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EDITORIALS: Evan Harris Science in court BMJ 2009; 338: b2254 [Full text]

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Ignorance in Court

Rashed Akhtar   (7 June 2009)

Debunking mis-information

David JR Hutchon   (8 June 2009)

Respect in Court

Naveed Iqbal   (12 June 2009)

Science and polemic

Bob Leckridge   (12 June 2009)

Re: Science and polemic

Leslie B Rose   (14 June 2009)

Chiropractors: clarifying the issues

Richard Brown   (17 June 2009)

Response to the BCA

Richard Bartley   (20 June 2009)

Re: Response to the BCA

Stephen M. Perle   (25 July 2009)

Ignorance in Court 7 June 2009
Rashed Akhtar, GP Leicester, LE2 0JN Send response to journal: Re: Ignorance in Court	Why should I feel sympathy for someone who has invoked the wrath of the British Chiropractic Association and landed himself in court with his ill-judged remarks such as Mr Simon Singh? Presumably he was well aware of such a risk when he took scientific debate outside the normal forums and decided instead to lambast an entire professional group in a mainstream newspaper. When I am asked about chiropractice, osteopathy and other modalities of treatment in my GP surgery, I defend the scientific evidence base but in a respectful and non-confrontational way which is likely to help my patient rather than build resentment. I am also willing to concede that science doesn't have all the answers that my patient is looking for. It is a shame that some people use the mantra of 'freedom of speech' to defend the indefensible. For most people, including myself, freedom of speech has limits of dignity to protect the rest of society. If one transgresses this limit - be they a fundamentalist scientist or a religious extremist - he or she cannot cry foul if they find themselves defending their comments in court. Competing interests: None declared
Debunking mis-information 8 June 2009
David JR Hutchon, Consultant Obstetrician Memorial Hospital, Darlington. DL3 6HX Send response to journal: Re: Debunking mis-information	Debunking mis-information I agree that the law court is not the place to settle general scientific or medical issues. Science, medicine and art are not as distinct as we generally think. When Simon Singh tells me in his book that Andrew Wiles solved Fermat’s last theorem I simply have to take his word for it, persuaded by the fascinating story. I have to have faith in Simon Singh’s investigation and in the integrity of Andrew Wiles and the mathematical community. There is no way I could ever confirm this fact myself. Mathematicians like Wiles, I understand, to prove a theory must go right back to first principles of mathematics and in the course of their proof must make no assumptions. Such an approach is completely impossible in science and medicine. We have to have faith in the integrity of those who have gone before; “On the shoulders of Giants”. As Singh stated in his book on Fermat’s Last Theorem “Someone who flouts this system” (The integrity of professors at top-flight universities) “can create confusion for a very long time, since no one has the time or the motivation to follow him around and debunk his claims whenever he makes them.” Such “confusion” has occurred in the physiological description of transitional circulation at birth in the majority of standard physiology, paediatric and cardiology textbooks. Physiology is the study and description of a natural process and cannot include an artificial intervention. It might be appropriate, at the end of the physiological description, to include the effect of a common or routine intervention and perhaps an explanation as to why the intervention takes place. Without such explanation the intervention is perceived by the naïve student as part of natural physiology. Principles of Physiology (page 349) has a chapter on Circulatory Changes That Occur at Birth. The text describes the constriction of the umbilical vessels as a result of the bradykinins or clamping of the umbilical cord. Other Physiology textbooks (Functional Human Anatomy page 447, Physiology and Anatomy page 595, Textbook of Anatomy and Physiology page 444) describe cutting or application of a cord clamp in the changes at birth to the circulation, without adequate explanation that the clamp is not part of the physiological process. In Forfar and Arneil’s Textbook of Pediatrics ( page 106-107) in a paragraph entitled “The Normal Fetal-Neonatal Transition” the statement if lung expansion fails, death will occur quite rapidly and shortly after the umbilical cord is clamped. In Heart Disease, A Textbook of Cardiovascular Medicine (page 1512) describing the physiological changes at birth there is the statement that “Systemic vascular resistance rises when clamping of the umbilical cord removes the low resistance placental circulation.” These are just a few examples, virtually all textbooks include the cord clamp or an indirect referral to it. The only text which gives a full physiological explanation without any referral to a cord clamp or an indirect “removal of the placental circulation” is Gray’s Anatomy ( page 1053). Why this distortion is so wide I do not know. Why this distortion, which I have pointed out repeatedly, is largely ignored or considered unimportant, I cannot understand. Many of those I ask will respond claiming that “transition at birth” is not a subject that they know much about. It does not take any knowledge to realise that an artificial intervention is not part of physiology. It is as simple as that. Is it of any importance? Firstly it is importance as a principle. I am not aware that Fermat’s Last Theorem has any real importance. (I could be wrong!) However, I suspect, Wiles was trying to solve it more as a principle, to champion Fermat’s reputation, rather than the amazing effect it would have on world mathematics. However, distorting transitional physiology does have serious world health consequences. The majority of the world’s obstetricians, paediatricians and some midwives consciously or unconsciously think that the cord clamp is necessary to complete transition at birth. They think that it is a necessity, a recent article in the British Journal of Midwifery claimed it is a “physiological necessity”. Obstetricians and paediatricians are prepared to investigate how quickly the clamp should be applied, the institutions consider delayed clamping is the intervention which needs to be assessed for safety. What evidence there is, all points to harm for the current common practice of immediate or early cord clamping. There are a few of us prepared to go around to try to debunk the idea that the cord clamp is part of physiology. The law court is not the place to argue the principle of physiology. Let us hope it is not the place where, in years to come, those harmed by the cord clamp will seek redress. Competing interests: None declared
Respect in Court 12 June 2009
Naveed Iqbal, Foundation Year 1 King George Hospital, Barley Lane, Goodmayes IG3 8YA Send response to journal: Re: Respect in Court	Mr Evan’s article entitled ‘Science in court’ suggests that as health professionals, we are supposedly, members of the Richard Dawkins Alliance by default, and we therefore join the struggle to suppress and ridicule anything outside the realms of science. It is irrelevant to state my agreements with any party involved at this critical juncture, as this debate is fast moving away from evidence based science and instead, it now focuses on the need for respect and courteousness within the public domain. Simon Singh’s public lynching of the British Chiropractic Association with statements such as “happily promotes bogus treatments” seem unprofessional and shows lack the respect for a profession which continues to play a role in the NHS most notably in primary care. It is often forgotten that writers such as Simon Singh hold an influential and powerful role in the media and therefore diplomacy and sensitivity is imperative if he feels pushed to make his case for the evidence based community. It is easy to claim ‘free speech’ whilst on the run and tossing a grenade behind you to create confusion and increasing distrust amongst the public. The relationship between knowledge and arrogance is often witnessed in the science community which can affect morale and confidence but I guess this cannot be argued here due to lack of epidemiological evidence! Competing interests: None declared
Science and polemic 12 June 2009
Bob Leckridge, Locum Consultant Physician Glasgow Homeopathic Hospital. G12 0XQ Send response to journal: Re: Science and polemic	There's a confusion here between scientific debate and insults. Singh is not being sued for his publication of a peer reviewed article. He's being sued for his allegedly defamatory remarks published in the mainstream media. Should "journalism" be exempt from the libel laws of our country because it claims to be "science journalism"? Should we expect a lower standard of public debate from scientists than from other citizens? It does not suppress scientific progress to insist those engaged in debate adhere to the libel laws of our country in their public pronouncements. I know most of the most vociferous "critics" are not medically qualified doctors, but current GMC guidance on good practice sets a good standard on interprofessional relations - 46. You must treat your colleagues fairly and with respect. You must not bully or harass them, or unfairly discriminate against them by allowing your personal views* to affect adversely your professional relationship with them. You should challenge colleagues if their behaviour does not comply with this guidance. 47. You must not make malicious and unfounded criticisms of colleagues that may undermine patients' trust in the care or treatment they receive, or in the judgement of those treating them. Setting aside the issue of libel laws, wouldn't the interests of patients be better served if the individuals involved in this discourse adhered to the standards of the GMC, not least to communicate with respect and to be careful not to "undermine patients' trust in the care or treatment they receive, or in the judgement of those treating them" Competing interests: Full time doctor employed at Glasgow Homeopathic Hospital
Re: Science and polemic 14 June 2009
Leslie B Rose, Clinical Science Consultant Pharmavision Consulting Ltd, Salisbury, UK, SP2 8NJ Send response to journal: Re: Re: Science and polemic	I must first of all declare that I am not a physician, but I fully agree with Dr Leckridge that due professional courtesies are essential. I do not however see what is discourteous about being honest about evidence, whether it is that chiropractic does not work for asthma or colic, or that homeopathy does not work for anything. These are not statements born of malice or unbalanced opinion, they are what evidence tells us, as a result of applying the scientific method (which has served us for centuries by building our present understanding of the universe). If patients have beliefs about health that are not supported by evidence, doctors are doing them a service by correcting their beliefs, rather than undermining them. Indeed the GMC expects doctors to practise evidence based medicine, although fitness to practise hearings in respect of this seem to be confined to the most extreme cases. Otherwise how could NHS homeopathic hospitals continue to exist? Competing interests: None declared
Chiropractors: clarifying the issues 17 June 2009
Richard Brown, Vice President - BCA GL2 4RU Send response to journal: Re: Chiropractors: clarifying the issues	Chiropractor Richard Brown explains why he thinks that the critics have moved the goalposts. 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 Harris1, Simon Singh has redefined the battle as one of free speech and the stifling of scientific debate2. It is nothing of the sort. The British Chiropractic Association 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 having 'not a jot' of evidence to support them3, 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 conditions4- 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 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 which exists to protect the public and uphold standards of care. They are also bound to practice evidence-based medicine which, like their medical colleagues, comprises best available evidence from research, the preferences of the patient and the expertise of practitioners (including the chiropractor him/herself)24-25. 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 health care 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 enquiry with the BCA prior to 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 recently published NICE guidelines26 on low back pain was founded on peer-reviewed published research evidence demonstrating its efficacy. The risks of spinal manipulation have been researched and, in two comprehensive studies in Spine 27-28, have demonstrated it to be far safer as an intervention than commonly-prescribed medical interventions used for similar ailments29-31. 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, 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 whether or not he read the evidence relied upon by the BCA prior to the publication of the article, arguing, bizarrely, that it was because the request was not relevant or necessary in order for the BCA to understand his case. This is bizarre because of Dr Singh’s new found voice that the BCA are 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 healthcare. It has enjoyed phenomenal popularity 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. Richard Brown is a practising chiropractor and is the vice-president of the British Chiropractic Association. References 1. Harris E. Science in court. BMJ 3 June 2009; 338: b2254 (http://www.bmj.com/cgi/content/full/338/jun03_1/b2254) 2. Singh S. BCA v Singh: The Story So Far 3 June 2009. http://www.senseaboutscience.org.uk/index.php/site/project/340 3. Singh S. Beware the Spinal Trap. The Guardian 19 April 2008. 4. Klougart N, Nilsson N, Jacobsen J. Infantile colic treated by chiropractors: a prospective study of 316 cases. J Manipulative Physiol Ther 1989 Aug; 12(4): 281-8 5. Bronfort G, Evans RL, Kubik P, Filkin P. Chronic paediatric asthma and chiropractic spinal manipulation: a prospective clinical series and randomised clinical pilot study. J Manipulative Physiol Ther 2001 Jul-Aug; 24(6): 369-77. 6. Wiberg J, Nordsteen J, Nilsson N. The short term effect of spinal manipulation in the treatment of infantile colic. A randomised controlled trial with a blinded observer. J Manipulative Physiol Ther 1999; 22: 517-522. 7. Mercer C, Nook B. The efficacy of chiropractic spinal adjustments as a treatment protocol in the management of infantile colic. In Haldeman S, Murphy B (eds) 5th Biennial Congress of the World Federation of Chiropractic: Auckland 1999: 170-1 8. Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW. Chiropractic care for non-musculoskeletal conditions: a systematic review with implications for whole systems research. J Altern Complement Med. 2007 Jun; 13(5) 479-80 9. Bockenhauer SE, Julliard KN, Lo KS, Huang E, Sheth AM. Quantifiable effects of osteopathic manipulative techniques on patients with chronic asthma. J Am Osteopathic Assoc 2002 Jul; 102(7): 371-5 10. Guiney PA, Chou R, Vianna A, Lovenheim J. Effects of osteopathic manipulative treatmenton paediatric patients with asthma: a randomised controlled trial. J Am Osteopathic Assoc 2005 Jan; 105(1): 7-12. 11. Mills MV, Henley CE, Barnes LL, Carreiro JE, Degenhardt BF. The use of osteopathic manipulative treatment in children with acute recurrent otitis media. Arch Paediatr Adolesc Med. 2003 Sep; 157(9): 861-6 12. Froehle RM. Ear infection: a retrospective study examining improvement from chiropractic care and analysing for influencing factors. J Manipulative Physiol Ther 1996 Mar; 19(3): 169-77 13. Glazener CM, Evans JH, Cheuk DK. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 2005 Apr 23; 2: CD005230 14. Nilsson N. Infant colic and chiropractic. Eur J Chiropr 1985; 33(4): 264-265 15. Hayden C, Mullinger B. A preliminary assessment of the impact of cranial osteopathy for the relief of infant colic. Complementary Ther Clin Prac. 2006 May; 12(2): 83-90 16. Hipperson AJ. Chiropractic management of infantile colic. Clinical Chiropractic. 2004 Dec; 7(4): 180-186 17. Miller J. Cry babies: a framework for chiropractic care. Clinical Chiropractic 2007 Sep; 10(3): 139-146 18. Browning M, Miller J. Comparison of the short term effects of chiropractic spinal manipulation and occipitosacral decompression in the treatment of infant colic: a single blinded randomised controlled trial. Clinical Chiropractic 2008 Sep; 11(3): 122-129. 19. Leach RA. Differential compliance instrument in the treatment of infantile colic: a report of two cases. J Manipulative Physiol Ther 2002 Jan; 25(1):58-62 20. Reed WR, Beavers S, Reddy SK, Kern GJ. Chiropractic management of primary nocturnal enuresis J Manipulative Physiol Ther 1994 Nov; 17(9): 21. Blomerth PR. Functional nocturnal enuresis. J Manipulative Physiol Ther 1994; 17: 335-338. 22. Fallon JM. The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media. J Clin Chiropract Paediatrics 1997 Oct; 2(2): 167-183 23. General Chiropractic Council. Code of Practice. 2005 http://www.gcc-uk.org/files/link_file/COPSOP_Dec05_WEB(with_glossary)07Jan09.pdf 24. General Chiropractic Council. Code of Practice and Standard of Proficiency. 2005. http://www.gcc-uk.org/files/link_file/COPSOP_Dec05_WEB(with_glossary)07Jan09.pdf 25. Sackett DL, Rosenberg WH, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312: 71-72. 26. National Institute for Health and Clinical Excellence. Low back pain: early management of persistent non-specific low back pain. 2009 May. 27. Thiel HW, Bolton JE, Docherty S, Portlock JC. Safety of chiropractic manipulation of the cervical spine: a prospective national survey. Spine 2007 Oct; 32(21): 2375-8 28. Cassidy JD, Boyle B, Cote P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ. Risk of vertebro-basilar stroke and chiropractic care: results of a population based case control and case crossover study. Spine 2008 Feb 15; 33 (4 suppl): S176-83 29. Blower AL, Brooks A, Fenn CG, Hill A, Pearce MY, Morant S, Bardhan KD. Emergency admissions for upper gastrointestinal disease and their relation to NSAID use. Aliment Pharmacol Ther 1997;11: 283-91. 30. Hawkey CJ, Cullen DJ, Greenwood DC , Wilson JV, Logan RF. Prescribing of nonsteroidal anti-inflammatory drugs in general practice: determinants and consequences. Aliment Pharmacol Ther 1997;11: 293-8. 31. MacDonald TM, Morant, Robinson GC, Shield MJ, McGilchrist MM, Murray FE, McDevitt DG. Association of upper gastrointestinal toxicity of non-steroidal anti-inflammatory drugs with continued exposure: cohort study. BMJ 1997 315: 1333-7. Competing interests: Richard Brown is Vice President of the BCA
Response to the BCA 20 June 2009
Richard Bartley, Physiotherapist Wales Send response to journal: Re: Response to the BCA	It has always been my opinion that chiropractic, like physiotherapy, has one foot firmly placed in allopathic medicine and the other in alternative medicine. Balancing these two fundamentally different systems can be confusing and often leads to disagreements with proponents of science-based orthodoxy. If a profession like chiropractic want to explore areas that lead to conflict with other professions then perhaps they just need to develop thick skins and stand their ground through intelligent argument and debate. To resort to legal recourse suggests that the profession hasn’t matured yet. Competing interests: None declared
Re: Response to the BCA 25 July 2009
Stephen M. Perle, Professor of Clinical Sciences University of Bridgeport, Bridgeport, CT, USA 06604 Send response to journal: Re: Re: Response to the BCA	Mr. Bartley is correct that chiropractic medicine, my profession, ought to have "thick skins and stand their ground through intelligent argument and debate." And in fact we have. The profession has been more than willing to participate in scholarly debate via scientific publication. Not only have chiropractors published primary research but they are also engaged in the secondary analysis though systematic review/meta-analysis as part of the Bone and Joint Decade and Cochrane Study Groups, for example. Thus, we have placed our skin at risk and are prepared to do intellectual combat. Unfortunately, many critics of chiropractic want to debate by popular media, which allows argument well beneath accepted standards for scientific rigor. One need not blithely accept vitriol disguised as scientific debate in the popular media. Thus, legal recourse seems to be an appropriate and mature response. Or would Mr. Bartley suggest that the profession publish a competing polemic in the popular media as a sign of professional maturity? Competing interests: I make my living practicing, teaching, and studying chiropractic medicine and thus have a financial interest in the success of the profession.