A couple of weeks ago a news commentator reported that Hurricane Floyd had provided something of an economic windfall for North Carolina, due to the obligatory and massive reconstruction. Carpenters, contractors, suppliers of building materials - all were doing just fine. This commentator did not comment on the people who had lost everything, most of whom were not covered by flood insurance. Presumably, these people didn't find the hurricane all that beneficial. When there is a natural disaster, some individuals may benefit, but the region as a whole cannot benefit: homes, infrastructures and lives are lost.
The same type of reasoning has been used to explain the enormous success of the post-war economies of Japan and Europe and how they attained a competitive edge over the American producers of steel, automobiles and consumer electronics. When the immense destruction of factories and equipment during the war forced the Japanese and Europeans to rebuild, they took advantage of a bad situation by deploying the most up-to-date technology. By comparison, American industry at that time was consumed by systemic inertia: obstructionist labor unions, overly cautious stockholders, unsupportive government leaders, prohibitive capital improvement costs and stodgy chief executive officers.
One of my professors in economics, somewhat quizzical on the notion that the Japanese were lucky to have had their factories destroyed during WWII, suggested that if this were true, it would be sound economics to have the U.S. Air Force bomb Pittsburgh and Detroit to improve their competitive standing. Now, this was a rather bold proposal, and one unlikely to be equally palatable to all the citizens of Pittsburgh and Detroit. It certainly raises an interesting question. Must we always destroy in order to rebuild? Hurricanes and wars notwithstanding, are there any other means by which an intelligent, clairvoyant society may intentionally create a preferred future? Probably not, you say? OK, well, if not a society, would you believe a profession? How about chiropractic?
Illusion of Unity, Unity of Illusion
After more than a century of internecine struggle and even fratricide, chiropractic remains a profession divided. Empty appeals for unity compete for our attention with unrepentant calls to arms, as one side or another maneuvers about in an attempt to become the engine of change. (The battle line keeps changing, but that old straight-mixer thing - call it whatever you want - keeps coming back.) If chiropractic were an automobile, its engine would be found blowing smoke through bad rings and worn valves, kept running largely thanks to various additive sludges poured into its vital fluids: gunk to seal the rings, more gunk for the leaking head gasket, and even a palliative aerosol can for that "new car smell." But when an engine needs rebuilding, there is no substitute for rebuilding. Consensus processes, negotiated agreements over terminology, and temporary alliances born of chiropolitics are inevitably short-lived fixes, providing merely illusory unity. They are no substitute for sincere and substantive agreement. United fronts collapse when the transient goals of the alliance are either met or definitively crushed.
Does chiropractic need to be demolished by an evidence-based Hurricane Floyd or bombed by the U.S. Air Force to rebuild? Or can it intentionally create its own preferred future, one in which there is real professional cohesion? Maybe there is a way to sit down and calmly brainstorm the characteristics of a reborn chiropractic unshackled by its past. If chiropractic had never existed and we had the opportunity in 2000 to invent a new profession, how much would it resemble what we have today?
The formal problem posed is comparable to re-evaluating an investment portfolio. Investors often agonize over whether to sell certain assets, some of which have gone down and others up in price. However irrational, they can't stand selling off some issues at a loss, nor can they tolerate "betraying" their winners by selling them off at a profit. Obviously, what matters is not how a stock has performed in the past, but what it is likely to do in the future. The solution is relatively simple. For each component in the portfolio, the investor must decide if they would purchase their current position at today's market prices, as if they had never owned it at all. If the answer is no, logic dictates selling the asset (taking tax implications into account).
The Economics of Chiropractic Reconstruction
Let us evaluate our chiropractic portfolio using a similar methodology, considering whether we would invest in each component in the climate of today's health care industry. As a baseline, however open to debate, I assume that this new profession - we'll name it by an adjective, "chiropractic" - is to address pathologies attributable to the musculoskeletal system, primarily through the use of manual intervention. Here are some tough questions each of us should be willing to answer, as if we had it to do all over again (since we do). Admittedly, today's chiropractic cannot and should not be stripped of its past. That would be like selling stocks without thinking about the tax implications. But the proposed exercise may help prioritize areas especially deserving of constructive criticism.
• In light of everything that has been learned about genetic and environmental causes of disease, would you feel comfortable attributing virtually all human disease to some primary entity?
• Would you try to avoid the clumsy consequences of such a monocausal theory of disease by asserting that this primary entity itself has multiple causes? If so, do you think that would help very much?
• Would you invest this one primary entity with the essential character of vertebral misalignment?
• Would you choose to define this new profession in terms of how it treats this one primary entity, whatever it is to be called?
• In setting up this new profession, would you heavily invest in only one type of treatment modality, notwithstanding evidence that other conservative approaches may work under certain circumstances?
• Would you define the profession so that the chiropractors' metaphysical beliefs by definition impact centrally on their clinical practices?
• Would you de-emphasize the patient's subjective complaints (i.e., symptoms) in favor of "objective" indicators of the single entity, like motion palpation, thermography and leg checks?
• How frequently would you concentrate on correcting (adjusting, aligning, etc.) one bone in the vertebral column, no matter the patient's signs and symptoms?
• Would you base this new profession on the belief that the spinal entity always has a neurological component?
• Would you present yourself to society as a profession of primary health care providers without providing tangible evidence that chiropractic intervention is at least as effective as alternative treatment approaches?
• Would you set aside several words inextricably bound to the health care lexicon, e.g., treatment, diagnosis, therapy, etc., as having no legitimate use by the doctors who would serve in this new profession?
From the Meritorious Contributions Department
Many individuals have significantly contributed in recent years to reconstructing chiropractic, some of whom I would like to acknowledge, without having felt the need to first demolish it. O'Malley1 explores how perception and chiropractic's historical environment bias contemporary chiropractic theory and clinical practice, although his Hegelian bent lends unnecessary complexity to his argument. Leboeuf-Yde2 adds to O'Malley's work by developing its research implications in a completely straightforward, what-needs-to-be done vein. Her lucid commentary shows incredible patience for ideologies that frankly often get the better of more irascible individuals (like me). After a detailed look at contemporary knowledge about joint pathology, Seaman3 proposes abandoning altogether the term subluxation and its variants in favor of joint complex dysfunction. Although his departure is not as bold as he thinks, retaining an unmistakable monocausal flavor, we understand that Seaman thinks it appropriate to proactively reconstruct chiropractic on an evidence base.
After pointing out that although "there have been several efforts and projects devoted to redefining subluxations," Nelson adds that "this movement has not brought clarity and consensus to the subluxation debate but rather obfuscation and confusion."4 Like Leboeuf-Yde, except more rhetorically, he develops the research implications of the subluxation theory, concluding that the profession can't move forward by semantic juggling or consensus panels. Meeker, forced to set the facts straight about what happened and didn't happen at the recent Research Agenda Conference, asks, "What happens if science and research can't get a handle on the subluxation as we currently conceive it? What if, even with our best efforts, we can't prove it? Could we change the way we scientifically view subluxation? ... The truth is that subluxation is a concept in need of operational definition, description, explanation and predictability."5 The point cannot be better made.
References
- O'Malley JN. How real is the subluxation? (see comments). J Manipulative Physiol Ther 1997;20(7):482-7.
- Leboeuf-Yde C. How real is the subluxation? A research perspective. J Manipulative Physiol Ther 1998;21(7):492-4.
- Seaman DR. Joint complex dysfunction, a novel term to replace subluxation/subluxation complex: etiological and treatment considerations. J Manipulative Physiol Ther 1997;20(9):634-44.
- Nelson C. The subluxation question. Journal of Chiropractic Humanities 1997:46-55.
- Meeker W. Dump subluxation? Give me a break! Dynamic Chiropractic 1999;17(23). Available at www.chiroweb.com/archives/17/23/17.html.
