Stephen M. Perle, DC, MS
As doctors of chiropractic, we call ourselves "professionals," but what do we mean by the word? Is it appropriate for a photographer, a truck driver or a Major League Baseball player? People sometimes say they are a professional photographer, a professional driver, or a professional baseball player. To the question, "What is your profession?" an acceptable response for the appropriate individual could be "mechanic" or "computer programmer." However, I believe there is a fundamental difference between our profession and others.
The dilemma is due to the multiple meanings of words in the English language. In one sense of the word, the opposite of professional is "amateur." In another meaning, a profession is one's vocation. In yet another meaning, the one that applies to us, it is the occupation that one professes to have the knowledge and skills of, and to apply to the affairs of others. The knowledge of this type of professional is so specialized that only another professional is qualified to judge his or her competency. Hence, there is self-regulation, with licensing boards predominantly comprised of members of the profession regulated by the board. In this context, the terms "professional" and "layperson" contrast. Classically, this type of professional is a doctor, lawyer or member of the clergy.
For the laity, their relationship with other laypersons is often ruled by the dictum caveat emptor; let the buyer beware. For professionals, their relationship with the layperson is governed by the dictum credat emptor, "let the buyer trust." Thus, the patient/client/parishioner is expected to trust the opinions and skills of the doctor, lawyer or clergy, who have an ethical duty to put the interests of their patients, clients or parishioners ahead of their own. This is why doctors have attended to the ill, even when the etiologies of diseases were unknown; why lawyers can provide for the vigorous defense of those they do not believe are innocent; and why the clergy can comfort those it believes are damned.
Credat emptor imposes upon professionals an assortment of specific ethical duties in their relationship with the laity. Among these is the duty of veracity, to tell the truth; and the duty of fidelity, complying to the reasonable expectations of the patient (e.g., competence, keeping promises, up-to-date knowledge, etc.). There are others, but in this article only these two will play a central role.
When a chiropractor tells a patient that a specific treatment can help with a particular condition, is he or she telling the truth? The answer to this question is found in the knowledge or beliefs of the doctor. If the doctor truly believes one treatment will be effective for the patient's problem, that is not a lie, but a violation of the duty of veracity.
One problem with this is how we define "knowledge". To the empiricist, all knowledge comes from personal experience alone. While this appears to be a valid way to acquire knowledge, it suffers from the threat to validity of bias. Our biases color how we perceive that which we experience. If a patient we are treating discontinues care, we may believe this is because he or she got better (the optimist's viewpoint). Thus, our memory of the experience will be that we were effective in treating that case. Conversely, that same patient, we might believe, stopped treatment because it was not effective (the pessimist's viewpoint), and now our memory is of a clinical failure. In either case, our perception of the patient's outcome may or may not be valid, but lacking a structured method of observation (e.g., short- and long-term outcome measures), we have no way to know the truth. Nevertheless, in an uncritical manner, we may believe we have acquired valid knowledge of our clinical effectiveness from this encounter and use it in dealing with future patients.
Sometimes we have gained knowledge because a doctor we respect presents his/her experience of clinical effectiveness. This is part of the rich oral history of clinical effectiveness of chiropractic care. There are also "truisms" in health care that are accepted because their validity is taken for granted. These truisms and the oral history can become internalized within our beliefs about what we can and cannot treat, and how to do so.
Using our knowledge; or what we believe to be true, we give the patient our assessment of the effectiveness of our intervention. This assessment may be valid, but it is still possible that we could be speaking a falsehood without telling a lie, for our knowledge or beliefs might actually be invalid. While complying with our veracity of duty, we may be guilty of violating the duty of fidelity. Patients expect that the information a doctor presents to them is not just that doctor's belief. They expect that the information the doctor gives them is valid.
Some truisms in health care are not true given our current state of knowledge. Osteoarthritis and tendinitis are not inherently inflammatory conditions. Ice has not been shown to be an anti-inflammatory, but then again, inflammation is not necessarily bad in every case. We all know that stretching prevents sports injuries, except that the most recent systematic review contradicts this truism.
If a doctor of chiropractic tells a parent that standard childhood immunizations are the worst thing a parent can allow to be given to their child, has the doctor violated his or her ethical duty to the patient? I would suggest that, lacking a systematic review of the effectiveness and harmfulness of the specific immunization, the answer is clearly "yes." Most people who have told me this base their evidence on websites or brochures, not rigorous science.
As another example, if a DC tells a patient that chiropractic care will remove interference to the nervous system and allow innate intelligence to heal any disease, is that a violation of one's ethical duty to the patient? Again, lacking a compelling body of research, the answer is "yes." The evidence for this seems to be the writing of B.J. Palmer, or extreme extrapolation for some research. What about the chiropractor who recommends gem elixirs, Bach flower remedies or weekly maintenance care, or tells the patients that subluxations kill? I submit that all of these violate our duties.
Some readers will respond with a quote from Carl Sagan: "Absence of evidence is not evidence of absence." While this is true, my reply is another Sagan quote: "I believe that the extraordinary should certainly be pursued. But extraordinary claims require extraordinary evidence."
Our relationship with patients is such a special one that they put their trust in us, following the dictum credat emptor. This imposes upon us the ethical duty to determine the validity of what we tell patients. We do not have the right to say something is valid just because we believe it to be valid or because it is our philosophy. Patients have faith that we tell them the truth.
Stephen M. Perle, DC, MS, CCSP
Bridgeport, Connecticut
