In 1977, the Austrian philosopher Ivan Illich suggested that the mid-twentieth century should be named as The Age of Disabling Professions: it was when people had ‘problems’; experts had ‘solutions’; there was an ‘acceptance of the illusion of professional omniscience and omnipotence’; but in a future age ‘self-indulgence might be the safest assertion of independence’ (Illich et al, 2000).
Perhaps Illich was right and we are now living in that ‘future age’, because in exploring the relationship between ‘needs’ and ‘wants’, he suggests that needs are created by advertising slogans, and that meeting so-called ‘needs’ promotes an indifference to potentially felt wants (Illich et al, 2000). The present headlong pursuit of ‘needs’ was exemplified for me by the results of a recent cross-sectional survey of non-steroidal anti-inflammatory drug (NSAID) use among 806 Parkrun UK participants (average age 48 years). In the study, Rosenbloom et al (2020) found that 87.8% had taken NSAIDs in the past 12 months; a third had experienced an adverse drug reaction; and half used NSAIDs without taking advice.
Rosenbloom et al (2020) concluded: ‘Some recreational runners have a high use of NSAIDs, which is chronic in nature and a potential health risk.’ Another highly significant finding, in my view, was that the vast bulk of these runners ran less than 30 miles per week, with only 7.6% running more than that (Rosenbloom et al, 2020). As a former average cross-country and road running club member who ran 50 to 60 miles a week for several years, and sees many overweight recreational runners on the streets, the thought that many of these individuals might be consuming NSAIDs on a Wagnerian scale – just because they feel like it – recalls Illich's supposition that ‘self-indulgence might be the safest assertion of independence’ (Illich et al, 2020).
Hence my question: when I walk into my local pharmacy am I a customer or a patient, and to what extent does being one or the other influence the ethics of customer/patient interactions with the pharmacist? Should a pharmacist be available to counsel me against stocking up on ibuprofen – almost 80% of participants selected this as their NSAID of choice (Rosenbloom et al, 2020) – before a Parkrun, or should I be allowed to exercise my right to be self-indulgent and abuse my health?
I suppose this could be framed as a dilemma … but for whom? Rosenbloom et al (2020) suggest that ‘[o]rganisers of longer endurance events should consider providing evidence-based advice on the use of NSAIDs.’ Perhaps such advice should come from pharmacists. But pharmacists are busy people, and to what extent should they be expected to influence the behaviour of their customers/patients? Would dispensing placebo ibuprofen to Parkrunners be an acceptable approach? It is an outlandish proposition, but then as Louhiala (2012) asked: ‘What do we really know about the deliberate use of placebos in clinical practice?’ His analysis of twelve studies of doctors who prescribed or administered placebos showed that ‘[t]he lowest and highest reported proportions of doctors who confirmed that they prescribed or administered placebos in their clinical practice were 20% and 88%’, with one cited questionnaire asking about the provision of saline infusions/intramuscular injections rather than ibuprofen for pain relief (Louhiala, 2012).
The internet is arguably the place where ‘self-indulgence might be the safest assertion of independence’ (Illich et al, 2020), and while ‘self-indulgent’ Parkrunning NSAID consumers may assert their rights to become ill, what if societal interests outweigh individual ones? Thus, when Boyd et al (2017) undertook a UK study of the sale of online antibiotics they found that it ‘poses a serious threat to patient safety and national antibiotic stewardship initiatives’ and suggested that ‘[i]n order to promote patient safety and preserve antibiotic therapy, an efficient and operational multidisciplinary taskforce is needed to address the issues we have identified.’ Further, Curtis and Milner (2020) have raised ethical concerns in relation to online direct-to-consumer pharmaceutical businesses, identifying issues of conflicts of interest.
It seems that as society evolves, so too does the concept of the rights and responsibilities of individuals and communities: a sometimes-blurry interface that members of the pharmaceutical profession may find themselves patrolling. Whether this is a task that pharmacists feel is one that they should be involved in is a matter worthy of debate.