Chiropractic
Ethics: An oxymoron?
Contemporary Ethical Issues in Chiropractic
by
JC Smith, MA, DC
jcsmith@smithspinalcare.com
fax 912-929-8822
Any discourse on ethical issues seems comparable to a discussion of religion where
everyone has his own very personal and staunch opinion. Without a doubt, if one wants a
good argument, just mention politics, religion or chiropractic. And, as a chiropractor, if
one wants a good fight, just mention technique, philosophy or practice management
methods and prepare for a lengthy argument with little hope of resolution.
Just as one common religion is unthinkable in this country, it seems that any genuine
consensus of ethics in chiropractic, let alone any call for improvement, is also ill-fated.
Rarely do our periodicals discuss this issue of ethics, perhaps knowing the inevitable
controversy it certainly will cause. However topical any discussion about ethics
may be, it is subject in dire need of debate because the chiropractic profession appears
to some in the public arena to be the least ethical of all the health professions, due to
years of intense medical misinformation/slander as well as the use tacky advertising,
outlandish claims, sensational leadership and cases of insurance fraud that appear on
news programs such as 60 Minutes.
Reportedly, polls
taken in shopping malls around
1990, found that of 19 professional groups, chiropractors ranked 19th in the majority of
categories (1). Another poll taken
in
experienced positive results with chiropractic, 80% would not return to their previous
chiropractor (2). If this isn’t a wake-up call to our profession, what is?
According to former chairman of the ACA, Dr. Lou Sportelli, writing about this very
issue in an excellent article, The Pursuit of Image: Chiropractic in the Next Millennium,
mentions that public relations and image is at the crux of our dire situation:
“Public relations will play a crucial role in the future survival of the profession. The image we now develop will be the image we carry into the next century. It has taken almost 100 years for the chiropractic profession to shed the image of charlatanism, quackery, illegitimacy and ineffectiveness... We can and should now begin to consider the elimination of all yellow page advertising and pooling that 20, 30 or 40 million dollars and use it to develop and portray a collective chiropractic image which will reinforce the image of the doctor of chiropractic as a well-qualified, competent, compassionate, caring and cost-effective provider... anything less will not be effective in marketing our services to the 85 percent of the population which now does not utilize the services of a chiropractor.” (3)
Obviously with the
low opinion and utilization rate for chiropractic in the
public’s perception of the profession is not what we desire, and it certainly needs urgent
improvement. While this subject may be controversial and/or even seem disloyal to
some chiropractors, I think it is a legitimate issue which demands discussion.
LEGAL VS. ETHICAL STANDARDS
State law addresses issues of ethics and defines immoral and unprofessional practice, in
part, as fraudulent or misleading representations in practice; offering free
services, then
billing insurance companies; an altering fee
structure; soliciting patients with
“runners”; and sexual improprieties, (4) to name but a few of the questionable practices
that violate professional ethics and state law. While these canons are reasonable standards,
they only address the most egregious examples. Other ethical issues remain outside this
legal scope; these may not be illegal, but certainly remain debatable relative to professional
standards. Among these ethical considerations must be included practice management
issues such as the preponderance of advertising free or discounted services.
Unlike other health professionals, some chiropractors have relied upon offering free
services to attract patients. Although they insist that free spinal exams are designed to
teach the about the wonders of chiropractic under the guise of public promotion to
educate them about chiropractic care, the impact is much different despite this clarion call.
Indeed, whenever an offer of free services is seen, much of the public must wonder, “If
chiropractic is so great, why do they give it away?” There does seem to be a paradox here.
Often proponents of free services complain that it is ethical to convert people to
chiropractic using whatever means they can. In a response to a letter-to-the-editor I wrote
on this subject, one doctor responded in the April, 1998 Journal of the ACA (5):
“J.C. Smith, DC, is incorrect. A free lecture or spinal screen is a great way to educate people and can be done ethically. Free does not equal unethical.”
To what does “free” equate? Of no value! While proponents of spinal
screenings in shopping malls contend it’s an inexpensive method to recruit new patients,
they refuse to admit the damage it does to our image en masse. While a lecture or
screening may be less harmful than those DCs who advertise free spinal exams on a
continuous basis, the profession is still tainted whenever free services are rendered. Can
you imagine an attorney sitting at a table at K-Mart offering free legal advice?
Sounds like some sleazy character from The Simpsons, doesn’t it?
Furthermore, they claim, other medical groups offer free screenings for high blood
pressure or diabetes, as examples. But, the difference is that these groups usually don’t
have the hidden agenda of recruitment of patients for one particular doctor. The bait-and-
switch nature of free chiropractic spinal exams is obvious to most people, in spite of the
|
If chiropractic is so
great, why do they have to give it away? |
chiropractor’s open intention of
offering free advice. J.F.
president of The National College of Chiropractic, mentioned this subject:
“One does not usually see these professionals ‘hawking their services’ as some of us do. We will gain credibility only when we earn it.... We don’t help this image by all of the ‘unprofessional’ advertising we do. These ads range from those that imply that spinal adjusting is the panacea of all ills, to those that suggest that the panacea lies in the use of crystals. In my experience, when members of the general public see such things, their belief that we are on the fringe is simply reinforced. ” (26)
Another example of chiropractic embarrassment is the new graduate DC who offers a
consultation, complete spinal exam including x-rays, and one adjustment for $25. Of
course, the $25 offer is the bait, and the new practitioner’s hope is to switch new patients
to long-term care. Ironically, the cost-conscious patients attracted with this bait will, most
likely, never indulge themselves in any type of care other than temporary crisis care.
“Out of pain, out of sight,” is their motto. Even the offer of NOOPE fails to induce these
K-Mart shoppers. With little invested in their health care, the shoppers who respond to
this bait rarely pan out as reliable patients with whom one could build a practice, unless
the goal is to operate a chiropractic emergency room handling only short term acute cases.
On the other hand, those value-conscious patients who would continue for rehabilitative
or maintenance care would be repelled by such bait-and-switch tactics. And, why is it that
few other health providers stoop to such tacky methods as the continuous free exams or
the ruse of free chicken dinners other than certain chiropractors? Is it because of our
tainted image that some people need to be tricked into care with discounted prices?
Regrettably, yes it is.
This practice has become so ingrained that free spinal exams and, more unfortunately,
free chicken dinners are now acceptable forms of practice management in some
chiropractic circles. This model of practice may seduce a few very cost-conscious new
patients; the overall damage that it does to our collective image certainly appears suspect
to those value-conscious patients who prefer a good doctor as opposed to the cheapest
one. Indeed, when it comes to health, most people want the best of care, not the cheapest.
|
“Rigor mortis is the only
thing that we can’t help!” -- |
Of course, any criticism of free/discounted services illicits various reactions from both
sides and, most of all, from those DCs who use free offers or discounted fees as their main
advertising solicitations. One such chiropractor who disliked my criticism of
free/discounted services, wrote to me saying,
“If someone wants to work for $10 a visit,
that's a problem, but it's THEIR problem... Some of them may simply be
ignorant, desperate or even stupid... I say let the market decide if these
people survive.” (Klapp T. Personal communication.
Although most chiropractors admit free/discounted services reflect poorly on the
profession, some believe this is part of the evolutionary process in our profession.
Out of a desire to expose as many people as possible to chiropractic in order to
build their practices, regardless of the method, they hide behind their “philosophy”
or zealous, missionary banner in order to justify their tacky methods. Oddly, this
sentiment is widely held by many DCs.
Dr. Jerry
McAndrews, ACA spokesman and former president of
disagrees with such viewpoints and mentions that:
“Letting the marketplace handle the problems is about
as unprofessional as we could get. A ‘profession’ is suppose to regulate itself. Otherwise, we’re not much more than local labor unions, with local building codes, running a trade. We have fifty different local building codes, represented by the fifty state laws.
He (George McAndrews) thinks we have
50,000 ‘professions/local codes.’” (McAndrews J. Private
communication.
Indeed, it does appear that every DC has his/her own code of ethics, the profession be
damned! Dr. McAndrews continued in his assessment of this rationalization of the
marketplace.
“I am reminded when I hear or read
comments about ‘letting the marketplace handle it,’ of the time my brother
George spent a full morning in the first trial in the Wilk case. He called me that
“I apologized for the tough time ‘our’
behavior had caused for him. He then said, ‘Don’t get me wrong. The toughest
part wasn’t the trash so many chiropractors put out,
it was that I couldn’t find any evidence (for the then 80-some years of
chiropractic’s existence) of a single chiropractor speaking out against the
atrocious behavior.’ ” (McAndrews J. Personal communication.
Other than the obvious code of ethics by our national and state organizations about
egregious legal matters like fraud and sex harassment, why hasn’t the discussion of
these borderline practice ethics and unsubstantiated claims/ads been a topic of debate?
When writers have mentioned the need for chiropractic to clean up its act of
undocumented claims, for the most part, it falls on deaf ears. Dr. Keating, columnist for
the Dynamic Chiropractic tabloid, has long railed against the unsubstantiated claims made
by many chiropractors. In his article, “It Works, It Works, It Works,” he mentioned Mr.
McAndrews’ plight to make chiropractic’s case in court while withstanding the
unsubstantiated claims, and warned that such ‘unsubstantiated ads’ are doing the
profession ‘enormous damage.’
“Will Mr. McAndrews' warning against unsubstantiated claims be
heard in chiropractic? Perhaps not so long as a majority of
chiropractors continue to perceive ‘philosophy’ (and marketing) as
defensive crutches against the historic assault by organized
medicine, and as substitutes for hard core scientific information.
The anti-scientific traditions in the profession are very strong,
and although blatant anti-competitive activities by AMA et al. have
been ruled illegal, criticism of the chiropractic profession (and
posting of killer subluxation advertisements on hospital bulletin
boards) are clearly within the free speech prerogatives of any
would-be critics. The more we stretch the available scientific data
to support ‘what we always knew was true,’ the more we can
expect to be held up to ridicule. The chiropractic profession dearly
needs an attitude adjustment.” (28)
Before the ACA
House of Delegates on
legislative consultant, was just as harsh in his opinion of chiropractic's image dilemma and
what he believed was our main threats which came from within.
"You know who they are. They exist in virtually every community in which you practice. Their garish yellow page advertisements hawk free exams and x-rays - tests that, lo and behold, discover a variety of subluxation-related ailments which, if not treated immediately, threaten the life of the unwitting patient. They intentionally promote and practice the over-utilization of chiropractic.
"They are the small, but vocal class of professional nay-sayers who continue to enrich themselves, all the while dragging down an entire profession which now stands at the very brink of long-term success or instant failure and continued ignominy... The question that vexes me most is why? Why does this profession continue to tolerate their excesses?"(23)
Is it because chiropractors generally look upon ethics with a laissez faire attitude like
religion, believing that everyone should have a personal freedom of choice; thus, practice
ethics should be considered in the same light of personal freedom? Is a debate, let alone a
consensus, on ethics something that will never occur due to this ‘anything goes’ attitude?
Indeed, do we actually have 50,000 different codes of ethics in our profession? Or is it a
desperate situation of survival where anything goes as long as it makes money?
THE ERA OF WEIRDNESS
“Rigor mortis is the only thing that we can’t help!” so says Dr. Sid Williams (6). While
Williams and his followers may somehow extrapolate the healing capacity of chiropractic
to reach outside scientific legitimacy or clinical reality, few outside his circle reading such
a statement can understand his claim, hence, our entire profession is tainted as unscientific.
We all are painted with one stroke of this brush, whether or not we agree, and our
profession is besmirched by this outrageous claim.
Tongue-in-cheek or not, these types of outlandish statements and chiropractic
hyperbole echoes throughout the medical/scientific/media community louder than any
research from AHCPR (7) or Manga (8), and is often thrown back into our faces by our
opponents. Recently I had an encounter with a local medical physician who told me he
would never refer to a chiropractor because, supposedly, we made claims to help diabetes.
Although I’ve never made such a claim, I was guilty by association. Meanwhile, we
wonder why many won’t take us seriously in light of the latest governmental
endorsements when they harbor mistaken beliefs about our clinical scope of practice.
The consequences of unsupported chiropractic claims and the criticism of medical
care are misperceived by much of the public, which has been well-conditioned to view the
medical profession without question and to view chiropractic with great skepticism. Even
when medical critics or chiropractors bring to light medical excesses, shaking the medical
pedestal is still viewed as heretical, rather than as progressive. As Dr. Jerry McAndrews
wrote:
“For all these problems, the reward
seems to be an image more of ‘anti-medicine’ and ‘anti-science’ than one of
‘pro-chiropractic.’ The confusion to the public and the power brokers is
extreme. They simply will not tolerate anecdotal stories about the lack of
benefits of the mainstream health delivery system.” (McAndrews
J. Private communication.
In 1992, Mr. George McAndrews, the ACA Board General Counsel, wrote in the ACA
Journal his opinion of chiropractic's suspect image:
|
"I believe this is
the era of image. It is time for the
'deweirdization' of the profession...” --George McAndrews, Esq. |
"I believe this is the era of image. It is time for the 'deweirdization' of the profession... An aura of 'weirdness' is the necessary consequence of some chiropractic literature, advertisements... a sampling of yellow page ads makes one wonder if chiropractors are financial advisors or health care professionals... It is time to isolate the rascals."(9)
SCOPE OF PRACTICE VS. SCOPE OF COMPETENCY
Another practice issue that must be considered is the solicitation of cases that fall
outside the scope of expertise/clinical competency. For instance, some straight
chiropractors advertise themselves as “whiplash” experts when, in fact, they have no
specialized training or equipment for rehabilitation of soft tissues--continuous passive
motion equipment to restore normal joint play or isotonic muscle strengthening
equipment, as the real experts encourage in the treatment of these injuries. (10)
Some chiropractors advertise other specialties that require advanced training, such as
nutrition, weight loss, pediatrics or sports injuries, yet few have any real training.
Apparently, some chiropractors want to be all things to all patients. Even though very few
DCs have advanced training in these specialties, most all DCs make the same claims in
their telephone book ads. Unfortunately, “consumer beware” is sage advice for anyone
looking for a good chiropractor. Indeed, when prospective patients, seeking a referral
from friends, ask “Do you know of a good chiropractor?”, this illustrates the public’s
pervasive suspicion about many in our profession.
To make matters worse for the consumer, all chiropractors are then lumped
together in the phone book without any delineation of expertise or any proof of
specialized training, obviously confusing prospective new patients about the actual
qualifications of individual chiropractors. Is this ethical or a misleading representation of
practice? Indeed, is every DC qualified to handle every type of spinal case? Of course not.
The issue of competency was addressed on another occasion when Jerry and George
McAndrews were invited speakers to a state association’s banquet program. George
talked about the difference between “scope of practice” and “scope of competence.” He
told of an occasion when he was walking through the Everett McKinley Dirksen Federal
Building in
courtrooms. On the wall was affixed an oar. George wondered out loud about the symbol
and was told by the other attorney that “this courtroom is reserved for cases involving
Admiralty law.”
George pointed out how he is licensed to practice law in all of its branches--
corporate law, real estate law, tax law and, yes, even Admiralty law. But he knew he was
not “competent” to practice every one of these. His competence lie in the areas of
intellectual property law, patent law, copyright law and antitrust law.
“But,” he said, “if
the American Bar Association tried to limit my license in any areas where I am
‘incompetent,’ I would give them a thought or two! It is up to a professional
to prepare and apply his education so that he is competent. This is not a matter to be
restricted by license, but by ethics.” (McAndrews J. Personal
communication.
Unfortunately, too many chiropractors may have the legal right to treat a diversity of
cases, but the question remains: Are they competent to advertise and accept every case
that comes to their offices?
|
“This is not a matter to
be restricted by license, but by ethics.” --George McAndrews, Esq. |
ETHICS OF PATIENT MANAGEMENT
To illustrate the conflict of ethics within chiropractic competency, the president of one
chiropractic college for years has taught his students the concept of unconditional
acceptance: “To accept all cases regardless of condition or financial ability to pay.” (11)
While this statement hits a charitable tone, on another hand, it smacks of complete
irresponsibility. First of all, to accept all cases regardless of condition is problematic, to
say the least. Does this mean no diagnosis to determine whether or not the patient is
actually a chiropractic case? Should a straight chiropractor accept a diabetic or a cancer
patient without co-management from a medical doctor? Does every DC have the
|
“One Cause-One Cure-One
Correction” premise has been the bane of
chiropractic for decades... |
specialized equipment, knowledge or clinical skills to treat such cases? Of course not.
Unfortunately, some DC’s strong belief in the “One Cause-One Cure-One Correction”
premise has been the bane of chiropractic for decades, and one that is still thrown back
into our collective face by medical detractors, the press and society in general.
Secondly, “to accept all cases regardless of financial ability to pay” is also problematic.
While accepting pro bono cases certainly speaks well of our profession, hopefully such
cases are rare. Realistically, it is rather naive to think any health care provider can subsist
on free cases. While this phrase sounds charitable, legally and practically, it is very risky
business. “Accepting all cases regardless of financial ability to pay” may sound nice
rhetorically, but ethically it is spurious advice legally and financially.
DEBACLE OF DEADBEAT DOCS
The recent revelation that chiropractic students lead all health professionals in student
loan default rates is another glaring issue. Although some apologists may complain about
unfair repayment plans for DCs compared to MDs, or the infrequent scheduling of
licensing exams, the fact remains that the national and local press has printed numerous
articles about “Deadbeat Docs” featuring chiropractors as the leaders. Locally, a television
station recently sent its crew to interview one such chiropractor, showing his large office,
his Corvette and announcing his large net worth along with the salient question: Why can’t
this obviously wealthy chiropractor repay his student loan? Sheepishly, his attorney told
the TV crew that his client will begin making repayments, but only after this deadbeat
chiropractor was brought to the attention of the entire viewing audience. Again, is it
ethical for prosperous chiropractors to renege on their indebtedness, let alone besmirching
the collective image of all DCs? Of course not.
But, considering this doctor graduated from the leading default institution, perhaps the
real cause of this problem rests more with the leadership morality than with the
repayment process. This seems clear, inasmuch as students from other chiropractic
colleges in the same program were able to repay their loans with significantly fewer
defaults. Is it just coincidental or a lack of ethics? After all, this is the same leadership that
has brought embarrassment to our profession with its infamous Money Hum.
Recently, the federal government announced that all Medicare and Medicaid payments
to deadbeat docs will be withheld. As well, one state assembly passed a law which deems
failure to repay student loans (or child support) as unethical, and threatens to withdraw
the professional licenses of those deadbeat docs. Apparently, legislators and government
officials believe that unethical acts by health professionals includes non-payment of student
loans.
Why hasn’t this
been as obvious to us as it has been to the press and legislators? The
series about "The 'Life' and Times of Sid Williams" as well as a revealing follow-up
article, "Student DEBT",
about
loan defaults, to the tune of $28.2 million (12). The Associated Press picked up this story
and distributed another embarrassing article entitled, "Life College Students Top Federal-
loan Default List."(13) Dr. Williams' ineloquent response was just as embarrassing: "My
students are not skunks or scalawags. They got trapped in something they can't help.” (13)
Again, the question remains unanswered by Dr. Williams: Why have other chiropractic
colleges in the same program had much smaller default rates? The issue of student defaults
sends another red flag to the public and the press, and then we wonder why our public
image is again soiled?
|
“My students are not
skunks or scalawags. They got trapped in something they can’t help.” -- |
CONFLICT OF PRINCIPLES
Perhaps the most contentious issue on ethics stems from the endless argument about
vitalistic vs. mechanistic philosophies in chiropractic. While mechanistic proponents aim
their practices toward neuromusculoskeletal problems and mechanical low back pain,
vitalistic practitioners focus on so-called ethereal issue--the “force” behind the matter--
Innate Intelligence. The vitalistic philosophy espoused by straight chiropractors makes
great copy for motivational speakers, lifting the importance of chiropractic practice
beyond back pain and nerve dysfunction, the actual problems the majority of chiropractors
treat.
“It Works” is their rallying cry, despite the lack of evidence, other than occasional
anecdotal cases. Joe Keating, Ph.D., has written critically of this hallow
statement that has been the motto of chiropractors for nearly a century. Research is
secondary to these proponents of anecdotal “wonder” stories. As Mr. Keating has written
about extensively, chiropractic is short on the facts, while heavy on the rhetoric.
“Then again, who cares [about research]? It just WORKS! Indeed, the profession seems to suffer from a psychiatric disorder, what might be called Trabajitis Chiropracticus (It Works, It Works, It Works!) The condition is
characterized by a hardening of the categories, a lock of critical
assessment of causation, a tendency to substitute marketing slogans
for data, and a swelling of the neural tracts between the cortex and
the tongue. The growing experimental evidence in support of the
analgesic value of spinal manipulation for low back pain patients is
being inflated ad absurdum to suggest the "truth" of so-called
"chiropractic principles." Ironically, as greater scientific support for
chiropractic procedures becomes available, many in the profession
seem determined to prove that chiropractors are generally unable
to critically evaluate this new information.” (28)
“Rigor mortis is the only thing that we can’t help!” (6) will long echo in the minds of
many, as Prof. Keating indicated. Unfortunately, research cannot support these enigmatic
contentions since metaphysical explanations are impossible to prove, consequently
creating a pseudo-religious attitude (and image) about practice. While it is not
unthinkable to believe the chiropractic adjustment may free interference in the “force”
behind the matter, in this age of accountability is it little wonder these proponents find
themselves at odds with the insurance and medical establishments? Insurance payers and
other health care providers are looking at methods that are clinically and cost-effective.
|
“Indeed, the profession
seems to suffer from a psychiatric disorder, what might be called Trabajitis Chiropracticus (It Works, It Works, It Works!)” --Joe Keating, Ph.D. |
They are not looking at theories or “philosophy” that preach unproved concepts. Results
based on facts, not rhetoric, is the name of the game today.
As attorney George McAndrews wrote in a letter to one such “principled” DC,
“Chiropractors are just not getting
the message. Philosophy cannot show up on a computer screen. Neither can
theory. Like it or not, the conservative right and the progressive left are
going to have to come to grips with the simple fact that the era of
accountability is at hand.” (McAndrews George. Private
communication.
In this light, is it ethical for college presidents and “philosophers” to
encourage students and young practitioners in pseudo-religious rhetoric/dogma that is not
based in fact or science? How long can they ignore chiropractic’s actual clinical
effectiveness? Just when will the chiropractic hyperbole stop? Only when they accept
scientific methodology and valid outcome assessments. But, with their “anti-scientific”
mindset, that may be a long time coming, if ever. Actually, it may take a new generation
of better educated chiropractors who play within the rules of research rather than dogma.
George McAndrews address this problem about scientific credibility versus chiropractic
hyperbole.
“Make no doubt about it, no one is running from the subluxation complex. Society and the political and economic worlds in which we exist have simply put the theory under a microscope: either prove it exists and that real health problems are affected by it or surrender all right to be compensated for taking care of the phenomena. Argument will no longer suffice--data, results, costs are the order of the day.
“Those who are destroying the
subluxation complex and the philosophy of chiropractic are the demigods in the
profession who wish to treat their followers like members of a cult--‘believe
it because I and other leaders before me said it; don’t rely on the evil world
of science and data to confuse the issues.’” (McAndrews, George. Private communication.
|
“Chiropractors are just not
getting the message.” --George McAndrews, Esq. |
EDUCATED VS. INNATE
The academic indifference at some straight chiropractic colleges is also an ethical
consideration. It is odd to have a teacher stand up in my class the very first day
and say, "This is your textbook, but don't take it seriously because we don't want to have
your Educated Mind interfere with your Innate Mind." The anti-science attitude at some
colleges is to be expected when B.J. Palmer himself reportedly said, "Education
constipates the mind!" (14)
Regrettably, some chiropractic educators who fashion themselves after B.J. still regard
education as a hindrance to the development of the Innate Mind; hence, to the
development of a “principled” chiropractor. Only in certain rather obvious “straight”
chiropractic institutions do we see this anti-intellectualism embraced wholeheartedly.
Herein lies the dilemma: science versus vitalism, and the effect upon ethics. To
proponents of old-time chiropractic philosophy, “research be damned, stick to your
philosophy.” Or, as Sid Williams once said, “To hell with the scientists. They haven’t
proven a bumble bee could fly.” (15)
“Straight chiropractic,” according to Joseph B. Strauss, DC, editor of The Pivot Review(16),“has come to be not an alternative treatment for disease, but an alternative to the treatment of disease...Straight chiropractic does not address disease or its cause in any manner... Therefore, to perform tests associated with the diagnosis of disease processes would undermine that objective... To do these procedures is detrimental to the patient’s
understanding of straight chiropractic and hence dangerous to their health... When it comes right down to it, diagnosis is just as foreign to straight chiropractic practice as is automobile repair.”
|
“Education constipates the
mind!” --B.J. Palmer |
To the adherents of scientific inquiry, straight chiropractic philosophy is seen
more as dogma than as true philosophical inquiry. To those caught in between each
extreme, the problem lies with following guidelines/outcome assessments while adhering
to traditional meta-physical chiropractic dogma. Keeping the faith versus keeping
legitimate has always been a problem for chiropractic practitioners.
Dr. Kerwin Winkler, former chairman of the ACA Board of Governors, also mentioned
this plight in an editorial. (17)
“We, in 1993, have no right to let a rigid philosophy that says the subluxation complex causes every disorder and consequently, the correction of the complex will cure those disorders, to be our only guide. The world has a right to criticize us if we will not bend from that belief to the point that the life of a child or adult is placed in jeopardy... It is time to tear down the walls of isolation, bridge the moats of prejudice and work as a separate and distinct brigade of the same army. The enemy is not medicine; the enemy is disease.”
As I recall, chiropractic is an art, a science and a philosophy. But nowhere is it written
that chiropractic is a religion (or, for some, a dogma), which is exactly
what the super-straights have created. Ascribing elements of higher consciousness to
Innate is ridiculous and listening to the “wee small voice from within” (18) is delusional.
What's next? Has our profession become a bastion for pseudo-religions, metaphysicians,
new-agers, or what? Apparently, on the fringe of the chiropractic profession, it certainly
has become a focus for the eccentric and extreme viewpoints.
|
“...diagnosis is just as
foreign to straight chiropractic practice as is automobile repair.” -- |
BEGIN WITH THE END IN MIND
The question remains: Has traditional chiropractic philosophy and low-brow ethics taken
our profession where we want to be? Inasmuch as most people use chiropractors for
musculoskeletal problems, few Americans consider DCs as primary providers for the
majority of their health needs. Although vitalistic proponents maintain their wish to be
considered as PCPs, the medical and insurance worlds fail to agree. Indeed, perhaps
Stephen Covey’s insightful adage applies here: “It’s no fun to climb the ladder of success
only to realize it’s leaning against the wrong wall.” (19)
Has chiropractic vitalism led our profession to a position that cannot be supported by
clinical results or scientific inquiry? Is this why this super-straight crowd must rely upon
metaphysics to justify itself since science cannot? Apparently so, because just as with any
religion, faith supersedes when science cannot prove their claims.
The introduction of adjunctive methods of healing into the art of chiropractic practice
has long been the source of debate between the mixers and straights. Wrapping themselves
in the banner of B.J. Palmer, the proponents of straight chiropractic have rejected the
introduction of any other therapeutic procedures into their practices, and their prideful
disdain for anyone who has is easily detected. In a private communication, a
supporter of the conservative right made his dislike of modern chiropractic perfectly clear
with his cynical view of broad-scope chiropractors, referring to them as “allopractors.”
To his way of thinking, an “allopractor” is any DC who uses chiropractic and other
procedures to diagnose and treat symptoms, which includes the majority of DCs.
In line with his belief, in the Jan/Feb (1998) issue of Today’s Chiropractic, Dr.
Williams also wrote disparagingly about chiropractors who use other therapies aside from
spinal adjustments, calling it the practice of “chiro-opathy,” and likening it to snake oil
salesmen of the past who were run out of town for their scams.
While his call for ethics may sound noble to some, Dr. Williams then continues in his
Lyceum article, “Learning a Lesson from the Snake Oil Salesman,” to describe his
version of perfectly legitimate health care in which he describes the only “auxiliary
procedure” required is to consistently and diligently apply--the “You’re Better”
protocol.
“You tell your patients that they look better... they’re going to walk better and feel better... That is perfectly legitimate health care.”(20)
Ironically, this “You’re Better” protocol actually smacks of the snake oil
salesman who claimed that their product would “cure anything that ails you,” when, in
fact, it was only a sham remedy. It appears that Dr. Williams is endorsing exactly what he
intends to criticize, yet he remains oblivious to this likeness. To him, convincing
patients that “they look better” and regarding this as “perfectly legitimate health care” is
obviously his attempt of mind-over-matter. Oddly, learning a lesson from a snake oil
salesman appears more to be a Freudian slip for Dr. Williams than a slap at “chiro-
opathy”.
This attitude is commonplace among the supporters of straight chiropractic--the
Innatists and “subluxation-based” practitioners. Adherents to “old-time” chiropractic
philosophy often embrace metaphysical phrases, anecdotal stories and vitalistic concepts
to express themselves, avoiding any factual or scientific reasoning in this debate. Their
modus operandi seems to be heavy on the rhetoric, light on facts.
This approach is not lost among other observers. For instance, Dr. Winterstein addressed this issue.
“If that segment wishes to engage in subluxation-based practices, and that is within the statutory privilege, then so be it. If that segment of the profession wishes, however, to define chiropractic as the location and correction of vertebral subluxations, then there is a problem. Our purpose is not to inconize the subluxation... Our purpose is to help our patients... To that end, I suggest we all concentrate on patient-based education and on patient-based practices.” (27)
Dr. Jerry McAndrews, also described his attempts to bridge the gap with the straight,
subluxation-based segment within chiropractic, only to be discouraged by their resistant,
dogmatic attitude of “we’re right, the profession’s wrong.”
“Just where is the
research on the things these people talk about? We only have to take a
look at the so-called “Wyndham Guidelines,” that have some 40 references that
were pre-1940....Conversation proves to be a waste of time when you’re dealing
with fortune-telling-like faith. (McAndrews, J. Private communication.
Joe Keating, Ph.D, recognized this intransigent attitude among some chiropractors
about the value of research, some viewing it more as a threat than an ally, and rallying
behind their historical call that ‘it works, enuf said!’ On the other hand, Mr. Keating
suggests some chiropractors need an adjustment above Atlas.
“But what should the DC adjust at this point in time? Attitude! I
know, we've been talking for nearly a century about how
chiropractic is a ‘well developed science,’ but that's nonsense. But
the old war stories will not carry us much further. Certainly, few if
any scientists are swayed by such rhetoric, and third-party payers
are not impressed. Moreover, if chiropractic's market share (10
percent of the population?) is any index, the traditional chiropractic
rhetoric has not been very convincing to the general public. Write it
off to abuse by organized medicine if you wish, but we've been
strutting around without data for nearly a century, and we still have
only 10 percent of the market. The best press we've ever received
has come on the coat tails of research by non-chiropractors.”
|
“Conversation proves to be
a waste of time when you’re dealing with
fortune-telling-like faith.” --Dr. Jerry McAndrews |
DOGMA VS. RESEARCH
“Objectivity and dogma do not coexist well. One could say that juxtaposing these two words produces the ultimate oxymoron. In our profession, at this time some members are thoroughly dedicated to the dogma that has been part of chiropractic since its beginning... early principles have been turned into contemporary dogma by the zealots of the profession.... If we say ‘it works,’ people have the right to ask how we know it works. We must provide some answers that are more than just ‘I had a patient,’ or even ‘I had a hundred patients and they all got better.’”(26)
Indeed, it’s very difficult to discuss objective chiropractic science when the Innatists
wrap themselves in their religious banner, convincing themselves that they alone are
carrying on the Big Idea of “principled” chiropractic with the simplistic attitude of “it
works.” This conflict between dogma and valid research has hindered the growth of our
scientific research as well as the public’s understanding of our professional scope.
Mr. George McAndrews remarked about the irony of “principled” chiropractic.
“Cute phrases like ‘Above-down, inside-out’ or ‘The Big Idea,’ may be soul-stirring at chiropractic conclaves; they are meaningless to economic experts (or even to HMOs) who must deal with the real problems of health care costs. It is the demigods who fear real research and fear advances in real knowledge who threaten your philosophy and your profession. Fact has a way of squeezing myth. Sometimes what is credible is not true.
Beliefs die hard. Again, I believe that
research can result in an explosion of need for the services of chiropractors.
I believe that certain headaches, ulcers, respiratory problems, allergies, etc.
may prove to be singularly responsive to correction of the so-called
subluxation complex. It will be a real shame if the fringe elements and the
demigods in the profession destroy any hope of survivability by putting
chiropractic in a death grip while the American Chiropractic Association and
other research oriented bodies [NCMIC, FCER] attempt to deal with the real
problems of the 1990’s--research and active representation before government
and third party payers.” (McAndrews George. Private
communication.
Mr. McAndrews shared his concern about the future threats to chiropractic, mostly
coming from within our own ranks.
“...I consider them [the Innatists] more of a danger to
the survival of the profession than the American Medical Association ever was. ‘Separate and distinct’ has a nice ring to it. The same might be said for the phrase ‘ghettoized and weird.’ The doctors to whom I make reference seem happy with the second phrase. ‘Separate’ need not be synonymous with the word ‘ghettoized’ and ‘distinct’ need not be
synonymous
with ‘unrecognizable’ or ‘weird.’...A doctor who primarily focuses on the neurobiomechanical aspects of health need not be ghettozied or weird. Such a person is not a ‘backslapper’
or ‘technician’ and a person who is capable of utilizing well-proven additional
modalities or services in his or her practice is neither a traitor, a heretic,
a ‘toid,’ nor a ‘medipractor.’ The
fact that Palmer, as brilliant as he was, or some other leader said something
does not make it true. Chiropractic is a health care profession that is
based on scientific principles. It is not a religion.” (McAndrews George. Private communication.
One veteran chiropractor wrote to me describing his impression of the
fringe elements and their quasi-religious, pious attitudes, referring to them as the “Ouiji
board” chiropractors who manipulate young minds with their mystical sayings and
charismatic personalities, playing on their love of chiropractic and exploiting
impressionable DCs in the end for their ultimate profit with visions of sugar plums in
terms of big practices and income. (Rowe J. Private communication, April 14, 1998)
Richard H. Tyler, DC, former associate editor of Dynamic Chiropractic, in a
1990 editorial, mentioned this religiosity phenomenon in some factions of chiropractic.
“Members of the profession quote him
(BJ Palmer) like the Scriptures, hang his picture on their walls, collect his
books, and buy his home to make a shrine out of it. Folks, this is sick. Any
human who puts his pants on the same as I, and is so worshipped, is a little
strange. The parallels are all around, because it seems human nature wants to
adore one of our own. Jim Bakker, for example, could
be proven to be the biggest con artist in the world and even if proven guilty,
would still have a mindlessly loyal following. There is always that charismatic
character who can bend the will of his follower, and
B.J., presumably well motivated, certainly had that power. As a member of the
profession, this, to me, is embarrassing... So let’s take down some of those
pictures of the old fellow, stop quoting him like he was a god, and please get rid
of that temple he lived in, in
|
“Let’s say hello to
progress by saying bye bye to B.J..” --Richard H. Tyler, DC |
SHOOTING OUR OWN FOOT
At the 1998 ACA
Convention in
more memorable instances from the Wilk v. AMA antitrust case, and noted his frustration
with the chiropractic profession’s inability to organize itself into a unified front to fight
against the AMA’s continual onslaught.
“5 percent of you are cultists, 5 percent are freaks, and the rest of you, who offer care that uplifts the quality of life for millions of Americans, keep your mouths shut!” (22)
While the audience laughed at Mr. McAndrews’ comment, he did hit a nerve
nonetheless. Chiropractic does have a large silent majority which seems content to tolerate
|
“5 percent of you are
cultists, 5 percent are freaks, and the rest of you... keep
your mouths shut!” --George McAndrews, Esq. |
the fringe elements and to let other people fight their political battles, allthewhile
wondering why our situation doesn’t seem to be improving.
One of the goals of the AMA’s anti-chiropractic policy was to keep our
profession split and, oddly, some chiropractors are actively working to achieve
this goal for them. The obstructionist policies of the
Dr. Williams now objects to raising the minimum GPA for students
proposed by the CCE (and recently endorsed by the ACA House of Delegates),
which he is presently suing over this issue. Can anyone understand why the
president of a chiropractic school would not insist on having only the very
best students with the highest GPAs? Do you think we would hear the same
objection from the president of a medical school? Perhaps it’s the Money Hum
thing and Williams is afraid higher standards might cut into his own cash-flow
if unqualified or marginal students were excluded. Not only has his college
flooded the marketplace with new DCs in the
Mr. Mark Goodin, the ACA's former legislative consultant, was painfully honest in his
opinion of chiropractic's self-inflicted wounds.
"That enemy, of course, is this profession itself - and those elements within it that are unwilling to deal forthrightly with the charlatans, hucksters, profiteers, and wild-eyed 'philosophers' who put their own selfish interest ahead of science and the ethical and professional demands that every true healer must shoulder.
"They pass themselves off as 'educators,' but cut corners and counsel their students with messianic appeals on ego and self-promotion. They spend their out-of-practice careers in a cause to stop legitimate reform. They bring nothing of value to the future of this profession - but will resist, oppose, reject, undercut, and nit-pick any effort to lift it up through higher accreditation, more comprehensive education, real standards of care and more ethical practice requirements."(23)
|
"They pass themselves
off as 'educators,' but cut corners and counsel their students with messianic
appeals on ego and self-promotion.” --Mark Goodin, former ACA lobbyist |
Why do we tolerate the charlatans, hucksters, profiteers, and wild-eyed
'philosophers' who taint our profession’s image, who obstruct political unity and espouse
untrue science that cannot withstand the test of research; who recruit patients with
gimmicks, and who mislead naive students and young practitioners with dogma and
promises of great wealth? Is it because professional ethics is mostly lacking in
chiropractic? Is it due to a laissez faire attitude within chiropractic where anyone can say
anything under the guise of “philosophy”? Or is mainstream chiropractic simply scared to
confront these fringe elements, fearful of litigation or argument?
Have we become a profession ruled by a vocal minority (the Ouiji board practitioners),
hell-bent on keeping our profession in the past with dogma dominating over science,
with leaders who espouse anti-scientific rhetoric, with practitioners who give free spinal
exams and $10 office visits, all the while masquerading as “principled” chiropractors who
preach unproved health gospel? Is this characterization wrong, or painfully accurate? You
tell me.
Mr. George McAndrews summarized this predicament when he said, “Chiropractic has
survived because of what chiropractors do, not what they say.” (McAndrews, G. Private
communication, August, 1998) Fortunately, despite much of the unproved chiropractic
hyperbole, the good clinical results patients have gotten in chiropractic offices over the
past century have helped to attain a strong following among satisfied patients.
Dr. Chester Wilk
wrote about this very issue in a September, 1993 edition of the
Dynamic Chiropractic:
“A top priority in every state chiropractic association should be establishing a nationally standardized code of ethics, quality and standard care, then have the commitment to enforce it thoroughly. This may provoke outcries from some chiropractors who will rationalize that this is ‘brother against brother’ and that we should live and let live, but this is pure nonsense. For a state association to look the other way and ignore illegal conduct within its ranks is to become guilty of a conspiracy of silence. It would, in effect, be getting in bed with a prostitute.” (24)
In another issue of Dynamic Chiropractic, Dr. Peter Martin, president of
Palmer-West, wrote along the same line:
“...I can say that I am as sick and tired of having to react politically by cleaning up the messes of an irresponsible few as is anybody else.... Unfortunately, it seems that the irresponsible few, like the biblical poor, will always be with us, forcing the majority to compromise in ways they might not prefer in order to protect the profession.” (25)
Just as Mark Goodin, Chester Wilk and others have challenged our profession to
regulate itself, George McAndrews also has made this call.
“It seems to me that someone just had to call
the bluff of the demigods before they do more damage. Good-bye chiropractic if
that never happens!” (McAndrews George. Private
communication.
It might never happen unless the chiropractic profession and its press takes on this
sensitive issue. Unfortunately, much of the chiropractic press has avoided this discussion,
fearful of the litigatious history of the powers-to-be who have repeatedly threatened
lawsuits whenever their platform is criticized. Instead, it appears that our state
“Chiropractic has
survived because of what chiropractors do, not what they say.” --George
McAndrews, Esq.
and national associations have taken the position of letting the emperor
wear no clothes, much to the chagrin of mainstream chiropractors who can
easily see the nakedness. Indeed, it may take three generations of chiropractors before this
damage is undone, because for now, it seems this profession and its press is unwilling to
deal forthrightly with this important issue of ethics, to confront the fringe elements or to
censor their behavior.
PURSUIT OF IMAGE OR IGNOMINY?
As Louis Sportelli mentioned in his article, The Pursuit of Image,
“Thus, a new era of professional ethics is emerging, and the chiropractic profession must recognize the challenge to meet the expectations, or suffer the consequences.” (3)
Are we, as a profession, willing to change our public image by containing our tacky ads,
our free spinal exams, free chicken dinners, to name but a few of the many questionable
advertising gimmicks currently in use? Are we willing to upgrade our clinical services, to
contain the outlandish and unproved claims about chiropractic’s scope of care, or to deal
forthrightly with the fringe elements who continue to soil our collective image? If not, are
we willing to deal with the consequences of being fringe practitioners on the edge of
acceptance, allthewhile wondering why we’re taking care of only 10% of the population?
In fact, it does seem that chiropractic ethics is an oxymoron which this profession and
its press have ignored for too long. How effective can any public relations campaign or
political influence be when these ethical issues remain unaddressed, let alone rectified?
Isn’t it time to address these ethical issues before we are attacked and ridiculed again by
the elite press for actions of the fringe elements? Indeed, can we regulate ourselves as Drs.
McAndrews, Sportelli and Wilk suggest? I hope so.
References:
1. Esteb WD, A Patient’s Point of View: Observations of a Chiropractic Advocate, Orion Associates, 1992, pp. 35.
2. Esteb WD, ibid., pp. 232.
3. Sportelli L, In pursuit of image; chiropractic in the next millennium, JACA vol. 32, no .5, May 1995. pp. 38.
4. Agency Publication: Georgia Board of Chiropractic Examiners Rules, Feb. 1993.
5. Mailbag, Journal of the ACA, vol. 35, no. 4, April 1998.
6. Health Magazine, July, 1993.
7. Bigos, S et al. Acute Low Back Pain in Adults, Clinical Practice Guidelines No. 14. Public Health Service, U.S. Department of Health and Human Services, AHCPR Publication No. 95-0642, Rockville, Md.: Dec. 1994.
8. Manga, P et al. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain. Ontario Ministry of Health, 1993.
9. McAndrews, Journal of the ACA, 1992.
10. Christensen,
KD, Rehabilitation Guidelines for
Chiropractic,
11. Williams, SE,
numerous lectures at
12.
13. The
Associated Press, “
14. Wardwell W. Chiropractic:
History and evolution of a new profession.
15. Campus Life, Dec. 1993.
16. Strauss, Joseph B., The Pivot Review, vol. IX, no. 5, 1993.
17. Winkler, Kerwin, Outlook;
Aug. 1993
18. Williams, Sid E., Lasting Purpose, Health Communications, 1996. pp 71.
19. Covey S.R., The 7 Habits of Highly Effective People, Fireside, 1990.
20. Williams, Sid E, Lyceum, Jan/Feb, 1998, Today’s Chiropractic.
21.
22. McAndrews,
George, speech before ACA Convention,
23. Goodin, Mark,
“Winning the
24. Wilk,
25. Editorial
Staff, Dynamic Chiropractic, The Cost
of Disunity--Did
26. Winterstein,
James F, Making the Best Better, Dynamic
Chiropractic,
27. Winterstein, James F, Patient-Based
Practice, Dynamic Chiropractic,
28. Keating, JC
and Bergmann, TF, It works, it works, it works!, Dynamic Chiropractic,