- Email: [email protected]
CHIROPRACTIC ETHICS: AN OXYMORON?
CONTEMPORARY ETHICAL ISSUES • SMITH
CHIROPRACTIC ETHICS: AN OXYMORON? Contemporary Ethical Issues in Chiropractic
J.C. Smith, DC
1
72
1. Private Practice of Chiropractic
Submit correspondence and requests for reprints to: JC Smith, MA, DC Smith Spinal Care 1103 Russell Parkway Warner Robins, GA 31088 Tel: (912) 922-4091 Fax: (912) 929-8822 Email: [email protected]
Journal of Chiropractic Humanities ©1999 The National College of Chiropractic
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 illfated. 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 Bloomington, Illinois in October, 1990, found that of 19 professional groups, chiropractors ranked 19th in the majority of categories (1). Another poll taken in California indicated that 90% of patients who 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
CONTEMPORARY ETHICAL ISSUES • SMITH
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 charla tanism, 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 U.S., 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 mis leading representations in practice; offering free ser vices, 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 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. 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.
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 letterto-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,
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
73
CONTEMPORARY ETHICAL ISSUES • SMITH
the profession is still tainted whenever free services are rendered. Can you imagine an attorney sitting at a table at KMart offering free legal advice? Sounds like some sleazy character from The Simpsons, doesn't it?
74
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 chiropractor's open intention of offering free advice. J.F. Winterstein, DC, and 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 xrays, 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 longterm 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 chiroprac-
tors? 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 appear 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. 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.
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
CONTEMPORARY ETHICAL ISSUES • SMITH
Personal communication. May 3, 1998) 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 Palmer College, 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. May 8, 1998) 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 market place handle it,' of the time my brother George spent a full morning in the first trial in the Wilk case. He called me that noon and asked me, 'What in the hell is the matter with you people?' When I asked him what he meant, he said, 'I just spent the worst period of my professional life trying to defend the behavior of some of the chiropractors out there who make claims far beyond any objective evidence. I felt like I should get up from my chair and go over and sit with the attorneys for the other side.' “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 80some years of chiropractic's existence) of a single chiropractor speaking out against the atrocious behavior.'” (McAndrews J. Personal communication. May 8, 1998)
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
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
75
CONTEMPORARY ETHICAL ISSUES • SMITH
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).
76
Before the ACA House of Delegates on May 13, 1992, Mr. Mark Goodin, the ACA's 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 then any research from ACHPR (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
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
CONTEMPORARY ETHICAL ISSUES • SMITH
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 main stream health delivery system.” (McAndrews J. Private communication. May 11, 1993) 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... 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 exper-
tise/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 specialities 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 specialities, 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 Chicago with another attorney. They wandered into one of the vacated 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
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
77
CONTEMPORARY ETHICAL ISSUES • SMITH
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 communications. May 8, 1998)
78
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? ETHICS OF P ATIENT 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 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
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
CONTEMPORARY ETHICAL ISSUES • SMITH
default institution, perhaps the real cause of this problem rests more with the leadership morality than with the repay ment 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 January 17-18, 1996, editions of the Atlanta Constitution newspaper contained a twopart series about “The Life' and Times of Sid Williams” as well as a revealing follow-up article, “Student DEBT”, about Life College leading
professional colleges in student 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. William's 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? 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 socalled 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 rally 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 chiroppractors for nearly a century. Research is secondary to these proponents of anecdotal “wonder” stories. As Dr. 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-
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
79
CONTEMPORARY ETHICAL ISSUES • SMITH
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).
80
“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. 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 “principal” 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 G. Private communication. March 24, 1992)
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.
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 “antiscientific” 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.
“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 G. Private communication. March 24, 1992)
George McAndrews address this problem about scientific credibility versus chiropractic hyperbole. “Make no doubt about it, no one is running from the subluxation complex.
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 antiscience attitude at some colleges is to be expected when
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
CONTEMPORARY ETHICAL ISSUES • SMITH
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 antiintellectualism 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.” 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 metaphysical 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 iso-
lation, 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 diease.” 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 superstraights 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 pseudoreligious, 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. 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 a 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
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
81
CONTEMPORARY ETHICAL ISSUES • SMITH
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.
82
The introduction of adjunctive methods of healing into the art of chiropractic practice has long been the source of debate between 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 communications, 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 salesman 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 “subluxationbased” 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, how ever, 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
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
CONTEMPORARY ETHICAL ISSUES • SMITH
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-tellinglike faith. (McAndrews J. Private communication. May 8, 1998)
science,' but that's nonsense. But the old war stories will not carry us much further. Certainly, few if any scientists are swayed by 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 with out 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.” DOGMA VS. RESEARCH
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
“Objectively 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 “principle” chiropractic. “Cute phrases like 'Abovedown, 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
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
83
CONTEMPORARY ETHICAL ISSUES • SMITH
84
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 G. Private communication. March 24, 1992) 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 'dis-
tinct' need not be synonymous with 'unrecognizable' or 'weird.' ...A doctor who primarily focuses on the neurobiomechanical aspects of health need not be ghettoized or weird. Such a person is not a 'blackslapper' 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 G. Private communication. March 24, 1992) 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, hand 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 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 Florida. Think of all the better ways the money could be spent instead of buying
CONTEMPORARY ETHICAL ISSUES • SMITH
his furniture, plates, and the linens to deify. Let's say hello to progress by saying bye bye to B.J.” (21) SHOOTING OUR OWN FOOT At the 1998 ACA Convention in Vancouver, B.C. George McAndrews recounted the 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. McAndrew's comment, he did hit a nerve nonetheless. Chiropractic does have a large silent majority which seems content to tolerate 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 ICA have been most disturbing in this regard. Their anti-unity effort with the illfated ICA/ACA merger was the most obvious example of factionalism within chiropractic. Despite the fact that over 50% of ICA members voted for merger, they failed to attain the two-thirds majority required for passage. Most ironically, aside from obstructing political unity, the ICA's self-proclaimed “Defender of Chiropractic,” Sid Williams, had played right into the hands of our medial opponents to keep our profession split politically, illustrating once again chiropractic's unique ability to round up the wagons and shoot inward! 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 student 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 Southeastern U.S., but low entrance requirements may, in part, explain why his college led all chiropractic colleges in student loan default rates. While the connection between the egregious and infamous Money Hum and the high rate of student defaults may be difficult to prove, nevertheless the link is more than coincidental. Mr. Mark Goodin, the ACA's former legislative consultant, was painfully honest in his opinion of chiropractic's selfinflicted wounds. “That enemy, of course, is this profession itself - and those elements within it that are unwilling to deal forth rightly 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-ofpractice careers in a cause to stop legitimate reform. They bring nothing of value to the future of this profes-
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
85
CONTEMPORARY ETHICAL ISSUES • SMITH
sion - 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).
86
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 profession 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), hellbent 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.
of a conspiracy of silence. It would, in effect, be getting in bed with a prostitute” (24).
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.
In another issue of Dynamic Chiropractic , Dr. Peter Martin, president of PalmerWest, 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).
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
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 some one just had to call the bluff of the demigods before they do more damage. Good-bye chiropractic if that never happens!” (McAndrews G. Private communication. March 24, 1992) It might never happen unless the chiropractic profession and its press takes on this sensitive issue. Unfortunately, much of the chiropractic press has
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
CONTEMPORARY ETHICAL ISSUES • SMITH
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 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).
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
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
1. Esteb WD. A patient's point of view: observations of a chiropractic advocate. Orion Associates 1992:35
2. Esteb WD. ibid., pp. 232 3. Sportelli L. In pursuit of image; chiropractic in the next millennium. Journal of the ACA 1995; 32(5):38 4. Agency Publication: Georgia Board of Chiropractic Examiners Rules. February 1993 5. Mailbag. Journal of the ACA 1998;35(4) 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. Ridgefield, WA; 1992 11. Williams SE. Numerous
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
87
CONTEMPORARY ETHICAL ISSUES • SMITH
lectures at Life College and DE seminars. 12. Harrison, B. “The 'life' and times of Sid Williams,” The Atlanta Constitution, January 17, 1995. McKenna JAJ, Hardie A. “Student DEBT”, The Atlanta Constitution, January 18, 1995 13. The Associated Press, “Life College students lead federal loan default list,” January 19, 1995.
88
14. Wardwell W. Chiropractic: history and evolution of a new profession. St. Louis: Mosby; 1992:133. 15. Campus Life, December 1993. 16. Strauss JB. The pivot review. 1993;IX(5) 17. Winkler K. Outlook, August 1993 18. Williams SE. Lasting purpose, Health Communications, 1996:71 19. Covey SR. The 7 habits of highly effective people. Fireside 1990 20. Williams SE. Lyceum. Today's Chiropractic January/February 1998 21. Tyler RH. editorial, BJ--a love/hate relationship. Dynamic Chiropractic
July 18, 1990. 22. McAndrews G. Speech before ACA Convention. Vancouver, BC, July 20, 1998 23. Goodin M. “Winning the battle in legislative and regulatory arenas,” Journal of the ACA July 1992:45-47 24. Wilk C. Enforcing ethics, quality, and standards of care. Dynamic Chiropractic Sept 1, 1992 25. Editorial Staff, Dynamic Chiropractic, The cost of disunity--Did California Board do the right thing? September 1, 1993 26. Winterstein JF. Making the best better. Dynamic Chiropractic, February 12, 1993 27. Winterstein JF. Patientbased practice. Dynamic Chiropractic, April 20, 1998 28. Keating JC, Bergmann TF. It works, it works, it works! Dynamic Chiropractic, September 25, 1992
CHIROPRACTIC ETHICS: AN OXYMORON? Contemporary Ethical Issues in Chiropractic
J.C. Smith, DC
1
72
1. Private Practice of Chiropractic
Submit correspondence and requests for reprints to: JC Smith, MA, DC Smith Spinal Care 1103 Russell Parkway Warner Robins, GA 31088 Tel: (912) 922-4091 Fax: (912) 929-8822 Email: [email protected]
Journal of Chiropractic Humanities ©1999 The National College of Chiropractic
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 illfated. 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 Bloomington, Illinois in October, 1990, found that of 19 professional groups, chiropractors ranked 19th in the majority of categories (1). Another poll taken in California indicated that 90% of patients who 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
CONTEMPORARY ETHICAL ISSUES • SMITH
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 charla tanism, 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 U.S., 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 mis leading representations in practice; offering free ser vices, 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 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. 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.
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 letterto-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,
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
73
CONTEMPORARY ETHICAL ISSUES • SMITH
the profession is still tainted whenever free services are rendered. Can you imagine an attorney sitting at a table at KMart offering free legal advice? Sounds like some sleazy character from The Simpsons, doesn't it?
74
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 chiropractor's open intention of offering free advice. J.F. Winterstein, DC, and 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 xrays, 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 longterm 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 chiroprac-
tors? 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 appear 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. 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.
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
CONTEMPORARY ETHICAL ISSUES • SMITH
Personal communication. May 3, 1998) 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 Palmer College, 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. May 8, 1998) 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 market place handle it,' of the time my brother George spent a full morning in the first trial in the Wilk case. He called me that noon and asked me, 'What in the hell is the matter with you people?' When I asked him what he meant, he said, 'I just spent the worst period of my professional life trying to defend the behavior of some of the chiropractors out there who make claims far beyond any objective evidence. I felt like I should get up from my chair and go over and sit with the attorneys for the other side.' “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 80some years of chiropractic's existence) of a single chiropractor speaking out against the atrocious behavior.'” (McAndrews J. Personal communication. May 8, 1998)
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
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
75
CONTEMPORARY ETHICAL ISSUES • SMITH
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).
76
Before the ACA House of Delegates on May 13, 1992, Mr. Mark Goodin, the ACA's 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 then any research from ACHPR (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
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
CONTEMPORARY ETHICAL ISSUES • SMITH
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 main stream health delivery system.” (McAndrews J. Private communication. May 11, 1993) 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... 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 exper-
tise/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 specialities 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 specialities, 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 Chicago with another attorney. They wandered into one of the vacated 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
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
77
CONTEMPORARY ETHICAL ISSUES • SMITH
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 communications. May 8, 1998)
78
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? ETHICS OF P ATIENT 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 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
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
CONTEMPORARY ETHICAL ISSUES • SMITH
default institution, perhaps the real cause of this problem rests more with the leadership morality than with the repay ment 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 January 17-18, 1996, editions of the Atlanta Constitution newspaper contained a twopart series about “The Life' and Times of Sid Williams” as well as a revealing follow-up article, “Student DEBT”, about Life College leading
professional colleges in student 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. William's 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? 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 socalled 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 rally 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 chiroppractors for nearly a century. Research is secondary to these proponents of anecdotal “wonder” stories. As Dr. 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-
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
79
CONTEMPORARY ETHICAL ISSUES • SMITH
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).
80
“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. 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 “principal” 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 G. Private communication. March 24, 1992)
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.
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 “antiscientific” 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.
“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 G. Private communication. March 24, 1992)
George McAndrews address this problem about scientific credibility versus chiropractic hyperbole. “Make no doubt about it, no one is running from the subluxation complex.
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 antiscience attitude at some colleges is to be expected when
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
CONTEMPORARY ETHICAL ISSUES • SMITH
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 antiintellectualism 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.” 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 metaphysical 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 iso-
lation, 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 diease.” 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 superstraights 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 pseudoreligious, 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. 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 a 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
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
81
CONTEMPORARY ETHICAL ISSUES • SMITH
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.
82
The introduction of adjunctive methods of healing into the art of chiropractic practice has long been the source of debate between 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 communications, 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 salesman 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 “subluxationbased” 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, how ever, 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
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
CONTEMPORARY ETHICAL ISSUES • SMITH
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-tellinglike faith. (McAndrews J. Private communication. May 8, 1998)
science,' but that's nonsense. But the old war stories will not carry us much further. Certainly, few if any scientists are swayed by 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 with out 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.” DOGMA VS. RESEARCH
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
“Objectively 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 “principle” chiropractic. “Cute phrases like 'Abovedown, 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
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
83
CONTEMPORARY ETHICAL ISSUES • SMITH
84
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 G. Private communication. March 24, 1992) 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 'dis-
tinct' need not be synonymous with 'unrecognizable' or 'weird.' ...A doctor who primarily focuses on the neurobiomechanical aspects of health need not be ghettoized or weird. Such a person is not a 'blackslapper' 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 G. Private communication. March 24, 1992) 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, hand 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 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 Florida. Think of all the better ways the money could be spent instead of buying
CONTEMPORARY ETHICAL ISSUES • SMITH
his furniture, plates, and the linens to deify. Let's say hello to progress by saying bye bye to B.J.” (21) SHOOTING OUR OWN FOOT At the 1998 ACA Convention in Vancouver, B.C. George McAndrews recounted the 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. McAndrew's comment, he did hit a nerve nonetheless. Chiropractic does have a large silent majority which seems content to tolerate 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 ICA have been most disturbing in this regard. Their anti-unity effort with the illfated ICA/ACA merger was the most obvious example of factionalism within chiropractic. Despite the fact that over 50% of ICA members voted for merger, they failed to attain the two-thirds majority required for passage. Most ironically, aside from obstructing political unity, the ICA's self-proclaimed “Defender of Chiropractic,” Sid Williams, had played right into the hands of our medial opponents to keep our profession split politically, illustrating once again chiropractic's unique ability to round up the wagons and shoot inward! 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 student 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 Southeastern U.S., but low entrance requirements may, in part, explain why his college led all chiropractic colleges in student loan default rates. While the connection between the egregious and infamous Money Hum and the high rate of student defaults may be difficult to prove, nevertheless the link is more than coincidental. Mr. Mark Goodin, the ACA's former legislative consultant, was painfully honest in his opinion of chiropractic's selfinflicted wounds. “That enemy, of course, is this profession itself - and those elements within it that are unwilling to deal forth rightly 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-ofpractice careers in a cause to stop legitimate reform. They bring nothing of value to the future of this profes-
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
85
CONTEMPORARY ETHICAL ISSUES • SMITH
sion - 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).
86
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 profession 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), hellbent 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.
of a conspiracy of silence. It would, in effect, be getting in bed with a prostitute” (24).
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.
In another issue of Dynamic Chiropractic , Dr. Peter Martin, president of PalmerWest, 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).
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
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 some one just had to call the bluff of the demigods before they do more damage. Good-bye chiropractic if that never happens!” (McAndrews G. Private communication. March 24, 1992) It might never happen unless the chiropractic profession and its press takes on this sensitive issue. Unfortunately, much of the chiropractic press has
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
CONTEMPORARY ETHICAL ISSUES • SMITH
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 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).
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
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
1. Esteb WD. A patient's point of view: observations of a chiropractic advocate. Orion Associates 1992:35
2. Esteb WD. ibid., pp. 232 3. Sportelli L. In pursuit of image; chiropractic in the next millennium. Journal of the ACA 1995; 32(5):38 4. Agency Publication: Georgia Board of Chiropractic Examiners Rules. February 1993 5. Mailbag. Journal of the ACA 1998;35(4) 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. Ridgefield, WA; 1992 11. Williams SE. Numerous
Journal of Chiropractic Humanities ©The National College of Chiropractic 1999
87
CONTEMPORARY ETHICAL ISSUES • SMITH
lectures at Life College and DE seminars. 12. Harrison, B. “The 'life' and times of Sid Williams,” The Atlanta Constitution, January 17, 1995. McKenna JAJ, Hardie A. “Student DEBT”, The Atlanta Constitution, January 18, 1995 13. The Associated Press, “Life College students lead federal loan default list,” January 19, 1995.
88
14. Wardwell W. Chiropractic: history and evolution of a new profession. St. Louis: Mosby; 1992:133. 15. Campus Life, December 1993. 16. Strauss JB. The pivot review. 1993;IX(5) 17. Winkler K. Outlook, August 1993 18. Williams SE. Lasting purpose, Health Communications, 1996:71 19. Covey SR. The 7 habits of highly effective people. Fireside 1990 20. Williams SE. Lyceum. Today's Chiropractic January/February 1998 21. Tyler RH. editorial, BJ--a love/hate relationship. Dynamic Chiropractic
July 18, 1990. 22. McAndrews G. Speech before ACA Convention. Vancouver, BC, July 20, 1998 23. Goodin M. “Winning the battle in legislative and regulatory arenas,” Journal of the ACA July 1992:45-47 24. Wilk C. Enforcing ethics, quality, and standards of care. Dynamic Chiropractic Sept 1, 1992 25. Editorial Staff, Dynamic Chiropractic, The cost of disunity--Did California Board do the right thing? September 1, 1993 26. Winterstein JF. Making the best better. Dynamic Chiropractic, February 12, 1993 27. Winterstein JF. Patientbased practice. Dynamic Chiropractic, April 20, 1998 28. Keating JC, Bergmann TF. It works, it works, it works! Dynamic Chiropractic, September 25, 1992