Chiropractic and ethics in the BJGP

The regular half page advert for the General Chiropractic Council appears in the BJGP as usual this month.

I am sure there is little or no editorial control over the advertising in a journal but I couldn’t help but notice that this month their advert is plastered directly opposite Prof Ernst’s article: ‘Ethics of complementary medicine: practical issues.’¹ I will leave the GCC to muse where on the spectrum between conspiracy and cock-up this sits. Perhaps the BJGP editorial board has similar feelings to Nature and the Daily Mail on the recent Simon Singh vs chiropractic legal battle?

The Prof Ernst article shines a harsh ethical light on some of the claims of the GCC. The banner headline in their advert is:

Why refer patients to Chiropractors? Because Chiropractors manage back pain effectively and use methods recommended in current evidence reviews.

Holding up my paper copy of the BJGP I move my eyes two inches to the right to read Prof Ernst’s comment:

A survey of promotional leaflets distributed by US and Canadian professional chiropractic organisations showed that all of those sampled claim chiropractic services that ‘have not been scientifically validated’. The authors concluded that this ‘reinforces an image of the chiropractic profession as functioning outside the boundaries of scientific behaviour’.

The article goes on to lay out some of the practical ethical issues that are not being addressed across the field of complementary medicine.

Informed consent is taken as a sine qua non of ethical medical practice. We teach students that it is an indispensable ingredient of modern medicine. The ethical issue is at its starkest when considering GPs that practice complementary medicine and in particular homeopathy. The overwhelming weight of evidence suggests that the actual homeopathic remedies are ineffective. I do not doubt that many people who visit a homeopath feel better. This is unsurprising as having an extended consultation with almost any practitioner prepared to sit and listen is clearly a massive intervention in itself. I am struggling to believe that any homeopath tells a patient that the pill itself is an inert blank and they are practising, in Dr Aust’s words, ‘stealth psychotherapy’.

The BJGP provides (presumably for ‘balance’) a commentary² by Brian Buckley, a Cochrane fellow and researcher in primary care in Ireland, with no obvious affiliation to complementary medicine. He offers a limp, half-hearted refutation of Prof Ernst’s article. He makes some effort to set up a straw man argument when he suggests that genuine informed consent is not obtained in the practice of conventional medicine. This bears a striking resemblance to the wholly discredited tack that conventional medicine has but a handful of evidence based options.

The example of prostate specific antigen is cited as an example of the dubious ethical nature of consent. Personally, I am careful to counsel patients on the notoriously limited value of this test. Not for nothing is it commonly considered by GPs that PSA stands for Promotes Stress and Anxiety. He suggests that:

Given pressures of time and other factors, it seems unlikely that all patients give genuinely informed consent… to give genuinely informed consent would require a considerable amount of time and preferable some knowledge of epidemiological principles to discuss it with their doctor.

While I am not suggesting I wouldn’t like more time this is exactly what being a GP is all about. Of course, it all depends where you set the bar for ‘genuinely informed consent’ but practising patient-centred medicine means that GPs spend all day trying to give people enough information to allow them to be genuinely empowered. I’m not suggesting it’s perfect but I am sure most GPs are trying damn hard to achieve it.

There are many areas that could be suggested for a discussion about the ethics of complementary medicine. One argument might highlight patient autonomy and this means that people are free to choose complementary medicine. That’s a powerful argument but it is undone by the premise of informed consent. No one can make an informed choice until they are in full possession of the facts.

Complementary medicine, when practised by GPs, skirts very close to the edge of ethical acceptability. Full informed consent is needed and surely that should involve informing patients of the absence of effect and the risks of treatment?

1.  Ernst, E. (2009). Ethics of complementary medicine: practical issues British Journal of General Practice, 59 (564), 517-519 DOI: 10.3399/bjgp09x453404

2.  Buckley, B. (2009). Commentary: Conventional medicine is less than perfect British Journal of General Practice, 59 (564), 519-519 DOI: 10.3399/bjgp09x453558