The confrontation between medicine and chiropractic is not a struggle between two professions. Rather it is more in the nature of an effort by an informed group of individuals to protect the public from fraudulent health claims and practices.
The book is self-published, long-winded, repetitive, and flawed. It is a vicious screed crammed with bias, half-truths, insulting language, and innumerable references to Nazis and racial prejudice. In my opinion, Smith not only fails to make his case but degrades chiropractic.
Practicing Medicine without a License
Before chiropractic licensure was approved, many chiropractors were jailed for practicing medicine without a license. Smith thinks this was a bogus charge because they never used drugs or surgery. (He’s wrong: practicing medicine is not defined as using drugs or surgery, but as diagnosing and treating any human disease, pain, injury, deformity, or physical condition. They were clearly breaking the law.) Chiropractors were forced to hide like Anne Frank or like slaves on the Underground Railroad. The Juice Man squeezed them for protection money; if they couldn’t pay, his thugs beat them up.
The AMA did some very regrettable things. They used inappropriate language, referring to chiropractors as rabid dogs. They attacked chiropractors as killers without any supporting evidence. Their intent was to destroy chiropractic. They tried to conceal what they were doing. Their biggest mistake was to prohibit MDs from associating with chiropractors.
The Code of Ethics stated:
A physician should practice a method of healing founded on scientific bases; and he should not voluntarily associate professionally with anyone who violates this principle.
According to Smith, this expanded to prohibit a physician from belonging to any club, church, or organization if a chiropractor was also a member. If this is true, it is inexcusable. He relates a story from a chiropractor whose mother came home from a bowling league game crying because an MD on the opposing team had made a big stink that he wouldn’t bowl against her husband just because he was a chiropractor.
The AMA distributed “Quack Packs” and 10,000 copies of an anti-chiropractic book, Ralph Lee Smith’s At Your Own Risk: The Case Against Chiropractic. The complete text of that book is available online.
It had made an enemy of Scientology when it accused it of practicing psychiatry without a license. Smith says L. Ron Hubbard turned Dianetics into a religion just to escape AMA persecution, but it’s my understanding that he deliberately set out to invent a religion. At any rate, Scientology was so mad at the AMA that it decided to help chiropractic retaliate against At Your Own Risk. Scientologists pilfered secret documents about chiropractic from AMA headquarters and published them in the book In the Public Interest. The book not only had ties to the Church of Scientology, but had a cover illustration that superimposed the AMA caduceus on a swastika.
The Wilk Case
In 1976 an antitrust lawsuit was filed by Chester A. Wilk and 4 other chiropractors (one of whom later dropped out) against not only the AMA but also against 9 other medical organizations such as the American College of Radiology, and against 4 individuals. This began an odyssey lasting 14 years, with two separate federal trials, a series of appeals, complicated legal wrangling, and conflicting evidence. Some of the defendants settled out of court; 6 organizations and one individual went to trial. The AMA won, but the judge was accused of improperly instructing the jury and allowing inaccurate documents into evidence, so there was a second trial. In 1987, Judge Susan Getzendanner dismissed the charges against some of the defendants but found the AMA guilty of violating Section 1 (but not Section 2) of the Sherman Antitrust Act. No damages were awarded. The AMA was only required to pay the plaintiffs’ legal costs and to change its policy and inform MDs that they could associate with chiropractors. Chiropractors crowed about their victory, but it actually did little to change “discriminatory” practices or to enhance the reputation of chiropractic.
The decision was not by any stretch of the imagination an endorsement of chiropractic. The judge said:
The study of how the five original named plaintiffs diagnosed and actually treated patients with common symptoms was particularly impressive. This study demonstrated that the plaintiffs do not use common methods in treating common symptoms and that the treatment of patients appears to be undertaken on an ad hoc rather than on a scientific basis… I am persuaded that the dominant factor was patient care and the AMA’s subjective belief that chiropractic was not in the best interests of patients… [but] this concern for scientific method in patient care could have been adequately satisfied in a manner less restrictive of competition.
Saved By George
He eulogizes chiropractor Jerry McAndrews and his brother George, the lead attorney in the Wilk v. AMA antitrust trial. The McAndrews family was heavily invested in chiropractic ever since their father’s asthma was relieved by a chiropractic adjustment where his heels allegedly touched the back of his head. (Really? What kind of adjustment does that?) They blamed his early death on persecution by the AMA. George “saved chiropractic.” Had it not been for him, the AMA would have destroyed chiropractic just as it destroyed homeopathy, naturopathy and other alternative health care professions. (Wait — aren’t those still around? And if chiropractic was saved, why is he still complaining?) Jerry reminisced to Smith, recalling that during the Wilk trial George’s office was burglarized and their phones were tapped, forcing them to speak in the cornfields behind Jerry’s home. (Really? Did they have any actual proof of wiretapping? Did they report it at the time? Did the corn have ears?)
How Powerful is the AMA?
The 1910 Flexner report attempted to reform medical education by recommending that American medical schools adopt higher standards and adhere to science. Smith thinks that the Flexner Report made the AMA an invisible branch of the government and an accrediting agency. It didn’t. He thinks the AMA controls the entire healthcare system, but today less than 30% of American physicians belong to it. It is a professional association that promotes the art and science of medicine, lobbies on issues that affect its members, and publishes several highly respected medical journals. The AMA never had any power to accredit or regulate physicians or punish them; the most it could do was deny membership.
Smith really hates Morris Fishbein, AMA spokesperson and quackbuster who fought quack MDs like John Brinkley, the goat gland doctor. He refers to Fishbein as a demagogue, dictator, Mussolini, and racketeer; he compares his persecution of chiropractors to Hitler’s persecution of the Jews. He thinks Fishbein took dictatorial control of state licensing agencies. (Total nonsense!)
To put Fishbein’s anti-chiropractic campaign into perspective, it began in the 1930s, two decades after the Flexner Report. The value of science was widely accepted but evidence-based medicine was in its infancy. Until 1974, chiropractors were still not licensed in Louisiana, where they were still guilty of practicing medicine without a license. Fishbein encountered rampant quackery in product and drug sales, among conventional medical doctors and among people practicing medicine without a license. He fought against it wherever he found it, and he found reason to put chiropractic high on his list.
Smith is irate because under Fishbein the AMA accepted advertising from tobacco companies, even touting the supposed health benefits of cigarettes. But they didn’t know any better. As soon as they did know better, in the 1950s, when evidence of harm mounted, they stopped accepting tobacco ads, well before the first Surgeon General’s Report was published.
How powerful could the AMA be when it was not able to prevent the licensing of chiropractors in all 50 states or block coverage of chiropractic by Medicare?
The Evidence for Chiropractic
Smith contradicts himself. He re-defines what chiropractic claims to treat, saying that no displacement can be seen on x-ray but that there is a problem with function. Then he continues to speak of subluxations and of misalignments that require correction. Then he says obvious misalignments like scoliosis may not be problematic. He speaks of proper flow of nerve energy, saying spinal dysfunctions disrupt this flow to cause heart attacks and visceral disorders like dysmenorrhea, asthma, enuresis, and infantile colic. He even believes that spine dysfunctions can cause brain damage and premature aging. He believes that manipulation is effective in all these disorders. Worst of all, he believes there is credible scientific evidence to support these beliefs. (Maybe there is some “evidence,” but it isn’t credible.) He claims that chiropractic has outgrown its origins and become more science-based, but in reality he sounds very much like D.D. Palmer.
He relies on old, discredited evidence like the 1979 New Zealand Chiropractic Report. Its three-person panel consisted of a barrister, a chemistry professor, and a retired headmistress of a girls’ school. It relied heavily on testimonials, failed to appreciate the scientific process, and demonstrated bias. He thinks it vindicates chiropractic, but its recommendations were actually devastating to chiropractic: chiropractors should be strictly monitored, should not present themselves as doctors, should not encourage patients to consult a chiropractor in preference to a medical doctor for any condition, and should not mislead the public into believing that chiropractic is an alternative to medicine.
He ignores more definitive, up-to-date evidence that spinal manipulation therapy (SMT) is effective but not superior to other treatments for low back pain and is ineffective for non-musculoskeletal conditions. Even the NCCAM damns it with faint praise:
[Spinal manipulation] can provide mild-to-moderate relief from low-back pain. Spinal manipulation also appears to work as well as conventional treatments such as applying heat, using a firm mattress, and taking pain-relieving medications.
He quotes Gary Null, Natural News, and Dana Ullman (all infamous on this blog.) He devotes several pages to attacking Ann Landers for being in cahoots with the AMA and getting her information from them. (Isn’t it reasonable for a non-medical columnist to consult medical experts to ensure accuracy?)
His defense of chiropractic is based on questionable evidence plus fallacious arguments from popularity, patient satisfaction, and cost-effectiveness. Also the argument from antiquity: Hippocrates and Imhotep wrote about it. (No, they didn’t write about chiropractic; they wrote about manipulation.)
He doesn’t understand what science means. He calls chiropractic “an unorthodox science.” He says the first chiropractor was not unscientific. I explained in a previous post why chiropractic is not scientific.
He presents the Cassidy study as if it were definitive proof that chiropractic neck manipulation doesn’t cause strokes. He fails to report or respond to the criticisms of that study.
He downplays the risks of chiropractic, resorts to tu quoque arguments about the risks of medical care, and cites the low cost of chiropractic malpractice insurance. He compares rate of neck manipulation stroke to rate of death from surgery (apples and oranges — but they are both fruits, so maybe I should say cabbages and carburetors!). He calls neck manipulation safe but doesn’t consider the risk/benefit ratio (if there is no benefit, any risk is unacceptable).
He devotes a great deal of space to criticizing doctors for doing back surgery, especially spinal fusions. He doesn’t need to: the medical establishment itself has already criticized back surgery. It has recommended reforms: elimination of unnecessary and ineffective operations and sticking rigorously to indications that are evidence-based. Smith says the disc theory is dead. It isn’t. He’s right that too many back surgeries have been done for disc disease, but ruptured discs can cause permanent nerve damage and disability, and surgery can improve outcomes when done only for proper indications. He quotes a doctor who called for a moratorium on back surgery when he found that after 2 weeks of rehabilitation his patients no longer required surgery. Rehabilitation, not manipulation. Smith doesn’t seem to realize this is as much an argument against chiropractic as against surgery. He doesn’t admit that back surgery is ever indicated and he blames its use on the machinations of a medical industrial complex motivated only by profits. One wonders how much he really understands: at one point he even refers to the disc as cartilage. He seems to think proving that back surgeries are unnecessary equates to proving that chiropractic is effective; it doesn’t. He calls for doctors to reform back surgery but doesn’t call for reforming chiropractic to adhere to similar evidence-based standards.
In 1994 a report by the Agency for Health Care Policy and Research (AHCPR) concluded that SMT was one of only 3 treatments for acute low back pain that were supported by evidence (the others were over-the-counter nonsteroidal drugs (NSAIDs) and heat/cold applications). The report didn’t recognize chiropractic or even mention chiropractors.
Because of the report’s endorsement of spinal manipulation and its criticism of spinal surgeries, the North American Spine Society and the manufacturers of spinal fusion hardware sought an injunction to prevent its release. When that failed, NASS took the fight to Congress, where the agency’s budget was cut and it was stripped of its ability to make treatment recommendations. Smith blames the AMA for this, although he does not show that they were involved.
He devotes 21 pages to the failed attempt to establish a school of chiropractic at Florida State University (FSU), an effort that was ridiculed in the famous campus map parody showing other pseudoscientific departments like the Bigfoot Institute. The state legislature had appropriated $9 million annually to support such a school, with 151 votes for and only 1 against. So Smith claims FSU went against the will of the people. Ironically, nearby Life Chiropractic College opposed the bill because of fear it would lose students to a cheaper and more scientific program. Several FSU faculty members threatened to resign, and eventually the school’s Board of Governors squashed the proposal, voting it down by a wide margin. 3 chiropractors at the Board meeting spoke out against a school.
According to Smith, a noble cause was killed by medical demagogues and political subterfuge. He argued that it would have allowed chiropractors to explore the clinical scope of chiropractic and conduct research in an academic setting.
He thought that MDs were only attacking chiropractic because it was based on a vitalistic philosophy, which doctors and scientists oppose because they are mostly atheists. He characterized the fight as a “religious war to keep the heretics out of the medical den of iniquity.” He also characterized it as an attack on academic freedom and compared it to the bigotry in America before Civil Rights, when desegregation led to resentment and deadly attacks.
Raymond Bellamy, MD, orthopedic surgeon and professor at FSU (and husband of our own Jann Bellamy), became the lightning rod leading what Smith calls an academic revolt. He characterizes Bellamy’s effort as “not a studious argument as much as it digressed into a tirade of propaganda and slanderous accusations.” He rants about Bellamy for several pages, accuses him of conflict of interest, and says “instead of demeaning black Americans as unworthy of a college education alongside white students, Bellamy and his mob debased chiropractors as unworthy of a university presence alongside them.” He likens it to Creationists being allowed to ban the study of evolution from the biology program. He compares FSU to a white country club that only invites its white friends.
He considers Bellamy the embodiment of the undercover dictatorship at FSU, says his book-burning mindset will go down in the annals of academia alongside the book-burning policy of Joseph Goebbels, accuses him of suppressing free speech, and even says:
Gov. Wallace demonstrated his racial politics to the world and Dr. Raymond Bellamy felt justified with the same intense prejudice to keep the “nigger-chiropractors” out of FSU.
Such despicable and defamatory accusations are beneath contempt and don’t even deserve a response.
The FSU project would have cleared the air on many issues and either proved chiropractic to be placebo as Bellamy contends or else it would have brought an ageless healing art to the forefront to help millions of people who suffer from both musculoskeletal disorders and those who suffer from spinovisceral reflex nerve disorders that mimic serious visceral disorders.
In other words, chiropractic should be accepted in a university on equal terms with established sciences so we can then test it and find out if it is scientific (!?). Don’t imagine for a minute that chiropractors would alter their practice if the tests found it to be unscientific. No, it would only give chiropractic a foot in the door and lend it a prestige it has not earned.
He admits that “a small percentage” of chiropractors can be viewed as charlatans, but then he makes excuses. They have been reduced to “desperation” and they are not to blame because they have been “ghettoized.” It is the medical societies who are to blame for any chiropractic malfeasance.
He feels slighted because chiropractors are not featured on national TV as spokespersons on health like Dr. Sanjay Gupta and because there has never been a chiropractor TV hero like Marcus Welby.
He says the AMA’s war has left a lingering stigma harmful to chiropractic, but he himself undermines that argument: he says chiropractic has achieved its place as “the third-largest physician level health profession in the world, only behind medical physicians and dentists.” Does he imagine that if prejudice were eliminated chiropractors would be first or second? Chiropractors are licensed in every state, are practicing in the VA and military hospitals, are funded by Medicare and insurance companies… and yet he still feels unfairly persecuted.
His use of language is inflammatory and offensive. He calls the AMA “the most terrifying trade association on earth.” Edzard Ernst is a “medical spin doctor.” Stephen Barrett is a “renowned medical propagandist” and a “medical misinformer.” The medical profession is guilty of war crimes. Suppression of chiropractic is a social injustice like racism and sexism. Marcus Welby is like Joseph Goebbels. Attacking chiropractic was like making Rosa Parks sit in the back of the bus. Doctors are like storm troopers. He accuses the AMA of bigotry and of attacking free enterprise. He compares it to the KGB, Gestapo and CIA, and even mentions the showers of Auschwitz.
Harriet Hall “Medical Chauvinist”
He devotes 4 whole paragraphs to attacking me, based only on 2 short sentences attributed to me in an article about alternative medicine in the Boston Globe. It reported my concern that “Congress will elevate [alternative] practitioners to the same level as medical doctors.” He said “Her arrogance was clear that there is no room on the medical throne for anyone other than MDs.” He said I showed my “bias” when I said “If it [alternative medicine] were shown to be truly effective, it would be part of regular medicine.” He countered that if conventional medicine were truly effective, we would not be in the present healthcare crisis — something of a non sequitur, no? He said I was “spewing propaganda.” And was a “medical monarchist” who didn’t want to see my “medical Bastille” toppled by equality. (I certainly don’t want to see science toppled by equality with pseudoscience and quackery.)
Consider that my two quoted comments were about alternative medicine and didn’t even mention chiropractic. Also consider that he didn’t bother to find out that I have written extensively about chiropractic (which he could easily have discovered just by Googling my name) and he has not tried to answer any of my arguments against chiropractic.
What He Doesn’t Say
Nowhere does he mention chiropractors like Sam Homola, a regular guest author here, who have criticized chiropractic from within. Nowhere does he mention that half of chiropractors are still undermining public health by discouraging immunizations. Nowhere does he acknowledge or respond to the arguments against chiropractic, for instance the wealth of material on Quackwatch’s Chirobase, Homola’s numerous books and articles, and magazine and blog articles by me, Steven Novella, David Gorski, and many others. Nowhere does he acknowledge the critiques of the Cassidy stroke study and the other studies he cites.
What Might Have Been
Throughout, he confuses chiropractic with spinal manipulation. They are not the same thing. SMT is a specific treatment also used by other practitioners including MDs, DOs, and PTs for specific indications; chiropractic is a whole system of care built around manipulation. Chiropractors do perform the majority of manipulations; but they do them for indications that the other professions do not accept, and many of them do a lot of other silly things that can only be described as quackery.
The Flexner report resulted in accreditation standards that closed half of American medical schools. Most schools of competing medical systems like homeopathy, naturopathy, and eclectic medicine closed. Many osteopathic schools stayed in business by bringing their schools into compliance with Flexner’s recommendations. Chiropractic might have done the same, but it didn’t.
The AMA fought optometrists the same way they fought chiropractors. Optometrists were in competition with ophthalmologists for the eye market, and the AMA tried to prohibit MDs from associating with them, but they lifted the prohibition when faced with an anti-trust lawsuit similar to Wilks. Optometrists agreed to play a limited role within mainstream medicine; they are licensed to do only certain of the many things ophthalmologists do. Chiropractic might have done the same, but it didn’t.
What if chiropractic had policed its own ranks, limited itself to providing only short-term treatment for certain types of musculoskeletal pain, worked hard to determine which manipulation techniques were most effective, abandoned techniques that it found ineffective, and denounced vaccine rejection, applied kinesiology, and other forms of quackery? Manipulation might have been more widely accepted as a therapeutic tool if it had not been so tainted by the company it kept. Chiropractors could have become “physical therapists for the back,” experts in manipulation that MDs could refer patients to with confidence. Chiropractic might have been integrated into the medical mainstream just like osteopathy and optometry, but it didn’t even try.
The AMA did some bad things in pursuit of a good end (fighting quackery), but Smith’s book does bad things in pursuit of a bad end (promoting unscientific health care).
I didn’t buy the book. I requested it from my public library through Interlibrary Loan. They had to search far afield for a copy, and they eventually located one in a library 2370 miles away, the Texas Chiropractic College Library. From the date due sticker, it appears to have never been checked out. I can only suspect the book is not very popular or widely read, even by chiropractors. I don’t regret reading it, because I learned a few things about history and about the thinking processes of chiropractors; but it left a very bad taste in my mouth and I certainly can’t recommend it.
This article was originally published in the Science-Based Medicine blog.