MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

The issue of informed consent has made regular appearances on this blog. It is important and has many intriguing aspects, particularly for so-called alternative medicine (SCAM). On the one hand, it is a ‘conditio sine qua non’ for any form of healthcare, while, on the other hand, it is a near impossibility in SCAM practice.

In this new article published in a chiro-journal, the authors review the origins of informed consent and trace the duty of disclosure and materiality through landmark medical consent cases in four common law (case law) jurisdictions. The duty of disclosure has evolved from a patriarchal exercise to one in which patient autonomy in clinical decision making is paramount. Passing time has seen the duty of disclosure evolve to include non-medical aspects that may influence the delivery of care. The authors argue that a patient cannot provide valid informed consent for the removal of vertebral subluxation. Further, vertebral subluxation care cannot meet code of conduct standards because it lacks an evidence base and is practitioner-centered.

The uptake of the expanded duty of disclosure has been slow and incomplete by practitioners and regulators. The expanded duty of disclosure has implications, both educative and punitive for regulators, chiropractic educators and professional associations. The authors discuss how practitioners and regulators can be informed by other sources such as consumer law. For regulators, reviewing and updating informed consent requirements is required. For practitioners it may necessitate disclosure of health status, conflict of interest when recommending “inhouse” products, recency of training after attending continuing professional development, practice patterns, personal interests and disciplinary findings.

The authors conclude that, ultimately such matters are informed by the deliberations of the courts. It is our opinion that the duty of a mature profession to critically self-evaluate and respond in the best interests of the patient before these matters arrive in court.

In their paper, the authors also provide a standard list of items required for ‘informed’ consent:

(1) emphasizing the patient’s role in shared decision-making

(2) disclosure of information

a. explaining the patient’s medical status including diagnosis and prognosis

b. describing the proposed diagnostic and therapeutic intervention, including the likelihood and effect of associated risks and benefits of the proposed action, including material risks

c. discussing alternatives to the proposed intervention, including doing nothing

(3) prompting and answering patient questions related to the proposed course of action (NB. this involves probing for understanding, not simply asking ‘do you have any questions’), and

(4) eliciting the patient’s preference (usually by signature). (NB. A signed form is not consent. The conversation between the clinician and the patient or carer is the true process of obtaining informed consent. The signature on the consent form is proof that the conversation took place and that the patient understood and agreed.)

The authors of this article – I do commend it to all chiropractors – take a mostly judicial view of informed consent (for an ethical perspective on the subject, I recommend our book). They do not discuss, whether chiropractors do, in fact, adhere to the ethical imperative of informed consent. As I have stated before, there is not much research on this issue. But the little that does exist fails to show that chiropractors care much about it.

But why?

If it’s an ethical imerative, why do chiropractors not abide by it?

The answer to this question is not difficult to find. Just imagine a conversation between a chiropractor (C) and a patient with neck pain (P):

  • P: What’s your diagnisis?
  • C: You are suffering from acute neck pain.
  • P: Thanks, that much was clear to me. What do you suggest I do?
  • C: I will perform a manipulation of your neck, if you agree.
  • P: Why would this help?
  • C: It can realign the vertebrae that are out of place, simply put.
  • P: And my pain will disappear?
  • C: Sometimes it does, yes.
  • P: But will it disappear quicker than without manipulation.
  • C: Some of the evidence says so.
  • P: Ok, but what does the most reliable evidence say?
  • C: It is not entirely clear cut.
  • P: Hmm, that does not sound too good.
  • P: So, tell me, are there any risks?
  • C: About 50% of patients suffer from minor to moderate pain for 2-3 days afterwards.
  • P: That’s a lot!
  • P: Anything else?
  • C: In some cases, neck manipulation was followed by a stroke.
  • P: Gee that’s bad; how often has this happened?
  • C: We know of about 500 such cases.
  • P: Heavens!
  • C: Now, do you want the treatment or not?
  • P: How much will you charge?
  • C: Only 60 Euros per session.
  • P: You mean I have to come back for more, each time risking a stroke?
  • C: Well… You don’t have to.
  • P: Thanks for the info; I am off. Cherio!

I rest my case. 

 

58 Responses to Informed consent: why chiropractors don’t like it

  • And let us not forget the case, discussed on this blog, of an elderly man with ankylosing spondylitis who consulted a chiropractor (who described herself as a ‘doctor’), and underwent went cervical manipulation by the drop technique (face down on a table) – and suffered a fatal stroke.

    Additionally, chiropractors should make clear they are practising a “different system from medicine” (as stated by D. D. Palmer). The intention being to release ‘innate intellegence’ (a form of un-evidenced ‘vital force’) from vertebral subluxations.

    If the practitioner is not intending to do that, they are not practising chiropractic.
    The patient must be informed – they might wish to consult a physiotherapist if they cannot obtain natural resolution.
    Self interest must be declared.

    Quite why folks thinking of studying and then practising chiropractic have not gone into physiotherapy, ostepathy, or medicine, has never been explained.

    Raising issues of consent damages commercial interests.
    Which is why the issue of chiropractors being quacks is raised.

    • RR: “The intention being to release ‘innate intellegence’ (a form of un-evidenced ‘vital force’) from vertebral subluxations.

      If the practitioner is not intending to do that, they are not practising chiropractic.”

      Why are chiropractors obligated to believe what DD Palmer wrote 100 years ago? Is there some rule that a profession (at least part of it) cannot evolve?

      • Would it not show greater integrity if, not going along with Palmer, or Andrew Taylor Still, an intending practitioner entered physiotherapy – or medicine?

        Or if, for some reason they had taken up with anachronistic chiropractic, they changed their profession –

        As many dentists, nurses,
        physios and plenty of others have done.

        Why hang on?
        Move on.

        • Many have moved on…we kept the title, not the silly beliefs.

        • With all due respect, I urge Richard to spend some time learning more about the chiropractic profession before making blanket statements. Science-based chiropractors began rejecting Palmerian ideology in the early 20th century and have continued to do so with ever increasing voice and numbers. I first published on this topic in 2012. The paper has had 19k accesses but perhaps Richard has missed it. Here is the doi: https://doi.org/10.1186/2045-709X-20-1 An in depth analysis of the ideological divide in chiropractic was published in 2012. With 10k accesses, this paper provides great insight into this topic. Here is its doi: https://doi.org/10.1186/s12998-017-0171-x
          Richard asks: why hang on? Again, an evidence based reply: Compared to 291 other health conditions, the low back pain causes more global disability than any other health problem studied. Rational chiropractic care is safe, effective and cost-effective for low back pain. Add to this some headaches and neck pain and there are plenty of valid reasons for evidence-based chiropractic to contribute to the healthcare system. I could go on, but this is enough for now.

          • @ JK Simpson

            but what advantage does chiro have over physical therapy?

            and don’t you think it is confusing for patients and other health professionals to have to try to distinguish between chiros who may be straight or mixed or anything in between (and this distinction may not be obvious on websites or anywhere else) and outsiders may not even know the difference?

            Chiros use the term “Dr” which often confuses patients who think they are medically qualified.

            It just adds to confusion for patients with no benefit.

          • And as we have seen in the tragic case of Mr John Lawler, sometimes the term Dr. is used illegally.

            How are patients to know which theories and practices any given “chiropractor” follows? (THis issue is aired well in “Trick or Treament”.

            If a group of chiros exist who fundamentally disagree with the theories of the founders of Chiropractice DD and JB Palmer, why on earth do they persist in calling themselves Chiropractors? Why not formulate their own theories and practices – hopefully evidence-based – properly, and call themselves something else?

      • Why would a person who rejects the Palmer model train in chiropractic rather than physiotherapy?

        • This is an interesting and important question. Evidence based chiropractors – i.e. those who have rejected Palmerian ideology – choose to concentrate on management of musculoskeletal conditions. We have no desire to delve into postpartum care, incontinence treatment, post-surgical rehab, cystic fibrosis therapy, etc, etc… The greater than 150 musculoskeletal conditions that affect the locomotor system are enough to keep us busy. The reality is that physiotherapists spend a comparatively minute amount of time studying these conditions because of their need to learn how to manage the others listed. A colleague of mine has a chiropractic degree and a masters degree in physiotherapy. He has confirmed this information as have I by examining physiotherapy course outlines.

          • JK Simpson, what’s your view, then, on whether DD Palmer cured a man of deafness by spinal manipulation?

            Why would anyone who rejects the ideas of DD and JB Palmer want to use the name Chiropractic? (DC suggested above, with no explanation, that somehow persons who reject Palmer are legally obliged to call themselves Chiropractors. Odd)

            Why not be called something else? Why not become a Physiotherapist working in private practice, specialising in whatever aspect of Physiotherapy they prefer? Or, in the USA, a D.O?

            Surely, to be called a Chiropractor is to be aligned with the Palmers?

  • Of course they may have other options…

    “Major complications of these injections include; epidural hematoma, infection (abscess, meningitis), new neurological deficits (e.g., monoparesis to quadriplegia) due to intramedullary injections, and strokes to the spinal cord, brain stem, and/or cerebellum attributed to intravascular injections among others.”

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5926212/#:~:text=Major%20complications%20of%20these%20injections,to%20intravascular%20injections%20among%20others.

    “NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal.”

    https://www.drugs.com/sfx/naproxen-side-effects.html

    • @ DC – but at least these interventions have known proven positive actions that on balance outweigh the risks. They are based on scientific principles and have been demonstrated to have certain clinical effects.

      This is at variance with the interventions undertaken by chiropractors which are so often based on imaginary subluxations and attempt to manipulate unproven vitalistic forces or even if they do not to perform manipulations or table-drops or “cracking” or use bizarre tapping tools all of which are totally unproven but serve to add a pseudoscientific mystical aura to trick clients into believing in their showmanship.
      This is all flim-flam and theatrical placebo more worthy of PT Barnum than a clinical setting.

      A risk of harm when there is a genuine clinical benefit is one thing – a risk of stroke when there is no possible hint of benefit is an entirely different thing altogether don’t you think? That is what makes chiros so dangerous – along with the fact that they seem so incorrigible in this regard.

      • What is the longest study done on steroid injections for neck pain? Anything longer than 2 years?

        NSAIDs? Around 100 people die everyday from its complications and it is barely better than placebo for back pain.

        No genuine benefit for cSMT? Even as a sole modality (which its usually part of a multimodal approach)…

        “CGHA are a common headache disorder. SMT can be considered an effective treatment modality, with this review suggesting it providing superior, small, short‐term effects for pain intensity, frequency and disability when compared with other manual therapies.”

        European Journal of PainVolume 24, Issue 9

        • DC wrote: “No genuine benefit for cSMT? Even as a sole modality (which its usually part of a multimodal approach)… “CGHA are a common headache disorder. SMT can be considered an effective treatment modality, with this review suggesting it providing superior, small, short‐term effects for pain intensity, frequency and disability when compared with other manual therapies.” European Journal of PainVolume 24, Issue 9”

          @ DC

          “The key points here are:

          – methodological quality of the primary studies was mostly poor;
          – adequate control for placebo effect was achieved in 1 RCT only;
          – this trial showed no benefit of SMT beyond a placebo effect;
          – the majority of RCTs failed to provide details of adverse effects;
          – this means they violate research ethics and should be discarded as not trustworthy;
          – the therapeutic value of SMT remains uncertain.

          The new paper was published by chiropractors. Its positive result is not clinically relevant, almost certainly due to residual bias and confounding in the primary studies, and thus most likely false-positive. The conclusions seem to disclose more the bias of the review authors than the truth. Considering the risks of SMT of the upper spine (a subject not even mentioned by the authors), I cannot see that the risk/benefit balance of this treatment is positive. It follows, I think, that other, less risky and more effective treatments are to be preferred for CGHA.

          Ref https://edzardernst.com/2020/07/spinal-manipulation-for-the-management-of-cervicogenic-headache-a-new-review-of-the-evidence/

        • @ DC
          in your dreams maybe.
          the problems with nearly all studies conducted by chiros is that they don’t do RCT’s, they don’t allow for placebo effects, they almost NEVER details adverse effects (alt med acolytes for obvious reasons have never instituted an equivalent of the VAERS or Yellow card adverse event reporting system systems so all their ADR equivalents go under the radar) – they are usually poorly conducted, very often of the A vs A + B variety which guarantees a positive result, they involve imaginary entities such as subluxations, they often rely on subjective end points, often the numbers involved are too small to obtain a meaningful result – they are so often published in low quality journals with meaningless peer review, chiros don’t actually understand science to begin with, and very often what is patently an equivocal or negative study gets spun as somehow positive or data mined or sub-groups get post hoc exhumed as somehow retrieving the study as viable in some way.
          These are reminiscent of the way Trump is desperately claiming he won the election – alt meddies will always somehow claim their “study” is somehow positive no matter how negative it is.

          • Chiropractors don’t do RCT? Do tell….

          • @ DC
            they haven’t learned how to do it very well – they nearly always manage to bodge it somehow.
            Haven’t you noticed?
            They get the randomization wrong, or the numbers are so small that it can’t possibly be meaningful, or they don’t allow for the placebo effect, or they don’t get proper consent or they use an A vs A + B model which virtually guarantees a positive result or they change end-points part way through or they end up doing sub-group analysis that wasn’t in the original design and they don’t mention adverse events and so on.

            It’s the usual fast and loose stuff that comes with alt med studies trying to slip under the radar. And whatever the results actually show they will always try to spin it as positive and the last paragraph will always say “more studies are needed.” They’ve been saying that for at least 50 years now and they still haven’t realized they are never going to get a decent rigorous study that is going to come out as positive.

          • Here is your claim…

            “problems with nearly all studies conducted by chiros is that they don’t do RCT’s,

            Now you say they do.

            “they haven’t learned how to do it very well”

  • How many posts regarding physio, osteopaths or podietrists informed consent have you published recently?

    And I am all in favour of informed consent forms.

  • If the D(umb)C(onfused) responding here can’t learn that TU Quoque is a logical fallacy and thus insufficient to win an argument they certainly aren’t going to succeed in comprehending the real concerns of informed consent. I’ve always found it extraordinary that the only reliable methods of viewing internal-architecture (MR and X-ray) remain immutable pre-pain and post pain and after Chiroquackery “treatments” i.e. THEY NEVER CHANGE. Ergo “alignment” should not be legally allowed to be “sold”. I suggest informed-consent must also include telling patients that IF such a thing as “alignment or misalignment” actually exists (and is the source of pain) their existence CANNOT be demonstrated via any means other than invalid, unreliable, purely subjective gypsy tricks. Objective post-treatment X-ray and MR will indubitably, 100% of the time reveal NO REALIGNMENT ever took place. 1. It (manipulation or the other entrepreneurial theatrics) are very expensive. 2. You could be injured…or die. 3. The entire underlying premise is demonstrably false. 4. Caveat Emptor sucker.

    • Uh, part of informed consent is discussing other options.

      • @ DC
        if it was true “informed consent” chiros would have to admit that there was no basis in reality for all their shtick at all. That it was all made up out of whole cloth by a huckster 100+ years ago and they have been flim-flamming it ever since.

        All the X-rays and drop-tables and the fancy tools are all window-dressing – theatrical placebos and nothing more. That is the truth that would have to come out in a real “informed consent.” That there is no basis for the claim to title “Dr” and the white coat is just for show. It’s all an illusion – and an expensive one at that.

        One can smell the sheer desperation from here – clinging to any shred of poorly run studies and any scrap of false evidence that might cover the bare nakedness of the “emperor has no clothes – and never had,”

        Chiro is a total fiction. A SCAM. It’s made up. Trade up to an honourable and decent profession where you don’t have to lie to clients all the time – and where true informed consent doesn’t mean channelling a long dead delusional wannabee. If you can’t do better than that it’s surely time to give up?
        Surely you owe your clients better than that?

        • Then they should ban SMT from the PT, DO and MD professions.

          • @ DC
            what evidence is there that MDs do SMT?
            anyway this is whataboutery – the fact that others do the same shtick is no excuse for chiros doing it.
            By this excuse you could excuse thieving, murder and any number of other activities – many other people are doing it so I may as well do it as well! Is that your best excuse?

            I think if you want to find an excuse for doing SMT you had better find a better one than “lots of other idiots are also doing it as well.” That isn’t very convincing or very science based is it? You might as well say “lots of lemmings are jumping off a cliff so it must be a good idea to do that as well.”

            (Before someone mentions it I know that lemmings don’t actually do this but it is such a good analogy I still like to use it anyway.)

          • “what evidence is there that MDs do SMT?”

            Case reports of AE.

            Shouldn’t all PTs, DOs and MDs stop doing SMT if what you state is true?

            Why haven’t they?

            Why do they keep doing research on SMT?

  • DC wrote on Sunday 08 November 2020 at 13:17 “No possible hint of benefit? Better contact the authors… ‘Cervical manipulations are effective in management of cervicalgia, epicondylalgia, temporomandibular joint disorders and shoulder pain’. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228797/#!po=15.9091

    @ DC

    From the authors’ conclusion: “Spinal manipulations can also have risks for the patient if applied when not appropriate but the frequency of complications due to vertebral manipulation is very low. Any type of therapeutic intervention has a risk-benefit ratio for the patient and the health professional, considering this relationship, chooses one therapy over another. The manipulation technique has some limitations: patients do not always have good compliance with treatment or sometimes have contraindications. The long-term benefits and frequency of manipulative therapy remain unknown.

    @ DC

    Bearing in mind that the frequency of complications due to vertebral manipulation *is unknown*, that chiropractors often apply manipulation when not appropriate, and that they have no reliable screening methods for their customers, the Precautionary Principle should be applied – IOW, no manipulations should be administered when there are cheaper, safer and more convenient options available.

    Of course, informing customers of such an unfavourable risk/benefit profile would negatively impact on chiropractors’ livelihoods. All of which brings us back to the title of this blog post.

  • For all the cynics (not critics on this blog):
    Informed consent has been a common law requirement in Australia since 2000 for ALL health professions. I have had informed consent in my practice since 1995 and it’s on its 7th revision. We have discussed this in the past Edzard.
    Stan and Keith wrote this paper with some very high powered legal input which is listed in the acknowledgments here:
    “The following legal professionals are acknowledged for their assistance. But-for their contribution some important legal aspects may have been overlooked.
    David Cheifetz, Retired Civil Litigation Barrister, Toronto, Canada.
    Michael Weir, Law Professor, Bond University, Queensland, Australia.
    Emma Cave, Professor of Healthcare Law, Durham Law School, UK.
    Nadia Sawicki, Georgia Reithal Professor of Law, Co-Director, Beazley Institute for Health Law and Policy, Loyola University Chicago School of Law, USA.”
    Michael Weir, law professor at Bond University in Australia has been a leading legal expert on informed consent since the 1980’s. Every profession listens to him. You would be hard pressed to find anyone more qualified and the others have similar eminence on this topic.

    @Edzard
    Informed consent is a LEGAL requirement and is checked every year by AHPRA (the government body that regulates every professions and the Chiropractic Board of Australia (CBA) that answer to AHPRA NOT the Chiro profession. My professional indemnity insurer also checks it as well. There is NO “Informed consent: why chiropractors don’t like it”.
    In 25 years of informed consent I have only had ONE patient who has refused care. The problem with patients now is that they have become blase with informed consent, which is done by every profession over and over and just sign. I then go through it in detail and carefully explain all the MANDATORY REQUIRED key points and add “discussed in detail with the patient” to my clinical notes. I also go through it again when clinically reviewing the patient and upon discharge. If the patient returns any time after 6 months then I do a NEW informed consent every time.

    Then in your dialogue you go on about:
    “About 50% of patients suffer from minor to moderate pain for 2-3 days afterwards”.
    Research for both physio’s and chiro’s put temporary soreness post Tx at approx 50%. It’s a non-issue except for cynics who want to put their spin on it. Temporary soreness is also added to my informed consent BTW.
    I also have had discussions with my referring doctors and specialists who I refer to about the risks associated with chiropractic care citing research (which I also forward to them) that puts serious adverse events at between 1/400,000-1/1,040,000. They look at me and say “that low? This is not a problem when compared to what medicine considers low risk”.

    “We know of about 500 such cases.”
    You should have written “We know of about 500 such cases over the last 100 years unfortunately the case studies are “extremely poor quality, written by doctors and full of medical dogma” (to quote neurosurgeons in the 2016 Church paper in the journal Cureus).See here:
    https://www.cureus.com/articles/4155-systematic-review-and-meta-analysis-of-chiropractic-care-and-cervical-artery-dissection-no-evidence-for-causation

    @John Travis
    I recommend you read the 2008 Supplement of The Spine Journal where Scott Haldeman got the leaders of 25 different approaches for the treatment of LBP to write papers on their evidence then tabulated the results. See here:
    https://www.sciencedirect.com/journal/the-spine-journal/vol/8/issue/1
    Until then, like you, I thought that chiro’s evidence base was poor and everyone else had evidence. After reading these articles I realized the chiropractic’s evidence was low to moderate while the rest was non-existent to low. Chiropractic stacked up well compared to the alternatives.
    There are aspects of chiropractic that are total fiction and the legal implications of these are discussed in the paper that Edzard cites.
    What Stan and Keith are discussing is the legal implications of philosophy based chiropractors who treat mythical subluxations NOT the majority of the profession. Unfortunately just like the philosophy based chiropractors who claim that “if it’s not subluxation then it’s not chiropractic” the regulars here sprout the same rubbish. The irony you are both using the same argument seems to elude the cynics here.

    @Michael Kenny
    Apart from your usual unprofessional name calling for a physiotherapist who should know better. You work under professional standards and should follow them. I recommend you actually read the paper that Edzard put his usual spin onto and realize what is going on. In the paper they discuss the lack of evidence for Tx misalignment. No different to physio’s like yourself treating mythical dysfunctions.

    This paper needs to be put into local perspective so you understand this paper.
    For 30 years Australia has had 4 university based faculties of chiropractic (MQU, CQU, Murdoch and RMIT). Recently the vitalistic chiropractors turned their backs on our universities and have been attempting to set a new vitalistic private college in South Australia. It has not been accredited yet and will not gain accreditation until their first group of students graduate and even then there is no guarantee.
    The private college applied to TEQSA for government higher education accreditation and were initially rejected. This would have allowed them to get government support and more importantly their students would qualify for government Fee-Help. Without this the college is sunk. They hired expert consultants including a former employee of TEQSA who once assessed accreditation’s and appealed to the Australian Civil Appeals Tribunal. TEQSA probably realized that they may get through so TEQSA gave the college “provisional accreditation” with conditions. All the conditions are the same reasons why they were initially rejected. See here;
    https://www.teqsa.gov.au/national-register/condition-decision/registration-25-january-2019-0

    Now accreditation for AHPRA is done for it by CCEA ( https://www.ccea.com.au/ ) which is separate to TEQSA. New Zealand Chiropractic College ticked all the necessary evidence based boxes to get accreditation then slip the subluxation BS in the back door and they “gifted” their curriculum to the new private chiropractic college to help them gain CCEA accreditation.
    Also recently one of our chiropractic associations ACA had their annual general meeting and the usual vitalists with the usual pocket full of proxy votes voted two vitaistic chiropractors onto their board. ACA tries to appeal to all factions within the chiropractic profession/tolerate BS (one of the reasons I left them and moved to the other association 20+years ago) but over the last few years they have started to reform and there was hope. One of the newly elected board members has come over from the ASRF which is a research foundation that got hijacked by the vitalists, were outed by chiro’s for their abysmal level of funding for research and the profession turned their back on them. The ASRF has lost money over the last two years and is on the way out so it looks like the vitalists are shifting their focus back to ACA’s board.

    NOW read the discussion and conclusion in the paper.
    Make sense now?
    This paper is a salvo by evidence based chiropractors across the bow of the vitalists. It also questions the legal aspects of the private college and questions the accrediting institutions and associations that remain silent when it comes to vertebral subluxations. It looks at the legal implications of subluxation within the context of informed consent.
    Edzard do you understand why the authors took a judicial view and got high powered legal input?
    There is a lot more to this paper and Stan Innes and Keith Walker have painted a big target on their backs.
    Perhaps you should dispense with your usual spin and support the authors/reformers for once?

    I am all for critics that discuss the issues and support reform. Critics both within AND without the profession are a precious resource for driving reform. But there is a big difference between a critic and a cynic.
    Unfortunately the regular cynics on this blog cherry pick the science to support their bias, willfully ignore the science that challenges their bias, make sweeping statements in regards to the chiropractic profession and think all chiropractors drink the subluxation Kool-aid.
    Arte you capable of supporting reform or will you double down an you bias and dogma like Donal Trump.

    • has it occurred to you that the world does not consist only of Australia?
      Has it occurred to you that the evidence I quoted [coming from chiros] is correct?
      Has it occurred to you to supply us with published evidence showing that chiros abide by informed consent?

    • @ Critical_Chiro

      bully for you if you think you have got it all under wraps in Australia – but that would appear to be far from the case in the UK and the USA and Canada where I have most of my experience.

      One has only to look at the excruciating examples on You-Tube to see the Chiros advertizing their wares and promulgating the terrifying ideas that subluxations are the cause of all ills, that people needs adjusting throughout life, that babies need adjusting immediately after birth and forever after – that chiropractic adjustments can cure asthma, colic, feeding issues, earache and all manner of ills as well as the ridiculous notion that chiros can be primary care doctors. All of this is highly irresponsible.

      A recent trawl of Chiro websites in the UK demonstrated a similar trove of such reckless claims entirely without merit.
      Further confusion is caused as both medical professionals and the public are unable easily to differentiate between more rational chiros and their subluxation led colleagues.

      None of this is helped by the laissez faire attitude of the so-called regulatory councils chiros have in these countries that act more like membership clubs and do nothing to police the activities of their supposed professionals – certainly they do not differentiate between subluxation fanatics and denialists but rather embrace members no matter how crazy their beliefs.

      The other beef I tend to have with chiros is their tendency towards anti-science beliefs. They so often seem to embrace other non-scientific belief systems such as Naturopathy and anti-vaccine and other woo which poisons the well when patients are having any kind of conventional medical therapy. It is difficult to take anyone seriously when they have already admitted they have abandoned any kind of science based assessment for a purely belief based system, or one based on anecdotes and testimonials.

      • https://edzardernst.com/2019/11/death-by-chiropractic-neck-manipulation-more-details-on-the-lawler-case/
        this recent UK case is a tragic confirmation of what can happen without informed consent.

        • @Edzard
          Has it occurred to you that the world does exist outside of Australia with chiro’s doing a great job with research and evidence based chiropractic in many countries?
          It has it occurred to you that the evidence I quoted [coming from chiros] is correct and we have discussed this topic before?
          Has it occurred to you to that I have supplied you repeatedly with published evidence showing that chiros abide by informed consent yet you ignore it?
          I held the belief for quite a while that your would evaluate the evidence on its merits as it presents itself and write a blog accordingly until your blog on Charlotte Leboeuf-Yde:
          https://edzardernst.com/2017/04/we-have-an-ethical-legal-and-moral-duty-to-discourage-chiropractic-neck-manipulations/
          That is when I realized you were aware of the research but choose to ignore it.
          I have chatted to world leading/highly respected physio and chiro researchers and asked them “why don’t you go on Edzard Ernst’s blog and reply to his claims?”
          Their answers were all a variation on “why bother he will never change?”

          Another tragic case by a physiotherapist who paralysed a patient.
          https://www.dailymail.co.uk/news/article-8860293/Physiotherapist-paralysed-RAF-contractor-struck-off.html
          Physio did no informed consent, dived in with Maitland Grade 5 mobilization (HVLA) without training and tagged you and Blue Wode on Twitter. Response – Crickets.
          Says it all.

          Unfortunately the cynics here just focus on chiro, ignore other profession with similar problems, make sweeping statements/assumptions in regards to chiro and the classic’s “become evidence based and retrain as a physio” and “any evidence chiro has is swiped from physio’s” (my favorite). Have you bothered to look at physio’s evidence base especially on hot button topics like pediatrics? Their raison d’être rehab exercises?. Or the classic mobilizations are safer than manipulations?
          Have a look at the research before you make these poor assumptions (read the red banner at the top of this page).

          @John Travis
          I share your beefs.
          Anti-science beliefs and a belief in mythical subluxations have similar percentages in the research. 15-18% of chiro’s. This is way too high in my view.
          This paper also coauthored by Stan Innes discusses this topic:
          Chiropractic, one big unhappy family: better together or apart?
          https://chiromt.biomedcentral.com/articles/10.1186/s12998-018-0221-z
          Time for a divorce IMHO.
          When selecting a chiro do your homework like you would any other health profession where there is the good, bad and ugly. Caveat emptor applies to all professions.
          If you trawl physio websites in the UK they are also replete with testimonials and questionable claims (which are banned here). Funnily enough 3 years after testimonials were banned in Australia 3 of the physio’s on the Physiotherapy Board of Australia still had them on their website. I pointed this out on Twitter at the time and within weeks they were quietly removed without a word from the critics. It’s guaranteed he chiro board on the other hand would have been examined by the critics. When I first started teaching one day a week I was warned “go through your website word by word as it is guaranteed that you will now be checked by critics like Friends of Science in Medicine”.
          The regulatory councils have a very broad definition of what is a chiropractors scope of practice. That is why the paper that this blog cites is so important and should by supported and not subject to Edzard’s usual cherry picking and cynical spin. This paper is saying to the subluxation based chiropractors, private vitalistic colleges, associations and regulators “the way you practice has legal ramifications”, “the way you teach has legal ramifications”, “your silence has legal ramifications” and “your tolerance of subluxation by your members has legal ramifications”.
          This paper has been published which means it is only a matter of time before it is used in a legal case.
          The vitalists (like the cynics here) will never change. I realized that a long time ago.
          They will have to have evidence based practice/best practice/patient centred care forced upon them.
          Great legal opinion piece paper with high powered legal input.


        • this recent UK case is a tragic confirmation of what can happen without informed consent.”

          Not really. The patient may have consented.

          • but he did not!

          • Read what you wrote.

          • @ DC: can you explain to me, please,
            1)what the law says about informed consent for Australian chiros,
            2) what info you must provide,
            3) who monitors it,
            4) and what published evidence we have about compliance?

          • You tell me how you know he would not have consented.

            “this recent UK case is a tragic confirmation of what can happen without informed consent.”

          • I am in contact with his family (in fact, they approached me for help); his wife was present at all times.

          • “I am in contact with his family (in fact, they approached me for help); his wife was present at all times.”

            So? That doesn’t establish that he would or would not have consented.

          • No?
            His widdow says he did not consent. What else do you want?

          • Even if one were to raise poor Mr Lawler from the dead, to provide his own testimony about his consent or lack of it, this would be unlikely to suffice, as he might be lying in order to get compensation……

            You can prove things beyond reasonable doubt, but not beyond unreasonable doubt…..

  • FOUR QUESTIONS TO DC + CRITICAL CHIRO:

    1) what does the law say about informed consent for Australian chiros?
    2) what info exactly do you have to provide?
    3) who monitors it?
    4) what published evidence do we have about compliance?

  • DC quoted Edzard Ernst on Wednesday 11 November 2020 at 11:51 “I am in contact with his family (in fact, they approached me for help); his wife was present at all times.” and then wrote “So? That doesn’t establish that he would or would not have consented.”

    @ DC

    Here’s a snippet from the statement written by the victim’s family:

    QUOTE
    “There were several events that went very wrong with John’s chiropractic treatment, before, during, and after the actual manipulation that broke his neck.

    Firstly, John thought he was being treated by a medically qualified doctor, when he was not. Furthermore, he had not given informed consent to this treatment.

    The chiropractor diagnosed so-called ‘vertebral subluxation complex’ which she aimed to treat by manipulating his neck.”

    Ref. https://edzardernst.com/2019/11/we-hope-that-the-publicity-surrounding-this-event-will-highlight-the-dangers-of-chiropractic-a-statement-of-the-family-of-the-man-who-died-after-treatment-of-a-vertebral-subluxation-complex/

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