Published 9 July 2009, doi:10.1136/bmj.b2782
Cite this as: BMJ 2009;339:b2782

Observations

Chiropractors: clarifying the issues

It is quite remarkable that scientists should expect themselves to become exempted from the laws of the land for publishing defamatory comments, be they about an individual or an organisation. Having mustered an army of supporters, including Evan Harris,¹ Simon Singh has redefined the battle as one of free speech and the stifling of scientific debate.² It is nothing of the sort.

The British Chiropractic Association (BCA) neither wished nor intended this matter to end up in the courtroom. When Dr Singh went on the offensive against the BCA and spoke of it promoting bogus treatments that had "not a jot" of evidence to support them,³ it was entirely understandable that the BCA should seek to have what were untrue and defamatory comments withdrawn in order to protect its reputation. It sought from Dr Singh a retraction of the allegations along with a public apology. Scientific debate could then have continued away from the law courts. However, despite receiving invitations to retract and apologise, Dr Singh refused to do either.

This case was never about enrichment; it was about fairly correcting libellous statements made about a respected national association representing more than half of the nation’s chiropractors.

There is in fact substantial evidence for the BCA to have made claims that chiropractic can help various childhood conditions.^{4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22} Contrary to how this case has been reported, it never claimed to cure these conditions, nor did it seek to dissuade parents from continuing with regular medical management.

Sadly, Dr Singh now argues for what he wished he had said, rather than what he did say. As a diversion from his defamatory comments, he has mounted a case for free speech and reform of the libel laws. The BCA fully supports free speech. However, with this fundamental right comes responsibility, and as a science journalist Dr Singh should not have published materials which he was fully aware would damage the BCA’s reputation.

Reform of libel laws will not take away the rights of a named individual or an organisation to protect their reputation when they are the victim of defamatory falsehoods. It is right that the law exists to protect them from the publication of untrue and unjust statements, and it is understandable that the government has hesitated in putting forward proposals for reform. Agreed, the costs of defending such actions may be prohibitive, but so are the costs of bringing an action. With awards for damages rarely exceeding the figure for costs, often neither party stands to gain financially, and reward is hardly ever the motive for resorting to the courts.

Chiropractors, as regulated healthcare professionals, should be accountable for their actions. They are subject to a code of practice²³ that exists to protect the public and uphold standards of care. They are also bound to practise evidence based medicine, which, like that of their medical colleagues, comprises the best available evidence from research, the preferences of the patient, and the expertise of practitioners (including the chiropractor him or herself).²⁴ To reduce the definition of evidence to only randomised controlled trials not only is impossible but would exclude many medical interventions performed in general practice each day.

Contrary to the suggestion that chiropractic is purely synonymous with spinal manipulation, it is a primary healthcare profession that employs a range of interventions that benefit tens of thousands of patients each day. Had Dr Singh been serious about reasonable scientific debate he might have made due inquiry with the BCA before publishing his defamatory allegations.

The BCA is fully supportive of chiropractic research and indeed gives tens of thousands of pounds every year to support research initiatives throughout the UK. It is preposterous to suggest that the BCA seeks to either "stifle scientific debate" or engage in "chilling" science writers from expressing their views. The inclusion of spinal manipulation in the guidelines on low back pain recently published by the National Institute for Health and Clinical Excellence²⁵ was founded on peer reviewed, published research evidence demonstrating its efficacy. The risks of spinal manipulation have been researched, and two comprehensive studies in Spine^{26 27} demonstrated it to be far safer as an intervention than commonly prescribed medical interventions used for similar ailments.^{28 29 30}

That esteemed figures within the scientific and medical communities have been mobilised to speak on this issue is a reflection of the feelings that this case has engendered. The indignance is palpable that a group of complementary health practitioners should dare to challenge the scientific establishment. Yet this case is not about challenging science or freedom of speech; it is about wrongly publishing damaging allegations.

Contrary to Dr Harris’s mistaken assertions,¹ the BCA never promoted or implied chiropractic as a cure, and peer reviewed papers that demonstrate symptomatic relief for childhood conditions were readily available. Dr Singh declined to answer the BCA’s request as to whether or not he had read, before the publication of his article, the evidence relied on by the BCA, arguing, bizarrely, that it was because the request was not relevant or necessary in order for the BCA to understand his case. This is odd because of Dr Singh’s new found opinion that the BCA is trying to stifle "scientific debate."

In conclusion, before the BCA is further dragged through the mud by a concerted smear campaign, consider this: chiropractic has made huge strides to integrate itself into mainstream UK health care. It has enjoyed phenomenal popularity that is based on consistently delivering high quality care. As a modern healthcare profession it welcomes examination of its methods, yet libellous statements are not the modus operandi that critics should employ.

Cite this as: BMJ 2009;339:b2782

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This article first appeared as a rapid response (www.bmj.com/cgi/eletters/338/jun03_1/b2254#214951). See Edzard Ernst’s response, BMJ 2009;339:b2766, doi:10.1136/bmj.b2766; and accompanying editorial by Harvey Marcovitch, BMJ 2009;339:b2759, doi: 10.1136/bmj.b2759.

References

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2. Singh S. BCA v Singh: The Story So Far 3 June 2009. www.senseaboutscience.org.uk/index.php/site/project/340.
3. Singh S. Beware the spinal trap. Guardian 2008 April 19 [withdrawn].
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11. Mills MV, Henley CE, Barnes LL. The use of osteopathic manipulative treatment as adjuvant therapy in children with recurrent acute otitis media. Arch Pediatr Adolesc Med 2003;157:861-6.[Abstract/Free Full Text]
12. Froehle RM. Ear infection: a retrospective study examining improvement from chiropractic care and analysing for influencing factors. J Manipulative Physiol Ther 1996;19:169-77.[Medline]
13. Glazener CM, Evans JH, Cheuk DK. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database of Syst Rev 2005;2:CD005230.
14. Nilsson N. Infant colic and chiropractic. Eur J Chiropractic 1985;33:264-5.
15. Hayden C, Mullinger B. A preliminary assessment of the impact of cranial osteopathy for the relief of infant colic. Complement Ther Clin Prac 2006;12:83-90.[CrossRef]
16. Hipperson AJ. Chiropractic management of infantile colic. Clin Chiropr 2004;7:180-6.[CrossRef]
17. Miller J. Cry babies: a framework for chiropractic care. Clin Chiropr 2007;10:139-46.[CrossRef]
18. Browning M, Miller J. Comparison of the short-term effects of chiropractic spinal manipulation and occipito-sacral decompression in the treatment of infant colic: a single-blinded, randomised, comparison trial. Clin Chiropr 2008;11:122-9.[CrossRef]
19. Leach RA. Differential compliance instrument in the treatment of infantile colic: a report of two cases. J Manip Physiol Ther 2002;25:58-62.[CrossRef][Web of Science][Medline]
20. Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuresis. J Manipulative Physiol Ther 1994;17:596-600.[Web of Science][Medline]
21. Blomerth PR. Functional nocturnal enuresis. J Manipulative Physiol Ther 1994;17:335-8.[Web of Science][Medline]
22. Fallon JM. The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media. Chiropract Paediatrics 1997;2:167-83.
23. General Chiropractic Council. Code of practice and standard of proficienty (2005) www.gcc-uk.org/files/link_file/COPSOP_Dec05_WEB(with_glossary)07Jan09.pdf.
24. Sackett DL, Rosenberg WH, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2.[Free Full Text]
25. National Institute for Health and Clinical Excellence. Low back pain: early management of persistent non-specific low back pain. http://guidance.nice.org.uk/CG88.
26. Thiel HW, Bolton JE, Docherty S, Portlock JC. Safety of chiropractic manipulation of the cervical spine: a prospective national survey. Spine 2007;32:2375-8.[CrossRef][Web of Science][Medline]
27. Cassidy JD, Boyle B, Cote P, He Y, Hogg-Johnson S, Silver FL, et al. Risk of vertebro-basilar stroke and chiropractic care: results of a population based case control and case crossover study. Spine 2008;33(suppl 4):S176-83.[CrossRef][Web of Science][Medline]
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30. MacDonald TM, Morant SV, Robinson GC, Shield MJ, McGilchrist MM, Murray FE, et al. Association of upper gastrointestinal toxicity of non-steroidal anti-inflammatory drugs with continued exposure: cohort study. BMJ 1997;315:1333-7.[Abstract/Free Full Text]

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