In a recent article, Dr. Thomas Klapp claims: "There is no credible moral argument that supports the idea that the world needs yet another profession to add to its ability to obtain prescription drugs."1 Well, as Dynamic Chiropractic's columnist on ethics, this sounded like a challenge. I accept.
First, let me be clear the purpose of this column is neither to advocate for the inclusion of prescription medication within the practice of chiropractic nor to argue against it. The purpose of this column is specifically to present what I think is a credible moral argument for the inclusion of prescription medication in the chiropractic profession. Dr. Klapp, having dismissed the possibility of a credible moral argument in favor of the inclusion of prescription medication, appears to have presented his moral argument against inclusion – that there isn't one for it. I do not think is much of an argument.
There are other sides to the debate about the inclusion of pharmaceuticals into chiropractic practice, but I will leave that to others to engage in the dialectic ... with one caveat. It is very hard to have a professional debate when one side starts with demonizing their opponents by using epithets such as "pharma-practors." I am sure that those interested in incorporating prescriptive pharmaceuticals are chiropractors (who primarily use their hands in treating patients) and for Dr. Klapp to suggest that those who disagree him a priori are not with name-calling only diminishes the force of his argument by using argumentum ad hominem.2
Dr. Ian Coulter has written that there are five basic philosophical constructs that form the basis of the philosophy of chiropractic; one of those five is therapeutic conservatism.3 Before Coulter articulated that philosophy, I heard it espoused by a friend of mine thusly: "Surgery is for the failure of other options." This sounds like something a chiropractor might say. However, that friend, a primary-care sports-medicine physician, practiced with me in New York City in the 1980s. Ning has argued that there really may not be as great a philosophical difference between those in the CAM professions and those in the conventional medical profession.4
I would suggest that therapeutic conservatism, while a nice shorthand for the concept, is more nuanced than is captured by that phrase. One should be as therapeutically conservative as is appropriate for the patient's current clinical situation, thus complying both with our beneficence and nonmaleficence duty to patients.
A person who experiences considerable trauma (say from a stabbing or gunshot) would not want anyone to call a chiropractor to give a hole-in-one adjustment, or for that matter apply the adage, "Surgery is for the failure of other options." I think surgery is probably the first option and is as therapeutically conservative as is appropriate.
For a patient experiencing an acute myocardial infarction, let's not talk about modifying their diet and adding exercise or a prescription of statins; get them to the cardiac catheter lab, that's the therapeutically conservative choice. But as happened to a friend of mine, that wasn't a therapeutic option and bypass surgery was the only therapeutically conservative option to save his life. Finally, for the patient with a life-threatening bacterial infection, therapeutic conservatism is not taking echinacea or an adjustment; therapeutic conservatism in this case is aggressive intravenous antibiotic therapy. Dr. Klapp and I agree on this, I think.
Our profession often likes to criticize the medical profession for its aggressive approach to treatment of those conditions we commonly treat (low back pain, neck pain and headaches). As noted often in the pages of DC and as Dr. Klapp correctly laments, allopathic medicine's overly aggressive approach is too common and often inappropriate.
There are copious data to show that far too many patients with back pain are X-rayed, given CTs and MRIs, prescribed steroid and narcotic medication, and operated on. Except in the case of those few people with hard neurological signs or a deteriorating neurological condition, most of these patients should be treated by more a therapeutically conservative approach, such as the care offered by doctors of chiropractic.
But it is critically important to keep in mind that the reason why we have these data showing the far-too-prevalent use of aggressive diagnostic and therapeutic procedures used by the medical profession is not because of research done by doctors of chiropractic, but research conducted by doctors of medicine. We are not initiating a data-driven argument; we are just echoing the data-driven argument initiated by the medical profession itself.
The medical profession's lament about overly aggressive diagnosis and treatment (and thus higher cost) without high patient outcomes (and thus low-value health care) is coming from multiple sectors of the medical community. It is coming from professional societies, medical schools, think tanks and health policy experts.
Thus, Dr. Klapp and I agree a more conservative approach is often a better starting point for most spinal pain disorders. So, what moral argument can be made for chiropractors to have the legal right and authority to prescribe medications, which in general are overprescribed?
The First Moral Argument
While the medical profession officially (societies, medical schools and health-policy think tanks) is all for therapeutic conservatism in the treatment of spinal pain disorders, it appears very difficult to get those on the front lines, those providing the care, to opt for more conservative approaches.5 As Abraham Maslow is often quoted as saying, if your only tool is a hammer, you see all problems as a nail.
The medical specialties overuse their primary tool: medication; and the surgical specialties overuse their tool: surgery. To our profession, the hammer is the adjustment, and sometimes we overuse that tool when there are times when a short course of medication is indicated.
DCs working in integrative environments can easily obtain the prescriptions for the patients, without added burden of time and money, by talking to the MDs with whom they practice. But for the patient seeking care with a doctor of chiropractic who has that legal authority and does not practice in an integrated environment, the patient would be able to get the needed prescription without the added burden of time, money and scheduling delay to see a medical doctor. Thus, a chiropractor who is able to write a prescription may save a suffering patient all of the above when getting a treatment they need. That is a moral good.
The Second Moral Argument
My colleagues and I have articulated our thoughts that there ought to be a primary care spine practitioner, a role to which we chiropractors are ideally suited.6 However, most patients with low back pain seek the care of a medical physician first,7 and we know that they are too therapeutically aggressive because they have little else than pharmaceuticals as their conservative treatment.
But chiropractors who have relied upon and developed an expertise in using more conservative approaches, and who are given the right to prescribe pharmaceuticals, are more likely to choose their more conservative, time-tested and clinically effective methods first. Chiropractors may be a better choice to prescribe pharmaceuticals for spinal pain syndromes, as they will be less likely to overprescribe. Why? Because they have an expertise with a more therapeutically conservative toolset: manual therapies and exercises. Thus, as more patients seek chiropractic care, we will be able to slow the growth of pharmaceutical treatment among spinal pain patients and only use the medication for its appropriate short-term use. That is also a moral good.
There may be more credible moral arguments, but I'll stop with these two. Debate is good and as President Gerald Ford said in his 1977 State of the Union address, we can disagree without being disagreeable.
- Klapp TM. "The Case Against Drugs in Chiropractic" (Parts 1-3). Dynamic Chiropractic, 2013 (Aug 15 - Sept. 15 issues).
- Perle SM. "Argumentum Ad Hominem." Dynamic Chiropractic, July 30, 2005.
- Coulter ID. Chiropractic: A Philosophy for Alternative Health Care. Oxford, UK: Butterworth-Heinemann Medical; 1999.
- Ning AM. How "alternative" is CAM? Rethinking conventional dichotomies between biomedicine and complementary/alternative medicine. Health, 2013 Mar;17(2):135–58.
- Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematic review. Eur J Pain, 2012 Jan;16(1):3–17.
- Murphy DR, Justice BD, Paskowski IC, Perle SM, Schneider MJ. The establishment of a primary spine care practitioner and its benefits to health care reform in the United States. Chiropr Man Therap, 2011;19(1):17.
- Chevan J, Riddle DL. Factors associated with care seeking from physicians, physical therapists, or chiropractors by persons with spinal pain: a population-based study. J Orthop Sports Phys Ther, 2011 Jul;41(7):467–76.
Click here for previous articles by Stephen M. Perle, DC, MS.