In India, the pharmacy of the world, people still suffer poor access to essential medicines, and the impoverishing effects of out-of-pocket expenditure on purchase of medicines. Prescription audits reveal prescriptions of harm with prescriptions not aligned to treatment guidelines, with unnecessary, unsafe medicines, including irrational fixed-dose combinations that are a dominant feature of the pharmaceutical landscape in India.This situation represents a crisis of both rationality and ethics at macro, meso and micro levels represented by different institutions, and actors; and these need to be addressed. The article argues for a a unified national drug authority with transparent evidence-based approvals, removals of all irrational medicines, a stronger quality assurance system, comprehensive cost-based price regulation and improved availability of essential medicines. Prescribers need training in the concept of rational use of medicines, essential medicines and of generics, and should be subjected to regular prescription audits. It also suggests a need to widen the focus from quality of medicines alone to quality of prescription.