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Alternative medicine

From Professor E. Ernst, FRCP

Our book ‘Trick or treatment? Alternative medicine on trial’, provides careful assessment of the pros and cons of homoeopathy remedies, which are ubiquitously for sale in UK pharmacies. It concludes that they are biologically implausible and that approximately 200 clinical trials have failed to demonstrate effectiveness.

The Royal Pharmaceutical Society’s code of ethics state that if pharmacists sell homoeopathic or herbal medicines, or other complementary therapies, they must assist patients in making informed decisions by providing them with necessary and relevant information.

Pharmacists should, therefore, inform their customers that a homoeopathy remedy is devoid of any biologically active material and it has not been shown to have relevant health effects beyond placebo.

This is currently not happening. On the contrary, customers are frequently misinformed with information, such as promotional material in the pharmacy or verbal advice given by pharmacists, and so pharmacists are breaching their code of ethics on a daily basis.

We call on the Society to take urgent action so that its ethical standards are adhered to.

Edzard Ernst

Peninsula Medical School

Exeter

Alternative Medicine

I have been counter-prescribing Homeopathic Medicines for 30 years and to my knowledge have never harmed anyone. I give everyone a choice when they ask my advice-conventional or homeopathic and I respect their wishes. I also explain if they choose homeopathic treatment that it is unproven but they usually know that or want to know more. I also mix conventional and homeopathic treatment if I think it is appropriate. As to whether it is ethical to act in this manner as a pharmacist, I think it is. However you cannot throw 200 years of knowledge and literature out of the window just because modern testing techniques do not work. I am a believer in God but can anyone prove his existence?

Poor logic

>However you cannot throw 200 years of knowledge and literature out of the window just because modern testing techniques do not work.

Oh yes you can. That's exactly the point of science rather than faith.

>I am a believer in God but can anyone prove his existence?

This is a basic logical error. Beliving something doesn't make it true. Extend your logic to the tooth fairy and you'll see the fatal flaw.

Alternative Medicine

I am sorry to note that you have simplified the word science. Science is an endless effort to find out the truth. Modern Science is nothing other than to describe different things in terms of our education, perception or philosophy and explanation. It should be noted that in course of time we have changed those three things several times.  I think our body is a very mysterious subject. Our current knowledge discovered some processes, some chemicals and their quantity which most of the times give some response for some abnormalities in the body. Mind it, it is not universal. Till today no one can say that he totally unveilled the body mechanisms. So I think we should not discard any belief rather to admire it because this may open a new kind of studies which is still not known to us and ultimately the Science will be enriched.

                Pradyot Biswas

Homeopathy and Professor Ernst

As a profession, we are brought up on scientific principles - we all accept that Boyle's law works, or that gravity pulls things down instead of making them go up, then why do some of our profession refuse to accept that going beyond Avogadro's number in a dilution, renders that solution devoid of any of the original molecules present? "Because water has a memory!!" they say, "..the original molecule has "imprinted" itself in the water and that's how it acts" Prof. Ernst in his book "Trick or Treatment" debunks this, with the tale of Jaques Benaviste and his paper published in Nature, where he seemed to show water had a memory - don't forget that this is the cornerstone of homeopathy, and if it was proved, then it was plain sailing for the homeopaths. The experiment was shown to have operator bias, and thus false. In his book, Prof. Ernst takes a number of alternative therapies and subjects them to analysis, and shows that on the whole, they are false. Where does this leave pharmacists? We are a profession that (I hope) will only accept that which is true, and has been proven in trials, no matter how distastfull they may be to us. It is the concensus of a large body of evidence, eg The Cochrane Collaboration or Bandolier, that gives us the facts that we use in our daily practice. Prof Ernst does the profession of pharmacy a very great service in giving impartial knowledge that we all can use. I would urge fellow pharmacists to go beyond Prof. Ernst's popular scientific works and read some of his scholarly papers, and the true genius of this man shines through. In writing his letter to the Journal, he has opened up a debate that will run and run. Ezard Ernst has said that - in effect - if the evidence proves this alternative therapy to be worng then it is so!! The homeopaths and their fellow travellers in the CAM (Complementary and Alternate Medicine) field seem to operate on the premise of The Bellman, in Lewis Carrols' " The Hunting of the Snark" - "...what i tell you three times is true." However,.... however, I will leave this posting with a parting shot: 1992 saw the hundreth aniversary of Kekules' discovery of the structure of benzene, how he sat in front of his fire and dreamed that the smoke rising was a snake taking hold of it's tail and thus the essential ring structure of aromatic compounds was born, and experimental evidence seemed to prove it was so. The American Chemical Society decided to mark this anniversary with a special meeting to celebrate how far aromatic chemistry had come since Kekule. The meeting ended up in a brawl!! There were chemists there who disagreed with Kekule's structure,the one that we are all familiar with, and put up equally viable (to them) structures of their own and would brook no argument, which lead to fisticuffs. Thus there is always the element of doubt, however small. Remember, only two things in life are certain - death and taxes!! Regards Bob Dunkley

From Mr D. Pruce, MRPharmS

Responding to the article “Is it ethical for pharmacists to sell unproven or disproven medicines” (PJ, 19 July 2008, p75) and Edzard Ernst’s letter “Homoeopathy not evidence-based” (PJ, 19 July 2008, p69), the Royal Pharmaceutical Society would like to clarify its position on homoeopathic medicine.

The Society’s code of ethics and professional standards state that pharmacists should assist patients in making an informed decision, and provide them with the necessary and relevant information that is available. The code does not attempt to define exactly what information should be provided. Until such time when homoeopathic treatments are regulated by the Medicines and Healthcare Products Regulatory Agency (MHRA), the selling of such products is a matter of professional judgement for the individual pharmacist.

Through undergraduate and postgraduate training, pharmacists are taught to apply scientific evidence, which in the case of homoeopathy can be lacking, inconclusive or ambiguous. Pharmacists are also taught clinical judgement based upon the clinical need, choice and belief systems of the individual patient.

Pharmacists endeavour to provide optimal clinical treatment with the minimal adverse effects to their patients and, at the same time, respect the role individual patients plays in deciding upon their own treatment. Rather than argue around any ethical dilemma of the pharmacist we believe it is now time for all homoeopathic medicines to be regulated by the MHRA and the Society welcomes Professor Ernst’s comments in raising this important and unresolved debate.

The Society believes this should now be done on a much wider scale than pharmacy alone, because it is a matter that affects all healthcare practitioners.

David Pruce

Director of Policy and Communications

Royal Pharmaceutical Society

"Through undergraduate and

"Through undergraduate and postgraduate training, pharmacists are taught to apply scientific evidence, which in the case of homoeopathy can be lacking, inconclusive or ambiguous." There is no scientific evidence whatsoever. None. Zero. Why is the Society refusing to state that homoepathy is no better than placebo at best, and responsible for deaths at worst?

Keep homeopathy within the Society- John Morgan MRPharmS

Homeopathic pharmacy has always been part of the Pharmaceutical Society and is an important part of the profession of which it should be proud to continue to embrace. Whilst I understand fully the difficulty for members to accept the nature, action and use of homeopathic products there is nothing unscientific or unethical about their place in pharmacy. Like it or not homeopathic remedies are medicines in law governed by the Medicines Act and a well established European Directive. The manufacture and dispensing of homeopathic medicines is as ethical, precise and as scientific as conventional dispensing. There are official homeopathic pharmacopoeias and the specialist homeopathic pharmacies and manufacturers in the UK are already governed by MHRA manufacturing and specials licences. Homeopathy is still part of the NHS and tens of thousands of NHS prescriptions are being dispensed by UK pharmacists every year. Many pharmacists, who have an interest in homeopathy, have educated themselves or attended courses so their knowledge and expertise can back up customer demand. In fact I believe these members and the specialists provide a service which fully covers the five ethical points Professor Ernst highlights in his article. If more support for CPD is needed, the Society has many knowledgeable and experienced pharmacists who I'm sure would be prepared to help improve its knowledge base. Finally there have been several studies which have proved homeopathy scientifically, just not enough of them. The direct experience of customer satisfaction, and the relief of conditions which conventional drugs have failed to cure, is a source of encouragement for those pharmacists who really want to help people and a very basic freedom of choice it is very important to preserve.

Homeopathic pharmacy has

Homeopathic pharmacy has always been part of the Pharmaceutical Society and is an important part of the profession of which it should be proud to continue to embrace > Why? I want nothing to do with the kind of people who claim that magic water in fancy bottles can treat malaria, or AIDS, or cancer. If homeopathy is an important part of the profession, then it is not a profession I wish to belong to. Homeopathy is still part of the NHS and tens of thousands of NHS prescriptions are being dispensed by UK pharmacists every year. >In other words, about a hundred items a day, across the whole of the UK. Vital stuff that. Finally there have been several studies which have proved homeopathy scientifically, just not enough of them > You're lying. Or mistaken. To use layman's terms, Mr Morgan should put up, or shut up. It is his responsibility to provide evidence for his fanciful claims.

Homeopathy Trials

A summary of homeopathic clinical trials and research projects can be found on the Faculty of Homeopathy web site. http://www.trusthomeopathy.org/case/res_research.h...

Yes, yes, very good. Found

Yes, yes, very good. Found any real evidence yet?

From Mr P. H. Dawson, MRPharmS

In your editorial (PJ, 19 July 2008, p58), why single out homoeopathic products to bear the burden of proof of efficacy?

If over-the-counter products were subjected to a similar demand for evidence of effectiveness in the form and strengths available, pharmacy shelves would be far less crowded, starting with the cough and cold section.

As a community pharmacist, I find it is not always possible to adhere to the code of ethics requiring that I ensure safe and effective use of medicinal products.

Primum non nocere, or “first do no harm”, may be a fine principle for physicians, but for community pharmacists the absence of harm is a tenuous basis on which to promote and sell OTC products.

Peter Dawson

Ilkley, West Yorkshire

From Mr. D. B. Needleman, MRPharmS

Edzard Ernst states there is little or no evidence to support homoeopathy and complementary therapies (PJ, 19 July 2008, p69). There are thousands of trials that show that homoeopathy is better than placebo, but these are ignored.

If it is unethical to supply medicines that have not been scientifically proven, should I refuse to dispense selective serotonin reuptake inhibitors as they have recently been shown to be of no greater value than placebo for mild depression (PJ, 1 March 2008, p235)? And how about aspirin or amoxicillin or other effective drugs that have not been clinically trialled?

D. Needleman

Stanmore, Middlesex

"There are thousands of

"There are thousands of trials that show that homoeopathy is better than placebo, but these are ignored." No, there aren't. Not good quality trials. Go and read the evidence. I assume you're not deliberately lying, but instead misinformed.

From Mr M. E. Q. James, FRPharmS

Is there some inconsistency here? Your leading article (PJ, 19 July 2008, p58) discussed critically the ethics of supplying homoeopathic products. In the same issue you published a letter (PJ, 19 July 2008, p69) and an article (PJ, 19 July 2008, p75) on the subject by Edzard Ernst, both of which could reasonably be said to take a negative view of homoeopathy.

However, on pA8 and pA12 you carried two colour advertisements for books on, respectively, homoeopathic prescribing and homoeopathic practice, both of which are stated to be published by the Pharmaceutical Press.

If pharmacists should consider the ethics of supplying homoeopathic products, surely that extends to the Pharmaceutical Press.

Miall E. James

Colchester, Essex

From Mrs Jyotika Singh, infectious diseases pharmacist

I do support homoeopathy as I am a homoeopathic practitioner myself and have studied for 4 years a degree in homoeopathy and have been practising for 5 years. However as a pharmacists, we are not given the knowledge, tools or understanding about homoeopathy, therefore I do not think it is right for pharmacists to sell something they have no or little knowledge about.

Giving a homoeopathic prescription is something that should not be taken lightly and it is not like giving paracetamol for a headache. There are hundreds if not thousands for prescriptions that could be indicated and therefore a prescription should be chosen carefully.

As to the evidence, well evidence based medicine has only come about recently, whereas homoeopathy has been around for hundreds of years. Even today we do not know how all our drugs work, e.g. the full mechanism of paracetamol is not known, but we know it works.

The two systems of medicine are totally different, like you can't drive a car in water or sail a boat on the road, the two systems will always be different.

I just believe that it is not ethical to sell, as a professional, something that you have no knowledge or understanding about. These medicines should only be sold from outlets where people know about the medicine, and are using it in conjunction with conventional medicines for your well being.

A degree in homoeopathy!

A degree in homoeopathy! That must be worth seeing! Year 1: Learn how to shake vials of water against a book Year 2: Make your "patients" feel special Year 3: Make up evidence. Year 4: Learn excuses for why homoepathy does not work. Mrs. Singh, I know that homoepathy is nothing more than tarted-up water in a fancy bottle. Could you please provide some EVIDENCE of the effectiveness of homoepathy?

Alternative medicines (sic)

By offering for sale homeopathic and other unregulated products the profession offers a legitamacy to this area which it does not deserve. Friendly words are used like "alternative medicine" and "complimentary medicine" which suggests to the consumer that they are purchasing something purporting to be a medication. In the vast majority of cases this is not true. It would be closer to the truth to call them "improbable therapies", thus Prof. Ernst would become Professor of Improbable Therapies! As pharmacists we are trained in the scientific method and condoning improbable therapies in this way is the antithesis of this principle. I am all for informed consumer choice, but the consumers are being misinformed by the fact they are buying these products from pharmacies and not from the local witch-doctor.

Leadership required

It's time the pharmacy profession, led by the RPSGB made a clear statement about homeopathy. Professor Ernst and his colleagues have highlighted the issue and created the opportunity; now would be an excellent time for the RPSGB to release an unequivocal statement about this so called therapy which misleads patients and is only backed up by pseduo science and mystery.

And look, there's some

And look, there's some flying pigs...

From Dr L. R. Kayne, MRPharmS, and Dr S. B. Kayne, FRPharmS

Edzard Ernst’s article “Is it ethical for pharmacists to sell unproven or disproven medicines?” (PJ, 19 July 2008, p75) implies a discussion of all unproven medicines. However, we note that he has omitted to mention those over-the-counter allopathic medicines with no evidence of effectiveness. In fact it is a misleading title for what is just another attack on homoeopathy.

Campaigns to persuade the Medicines and Healthcare products Regulatory Agency and the Veterinary Medicines Directorate not to register homoeopathic medicines under the relevant legislation and to persuade consumers not to use homoeopathy have failed. Professor Ernst is now trying a new strategy in attempting to shut off supply by embroiling the pharmacy profession in the debate. He takes a large number of words to make a simple point. He believes it is unethical for pharmacists to prescribe and sell homoeopathic medicines because, in his view, there is no evidence of positive outcomes.

We, as pharmacists, say it is ethical and there is evidence. Professor Ernst believes there is often a gap as wide as a canyon between homoeopaths’ and non-homoeopaths’ views of what constitutes evidence.1 Would it, therefore, not be more productive to debate the issue of what constitutes evidence rather than cast aspersions on our professional integrity?

Professor Ernst cites two systematic reviews 2,3 and a comparative meta-analysis4 to support his assertion that only negative evidence is worthy of consideration. Both reviews are his and so employ his own evaluation criteria, while the comparative study has been subject to methodological criticism.5,6 Although the latter paper claimed to be based on over 100 homoeopathy studies, the conclusion was based on only eight. Professor Ernst discounts positive evidence, saying that he considered the two articles that he chose to cite “lacked rigour”.

Homoeopathy may be unproven in the view of Professor Ernst and some others, based on scientific principles, but these are not the only measures of effectiveness. Randomised controlled trials (RCTs) are not even the gold standard — merely an accepted standard, until something better comes along. For every article defending the rigour and reliability of RCTs, one finds others raising questions about their utility.7,8 Although many RCTs do exist in homoeopathy,9 the validity of the concept has been questioned.10

Homoeopathic outcomes are widely studied using patient-oriented outcome, measures under so called “field conditions” not under the rigid standardised dose regimens that form part of RCT methodology.11 It is acknowledged that historical case reports and observational studies do not rate highly on the hierarchy of evidence scales but, nonetheless, they provide support for the administration of homoeopathy in a wide range of conditions and form the basis of the limited claims of effectiveness allowed by the MHRA for homoeopathic medicines registered under UK national rules.

To suggest that homoeopathy is provided for profit alone is a slur on the good name of our profession. We know our limits of competency. Patients demand the right to choose how they are treated and are prescribed homoeopathic medicines under the NHS. Are we to abrogate our dispensing responsibilities too?

Lack of evidence and inaccuracies in the article spoil the central argument. Where is Professor Ernst’s evidence for the statement “most UK pharmacies have shelves full with herbal remedies, aromatherapy oils, flower remedies and homoeopathic products”? And what does he mean by the healthy profit we are supposed to be making?

His statement “most of the remedies for sale do not contain a single molecule of what it says on the package” is misleading. Medicines at the 6c potency level certainly do contain molecules of the specified source material. He says “necessary or relevant information is not available in UK pharmacies”. This again is untrue and seems to be based on anecdotal evidence, which is apparently acceptable to the author in this instance.

Professor Ernst should stick to his areas of expertise. We will make our own professional judgements without his unsolicited advice.

Lee Kayne

Pharmacy Dean

Faculty of Homoeopathy

Steven Kayne

Hon Consultant Pharmacist

Glasgow Homoeopathic Hospital

References

1. Ernst E. The Importance of giving a robust evidence base — a personal view. In: Kayne SB, editor. Homoeopathic Practice. London: Pharmaceutical Press; 2008. p34.

2. Ernst E. A systematic review of systematic reviews of homoeopathy. British Journal of Clinical Pharmacology 2002;54:577–582

3. Altunc U, Pittler MH, Ernst E. Homoeopathy for childhood and adolescence ailments: systematic review of randomised clinical trials. Mayo Clinic Proceedings 2007;82:69–75.

4. Shang A, Huwiler-Muntener K, Nartey L, Juni P, Dorig S, Sterne JA et al. Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy. Lancet 2005;366:726–32.

5. Kiene H, Kienle GS, von Schön-Angerer T. Failure to exclude false negative bias: a fundamental flaw in the trial of Shang et al. Journal of Alternative and Complementary Medicines 2005;11:783.

6. Peters D. Shang et al. Carelessness, collusion, or conspiracy? Journal of Alternative and Complementary Medicines 2005;11:779–80.

7. Smith G, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ 2003;327:1459–61.

8. Searching for gold standards — the construction and governance of RCTs and EBM in psychiatry. Available at tinyurl.com/5hmtbm (Accessed 29 July 2008)

9. Mathie RT. The research evidence base for homoeopathy: a fresh assessment of the literature. Homoeopathy 2003;92:84–91.

10. Weatherley-Jones E, Thompson EA, Thomas KJ. The placebo-controlled trial as a test of complementary and alternative medicine: observations from research experience of individualised homoeopathic treatment. Homoeopathy 2004;93:186–189.

11. Kayne SB. Homoeopathic Pharmacy. 2nd Edition. Edinburgh: Elsevier Churchill Livingstone; 2007. pp281–285.

You are aware that Professor

You are aware that Professor Ernst is a Professor of Complementary Medicine? This would seem to indicate that homeopathy is well within his "areas of expertise". He has investigated homeopathy using scientific principles and found that it is at best a placebo. Homeopathy is not a science, it is a sham that belongs in the Dark Ages. How fellow pharmacists can maintain that magic water works miracles baffles me.

"Medicines at the 6c potency

"Medicines at the 6c potency level certainly do contain molecules of the specified source material" How many molecules? Perhaps the Kaynes would be so good as to provide us with a quick guide as to the principles behind homeopathy. I'd do it myself, but every time I think about it I start giggling uncontrollably. Any views on 200C "remedies" ?

Could you possibly give

Could you possibly give us an idea of the type of patients you "treat" with your magic water? Are they people with serious conditions, or people with minor, self-limiting conditions. Also, who's paying the bill for the magic water that your "hospital" uses to treat your patients?

The Kaynes, bless them, seem

The Kaynes, bless them, seem to think that cystitis can be treated effectively by placebo, sorry, by homeopathy. I would love to hear how Berberis (a bush) or Cantharis (a beetle) are effective in the treatment of homeopathy. Anecdotes are not evidence. Do you really believe this nonsense, or are you purely profit-driven? Edit: Link: http://dcscience.net/health-and-homeopathy-2001.pd... (Scroll down to the bottom)

From Professor G. F. Baxter, MRPharmS

As a research scientist, I am frustrated and appalled by the absurd claims made of complementary and alternative medicines (CAM), such as, homoeopathy, Bach flower remedies, Hopi ear candles, aromatherapy and other assaults on scientific rationalism that prey on public gullibility.

As a pharmacist, I am embarrassed by the attitude of the Royal Pharmaceutical Society to complementary and alternative medicines — and to homoeopathy particularly — where the scientific evidence base clearly points to no benefit greater than placebo.

Edzard Ernst (PJ, 19 July 2008, p69) has provided a great service in highlighting the disingenuous stance of the Society in not making a clear denunciation of the supply by pharmacists of unproven therapies, which includes nearly the entire CAM repertory.

David Colquhoun is the author of the science blog dcscience.net, which I commend to all your readers. He describes, with embarrassing detail, in a written transcript “Royal Pharmaceutical Society defends quackery”, his encounters with the Society in trying to get a clear statement from the former director of practice and quality improvement David Pruce. Mr Pruce’s response was waffling and non-committal and I can only hope that he brings more clarity of thinking to bear in his new position at the Society.

I cannot emphasise strongly enough that the reputation of the profession as a reliable and trustworthy source of information on drugs and their use is at great risk. I believe that the Society’s attitude in not providing clear and unequivocal leadership on this issue says little for it as a responsible professional leader and guardian of the public good.

Moreover, the attitude of profit over evidence and ethics appears to pervade other aspects of the Society’s activities. The Society’s publishing arm lists a number of titles that pander to the CAM market. They include two titles on homoeopathy and the oxymoronic ‘Aromatherapy science’.

Most pharmacists and outside observers of the Society’s activities would expect these activities, whether they are leadership roles, protection of the public or commercial enterprises, such as publishing, to be based on scientific and ethical principles. I do not believe this is the case at present.

I hope that Professor Ernst’s contribution will provoke an urgent and thorough re-evaluation by the Society of its attitude towards the supply of unproven products, such as homoeopathic preparations and other forms of CAM.

Gary Baxter

Professor of Pharmacology Welsh School of Pharmacy

From Mr I. Jackson, MRPharmS

Edzard Ernst (PJ, 19 July 2008, p75) does himself no favours by continually writing articles on natural medicines. These regularly cite references from his own papers and publications, which detracts greatly from the strength of any argument he puts forward.

Before we clear our shelves of natural medicines perhaps we should all have a look at the BMJ’s Clinical Evidence website. Of the 2,500 commonly used conventional treatments, only 13 per cent were rated as beneficial and 23 per cent likely to be beneficial; 46 per cent are considered as having unknown effectiveness and 4 per cent are likely to be ineffective or harmful. Is it ethical to sell or dispense such conventional treatments, which are of such dubious therapeutic benefit?

In terms of patient safety, I believe this is the question we should be asking over the summer. Our dispensary shelves might have a few gaps in the autumn.

Ian Jackson

Mansfield, Nottinghamshire

From Mr J. R. Sharp, Hon MRPharmS

In his letter (PJ, 19 July 2008, p69) and article (PJ, 19 July 2008, p75), Edzard Ernst calls into question the ethics of pharmacists selling homoeopathic remedies. He is right to do so. It is not merely unethical, it is also irresponsible and stupid. However, in his critique of homoeopathy, Edzard Ernst omits a number of relevant points.

It is true that there is no evidence from properly controlled scientific trials of the clinical effectiveness of homoeopathy. The view from the Society of Homoeopaths that “there are many things that science cannot yet explain” is fatuous. Anyone making a claim for a particular effect should be able to demonstrate that effect and explain its mode of action.

Emphasis is placed in homoeopathic literature on the crucial importance of “treating the whole person and not just the disease” after a detailed study of the individual’s physical, mental and emotional state. A stroll around any high street pharmacy would reveal scores, if not hundreds, of homoeopathic remedies for all sorts of conditions, offered for sale on an entirely self-select, self-serve, pay at the counter, no questions asked and no advice offered basis. How can this be reconciled with “treating the whole person”?

I made these, and a number of other points in a past paper “Reflections on homoeopathy” (PJ, 14 June 1986, p758). In that same edition of The Journal (p770), a Council Statement was issued. It stated:

---

The Council of the Pharmaceutical Society of Great Britain recognises that the essence of homoeopathy involves a thorough and lengthy consultation with a homoeopathic practitioner, which takes into account the whole condition of the patient. There are many reports that such consultations are beneficial. The consultation may include, in addition to advice, the prescription of a homoeopathic remedy.

With regard to the actual composition of the ‘homoeopathic remedies’, there is no scientific evidence for their efficacy, only anecdotal and subjective reports. It is unlikely that the benefits attributed to homoeopathy could extend to over-the-counter recommendation or self-selection sale.

The Council of the Society, therefore, recommends members to inform anyone seeking advice on homoeopathic products, that there is no scientific evidence for their efficacy, beyond that to be expected from a placebo response.

---

Thus, the sale of homoeopathic remedies is not merely contrary to the code of ethics, it is in direct defiance of the policy of the Council. In conclusion, there is a further oddity in the letter (PJ, 26 July 2008, p97) from David Pruce, director of policy and communication at the Society. He states: “Until such time when homoeopathic treatments are regulated by … MHRA …”. Theoretically, the manufacture, sale and supply of homoeopathic preparations have been controlled under the 1968 Medicines Act, ever since its implementation in late 1971. It is just that, for no rational reason, criteria different from those applied to real medicines are adopted.

John Sharp

Woodley, Berkshire

Homeopathy and Herbal

I, like many other pharmacists, have long felt uncomfortable about the acceptance of homeopathy by some pharmacists and the RPSGB which undermines the scientific basis of the profession. I also become concerned when the word natural is used by some correspondents as it begins to mix homeopathy and herbal medicine in people's minds - the public are often confused about this. Some herbal medicines have definite effecicacy and some have a good safety profile and often contain many potent compounds - not to be confused with homeopathy in which the any efficacy is related to the time and input to the patient by the practitioner

Homeopathy Hmm...

Having spent an afternoon with a qualified homeopath, I still come to the same conclusions regarding the scientific basis of this pseudoscience, and still come to conclusion that there is no scientific evidence base whatsoever, she talked about the "miasms" inherent in homeopathy, gonorrhoeic, syphylitic, and sychotic (yes no P) she went on to expound that infinitestimal dilutions still have an effect - it's water memory. Anyone supporting homeopathy from this pseuodoscience point of view deserves to drummed out of science and spend the rest of their lives in sack-cloth and ashes with a board round their neck saying "I supported homeopathy" BUT, BUT.... She detailed a consultation with a patient, and the depth she went into the patient's case, made me weep - OK the [patient was paying for it, but a depth of understanding was obtained from the patient, that probably made them feel better. This was highlighted in her treatment of a cancer case. CANCER CASE?? Alarm bells started ringing, but she explained that she was not treating the actual tumour, but the concommitant symptoms, such as anxiety that surrounds it. OK it might be a placebo effect, but if I was diagnosed with cancer - half an hour with this homeopath (my wife's cousin) would make me feel a lot better. She also recognised the limits of her competance, and would not hesitate to refer to a "normal" treatment stream. Interestingly, only a very small portion of her practice came from the worried well, the majority were consulting her as a court of last resort. Even then she recognised her limits, and if she felt she could not treat them, would refer them to conventional medicine. Whilst all right thinking pharmacists should reject the pseudoscience of homeopathy outright, as having no basis in science whatsoever, we could learn a lot from homeopaths of how to HANDLE patients, and how to LISTEN to them. Whilst Hanheman was undoubtedly a quack, he set in motion a way of treating patients as a WHOLE. All in all, a very productive afternoon. Regards Bob Dunkley

Placebo power

Professor Ernst argues that we should stop selling homoeopathic medicines because it is unethical to sell something that is not effective. He bases his arguments on trials of homoeopathy versus placebo. Perhaps homoeopathy cannot be proven to be more effective than placebo, but any practitioner of medicine knows that placebos can be very effective, especially in reducing pain, helping sleep and reducing the perceived severity of symptoms. For many conditions, the body will heal itself if the patient can relax sufficiently. I have no hesitation in prescribing and using homoeopathic remedies where appropriate, even though as a scientist I find them difficult to rationalise. I would argue that homoeopathy is as effective as the most powerful placebo and we are quite within our ethical boundaries in using it.

From Dr A. M. Alexander, FRPharmS

In recent articles and correspondence there has been much discussion about the ethical aspects of pharmacists’ involvement in homoeopathy. We should also be aware of the potential legal implications in cases of negligence. Readers may be familiar with the Bolam case (Bolam v Friern Hospital Management Committee 1957), the implications of which are that there is no breach of standard of care if a responsible body of similar professionals support the practice.

I have no doubt that some of those who have written in support of homoeopathy could pull together such a body of like-minded professionals and consider themselves immune to prosecution.

However, they may be less familiar with the Bolitho case, (Bolitho v City and Hackney Health Authority 1997) in which it was stated: “The court should not accept a defence argument as being reasonable, respectable or responsible without first assessing whether such opinion is susceptible to logical analysis.”

The Bolitho judgment qualifies the Bolam case, requiring the opinions of a body of similar professionals to be evidence-based. It is at the point of logical analysis and evidence-base that I believe that those pharmacists practising homoeopathy and selling homoeopathic remedies would have some difficulty in gathering the necessary support.

To protect its members and the public the Royal Pharmaceutical Society should finally accept that there is no logic in homoeopathy and produce a stronger position statement, indicating that it is not compatible with our professional healthcare role.

Practice as a homoeopath and registration as a pharmacist are not compatible and, similarly, premises registered with the Society should not be used for promotion of homoeopathy.

Angela Alexander

Maidenhead, Berkshire

From Mrs E. S. Kirton, MRPharmS

I read with interest the considerations of Edzard Ernst (PJ, 19 July 2008, p69 and p75) pertaining to the lack of scientific evidence to support the use of homoeopathic remedies and whether pharmacists ought to be selling them.

Following that argument we should remove all cough syrups from our shelves since their efficacy has been shown to be nothing more than placebo.

As a pharmacist, I believe the role entrusted to me is to ensure anyone wishing to take any substance, whether it is over-the-counter medication, alternative remedy or something prescribed by a physician, does so in the best way in order for him or her to gain benefit from it. I do not think it is my place to remove free will any more than I should select what people consume in the way of nutrition.

It is a sad reflection of the world today where we think everything should be be explained by science and, if not, then it obviously does not work. When I sell homoeopathic remedies, I explain to the customer that we do not know how they work but in many cases they do provide relief where conventional therapies have failed or have undesirable side effects to accompany the satisfactory outcome.

Finally, why should anyone who spends such a long time to achieve the highest level of understanding of substances within the body relinquish an area that can generate income outside of NHS constraints to other less qualified retailers, since our refusal to sell will not remove the demand.

Elspeth Kirton

Barbados

Oh really -  this "world

Oh really -  this "world today" against which you rail would appear to be the world extant since the Enlightenment. You deliberately misquote the argument when you say;

 " everything should be be explained by science and, if not, then it obviously does not work".

Actually homeopathy doesn't work by any reputable measure, and is scientifically indefensible, so that's why it should be rejected by pharmacists.

True, our refusal to sell will not remove demand, but it will remove a veneer of scientific credibility from a pseuodscience. If anyone disputes whether homeopathy is a pseudoscience, give me a mechanism of its action which can be tested by scientific experimentation.

From Professor E. Ernst, FRCP

David Pruce seems to confuse regulation and law with ethics and morals.

Regulation is important but it will not resolve the ethical dilemma I referred to (PJ, 19 July 2008, p69 and p75). Mr Pruce states that “pharmacists should assist patients in making an informed decision, and provide them with the necessary and relevant information that is available”.

This is a deviation from the actual text of the code of ethics, which states that pharmacists “must assist patients in making informed decisions by providing them with the necessary and relevant information”, with no mention of availability of information.

The Royal Pharmaceutical Society seems to think it is not important or relevant to tell consumers that homoeopathic products and Bach Flower remedies contain no active molecules and are clinically unproven, possibly even disproven. Perhaps it should ask its customers whether they agree. It may learn that honesty and transparency count more than it had assumed.

I find it difficult to decide whether Mr Pruce and the Society do not understand this ethical dilemma or whether they are trying to put up a smokescreen, and hoping the problem might disappear.

Meanwhile, in the poll conducted on PJ Online, 57 per cent of pharmacists answered “no” to the question “Is it ethical to sell homoeopathic or other remedies that have no evidence base to support their effectiveness?” (poll accessed 30 July 2008, number of votes = 131).

Considering that this vote is against their commercial interest, I find this result remarkable and clearer than the Society’s position.

Edzard Ernst

Peninsula Medical School

Exeter

From Dr R. J. Woodward, MRPharmS

Homoeopathy is the tip of the complementary and alternative medicines iceberg. In her recent book ‘Suckers — how alternative medicine makes fools of us all’ (Harville Secker, London, 2008), Rose Shapiro states: “There are as many as one thousand different alternative therapies.”

In reality, we have two systems of healthcare:

1. Evidence-based, following currently approved scientific criteria

2. Placebo or belief-based, following unscientific criteria

The law needs to recognise these. System 1 is the current Medicines and Healthcare products Regulatory Agency licensed area, which excludes homoeopathy and most herbals. System 2 embraces all therapies that cause the establishment so much angst and cost to the taxpayer, through fruitless attempts at detailed regulation of hundreds of therapies and tens of thousands of products.

System 2 should be regulated by compulsory registration of therapies and practitioners. Any physical or psychic practice embraced within therapies seen as unsafe by the registration authority could readily be banned and overt health claims by therapists disallowed. Products associated with system 2 therapies should be regulated by statutory registration with full quantitative composition, manufacturer, distributor and overt or implied health claims disallowed. All products containing substances found to be unsafe after registration could be immediately identified on a master database.

Patient safety must be assured. If manufacturers want products and therapies to become recognised under system 1 then they would have to accept scientific scrutiny and provide evidence with a payment to the MHRA up front.

Recently, psychics, fortune tellers, spiritualist mediums and tarot card readers have been legally compelled to tell their clients and audiences they are offering “an entertainment”. This has warned their followers but not necessarily deterred them. All healthcare practitioners, including GPs and pharmacists using any aspect of system 2’s therapies should display a notice: “(The named therapy) is a scientifically unproven placebo therapy.” Similarly, all products should be clearly labelled: “This is an unproven therapy, for which no health claim is made.”

Any advertisement should carry a similar warning. Publicity in the media should have to refer to the placebo nature of any system 2’s therapy or product. Finally, recommended dietary allowance-based nutritional supplements should be classed as foods and outside system 2.

Robert Woodward

Liss, Hampshire

From Mrs A. Shah, MRPharmS

Following Edzard Ernst’s article on whether it is ethical for pharmacists to sell unproven therapies (PJ, 19 July 2008, p75), there have been many letters highlighting the fact that most over-the-counter preparations, not merely complementary medicines, have not undergone vigorous randomised controlled trials and are not evidence-based.

Lee and Steven Kayne’s letter (PJ, 2 August 2008, p126) questioned whether RCTs are the most effective means of judging effectiveness. Bearing this in mind, I suggest there is an evidence base for homoeopathy. In 2005, the Bristol Homoeopathic Hospital published the largest outcome study of homoeopathic treatment. This reported that 70 per cent of follow-up patients experienced improvement in their health and difficult chronic problems reported positive health changes1 (PJ, 26 Nov 2005, p657). Additionally, there are several randomised placebo controlled trials with positive outcomes in favour of homoeopathy.2–5

Pharmacies are the right environment for selling complementary medicines. We are the experts on medicines, therefore, we should be able to advise on all forms of medicines on the market and advise appropriately on interactions, side effects and doses among all categories of medicines. I think if all pharmacies stock homoeopathic remedies and educated themselves on homoeopathy then we would really make a difference in treating the general public’s minor ailments and achieve greater satisfaction.

Rather than criticising and dismissing homoeopathy we need to put our efforts and energies into doing some practice-based research in homoeopathy.

Ananti Shah

Superintendent Pharmacist

Royal London Homeopathic Hospital

References

1. Spence D, Thompson E, Barron S. Homoeopathic treatment for chronic disease: a six-year university hospital based outpatient observational study. Journal of Alternative and Complementary Medicine 2005;5:793–8.

2. Linde K, Clausius N, Ramirez G, Melchart D, Eitel F, Hedges LV et al. Are the clinical effects of homoeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet 1997;350:834–43.

3. Cucherat M, Haugh MC, Gooch M, Boissel JP. Evidence of clinical efficacy of homoeopathy — a meta-analysis of clinical trials. European Journal of Clinical Pharmacology 2000;56:27–33.

4. Jacobs J, Jonas WB, Jimenez-Perez M, Crothers D. Homoeopathy for childhood diarrhoea: combined results and meta-analysis from three randomised controlled clinical trials. Pediatric Infectious Disease Journal 2003;22:229–34.

5. Vickers A, Smith C. Homoeopathic oscillococcinum for preventing and treating influenza and influenza-like syndromes (Cochrane review). In: The Cochrane Library. Chichester:John Wiley and Sons Ltd.

"Rather than criticising and

"Rather than criticising and dismissing homoeopathy we need to put our efforts and energies into doing some practice-based research in homoeopathy." Been done. The evidence has shown that homeopathy is no better than placebo. Why continue to waste money on it? The problem with homeopaths is that their system is based entirely upon belief. If you believe that water with zero inactive ingredient will have any effect whatsoever, then you are either blinded by faith, a nitwit, or a charlatan. How exactly does a homeopathic hospital go about treating broken bones, or cancer, or diabetes? Do you have homeopathic surgeons, who think about removing tumours instead of doing real surgery. How on earth can you justify your position?

From Mr C. F. Brewer, MRPharmS

Edzard Ernst, Robert Woodward and others display determination in their quest for regulatory teeth to support a ubiquity of evidence-based medicine (PJ, 9 August 2008, p160). However, they also seem determined to confuse the abstract notion of treating a population with the business of treating real-life individual patients.

An evidence-based option is a logical first choice for most conditions but when a patient returns, practitioners must remain free to recommend another option of treatment based on their experience. Whenever a patient drops out of a clinical trial, this is the end-point and they become merely a statistical anomaly.

We cannot say to these patients: “You do not respond as you should to the evidence-based solution, therefore, you must suffer.” Any given treatment option may not suit everybody, but every patient deserves to be treated. It is true the exponents of some alternative therapies need to try harder to make a rational case for their practice.

However, the champions of evidence-based medicine need to look outside their ivory towers once in a while and try to understand the concept of real-life medicine.

Chris Brewer

Medicines Information Pharmacist

North Cumbria University Hospitals NHS Trust

From Mr P. A. Hardy, MRPharmS

Peter Dawson, D. Needleman and Miall James (PJ, July 26 2008, p97) present weak arguments on the issue of homoeopathic remedies and do not advance the discussion one iota.

Mr Dawson’s argument for similar standards to be applied to the sale of over-the-counter cold preparations may have some merit. However, the ingredients of cold remedies have undergone proper clinical assessment at some dose, for some condition, at some time.

Their role as promulgated in the glossy “home-remedy” packs may be spurious but they are manufactured to pharmaceutical grade and their adverse events are reportable through the yellow card scheme. Most importantly, for us as scientists, their proposed modes of action follow scientific hypotheses, which are genuinely proveable, not mystical hypotheses invoking energy systems.

The thousands of homoeopathy studies are ignored because none of them reaches a minimum standard of a clinical trial. I challenge Mr Needleman to produce a single randomised double-blind trial that shows homoeopathic products to be superior to placebo.

The results of the Kirsch study on selective serotonin reuptake inhibitors told us what we know: that SSRIs are no more effective than placebo in mild depression. This has been enshrined in the National Institute of Clinical Excellence guidelines since 2004.

If an SSRI prescription is presented and pharmacists know it is not for severe depression and they can somehow replicate the profound placebo effect highlighted in the Kirsch meta-analysis then they can refuse to supply.

However, remember that Kirsch analysed data from 45 randomised trials, so a homoeopathic placebo stand-in needs good data behind it.If Mr Needleman truly believes aspirin has not been clinically trialled, he has overlooked several iterations of the ISIS study, one of the largest randomised double-blind multi-national series of studies undertaken.

What inconsistency is Mr James referring to? Professor Ernst asks pharmacists to consider the scientific credibility of products before being prepared to sell them (PJ, 19 July 2008, p69 and p75). Pharmacists wishing to continue to advocate such products could peruse the advertised tomes and be sure of reading a scientifically disciplined investigation of the subject. If, after reading, they remain convinced they can honestly recommend such products, they have done the least that their ethical standards might require of them.

P. A. Hardy

Wakefield, West Yorkshire

From Professor E. Ernst, FRCP

I continue to be baffled by the fact that many pharmacists, including Ananti Shah (PJ, 16 August 2008, p190) and Chris Brewer (PJ, 16 August 2008, p190), seem to misunderstand my article (PJ, 19 July 2008, p75). I clearly state that homoeopathy was only chosen as an example of an unproven therapy sold in UK pharmacies.

My concern is not primarily about homoeopathy but about the fact that pharmacists behave unethically if they fail to provide customers with the most important facts about the preparations they sell. In the example of homoeopathy, this should be that there is no plausible mode of action, trial data are mixed and the best evidence fails to be positive.

Customers who walk into a UK pharmacy today are not only unlikely to get such information, they are likely to receive verbal or written material that is wrong or misleading.

I sympathise with the pharmacists’ dilemma, we all want to have the cake and eat it. But one can turn and twist it as one likes, breaking one’s code of ethics is simply unethical.

Edzard Ernst

Peninsula Medical School

University of Exeter

Ethical dilemma

The ethical dilemma is whether pharmacists only offer for sale products with a defined standard of evidence of efficacy (which could wipe half the products off their shelves such as all cough linctuses apart from codeine) or provide what customers think they want.  I think there are arguments for both cases.  Maybe we should ask the general public what they want as service users.  Will they get even more variable advice from health food shops if alternative therapies are only available from such outlets?

Homeopathy

 

This forum is not the correct forum to review the evidence base for therapies -  and particularly homeopathy. Readers may however be interested to know that the oft quoted Bristol study which basically discovered that people self reported clinical improvement after an intervention. "The outcome score was assessed during the consultation, with patients being asked to rate their overall improvement or deterioration compared to their status at first visit."

Hardly objective, not controlled, no comparator. I imagine we could get similar data from any intervention - or even a chat with a mate over a pint.

(Spence DS, Thompson EA, Barron SJ. Homeopathic treatment for chronic disease: a 6-year, university-hospital outpatient observational study. J Altern Complement Med 2005; 11: 793-798. (Full text available at http://www.liebertonline.com/toc/acm/11/5))

I also have to disagree with my learned colleague Mr Hardy.  Whilst the results of the Kirsch paper were widely reported SSRIs as being the same efficacy as placebo this was not in fact what the authors reported not what their study showed. In fact SSRIs were consistently more effective than placebo but that this did not reach the arbitrary point for "clinical effectiveness" set by NICE in it's clinical guidelines. 

May I take the liberty or recommending www.badscience.net and especially http://www.badscience.net//?p=490 as a starter on the science that may (or may not) lie behind homeopathy? Although 200 years after the therapy was invented we are still awaiting good evidence - and, despite the oft quoted percentages from BMJs Clinical Evidence most interventions actually undertaken do have a sound evidence base.