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
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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
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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
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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.
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"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" ?
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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
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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.
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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
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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
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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
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From Mr I. Jackson, MRPharmS
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
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
You are aware that Professor
"Medicines at the 6c potency
Homeopathy Hmm...
Placebo power
From Dr A. M. Alexander, FRPharmS
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
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
From Professor E. Ernst, FRCP
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