Edzard Ernst published an excellent editorial today addressing the question of why pharmacists sell bogus products. Our own resident pharmacist, Scott Gavura, expressed similar points here on SBM a year ago. Their points are worth emphasizing and expanding upon.
Professional ethics
The explicit premise of both editorials is that pharmacists, like physicians, are health care professionals. Being a professional means adhering to certain professional standard of quality control and ethical behavior. A profession is essentially a contract with society – the profession gets exclusive rights to certain commercial behaviors, and in return promises to maintain adequate quality control and to act in the best interests of society and their individual clients.
When a profession puts their own commercial interests ahead of society or their individual customers, they have violated that contract.
There are multiple layers of regulation to maintain quality and ethical standards in the health care professions. Once a profession is licensed, they basically self-regulate, with members of the profession establishing the standard of care. Standardized testing designed by the profession is used to establish competence or specialized expertise.
In the US, the states largely have the power to license and regulate professionals. States have boards of health that set ethical standards and will investigate professionals who may have violated either the standard of care or those ethical standards.
Institutions also provide a layer of quality control, by hiring or granting privileges to professionals. The last line of defense is the law; when all the other layers fail a patient or customer can always sue for malpractice.
Some professionals are salaried and work for an institution or the government, but in the US many are private, which means they are essentially shopkeepers as well as professionals. Many pharmacists fall into this category. Often pharmacists work for large chains and so they do not have direct control over what their shop sells, but that does not alleviate them of their professional responsibilities.
Selling snakeoil
For over-the-counter (OTC) products, the pharmacist is the only professional with whom a client may interact. By definition you do not need a prescription or to have seen a doctor in order to obtain an OTC drug or health product. In this case the pharmacist might be the primary or only source of health care advice.
The American Pharmacist Association (APA) recognizes this role:
You should also check with your pharmacist before taking any nonprescription medication. Even though they do not require a physician’s prescription, nonprescription medicines are powerful and can, if taken improperly, adversely interact with your prescription medications or badly affect another health condition.
The unfortunate fact is that the FDA does not have the power, or in some cases the desire, to properly regulate all health care products. Homeopathic products are sold as drugs. Supplements are sold with implied health claims but without any requirement for evidence of efficacy or even safety. There are also a large number of non-ingested products, like magnetic insoles or copper bracelets, that are sold in pharmacies with health claims.
The APA code of conduct states:
A pharmacist has a duty to tell the truth and to act with conviction of conscience. A pharmacist avoids discriminatory practices, behavior or work conditions that impair professional judgment, and actions that compromise dedication to the best interests of patients.
They do not specifically address selling products that do not work, but I think that is implied in the above statement. The Pharmaceutical Society of Australia is more explicit:
Our position is that pharmacists must use their professional judgement to prevent the supply of products with evidence of no effect.
And the Chief Scientist of the UK Royal Pharmaceutical Society, Professor Jayne Lawrence, was also more direct:
The public have a right to expect pharmacists and other health professionals to be open and honest about the effectiveness and limitations of treatments. Surely it is now the time for pharmacists to cast homeopathy from the shelves and focus on scientifically based treatments backed by clear clinical evidence.
The APA should add to their code of conduct a similar statement, specifically stating that it is their duty not to sell ineffective products with false health claims.
What is clear, regardless of the specific language used, is that selling snake oil or bogus products is a violation of the pharmacist professional ethics. Homeopathic and herbal product sales in the US reached $6.4 billion in 2013.
Edzard provided an excellent review of why pharmacists might knowingly sell ineffective products – they believe the products work (unlikely given their expertise), they defer to client autonomy, they use their sale as an opportunity to educate their customers, they do not have control over their corporate masters, and they are putting profits ahead of ethics. All but the last reason does not hold up to scrutiny.
Call to action
Clearly the pharmacist profession needs a wake-up call. That is why I would like to add my voice (and I’m sure I am joined by all my SBM colleagues) to Edzard and Scott in detailing the professional failure of pharmacists, as a group, to meet their own ethical standards of putting their patients and society before their own commercial interests.
This problem exists in all professions, and I do not mean to imply that it is unique to pharmacists or to unfairly single them out. We are equally critical of the failure of any health care professions to meet standards of quality and ethics. It’s just the pharmacists’ turn today.
For pharmacists there is also a very simple and clear course of action that they can take. Just stop selling health care products that have no evidence of efficacy or evidence of lack of efficacy. Stop selling products that don’t work, can’t work, or are unproven to work.
This means a refusal to sell any homeopathic product. If you work for a large corporate pharmacy chain, that still does not obligate you to violate your professional ethics, and you should express your position up the corporate chain. If pharmacists as a profession refused to sell homeopathy, big pharmacy chains would have no choice but to drop the products.
Failure to take such a stand is interpreted by the public as endorsement. Most people believe that pharmacists would not be selling homeopathic products alongside actual drugs if they were nothing but snake oil. Failure to oppose the sale of snake oil is implicit acceptance.
This would also send a huge message to the public. Professionals and academics need to take a stand for a high standard of science within health care. Otherwise we are just shopkeepers, or worse, witchdoctors.
