Ethical Analysis of Vertebral Subluxation Based Chiropractic
Ethical Analysis of Vertebral Subluxation Based Chiropractic
Stephen Perle, DC, MS
Chiropractors often talk about philosophy. However, we lack a consistent understanding of philosophy: the love of wisdom.1 Philosophers exchange ideas within four basic domains: logic, metaphysics, epistemology, and ethics (see table below for more details).2 I guess this means that I am a philosopher of sorts, since I both teach and write about ethics. So, when I heard about Sherman College of Straight Chiropractic's International Research and Philosophy Symposium, I figured I should submit a paper (under the same title as this article), which was accepted. What follows is a written summary of the paper I presented.
Domain. . . . . . Description
Logic . . . . . . . Distinction between correct and incorrect reasoning
Metaphysics. . . General features of reality as a whole
Epistemology . . Possibility, origins, nature, and extent of human knowledge
Ethics . . . . . . . Evaluation of human conduct
Definitions
To ensure that there is no confusion, when I refer to Vertebral Subluxation Based Chiropractic (VSBC), I want to define the distinction between Traditional (Palmerian) Straight Chiropractic (TSC) and Objective Straight Chiropractic (OSC).3-5
For TSC, the purpose is to get sick people well (and maintain health) by correcting or removing subluxations. The scope of practice is subluxation detection and correction by adjustment (and "ancillary" methods). Symptoms can be important to TSC, because symptoms are thought to be caused by subluxations. Thus, one removes subluxations and thereby relieves the syndrome of signs and symptoms.3-5
On the other hand, the primary purpose of OSC is to remove subluxations, because no one can reach their "full potential" if they have "nerve interference." For OSC, the scope of practice is subluxation detection and correction by adjustment - period. In OSC, given the belief that symptoms may or may not be caused by subluxations, symptoms are ignored and are not a professional concern.3-5
Ethics
Applied ethics, such as ethics applied to chiropractic, consists of three parts. Descriptive ethics is when one describes, without value judgments, actions that have ethical ramifications. Metaethics is often a look at the motivations for those actions one has described. Finally, normative ethics involves looking at those actions one has described and comparing them to societal norms of behavior.6
There are only four norms I'll deal with and define in this article: Beneficence is to do good; an action that specifically brings about a positive response. On the other end of a continuum is nonmaleficence, which is to prevent harm. Most of us have heard this expressed in Latin as primum non nocere, first do no harm. Veracity is the duty to tell the truth. The final norm is fidelity, which is to comply with reasonable requests.6
Examining Ourselves
The purpose of this paper is to examine ourselves from two different viewpoints. As I have mentioned before in this column, our profession cannot improve unless we take a critical ethical look at ourselves. We cannot fix a problem we don't acknowledge exists, even if the problem is only one of outsiders' perceptions of us.
The Ethical Argument in Favor of VSBC
A descriptive ethical analysis of VSBC finds that both types of straight chiropractors tend toward high-volume practices.7 Both types tell patients that they only remove vertebral subluxations. In TSC, this is done because they say that vertebral subluxations cause dis-ease, while for OSC, this is done because they say that the vertebral subluxation prevents full expression of innate intelligence.3-5
My metaethical analysis is that there is an altruistic motivation to remove vertebral subluxations from as many people as possible. This is because chiropractors are the only ones who do this, and because those who follow VSBC say that vertebral subluxations are a significant cause of disease (TSC), or prevent a full expression of life (OSC).
Applying the principles of normative ethics to VSBC, both types believe that removal of a vertebral subluxation is an act of beneficence, because it either removes the cause for disease (TSC) or is good for the function of the nervous system and thus the patient (OSC). Both types believe that it would be a violation of one's duty of nonmaleficence to leave subluxation that would cause disease or death ("subluxations, the silent killer" - TCS), or will result in lessened expression of innate (OSC). Both forms of VSBC think that they comply with their fidelity duty because they believe that they are doing for patients what their patients expect of them.3-5
The Ethical Argument in Opposition to VSBC
When TSC doctors say that the removal of subluxation removes the cause of the dis-ease, some patients understand this as an implied cure. Some just do not understand the distinction between adjusting the purported cause of the disease (subluxation) and not treating the disease. Likewise, when OSC doctors say that vertebral subluxations are bad for one's health and cause nerve interference, leading to reduced expression of life force; and that the removal of the subluxation improves function of body, some patients see this as an implied cure, because they don't understand the distinction between adjusting the subluxation and not treating the disease. A nontherapeutic approach such as OSC is too foreign to people's conception of the role of a health care professional.
The obvious cynical metaethical analysis of VSBC is that the only rationale for high-volume practices and maintenance care is to make more money. The evidence to support this analysis is the great attention to volume,8 patient visit average, and attempts at fraud to obtain payment.9 (This is not to suggest that any one type of chiropractic practice is more prone to fraud.)
Joseph B. Strauss, DC, in The Pivot Review, wrote: "...for we know that an individual without vertebral subluxations functions better on every level."10 The question is, what level of evidence do we have for that "knowledge"? Thus, a normative ethical analysis is predicated upon one thing - does a subluxation have significant negative impact upon a human's health?
The problem is that there are no prospective studies, that I am aware of, showing that people without subluxations are healthier than those with subluxations. Further, in my experience, the clinical trials that have examined spinal adjusting have not tracked changes in health with changes in indicators for the presence of subluxations. So, while we have evidence that chiropractic care can be an effective treatment for certain conditions,11 I am not aware of any evidence showing that what helped the patient was the removal of subluxations. This leads people to quote Carl Sagan: "Absence of evidence is not evidence of absence."12 However, the person who does not "know" that subluxations prevent good function on every level might think that such a belief is bizarre, and thus might rely on another Sagan quote: "I believe that the extraordinary should certainly be pursued. But extraordinary claims require extraordinary evidence."13
Thus, lacking evidence that vertebral subluxations are detrimental to one's health, chiropractic care in the absence of a clinically valid rationale for that care may be a violation of one's nonmaleficence duty, as it exposes the patient to a small but significant risk of harm (stroke, disk herniation, cauda equina, rib fracture) from adjusting. Additionally, taking a patient's money and time for a treatment (adjusting) that has not been shown to be helpful is harmful in and of itself. Suggestions that vertebral subluxations are a significant cause of dis-ease or prevent complete expression of innate health can prevent people from seeking effective care from other health care providers. Patients expect that the things doctors tell them are based upon objective facts, not an untested philosophy or a religion. Therefore, promoting VSBC may be a violation of one's fidelity duty. Presenting the VSBC as a significant cause of illness may not be a lie. If one believes VSBC, one is not lying. Thus, the VSBC doctor complies with the veracity duty; however, VSBC may be untrue, and thus promoting it violates fidelity duty.
Conclusion
Is either of my analyses correct? Yes and no. They are just two different ways of looking at the same situation. I am not saying that one is correct and the other is wrong. I am suggesting that there are issues our profession needs to address and discuss. I hope doctors of chiropractic will demonstrate how we can disagree without being disagreeable; however, if history is any guide, I expect that the only feedback I'll get will be vitriol.
References
1. Coulter ID. Chiropractic: A Philosophy for Alternative Health Care. Oxford, UK: Butterworth-Heinemann Medical; 1999.
2. Kemerling G. A Dictionary of Philosophical Terms and Names. www.philosophypages.com/dy/.
Keating JC, Jr. Shades of straight: diversity among the purists. J Manipulative Physiol Ther 1992;15(3):203-9.
3. Keating JC, Jr. Purpose-straight chiropractic: not science, not health care. J Manipulative Physiol Ther 1995;18(6):416-8.
4. Gold R. The third paradigm. Dynamic Chiropractic, April 3, 2000: www.chiroweb.com/archives/18/08/02.html.
5. Purtilo R. Ethical Dimensions in the Health Professions, 3rd ed. Philadelphia: W.B. Saunders; 1999.
6. McDonald WP, Durkin K, Iseman S, Pfefer M, Randall B, Smoke L, et al. How Chiropractors Think and Practice: The Survey of North American Chiropractors. Ada, Ohio, Institute for Social Research, Ohio Northern University; 2003.
7. WCA issues position paper supporting high-volume practices. WCA News, Sept. 4, 2002.
8. Perle SM. Scientific misconduct, error or willful ignorance? Dynamic Chiropractic, June 30, 2003: www.chiroweb.com/archives/21/14/15.html.
9. Straus JB. A subluxation-free world. Pivot Review 1999;15(4).
10. Meeker WC, Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 2002;136(3):216-27.
11. Sagan C. The Demon-Haunted World: Science as a Candle in the Dark. New York: Random House; 1995.
12. Sagan C. Broca's Brain: Reflections on the Romance of Science. New York: Ballantine Books; 1993.
Stephen Perle, DC, MS
Bridgeport, Connecticut
=============================================
Perle is a tenured professor at the University of Bridgeport College of Chiropractic.
Search: "Stephen M. Perle"
UBCC Research Laboratory
Abstracts of Recent Publications
Ethics Columns in Dynamic Chiropractic
Ethical Analysis of Vertebral Subluxation Based Chiropractic. Dynamic Chiropractic 2004;
Two Wrongs Don’t Make a Right. Dynamic Chiropractic 2004;22(22): 28-9
Professional Courtesy. Dynamic Chiropractic 2004;22(17): 14
J'Accuse...! (I Accuse). Dynamic Chiropractic 2004;22(11)
Morality and Ethics: An Introduction. Dynamic Chiropractic 2004;22(6)
Teach What They Will Pay For. Dynamic Chiropractic 2004;22(1): 20, 25
One Bad Apple. Dynamic Chiropractic 2003;21(21):44, 48
Scientific Misconduct, Error or Willful Ignorance? Dynamic Chiropractic 2003;21(14):14, 26
Ethical Pragmatic Skepticism. Dynamic Chiropractic 2003;21(9):50
Credat Emptor. Dynamic Chiropractic 2003;21(1):24, 33
Sign out the sign-in sheet. Dynamic Chiropractic 2002;20(24):C-4
Stephen Perle, DC, MS
Chiropractors often talk about philosophy. However, we lack a consistent understanding of philosophy: the love of wisdom.1 Philosophers exchange ideas within four basic domains: logic, metaphysics, epistemology, and ethics (see table below for more details).2 I guess this means that I am a philosopher of sorts, since I both teach and write about ethics. So, when I heard about Sherman College of Straight Chiropractic's International Research and Philosophy Symposium, I figured I should submit a paper (under the same title as this article), which was accepted. What follows is a written summary of the paper I presented.
Domain. . . . . . Description
Logic . . . . . . . Distinction between correct and incorrect reasoning
Metaphysics. . . General features of reality as a whole
Epistemology . . Possibility, origins, nature, and extent of human knowledge
Ethics . . . . . . . Evaluation of human conduct
Definitions
To ensure that there is no confusion, when I refer to Vertebral Subluxation Based Chiropractic (VSBC), I want to define the distinction between Traditional (Palmerian) Straight Chiropractic (TSC) and Objective Straight Chiropractic (OSC).3-5
For TSC, the purpose is to get sick people well (and maintain health) by correcting or removing subluxations. The scope of practice is subluxation detection and correction by adjustment (and "ancillary" methods). Symptoms can be important to TSC, because symptoms are thought to be caused by subluxations. Thus, one removes subluxations and thereby relieves the syndrome of signs and symptoms.3-5
On the other hand, the primary purpose of OSC is to remove subluxations, because no one can reach their "full potential" if they have "nerve interference." For OSC, the scope of practice is subluxation detection and correction by adjustment - period. In OSC, given the belief that symptoms may or may not be caused by subluxations, symptoms are ignored and are not a professional concern.3-5
Ethics
Applied ethics, such as ethics applied to chiropractic, consists of three parts. Descriptive ethics is when one describes, without value judgments, actions that have ethical ramifications. Metaethics is often a look at the motivations for those actions one has described. Finally, normative ethics involves looking at those actions one has described and comparing them to societal norms of behavior.6
There are only four norms I'll deal with and define in this article: Beneficence is to do good; an action that specifically brings about a positive response. On the other end of a continuum is nonmaleficence, which is to prevent harm. Most of us have heard this expressed in Latin as primum non nocere, first do no harm. Veracity is the duty to tell the truth. The final norm is fidelity, which is to comply with reasonable requests.6
Examining Ourselves
The purpose of this paper is to examine ourselves from two different viewpoints. As I have mentioned before in this column, our profession cannot improve unless we take a critical ethical look at ourselves. We cannot fix a problem we don't acknowledge exists, even if the problem is only one of outsiders' perceptions of us.
The Ethical Argument in Favor of VSBC
A descriptive ethical analysis of VSBC finds that both types of straight chiropractors tend toward high-volume practices.7 Both types tell patients that they only remove vertebral subluxations. In TSC, this is done because they say that vertebral subluxations cause dis-ease, while for OSC, this is done because they say that the vertebral subluxation prevents full expression of innate intelligence.3-5
My metaethical analysis is that there is an altruistic motivation to remove vertebral subluxations from as many people as possible. This is because chiropractors are the only ones who do this, and because those who follow VSBC say that vertebral subluxations are a significant cause of disease (TSC), or prevent a full expression of life (OSC).
Applying the principles of normative ethics to VSBC, both types believe that removal of a vertebral subluxation is an act of beneficence, because it either removes the cause for disease (TSC) or is good for the function of the nervous system and thus the patient (OSC). Both types believe that it would be a violation of one's duty of nonmaleficence to leave subluxation that would cause disease or death ("subluxations, the silent killer" - TCS), or will result in lessened expression of innate (OSC). Both forms of VSBC think that they comply with their fidelity duty because they believe that they are doing for patients what their patients expect of them.3-5
The Ethical Argument in Opposition to VSBC
When TSC doctors say that the removal of subluxation removes the cause of the dis-ease, some patients understand this as an implied cure. Some just do not understand the distinction between adjusting the purported cause of the disease (subluxation) and not treating the disease. Likewise, when OSC doctors say that vertebral subluxations are bad for one's health and cause nerve interference, leading to reduced expression of life force; and that the removal of the subluxation improves function of body, some patients see this as an implied cure, because they don't understand the distinction between adjusting the subluxation and not treating the disease. A nontherapeutic approach such as OSC is too foreign to people's conception of the role of a health care professional.
The obvious cynical metaethical analysis of VSBC is that the only rationale for high-volume practices and maintenance care is to make more money. The evidence to support this analysis is the great attention to volume,8 patient visit average, and attempts at fraud to obtain payment.9 (This is not to suggest that any one type of chiropractic practice is more prone to fraud.)
Joseph B. Strauss, DC, in The Pivot Review, wrote: "...for we know that an individual without vertebral subluxations functions better on every level."10 The question is, what level of evidence do we have for that "knowledge"? Thus, a normative ethical analysis is predicated upon one thing - does a subluxation have significant negative impact upon a human's health?
The problem is that there are no prospective studies, that I am aware of, showing that people without subluxations are healthier than those with subluxations. Further, in my experience, the clinical trials that have examined spinal adjusting have not tracked changes in health with changes in indicators for the presence of subluxations. So, while we have evidence that chiropractic care can be an effective treatment for certain conditions,11 I am not aware of any evidence showing that what helped the patient was the removal of subluxations. This leads people to quote Carl Sagan: "Absence of evidence is not evidence of absence."12 However, the person who does not "know" that subluxations prevent good function on every level might think that such a belief is bizarre, and thus might rely on another Sagan quote: "I believe that the extraordinary should certainly be pursued. But extraordinary claims require extraordinary evidence."13
Thus, lacking evidence that vertebral subluxations are detrimental to one's health, chiropractic care in the absence of a clinically valid rationale for that care may be a violation of one's nonmaleficence duty, as it exposes the patient to a small but significant risk of harm (stroke, disk herniation, cauda equina, rib fracture) from adjusting. Additionally, taking a patient's money and time for a treatment (adjusting) that has not been shown to be helpful is harmful in and of itself. Suggestions that vertebral subluxations are a significant cause of dis-ease or prevent complete expression of innate health can prevent people from seeking effective care from other health care providers. Patients expect that the things doctors tell them are based upon objective facts, not an untested philosophy or a religion. Therefore, promoting VSBC may be a violation of one's fidelity duty. Presenting the VSBC as a significant cause of illness may not be a lie. If one believes VSBC, one is not lying. Thus, the VSBC doctor complies with the veracity duty; however, VSBC may be untrue, and thus promoting it violates fidelity duty.
Conclusion
Is either of my analyses correct? Yes and no. They are just two different ways of looking at the same situation. I am not saying that one is correct and the other is wrong. I am suggesting that there are issues our profession needs to address and discuss. I hope doctors of chiropractic will demonstrate how we can disagree without being disagreeable; however, if history is any guide, I expect that the only feedback I'll get will be vitriol.
References
1. Coulter ID. Chiropractic: A Philosophy for Alternative Health Care. Oxford, UK: Butterworth-Heinemann Medical; 1999.
2. Kemerling G. A Dictionary of Philosophical Terms and Names. www.philosophypages.com/dy/.
Keating JC, Jr. Shades of straight: diversity among the purists. J Manipulative Physiol Ther 1992;15(3):203-9.
3. Keating JC, Jr. Purpose-straight chiropractic: not science, not health care. J Manipulative Physiol Ther 1995;18(6):416-8.
4. Gold R. The third paradigm. Dynamic Chiropractic, April 3, 2000: www.chiroweb.com/archives/18/08/02.html.
5. Purtilo R. Ethical Dimensions in the Health Professions, 3rd ed. Philadelphia: W.B. Saunders; 1999.
6. McDonald WP, Durkin K, Iseman S, Pfefer M, Randall B, Smoke L, et al. How Chiropractors Think and Practice: The Survey of North American Chiropractors. Ada, Ohio, Institute for Social Research, Ohio Northern University; 2003.
7. WCA issues position paper supporting high-volume practices. WCA News, Sept. 4, 2002.
8. Perle SM. Scientific misconduct, error or willful ignorance? Dynamic Chiropractic, June 30, 2003: www.chiroweb.com/archives/21/14/15.html.
9. Straus JB. A subluxation-free world. Pivot Review 1999;15(4).
10. Meeker WC, Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 2002;136(3):216-27.
11. Sagan C. The Demon-Haunted World: Science as a Candle in the Dark. New York: Random House; 1995.
12. Sagan C. Broca's Brain: Reflections on the Romance of Science. New York: Ballantine Books; 1993.
Stephen Perle, DC, MS
Bridgeport, Connecticut
=============================================
Perle is a tenured professor at the University of Bridgeport College of Chiropractic.
Search: "Stephen M. Perle"
UBCC Research Laboratory
Abstracts of Recent Publications
Ethics Columns in Dynamic Chiropractic
Ethical Analysis of Vertebral Subluxation Based Chiropractic. Dynamic Chiropractic 2004;
Two Wrongs Don’t Make a Right. Dynamic Chiropractic 2004;22(22): 28-9
Professional Courtesy. Dynamic Chiropractic 2004;22(17): 14
J'Accuse...! (I Accuse). Dynamic Chiropractic 2004;22(11)
Morality and Ethics: An Introduction. Dynamic Chiropractic 2004;22(6)
Teach What They Will Pay For. Dynamic Chiropractic 2004;22(1): 20, 25
One Bad Apple. Dynamic Chiropractic 2003;21(21):44, 48
Scientific Misconduct, Error or Willful Ignorance? Dynamic Chiropractic 2003;21(14):14, 26
Ethical Pragmatic Skepticism. Dynamic Chiropractic 2003;21(9):50
Credat Emptor. Dynamic Chiropractic 2003;21(1):24, 33
Sign out the sign-in sheet. Dynamic Chiropractic 2002;20(24):C-4
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