Criticism of Chiropractors: No Competing Interests?
In his commentary (1), Edzard Ernst has deconstructed a single
sentence of my paper (2) and has selectively overlooked the main thrust of
the article. While the article focused on matters related to a range of
issues, not least of which were the defamatory statements made of the
British Chiropractic Association (BCA) by Simon Singh, Ernst devoted the
entirety of his response to a dissection of evidence put forward by the
BCA in response to Singh’s assertion that there was ‘not a jot’ of
evidence existing in relation to chiropractors being able to help (not
treat, or cure) various childhood conditions. Regarding competing
interests, he omits to mention that he, with Simon Singh, co-authored a
book on alternative medicine (3). Fiona Godlee, in her editorial (4),
describes Ernst’s analysis as ‘a demolition’ and supports calls to keep
the libel laws out of science.
The BCA does not contest the need for further research. It is quite
proper that responsible health professionals should seek to improve their
knowledge by undertaking rigorous trials to test hypotheses and clinical
experience. Contrary to Ernst’s assertion that the evidence denying
benefit is strong, the reality is that there is a paucity of comprehensive
clinical trials in this area and further quality research is needed. There
is clearly, however, more evidence than ‘not a jot’ and it was quite wrong
of Singh to label the treatments promoted by the BCA as ‘bogus’.
The case has clearly ignited fierce debate, and a number of
correspondents have allowed emotion and bias to cloud the pursuit of
scholarly debate, dismissing chiropractic as quackery (5) and caricaturing
the profession as deserving of unprofessional language (6). Surely such
vitriol is not the way to advance debate in the pages of a prestigious
medical journal?
Amongst the responses, a physiotherapist has sought to elevate the
status of his profession at the expense of chiropractic by alleging that
‘[chiropractic’s] business model has always been profit-based’, whilst his
own has been based on public service (7). Such regrettable and misinformed
comments do little to advance the debate and the lack of references for
his allegations is telling.
Some have called for forceful manipulation of the neck to be made
illegal, after having observed a rheumatological colleague undertaking the
procedure (8). I do not know, of course, what level of training this
colleague had received, but in like manner I could call for extraction of
wisdom teeth to be outlawed based on having observed a physiotherapist
performing the procedure. The safety of chiropractic techniques,
particularly spinal manipulation, should rightly be subjected to scrutiny,
yet it seems ironic that Ernst characterises it as potentially lethal
based on single case reports when he summarily dismisses any potential of
benefit demonstrated by a similar level of evidence. There is no doubt
that, as with any medical intervention, manipulation of the spine may
result in adverse events, some of which may be serious. However, to
portray chiropractors as reckless and dangerous is wholly misleading and
ignores both the quality of undergraduate training present throughout
Europe and the lauded regulation of the chiropractic profession in the UK
(9).
Readers should not forget that the BCA resorted to legal action only
after requests to correct libellous statements were refused. While it has
been criticised for its stance, at no time prior to publicising his
article did Singh approach the BCA to question its claims; he simply
commenced the debate in The Guardian and in so doing defamed the BCA and
its reputation.
The BCA has no difficulty in accepting the proposal that views and
suggestions about the perceived efficacy of healthcare interventions
should be permitted in quality peer-reviewed journals. It supports high
quality research which objectively informs and evolves the evidence base
and would exhort chiropractors to modify their practices where conclusive
evidence demonstrates ineffectiveness or a real risk of serious adverse
events.
Greenhalgh (10) and Thornton (11) summarise the position well in
urging authors to be professional and scholarly. Had Singh expressed his
argument thus, rather than accusing the BCA of dishonestly promoting bogus
treatments for which there was no evidence whatsoever, it is almost
certain that this action would never have taken place.
1. Ernst E. Chiropractic for paediatric conditions: substantial
evidence? BMJ 2009; 339: b2766
2. Brown R. Chiropractic: clarifying the issues. BMJ 2009; 338: b2782
3. Singh S, Ernst E. Trick or Treatment? Alternative Medicine on Trial
(2008) Bantam Press
4. Godlee F. Keep libel laws out of science. BMJ 2009; 339:b2783
6. Colquhoun D. Unprofessional language is appropriate when dealing with
unprofessional people. BMJ Rapid Responses. 2009 July 15. Accessed at www.bmj.com/cgi/eletters/339/jul08_4b2783
Rapid Response:
Criticism of Chiropractors: No Competing Interests?
In his commentary (1), Edzard Ernst has deconstructed a single
sentence of my paper (2) and has selectively overlooked the main thrust of
the article. While the article focused on matters related to a range of
issues, not least of which were the defamatory statements made of the
British Chiropractic Association (BCA) by Simon Singh, Ernst devoted the
entirety of his response to a dissection of evidence put forward by the
BCA in response to Singh’s assertion that there was ‘not a jot’ of
evidence existing in relation to chiropractors being able to help (not
treat, or cure) various childhood conditions. Regarding competing
interests, he omits to mention that he, with Simon Singh, co-authored a
book on alternative medicine (3). Fiona Godlee, in her editorial (4),
describes Ernst’s analysis as ‘a demolition’ and supports calls to keep
the libel laws out of science.
The BCA does not contest the need for further research. It is quite
proper that responsible health professionals should seek to improve their
knowledge by undertaking rigorous trials to test hypotheses and clinical
experience. Contrary to Ernst’s assertion that the evidence denying
benefit is strong, the reality is that there is a paucity of comprehensive
clinical trials in this area and further quality research is needed. There
is clearly, however, more evidence than ‘not a jot’ and it was quite wrong
of Singh to label the treatments promoted by the BCA as ‘bogus’.
The case has clearly ignited fierce debate, and a number of
correspondents have allowed emotion and bias to cloud the pursuit of
scholarly debate, dismissing chiropractic as quackery (5) and caricaturing
the profession as deserving of unprofessional language (6). Surely such
vitriol is not the way to advance debate in the pages of a prestigious
medical journal?
Amongst the responses, a physiotherapist has sought to elevate the
status of his profession at the expense of chiropractic by alleging that
‘[chiropractic’s] business model has always been profit-based’, whilst his
own has been based on public service (7). Such regrettable and misinformed
comments do little to advance the debate and the lack of references for
his allegations is telling.
Some have called for forceful manipulation of the neck to be made
illegal, after having observed a rheumatological colleague undertaking the
procedure (8). I do not know, of course, what level of training this
colleague had received, but in like manner I could call for extraction of
wisdom teeth to be outlawed based on having observed a physiotherapist
performing the procedure. The safety of chiropractic techniques,
particularly spinal manipulation, should rightly be subjected to scrutiny,
yet it seems ironic that Ernst characterises it as potentially lethal
based on single case reports when he summarily dismisses any potential of
benefit demonstrated by a similar level of evidence. There is no doubt
that, as with any medical intervention, manipulation of the spine may
result in adverse events, some of which may be serious. However, to
portray chiropractors as reckless and dangerous is wholly misleading and
ignores both the quality of undergraduate training present throughout
Europe and the lauded regulation of the chiropractic profession in the UK
(9).
Readers should not forget that the BCA resorted to legal action only
after requests to correct libellous statements were refused. While it has
been criticised for its stance, at no time prior to publicising his
article did Singh approach the BCA to question its claims; he simply
commenced the debate in The Guardian and in so doing defamed the BCA and
its reputation.
The BCA has no difficulty in accepting the proposal that views and
suggestions about the perceived efficacy of healthcare interventions
should be permitted in quality peer-reviewed journals. It supports high
quality research which objectively informs and evolves the evidence base
and would exhort chiropractors to modify their practices where conclusive
evidence demonstrates ineffectiveness or a real risk of serious adverse
events.
Greenhalgh (10) and Thornton (11) summarise the position well in
urging authors to be professional and scholarly. Had Singh expressed his
argument thus, rather than accusing the BCA of dishonestly promoting bogus
treatments for which there was no evidence whatsoever, it is almost
certain that this action would never have taken place.
1. Ernst E. Chiropractic for paediatric conditions: substantial
evidence? BMJ 2009; 339: b2766
2. Brown R. Chiropractic: clarifying the issues. BMJ 2009; 338: b2782
3. Singh S, Ernst E. Trick or Treatment? Alternative Medicine on Trial
(2008) Bantam Press
4. Godlee F. Keep libel laws out of science. BMJ 2009; 339:b2783
5. Gøtzsche PC. Quackery, chiropractic and alternative medicine. BMJ Rapid
Responses 2009 14 July. Accessed at
www.bmj.com/cgi/eletters/339/jul08_4b2766
6. Colquhoun D. Unprofessional language is appropriate when dealing with
unprofessional people. BMJ Rapid Responses. 2009 July 15. Accessed at
www.bmj.com/cgi/eletters/339/jul08_4b2783
7. Bartley R. Business Models. BMJ Rapid Responses 2009 July 15.
www.bmj.com/cgi/eletters/339/jul08_4b2783
8. Gøtzsche PC. Quackery, chiropractic and alternative medicine. BMJ Rapid
Responses 2009 14 July. Accessed at
www.bmj.com/cgi/eletters/339/jul08_4b2766
9. Council for Healthcare Regulatory Excellence (2009) Performance Review
of Health Professional Regulatory Bodies 2008/09.
10. Greenhalgh T. But was it libel? BMJ Rapid Responses. 2009 July 13.
Accessed at www.bmj.com/cgi/eletters/339/jul08_4/b2783
11. Thornton H. Choosing our words carefully. BMJ Rapid Responses 2009
July 13: www.bmj.com/cgi/eletters/339/jul08_4/b2783
Competing interests:
Vice President, British Chiropractic Association
Competing interests: No competing interests