International Federation of Chiropractors and Organizations addresses Dr. James J. Lehman’s article in the December 1, 2015 Dynamic Chiropractic
The December 1, 2015 issue of Dynamic Chiropractic features an article by Dr. James J. Lehman titled Diagnosis: Your Legal and Ethical Responsibility. In the article, Lehman urges the Colorado Chiropractic Association (CCA) to rescind their most recent standards of care. Lehman’s rationale is that these standards “subject chiropractic patients in Colorado to dangerous and negligent doctor-centric behavior, and appear to be both illegal and unethical.”
On September 11, 2015, the CCA adopted the following position statements:
Whereas addressing subluxations and spinal adjustments are central to The Colorado chiropractic practice act. The Colorado Chiropractic Association considers it standard practice and an acceptable standard of care for practitioners to choose to deliver care solely for the location analysis and correction of spinal subluxations in child and adult patients, regardless of whether symptoms are present. Subluxations are in and of themselves a detriment to one’s health.
Whereas The Colorado Chiropractic Association is concerned with practitioners delivering quality chiropractic care, the CCA considers it standard practice and within the acceptable standard of care, as noted in recognized clinical practice guidelines, to take x-rays for the location and analysis of spinal subluxations when clinically indicated. Clinical indications include evidence of subluxation demonstrated by chiropractic examination, and is not limited to patients presenting with symptoms or a history of trauma.
Whereas the Colorado chiropractic Association considers patient safety a priority, the Colorado Chiropractic Association considers it an acceptable and standard practice for chiropractic practitioners to deliver chiropractic care solely for the location analysis and correction of spinal subluxation and for practitioners to choose to focus their scope of practice to that practice objective when an informed consent is obtained from the healthcare consumer.
Contrary to Lehman’s assertions, the position paper of The International Federation of Chiropractors and Organizations (IFCO) on vertebral subluxation as a sole rationale for care emphasizes patient safety and the duty of the chiropractor:
Nothing in this position statement absolves the chiropractor from knowing the limits of his or her authority and skill, and from determining the safety and appropriateness of chiropractic care. The chiropractor has a duty to disclose any unusual findings discovered in the course of examination. (1)
The Foundation for Vertebral Subluxation (FVS) has adopted a similar position paper Vertebral Subluxation as the Sole Reason for Care:
The chiropractor uses a variety of procedures to assess the vertebral subluxation in order to determine its presence and arrive at an impression of its location, character, type, and chronicity. Management of subluxation from a vitalistic perspective is applicable to any patient exhibiting evidence of its existence regardless of the presence or absence of symptoms and disease. Therefore, the determination of the presence of subluxation may stand as the sole rationale for care.
Nothing in this position statement absolves the chiropractor from knowing the limits of his or her authority and skill, and from determining the safety and appropriateness of chiropractic care. The chiropractor has a duty to disclose to the patient any unusual findings discovered in the course of examination, and may collaborate with other health professionals when it is in the best interests of the patient. (2)
A licensed practitioner may choose to limit their practice, and it is prudent to do so. The notion that one must practice to the entire scope of their license is absurd. Is a gynecologist compelled to perform neurosurgery? Are orthodontists compelled to perform root canals? Of course not. We are unaware of any plenary licensee (MD or DO) who claims to offer the service of operationalizing all 69,823 diagnosis codes in ICD-10 code sets. (3) The issue is whether they are performing to the standard of care for their selected subset of permissible procedures.
The ability of a doctor of chiropractic to limit the scope of their care has been recognized by law in several states. For example, under New Jersey Statutes, subluxation may be the sole basis for chiropractic care:
Nothing in this act shall be deemed to prohibit a chiropractor from caring for chiropractic subluxation. Chiropractic analysis which identifies the existence of a chiropractic subluxation may be the basis for chiropractic care even in the absence of a subjective complaint or other objective findings. (4)
In Kerkman v. Hintz (5) The Wisconsin Supreme Court clearly defined the extent of a chiropractor’s duty to diagnose:
In summary, we hold that a chiropractor has a duty to
(1) determine whether the patient presents a problem which is treatable through chiropractic means;
(2) refrain from further chiropractic treatment when a reasonable chiropractor should be aware that the patient’s condition will not be responsive to further treatment; and
(3) if the ailment presented is outside the scope of chiropractic care, inform the patient that the ailment is not treatable through chiropractic means.
The statutory definition of chiropractic in Colorado (6) is consistent with this approach:
(1.7) “Chiropractic” means that branch of the healing arts that is based on the premise that disease is attributable to the abnormal functioning of the human nervous system. It includes the diagnosing and analyzing of human ailments and seeks the elimination of the abnormal functioning of the human nervous system by the adjustment or manipulation, by hand or instrument, of the articulations and adjacent tissue of the human body, particularly the spinal column, and the use as indicated of procedures that facilitate the adjustment or manipulation and make it more effective and the use of sanitary, hygienic, nutritional, and physical remedial measures for the promotion, maintenance, and restoration of health, the prevention of disease, and the treatment of human ailments.
It should also be recognized that in clinical practice, medical or chiropractic, there are situations where no medical diagnosis is rendered. DOT physicals, anyone? “Well baby” checkups? Lifestyle advice. Athletic performance enhancement strategies, checking for vertebral subluxation, etc. This is acknowledged in the portion of the statute which includes “measures for the promotion, maintenance, and restoration of health, the prevention of disease, and the treatment of human ailments.”
Finally, let us address the issue of ethics. The Principle of Beneficence states that one should do only that which benefits the patient, and to hold the patient’s welfare as the first consideration. (7) Excessive and inappropriate diagnostic testing leads to patient harm, including iatrogenic effects and excessive costs. (8) Diagnostic testing that is not relevant to the clinical objectives of analysis of vertebral subluxations and determining the safety and appropriateness of chiropractic care may be unethical, particularly if the examination procedures employed have not demonstrated acceptable levels of reliability and validity. (9)
Doctors of chiropractic focusing on the analysis and correction of vertebral subluxations embrace a patient-centered, evidence informed, ethical, and cost-effective approach to health. Every chiropractor should be familiar with applicable state statutes, rules, and regulations. To state or infer that a subluxation-centered approach is illegal and unethical is wrong.
2. http://subluxationfoundation.sharepoint.com/Pages/subluxation.aspx Accessed 12/6/15.
3. http://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm Accessed 12/6/15.
4. New Jersey C.45:9-41.27 http://www.njpublicsafety.com/ca/chiro/chiro_rules.htm Accessed 12/6/15.
5. 418 N.W.2d 795, 142 Wis.2d 404
7. The Principle of Beneficence in Applied Ethics. Stanford Encyclopedia of Philosophy. http://plato.stanford.edu/entries/principle-beneficence/ Accessed 12/6/15.
8. ‘Over-treating’ patients is wasteful, unnecessary and can cause them harm, campaign claims. Independent. http://www.independent.co.uk/life-style/health-and-families/health-news/over-treating-patients-is-wasteful-unnecessary-and-can-cause-them-harm-campaign-claims-10245283.html Accessed 12/6/15.
9. Walsh MJ: Evaluation of orthopedic testing of the low back for nonspecific lower back pain. J Manipulative Physiol Ther. 1998 May;21(4):232-6. http://www.ncbi.nlm.nih.gov/pubmed/?term=9608377 Accessed 12/6/15.