The Appropriate Practice Scope of Chiropractic May Be a Political Question, Not a Scientific One

This article is part of a series on Health Policy. See also:

  1. Ground Control to Major Reform
  2. Hospital Salaries Could Cut Care Costs
  3. The Appropriate Practice Scope of Chiropractic May Be a Political Question, Not a Scientific One
Chiropractic isn't the only legal business with questionable scientific underpinnings

Chiropractic isn’t the only legal business with questionable scientific underpinnings

A Colorful History

At the turn of the 20th century, medicine was at a turning point. Unscientific practices like bloodletting, bonesetting, and magnetic healing still pervaded medical practice. On the other hand, trust in the scientific method was mounting. Darwin’s controversial Origin of Species, published several decades earlier, was gaining acceptance. Louis Pasteur proved that life, including bacteria, can’t generate itself spontaneously, and Robert Koch developed a testable set of postulates for determining whether a particular bacteria was the cause of an illness. A future of medicine could be envisioned in which medical intervention was chosen from the pages of science alone, rather than from the pages of history.

D.D. Palmer was, then, what one might call a conservative. He had opened a magnetic healing clinic 10 years earlier in his hometown of Davenport, Iowa. He believed that every human possessed a “vital source,” the integrity of which was crucial to one’s health. And, in 1895, he cured his first patient—a deaf man named Harvey Lillard—by manipulation of Lillard’s spine alone. The field of chiropractic was born.

According to the chiropractic doctrine, all human disease stems from a phenomenon called vertebral subluxation, a misalignment of the spine that interferes with the body’s innate intelligence, a vital energy source representing God’s presence in man [1]. The only way to cure the ailment is to correct the subluxation by spinal manipulation.

Chiropractic was capable of working miracles. A deaf man could hear; soon after, Palmer cured another patient of heart trouble. Indeed, D.D. Palmer strongly considered establishing chiropractic as a religion—in part, actually, to gain legal protection under the Free Exercise clause of the First Amendment! He decided against it, though, largely to avoid confusion with Christian Science [2].

In the early 1900s, D.D. Palmer was jailed for practicing medicine without a license. Soon after, though, he was back, crusading for chiropractic, now with his charismatic son B.J. by his side. And their success was considerable. By 1925, more than 80 chiropractic institutions had been established in the United States. Many were “diploma mills” offering “an easy way to make money.” [1] Many were “at one another’s throats.” [1] Their core tenets remained consistent, though, and the chiropractic profession gained considerable influence.

Modern science kept making strides, but chiropractors stuck to the doctrine. The gap between conventional medicine and chiropractic had widened “from a fissure into a canyon.” [1].

Two Factions

In the 1930s, in a climate characterized by the increasing advancement of scientific medicine, chiropractic saw a split into two camps: the “straights” and the “mixers.” These terms originate from the days of B.J. Palmer, who deemed himself a “straight” chiropractor, and scorned those who “mixed” the use of other instruments and techniques into their trade.

Modern-day straights still prescribe by the original doctrine set forth by D.D. Palmer. All diseases are a result of vertebral subluxation, and thus spinal manipulation can cure all disease. Mixers, on the other hand, retain chiropractic spinal manipulation techniques—mainly for the treatment of lower back pain—but also use other techniques for the betterment of patients, including diet and lifestyle recommendations. Mixers tend to be receptive to advances in modern medicine, and often act broadly as primary care providers.

About 20% of chiropractors today are straights. But by portraying themselves as “purists” and “heirs of a storied lineage,” they achieve influence disproportionate to their numbers [3].

Legal Battles

In 1963, the American Medical Association (AMA) established the “Committee on Quackery,” aimed at containing and eventually eliminating the field of chiropractic. The AMA deemed chiropractic an “unscientific cult” and urged its doctors not to associate with “unscientific practitioners.” [4]

The AMA’s boycott of chiropractic culminated in the landmark 1987 case Wilk v. AMA. Chester A. Wilk, Doctor of Chiropractic, and four co-plaintiffs, sued the AMA for anticompetitive behavior—and won! Judge Getzendanner noted that, while chiropractic isn’t supported by scientific evidence, it’s backed by plenty of anecdotal evidence. Interestingly, though, many reports of chiropractic’s success came from mixers, who, in effect, came to the rescue of the straights! This story evokes the memory of D.D. Palmer himself, who, in his legal defense, referenced the work of a mixer whom he had previously denounced. History really does repeat itself!

At any rate, the so-called Trial of the Century was a huge win for the field of chiropractic. Since then, chiropractic’s strength and political base has only grown. Nowadays, chiropractors enjoy coverage by many insurance policies, and even the occasional physician referral.

Still, though, scientific support remains limited. Chiropractic has proven effective, according to some studies, for the treatment of lower back pain, but has not been shown to be an effective treatment for any other disorder [3]. From a scientific standpoint, it seems that mixers ought to have free reign to practice, but perhaps straights should be more strictly regulated. And, in fact, straight chiropractors aren’t able to gain licensure in many (but not all) states [6].

Towards Consumer Freedom

The real issue at play here, though, may not be does chiropractic work, but rather, should chiropractic be allowed even if it doesn’t work. After all, even straight chiropractic is generally considered safe when performed properly. There have been reports of adverse effects, including serious or fatal ones, but these are extremely rare [3]. Generally, it seems that, though chiropractic may not be helpful, it’s not harmful either.

And the legal precedent seems to protect businesses with questionable scientific underpinnings, so long as they don’t particularly hurt the customer. Many attempts to ban palm-reading, fortunetelling and astrology have failed, with opponents claiming the right to free speech. Just a week ago, a ban on psychics in Deadwood, South Dakota was repealed [7]. About a year ago, a similar ban was struck down in Louisiana [8]. Fortunetelling may not be scientifically supportable, but that doesn’t mean that it necessarily ought to be banned. After all, plenty of people leave the psychic’s office feeling better. And the same is true of the chiropractor.

Of course, Ponzi schemes and con-artistry certainly aren’t legal. We must ask ourselves whether the benefits—even if these consist of nothing but the comfort of being listened to and the hope that things might get better—outweigh the costs. Straight chiropractic seems to fall on the good side of that line.

References:

  1. Chiropractic: A Critical Evaluation from the Journal of Pain and Symptom Management
  2. Actual letter written by D.D. Palmer on chiropractic as a religion
  3. Chiropractic: Origins, Controversies, and Contributions from the Journal of the American Medical Association
  4. Chiropractic and Public Health: Current State and Future Vision from the Journal of Manipulative and Physiological Therapies
  5. Summary of The Wilk Case
  6. ADJUSTING THE ROLE OF CHIROPRACTORS IN THE UNITED STATES: WHY NARROWING CHIROPRACTOR SCOPE OF PRACTICE STATUTES WILL PROTECT PATIENTS
  7. Deadwood City Commission repeals ban on psychics
  8. Fed Judge Strikes Down LA Ban on…Fortunetelling, Palm Reading & Astrology
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4 comments on “The Appropriate Practice Scope of Chiropractic May Be a Political Question, Not a Scientific One

  1. Albert Aboseif says:

    Great article, the history behind Chiropractic is quite fascinating. I’d love to see an article discussing the histories of MD & DO and the differences between the two currently. This may be a good starting point : http://www.forbes.com/sites/sciencebiz/2010/10/29/second-thoughts-on-osteopathic-medicine/

    Keep the good content coming!

    • Josh says:

      Thanks for your comment. I’m glad you liked the piece.

      DO also has a very interesting history. Its origins, actually, are very similar to those of chiropractic. Osteopathy was founded in 1874, just 10 years before chiropractic, by Andrew Still, MD. His new branch of medicine was based on bonesetting, a popular belief of the time, which held–much like chiropractic–that all disorders of the body are the result of misalignment of the bone and spine. When chiropractic came around 10 years later, osteopathy sought to differentiate itself from the emerging field, calling it a “bastardized form of osteopathy.”

      Today, DOs receive training equivalent to that received by MDs. Additionally, however, they’re trained in Osteopathic Manipulative Medicine (OMM) a modern carry-over of Still’s original beliefs. Nowadays, DOs certainly do not prescribe by Dr. Still’s belief that bone misalignment creates all disease. They might, however, use OMM for treatment of lower back pain, a treatment shown to be effective according to some studies.

      DOs, in my experience, are actually quite resistant to pseudoscientific ideas. They realize that the scientific backing behind OMM is limited, and would be unlikely to use it to treat anything besides back pain. I might compare DOs to mixer chiropractors who also possess a standard medical education.

      I think the reason DOs have been able to earn equal rights to MDs, while chiropractors haven’t, is their general respect for scientific medicine. In that sense, I think chiropractic has been restrained by the persistent resistance to modern science demonstrated by the straights (and, to some extent, the mixers too). Incidentally, though, Osteopathic Medicine’s fight to gain equal rights to MD was not an easy one. Osteopathy, along with chiropractic, was a target of the AMA’s Committee on Quackery. And the Osteopathic Medicine constituency also won several important court cases that charged the AMA with anticompetitive behavior.

      So it seems like, after all, the medical establishment has been successful in containing pseudoscience in medicine. The reason that respect for the DO degree is so high nowadays is the constituency’s consistently-high standard for scientific rigor.

      Actually, just a few days ago a merger was announced between the ACGME and the AACOM, the respective accreditation bodies for MD and DO residency programs.

  2. Ben says:

    “The legal precedent seems to protect businesses with questionable scientific underpinnings, so long as they don’t particularly hurt the customer.” This legal precedent might also enjoy philosophical justification. “Paternalism”, in political philosophy, refers to interference with a person’s liberty for a good which the person does not recognize as such. Gerald Dworkin, in an excellent paper, proposes a set of sufficient conditions for justified paternalism. These conditions include: (a) Failure to rationally evaluate dangers or to act on these evaluations, (b) Extreme psychological or sociological pressure, and (c) Potential for significant and lasting harm. Chiropractic seems to satisfy none of these conditions.

    Though chiropractic’s personal consequences might not justify a ban, its societal consequences might. Paternalism particularly applies in cases of self-harm. Chiropractic, though, could actually harm others. An unfavorable outlook — or experience — with chiropractic medicine might instill a disapproval of medicine as a whole, particularly if chiropractors are licensed under similar a regulatory process as are doctors. Provided that this ensuing distrust wouldn’t reflect the merits of standard medicine — and that, by consequence, sound medical service could go unadministered — this distrust could be considered a societal harm. Banning chiropractic might be justified under the much broader “harm principle” (attributed to Mill).

    An obvious solution would be to establish a sturdy cordon between chiropractic and more traditional branches of medicine. Chiropractors wouldn’t be licensed as physicians, but as, well, chiropractors, in the same way that psychics are licensed as psychics. This solution could preserve the liberty of chiropractors and their patrons, while preventing incident harm upon medicine as a whole.

    Chiropractic seems distasteful particularly because its benefits — attributable, in all likelihood, when they exist, to the placebo effect — are masqueraded as the results of medical rigor. Abstracting away from the particular undesirabilities of chiropractic medicine, though, the placebo effect seems like something we might embrace. In The Varieties of Religious Experience, William James describe a certain broad pattern of religious belief and attitude he refers to as “healthy-mindedness” . Healthy-minded believers eschew all negative thoughts whatsoever — sometimes going as far as to deny that evil or pain even exist — in favor of continual optimism, praise, and joy. Healthy-minded thinkers often also look to God and religion for physical healing. The results seem promising: James quotes many testimonies of people who’ve found respite from physical ailments — ranging from depression to “nervous prostration” to addiction — through prayer. Because this optimistic religious movement abandons pretensions to scientific rigor, it might seem more appealing.

    • Josh says:

      US chiropractic schools are actually accredited by the Council on Chiropractic Education (CCE). This is very different from the AAMC, which accredits US MD programs, and from the COCA, which accredits US DO programs. Interestingly, the ACGME now accredits both MD and DO residency programs (see my reply to Albert’s comment).

      CCE accreditation requires a mixing curriculum; actually, though, some states don’t even require education by a CCE-accredited school to practice chiropractic! (Source 6) Now that’s frightening. Also note, though, that psychics only require licensure in some cities and states.

      Anyway, the physician and chiropractic licensing bodies are distinct, but your point is right in that the potential to confuse chiropractors and physicians is a potentially-dangerous one. The AMA and AOA do enforce modest restrictions on who can call themselves Doctor. An MD or DO may call himself Dr. Smith, without explanation, but a chiropractor must call himself Dr. Smith, the chiropractor. Still, though, the potential for confusion is high. And, while a chiropractor will likely not inflict any damage in a regular treatment session, the greater danger is that a patient, upon feeling chest pains, will drive straight to the chiropractor’s office, instead of the emergency room. This danger is especially exacerbated given that the validity of chiropractic spreads greatly by word of mouth. It’s possible that an entire community might begin to view chiropractors as “the truer doctors.” At this point, as you mentioned, the scope of chiropractic’s danger becomes a societal one, not just an individual one.

      As for Healthy-Mindedness, I’m not surprised to hear that this approach has proven effective. Many believe that the power of the placebo is greatly understated, and even scorned, in modern medicine, while it should be embraced. And I agree that God, as opposed to Spinal Manipulation, is a better placebo, since the former makes no assumptions about scientific rigor. Still, though, Healthy-Mindedness should be viewed as a complement, rather than an alternative, to modern medicine. It certainly won’t cure a brain tumor. And, for the love of God, please don’t try it on your kids.

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