MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Informed consent is generally considered to be an essential precondition for any health care practice. It requires the clinician giving the patient full information about the condition and the possible treatments. Amongst other things, the following information may be needed:

  • the nature and prognosis of the condition,
  • the evidence regarding the efficacy and risks of the proposed treatment,
  • the evidence regarding alternative options.

Depending on the precise circumstances of the clinical situation, patient’s consent can be given either in writing or orally. Not obtaining any form of informed consent is a violation of the most fundamental ethics of health care.

In alternative medicine, informed consent seems often to be woefully neglected. This may have more than one reason:

  • practitioners have frequently no adequate training in medical ethics,
  • there is no adequate regulation and control of alternative practitioners,
  • practitioners have conflicts of interest and might view informed consent as commercially counter-productive

In order to render this discussion less theoretical, I will outline several scenarios from the realm of chiropractic. Specifically, I will discuss the virtual case of an asthma patient consulting a chiropractor for alleviation of his symptoms. I should stress that I have chosen chiropractic merely as an example – the issues outlines below apply to chiropractic as much as they apply to most other forms of alternative medicine.

SCENARIO 1

Our patient has experienced breathing problems and has heard that chiropractors are able to help this kind of condition. He consults a ‘straight’ chiropractor who adheres to Palmer’s gospel of ‘subluxation’. She explains to the patient that chiropractors use a holistic approach. By adjusting subluxations in the spine, she is confident to stimulate healing which will naturally ease the patient’s breathing problems. No conventional diagnosis is discussed, nor is there any mention of the prognosis, likelihood of benefit, risks of treatment and alternative therapeutic options.

SCENARIO 2

Our patient consults a chiropractor who does not fully believe in the ‘subluxation’ theory of chiropractic. She conducts a thorough examination of our patient’s spine and diagnoses several spinal segments that are blocked. She tells our patient that he might be suffering from asthma and that spinal manipulation might remove the blockages and thus increase the mobility of the spine which, in turn, would alleviate his breathing problems. She does not mention risks of the proposed interventions nor other therapeutic options.

SCENARIO 3

Our patient visits a chiropractor who considers herself a back pain specialist. She takes a medical history and conducts a physical examination. Subsequently she informs the patient that her breathing problems could be due to asthma and that she is neither qualified nor equipped to ascertain this diagnosis. She tells out patient that chiropractic is not an effective treatment for asthma but that his GP would be able to firstly make a proper diagnosis and secondly prescribe the optimal treatment for her condition. She writes a short note summarizing her thoughts and hands it to our patient to give it to his GP.

One could think of many more scenarios but the three above seem to cover a realistic spectrum of what a patient might encounter in real life. It seems clear, that the chiropractor in scenario 1 and 2 failed dismally regarding informed consent. In other words, only scenario 3 describes a behaviour that is ethically acceptable.

But how likely is scenario 3? I fear that it is an extremely rare turn of events. Even if well-versed in both medical ethics and scientific evidence, a chiropractor might think twice about providing all the information required for informed consent – because, as scenario 3 demonstrates, full informed consent in chiropractic essentially discourages a patient from agreeing to be treated. In other words, chiropractors have a powerful conflict of interest which prevents them to adhere to the rules of informed consent.

AND, AS POINTED OUT ALREADY, THAT DOES NOT JUST APPLY TO CHIROPRACTIC, IT APPLIES TO MOST OF ALTERNATIVE MEDICINE! IT SEEMS TO FOLLOW, I FEAR, THAT MUCH OF ALTERNATIVE MEDICINE IS UNETHICAL.

13 Responses to Informed consent in alternative medicine: the example of chiropractic

  • Alex says:

    Poor example for asthma with chiro. I am a chiro. I wouldn’t and many of my colleagues would not treat asthma. No evidence for it. Turned many a patient back to their GP for things that are outside my scope or for things that just weren’t getting better (albeit a small number). Overall I agree with a hell of a lot of what you say Ed but need to delineate better between EBM based chiro and woo based.

  • Thinking_Chiro says:

    Interesting article and I would like to add
    SENARIO 4:
    Patient visits a chiropractor who takes a thorough history and examination and medical history and the diagnosis is asthma. The chiropractor acertains that the patient has already seen a doctor and is on medication for their condition but wishes to explore possible alternatives (They have been consulting Dr Google). The chiropractor inquires about their activities, lifestyle, exercise, etc. The chiropractor prescribe exercises to help their condition, advises them on the benefits of activities like walking and swimming to improve their lung volume and breathing. He also says that chiropractic cannot help asthma directly. The chiropractor releases the hypertonic muscles in the back and chest caused by chronic coughing and gently mobilises the thoracic spine and rib cage to improve breathing and mobility, addressing the musculoskeletal side effects of the asthma. The chiropractor tells the patient to see their doctor as the asthma should be managed medically. He then calls the doctor and explains what he has done and co-manages the patient with the doctor. The chiro and doctor stay in regular communication.
    Welcome to my practice. I work in a medical centre and this is going on every day. I regularly refer patients to the doctors in the next consulting room if the problem is beyond the scope of chiropractic. The doctors are also regularly referring spine and musculoskeletal patients to me.
    The majority of chiropractors I associate with have good referral relationships with their local doctors. You could say that we are medically biased!

    In this senario, my informed consent would also cover what I can and cannot do for asthma along with all the usual risks. the informed consent form had a section where I add diagnosis care plan and prognosis so it is verbal and written and the patient signs. You should also add “Do you understand” to your list above before the patient signs the form.

    • Frank O says:

      “The chiropractor releases the hypertonic muscles in the back and chest caused by chronic coughing and gently mobilises the thoracic spine and rib cage to improve breathing and mobility…”. Would this be some of the EBM chiro Alex talks about? If so, please provide the evidence that you are doing what you say; it sounds as though you essentially give the patient a massage. We all feel good after a decent massage, but what demonstrable physiological effect does this have 60 minutes later?

      • jm says:

        Evidence is quite easy to gather for that – palpate the muscles, to feel if they’ve changed. Ask the patient how she’s breathing. Next time she comes in, ask how the last treatment helped, and how long it lasted.

          • jm says:

            In that situation, for the practitioner it would be evidence. For the patient it would be feeling better, or not. Anecdote would be telling someone else about it.

          • jm says:

            I can only hope so – especially if I was the patient. I would hope the practitioner could use common sense to gather relevant evidence for something as straightforward as a hypertonic muscle.

          • Frank O says:

            Confirmation bias in this sort of situation means the practitioner remembers every positive report from a patient as evidence and ignores every negative one. Anecdote means telling other people your collection of selectively remembered patient stories amounts to seriously credible evidence supporting the procedure as medically effective.

            Why do so many members of our species accept the word of others as evidence? People are such lousy witnesses, even when it comes to something as simple as saying how you feel. Take a look at http://www.planetperplex.com/en/item/checker-shadow/ for just one amazing example of how hopeless our subjective evaluations can be.

      • Emilio Anzon says:

        well the problem of a good massage is the only “demonstrable physiological effect” could be the self awareness…..and it is a valuable one, I think!
        If a person feels better, smiles, is more relaxed, sometimes goes easier to toilet (YES! a lot of people who come to me have this “side effect”) and especially if he comes back to have another massage (read “alternative treatment”) I think I am not stealing!
        Of course I am not saying I “cure” any ailments! For that go to a doctor!
        But I see there is a big problem: how risky can be an alternative treatment ???
        In my case I do Shiatsu and I do it carefully, the person should not feel any pain!
        Besides I never talk any rubbish about balancing Qi or whatever….
        But I have to tell you: people prefer to hear those superstitious fairy-tales, and I admit that science and medicine are too complex for the layman!

  • Nick says:

    There are definitely problems in mainstream medicine here too. For back-pain, there’s acceptance of biopsychosocial stuff that seems founded upon a disinterest in informed consent. Difficult to honestly discuss prognosis when there’s also an attempt to promote a positive and empowering cognitions about symptoms and illness. How many clinicians explain the problems with response bias which make it so difficult to interpret results for trials of behavioral interventions and exercises that rely upon patient reported outcome measures?

    “full informed consent in chiropractic essentially discourages a patient from agreeing to be treated” – I think that this is a fairly widespread problem for back-pain interventions (and quite a few other health problems)!

  • Thinking_Chiro says:

    If the patient has come to me after seeing the doctor and is already on medication, then what is the patient actually saying? Its a case of “How can I help myself” and “What can I do to manage this condition?”. I make it quite clear that we are not treating the asthma and that the medication is very important, and that we are only focusing on musculoskeletal side effects. The lifestyle advice and exercises are all about helping the patient help themselves. Unfortunately, if doctors just prescribe only without addressing these issues, it can be very disempowering for the patient.
    I agree with most of what you say Edzard especially if chiropractors claim that treating subluxations will cure asthma, which is a load of crock!

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