pharmacists to sell bogus medicines?

One reason would be that they are convinced of their efficacy. Whenever I talk to pharmacists, I do not get the impression that many of them believe in homeopathy. During their training, they are taught the facts about homeopathy which clearly do not support the notion of efficacy. If some pharmacists nevertheless were convinced of the efficacy of homeopathy, they would obviously not be well informed and thus find themselves in conflict with their duty to practice according to the current best evidence. On reflection therefore, strong positive belief can probably be discarded as a prominent reason for pharmacists selling bogus medicines like homeopathic remedies.

Another common argument is the notion that, because patients want such products, pharmacists must offer them. When considering it, the tension between the ethical duties as a health care professional and the commercial pressures of a shop-keeper becomes painfully obvious. For a shop-keeper, it may be perfectly fine to offer all products which might customers want. For a heath care professional, however, this is not necessarily true. The ethical codes of pharmacists make it perfectly clear that the sale of unproven or disproven medicines is not ethical. Therefore, this often cited notion may well be what pharmacists feel, but it does not seem to be a valid excuse for selling bogus medicines.

A variation of this theme is the argument that, if patients were unable to buy homeopathic remedies for self-limiting conditions which do not really require treatment at all, they would only obtain more harmful drugs. The notion here is that it might be better to sell harmless homeopathic placebos in order to avoid the side-effects of real but non-indicated medicines. In my view, this argument does not hold water: if no (drug) treatment is indicated, professionals have a duty to explain this to their patients. In this sector of health care, a smaller evil cannot easily be justified by avoiding a bigger one; on the contrary, we should always thrive for the optimal course of action, and if this means reassurance that no medical treatment is needed, so be it.

An all too obvious reason for selling bogus medicines is the undeniable fact that pharmacists earn money by doing so. There clearly is a conflict of interest here, whether pharmacists want to admit it or not – and mostly they fail to do so or play down this motivation in their decision to sell bogus medicines.

Often I hear from pharmacists working in large chain pharmacies like Boots that they have no influence whatsoever over the range of products on sale. This perception mat well be true. But equally true is the fact that no health care professional can be forced to do things which violate their code of ethics. If Boots insists on selling bogus medicines, it is up to individual pharmacists and their professional organisations to change this situation by protesting against such unethical malpractice. In my view, the argument is therefore not convincing and certainly does not provide an excuse in the long-term.

While discussing with the Swiss pharmacy students, I was made aware of yet another reason for selling bogus medicines in pharmacies. Some pharmacists might feel that stocking such products provides an opportunity for talking to patients and informing them about the evidence related to the remedy they were about to buy. This might dissuade them from purchasing it and could persuade them to get something that is effective instead. In this case, the pharmacist would merely offer the bogus medicine in order to advise customers against employing it. This strategy might well be an ethical way out of the dilemma; however, I doubt that this strategy is common practice with many pharmacists today.

With all this, we should keep in mind that there are many shades of grey between the black and white of the two extreme attitudes towards bogus medicines. There is clearly a difference whether pharmacists actively encourage their customers to buy bogus treatments (in the way it often happens in France, for instance), or whether they merely stock such products and, where possible, offer responsible, evidence-based advise to people who are tempted to buy them.

At the end of the lively but fruitful discussion with the Swiss students I felt optimistic: perhaps the days when pharmacists were the snake-oil salesmen of the modern era are counted?

46 Responses to Why do pharmacists sell bogus medicines?

  • Dear Professor Ernst
    I can’t believe a man of your experience and eminence is writing in such an unprofessional way.

    As you know the majority of homeopathic remedies are medicines in law because many are made from poisons and a significant number sold contain material doses, so are regulated in the same was as any pharmaceutical drug. This includes rigorous raw material testing and quality control procedures, of pharmaceutical industry standard, to which homeopathic products are subject to ensure products are genuine.

    You use the term ‘snake oil’ and repeated use of the word ‘bogus’. Ten times in this post. This implies they are counterfeit or fake which is simply not true. This is also disrespectful to the pharmaceutical profession and the discipline of good manufacturing practice which underpins medicine production. Surely these terms are ‘ad hominems’ which you so rightly criticize when they are applied to yourself.

    Pharmacy ethics states that pharmacists should be trained in the products they sell so if a company chooses to stock homeopathic products sufficient training should be in place for the staff. I find that even if pharmacists have no direct experience of homeopathy some have enough humility to consider there may be a possibility of some phenomena beyond placebo and see positive results with customers on the shop floor with those who choose to use it.
    The action of homeopathically prepared medicines has been observed for over 200 years with materia medica information from experimental provings. Many carried out blind to be later verified by known toxicological data. So if a substance can create symptoms it has a potential use a medicine. Do you honestly think this information is all unreliable and has no place in health care? And what should we do with the hundreds of books of scientific observation of natures laws, cured cases, outcome studies and valuable medical data on which homeopathy is underpinned – throw them out or burn them?
    I met you once in Exeter in the 90s when exploring a possible clinical study. I found you most encouraging and openly enthusiastic about homeopathy. I would go so far as to say I was inspired to go further in homeopathy thanks to you but now you want to close down something which in my experience does so much good in the world. What went wrong?

    • what went wrong?
      the evidence!
      please see the most recent, transparent and thorough report on the subject [http://edzardernst.com/2014/04/the-most-thorough-and-independent-assessment-of-homeopathy-ever/]. it shows that homeopathy is not demonstrably effective for any condition – and such a ‘medicine’ is in my view BOGUS.
      yes, I did change my mind about homeopathy since we met in the 1990s, but doing so in the face of scientific evidence is surely the correct thing to do.
      PS
      I think you forgot to tell the readers of this blog that you are the managing director of HELIOS, one of the larger UK homeopathic pharmacies.

      • Of course Homeopatic products work well on the human body.
        Lets compare the effect of the 4 times daily application of ketoconzole or Acyclovir or miconazole or any other cream mixes containing antibiotics over the lymphatic nodes of the neck, tonsiles and over the sinus cavities, to solve strep throat and severe bronchial problems, on the long run (even with candida or HPV), with the application of homeopatic creams in the same designated areas to solve exactly the same problems.
        Not to speak about resolving UTI and prostate problems with Homeopatic products.
        My experience is that homeopathy works well, if properly dosed.
        ………..
        In India and in China, anyone speaking against homeopatic medicine, is considered an idiot.
        cplts

        • I am not fascinated by your experience – I want to see evidence. do you have any?

        • Antonio Luis Pereira Coutinho said:

          In India and in China, anyone speaking against homeopatic medicine, is considered an idiot.

          What do you think can be done to rectify that appalling situation?

          • “In India and in China, anyone speaking against homeopatic medicine, is considered an idiot”
            may I take the liberty of re-phrasing this sentence?
            ANYONE WHO CLAIMS THAT SOMEONE SPEAKING AGAINST HOMEOPATHIC MEDICINE MIGHT BE AN IDIOT, MUST BE AN IDIOT!
            [and this version is surely closer to the truth, not least because it uses the correct spelling for ‘homeopathic’]

          • Guys, really, he’s referring to acyclovir as an antibiotic. It’s not hard to tell this guy is an idiot.

    • Dear Mr Morgan,

      As Prof. Ernst points out, you are the MD of Helios. Your comments are naturally biased in favour of homeopathy: to be otherwise would be to undermine your whole business. You claim that homeopathy is underpinned by “scientific observation of natures [sic]* laws, cured cases, outcome studies and valuable medical data”. This is not true, robust clinical trials and meta-analyses repeatedly demonstrate so-called homeopathic ‘remedies’ to be, at best, no better than placebo. Prof. Ernst uses the word “bogus” to describe homeopathy, and it is the ideal word. Bogus means “not genuine or true (used in a disapproving manner when deception has been attempted)”. Homeopaths try to deceive people by claiming that their so-called ‘remedies’ work, when all the evidence shows that they don’t. Homeopaths are nothing more than charlatans and snake-oil salesmen.

      “What went wrong?” Nothing went wrong, Prof. Ernst is a scientist, and well-respected expert, who has studied alternative medicine for many years, and, as a result of that study, has found no evidence that homeopathy is in any way effective. Nothing went wrong, Prof. Ernst changed his mind when presented with the facts.

      Homeopathy is a prime example of pseudo-scientific mumbo-jumbo, and should be confined to the dustbin of history.

      Jonathan Mason FRPharmS

      PS *The correct phrase is “nature’s laws”, with an apostrophe to denote the possessive. What exactly do the laws of nature have to do with homeopathy, which flies in the face of those laws?

      • Dear Mr Mason
        Thank you for your thoughtful reply and highlighting nature’s laws.
        I sincerely hope you haven’t come to the ‘mumbo jumbo’ conclusion after extensive study of homeopathic literature. It has a lot to offer the science and art of medicine.

        I can only suggest to you to the book by George Vithoulkas – The Science of Homeopathy if you wanted to look again.
        As for homeopathic medicines, as small doses of poisons, you already know the Arndt Shultz law. ‘For every substance, small doses stimulate, moderate doses inhibit, large doses kill.’

        • Yes, but there are ‘small doses’ and then there are homeopathic doses. You will be aware that, at the dilutions used in most homeopathic products, the chances of finding even a single molecule of any supposedly active substance are astronomically low. Therefore such preparations will not exert any pharmacological effect upon ingestion.

          I have to say that, as a pre-registration pharmacist, I really am quite ashamed that someone who professes to be a member of the RPS endorses something as patently and demonstrably false as homeopathy. I think you should be too.

          Good day.

          • I had hoped that John Morgan would have responded to your comment about ‘small doses’ and homeopathic ones – it might be quite enlightening.

          • Ah, but maybe John Morgan has answered homeopathically. Even now, the piece of paper on which he wrote his answer is being used to prepare a 300C solution, which will be held up to a scanner. And then we will all realize he was right all along, without quite knowing why.

      • What robust clinical trial/meta analysis shows homeopathy is no better than placebo? I could find only one Shang 2005 – and it was discredited afterwards. Other than that every other meta analysis has proven the opposite – i.e. homeopathy is better than placebo. In fact I have found no evidence proving homoepathy doesn’t work.

        • there are about a dozen more; you can start with this article http://www.ncbi.nlm.nih.gov/pubmed/12492603

          • 1. The report is by you.
            2. It does not prove homeopathy does not work.

          • 1) the ‘report’ is a systematic review that summarizes all systematic reviews on the subject most of which are NOT by me. and even if they were all by me, what would that change?
            2) nobody has to prove that a treatment does NOT work, but the onus is on those who promote it that it DOES work.

          • L.H. Olavius said:

            1. The report is by you.

            So?

            2. It does not prove homeopathy does not work.

            Your logical fallacy is Burden of Proof.

        • “Other than that every other meta analysis has proven the opposite – i.e. homeopathy is better than placebo.”

          “Our 1997 meta-analysis has unfortunately been misused by homoeopaths as evidence that their therapy is proven.” Linde & Jonas 2005.

          • 1) You seem to miss all the reports that comes to the opposite conclusion – even on the same page from the link provided by you.

            2) You claim is that it doesn’t work, but you can’t prove it.

            Same goes with a lot of other treatments according to the clinical evidence in BMJ (see link further down). Only 11% of all treatments carries sufficient evidence. Are you calling the remaining 89% bogus medicine and are you saying pharmacies should only sell from the 11% group?

          • 1) like what? please provide examples with links; I am not aware of such ‘reports’.
            2) grow up! proponents need to prove it – until they do, it is classified as unproven.

          • L.H. Olavius said:

            1) You seem to miss all the reports that comes to the opposite conclusion – even on the same page from the link provided by you.

            Which link and what reports? Please be specific.

            2) You claim is that it doesn’t work, but you can’t prove it.

            No. See my previous comment about your logical fallacy.

            Same goes with a lot of other treatments according to the clinical evidence in BMJ (see link further down). Only 11% of all treatments carries sufficient evidence. Are you calling the remaining 89% bogus medicine and are you saying pharmacies should only sell from the 11% group?

            I asked you earlier about this, but never got an answer. Your comment here shows that you do not understand what those bmj figures mean.

            However, even if “Only 11% of all treatments carries sufficient evidence” was, indeed, correct, that would still be 11 percentage points more than the evidence for homeopathy. Unless you can provide good evidence to the contrary, of course…

        • L.H. Olavius said:

          What robust clinical trial/meta analysis shows homeopathy is no better than placebo? I could find only one Shang 2005 – and it was discredited afterwards.

          How was it discredited?

          Other than that every other meta analysis has proven the opposite – i.e. homeopathy is better than placebo.

          Which ones?

          In fact I have found no evidence proving homoepathy doesn’t work.

          Why would you have expected to find any?

          • You have no concern here on you blog writing homeopathy is bogus medicine although you cannot prove it is so.

            Then my question – would you also call that part of conventional medicine without sufficient evidence behind it bogus medicine?

          • I give up! you are either unable or unwilling to understand my responses.

          • …and yes, of course, I would call any medicine bogus that 1) is implausible like homeopathy, 2) for which the most outrageous claims are being made by quasi-religious believers [like homeopathy], and 3) for which the totality of the reliable evidence is as negative as for homeopathy.
            I CANNOT PUT IT MORE PLAINLY THAN THAT…HAVE YOU GOT IT?

          • Edzard said:

            I give up! you are either unable or unwilling to understand my responses.

            I’m sure I can answer that one…

  • Dear Professor Ernst

    In your post you write “The ethical codes of pharmacists across the world quite clearly prohibit this”.
    Can you provide evidence for this. Do you know of any instance where this code has been enforced?

    I have an additional question:
    Do you know of any ethical codes that prohibits physicians to prescribe these medicines? And do you know
    of any instance where that code has been enforced?

    sincerely

    Hans De Loof

    • to list all the ethical codes of pharmacists across the world is a task I gladly leave to others.
      UK doctors are obliged to practice according to best evidence, and I have been twice an expert witness against colleagues who had failed to do so.

      • I should have asked the question more directly:
        Do you want a pharmacist to reply to a patient entering the pharmacy with a prescription for a homeopathic remedy:
        “my ethical code forbids me to sell you this”.

        And to make the question symmetric, if stocking these medicines is against the “code of ethics” there is no need for much expertise in judging your colleagues as the simple fact of writing the prescription is a breach of the code of ethics.

        sincerely
        Hans De Loof

        • 1) this is not what the code requires; it requires however that they say that these remedies are not supported by good evidence
          2) as we are talking about OTC medicines, your 2nd question is nonsensical.

          • Sorry but you are evading the second question: physicians can and do prescribe OTC (homeopathic) products.
            The contents-efficacy does not change by the simple regulatory fact of being OTC (or by being prescribed by a physician).

            In addition i would like you to give one example of an ethical code that “requires however that they say that these remedies are not supported by good evidence”. (even if the patient does not ask any questions, with or without a prescription)

            full disclosure: i would not oppose this being part of an ethical code for pharmacists, i simply ask an example as you state that “The ethical codes of pharmacists across the world quite clearly prohibit this”.

  • I definitely agree with you on many points, and the fact is that a lot of those medications simply aren’t proven to be effective. But a lot of them don’t have poroper studies funded. Why? I discuss these in my post here, http://nikhilthegrizzlybear.blogspot.com.au/2014/04/how-doctors-think-are-doctors-arrogant.html
    but basically, evidence based medicine is great, and should be abided by. But there are a few assumptions it makes too. First off, not everyone is aware of why doctors and pharmacists are told to operate on the basis of evidence, and that’s why integrity is important to maintain. But the whole field itself ignores the fact that some of these things don’t, or can’t have studies done on them. And there are some factors that just can’t be measured in studies too.
    Overall, I agree, pharmacists and doctors should ALWAYS disclose information about the PROVEN efficacy of the products they sell. At the same time though, they should also know there are limitations to the system of evidence based medicine, and sometimes patients may benefit from other things too.

    • That is nonsense. Alternative modalities have been studied ad nauseum in the US by the National Center for Complementary and Alternative Medicine (NCCAM). Nothing has come of it but the waste of millions of dollars and the damage to people who take it seriously and may, as a result, not seek valid treatment.

  • In the states, even when growing up, I wondered about pharmacies. I always went to small pharmacies owned by the pharmacist, as opposed to the chain store pharmacies that now dominate the landscape. I could never understand why they sold cigarettes, something that was known back then to be harmful to one’s health. So if they cell “cancer sticks” why not sell cures of questionable merit (OK, I’m being kind).

    On the bright side CVS in the US is stopping sales of cigarettes. Unfortunately they will continue selling Airborne.

  • The drug store cigarette analogy is a good one. In the UK no newsagent’s store could reasonably hope to survive without selling cigarettes. Morally, there’s a case to be made that any shopkeeper with a conscience should refuse to stock tobacco products. Economically, that approach would bring shopkeepers with a conscience to penury.

    Shops often stock things they don’t particularly wish to sell because they bring in customers who then see and buy other things. The same probably applies (as the OP indicates) to homeopathic products and other “alternative” remedies in pharmacies. I’ve never understood why shops like Boots don’t place a sign above their displays of snake oil saying something along the lines of “The products on this shelf have not been objectively proven to show any therapeutic effects”. In an age when many institutions bend over backwards to cover themselves against litigious customers this would seem to me to be a sensible approach.

    • my newsagent does however not pretend to be an ethical health care professional and does not have a code of ethics to follow.

    • In our part of the world it seems like the prefix “health-” is a magic barrier that protects anyone against liability and responsibility. Even professional pharmacists.
      You can sell whatever muck you can dream up and lie fantastically about its qualities and properties. At least as long it is not listed as hazardous. If only you use this magic prefix in your marketing, no one seems to care whether the stuff really has any validity.

      • Excellent point. Whenever I hear someone talking about various foods being “healthy” and “unhealthy” I often point out that a shipload of the “unhealthy” stuff would save a lot of people from death through starvation in many parts of the world. “Healing” is another medicine-associated weasel word in common currency.

  • In my part of Switzerland (French-speaking), I routinely see pharmacists push at me or other custormers homeopathy and more or less inefficient herbal treatments. I definitively get the impression that they believe in these products. This being said, anecdotal evidence, I never studied the matter systematically. 😉

    Of note, my university has a committee on “complementary medicine”:
    http://www.unil.ch/fbm/page88076.html

  • The amount of rubbish for sale in pharmacies is astounding: homeopathy everywhere, as well as dubious beauty products, herbs and whatnot: I am speaking about the situation in Catalunya. I even know pharmacists who dose their own children with homeopathy – what on earth is going on inside their heads?

  • What are bogus medicine and are you saying that pharmacies should only sell drugs from the 11% percent group?

    http://clinicalevidence.bmj.com/x/set/static/cms/efficacy-categorisations.html

Leave a Reply

Your email address will not be published. Required fields are marked *

Please answer the following: *

Recent Comments

Note that comments can now be edited for up to five minutes after they are first submitted.


Click here for a comprehensive list of recent comments.

Categories