Could there be an Evidence-based Chiropractic? An Uncomfortable Question Worth Considering (Part 1 of 5)
When some think about “alternative medicine” they envision a whole slew of quackery about to wreak havoc on the public, deceiving them with their lies and taking their money along the way. Reality is much more complicated, mainly because pseudoscience and science share similarities, making the separation between fact and fiction complex. This is the philosophical “demarcation problem”— a hot topic in early 20th century philosophy and one which remains alive today regardless of attempts to squash it. A key consideration in demarcating between science and pseudoscience is to first ask: why should we even bother? In taking a historical and philosophical stab at this topic, we could be going down a path in which many professional philosophers disembarked some time ago. While there are certainly the Larry Laudan’s (see the previous link, he is rather opposed to the demarcation problem) of the academic and political worlds, pseudoscience remains a threat in both. In our modern politic we hear the rallying cry to “follow the science.” But what do we even mean when we say science?
I think it is high time we approach this process with the temperance it is due. In my view, we should be doing so to determine how we can generate more reliable knowledge, not to discover hidden truths. The word “truth” has a particular air of certainty that seems to paralyze the brains of anyone searching for its illusive nature. Instead, we should be learning to critique the institutions surrounding us, including those considered to be “scientific” as well as those accused of mimicking science without the requisite substance underneath, what we call pseudoscience. Note that I included those considered to be “scientific.” After all, analytic philosophy attempts to question, deconstruct, unravel, and grasp the meaning behind language. Because this is a philosophical piece, I’ve chosen specific language here, institutions considered to be scientific and those considered to be pseudoscientific or even non-scientific. This is on purpose, intended to show that we should not accept a claim as scientific, pseudoscientific, or non-scientific (many will use these words to give something clout or establish it as “quackery” or bunk) without understanding where it comes from.
A quick word should be said here: not all pseudoscience is immensely harmful and not all science is what we might call “good.” After all, it is logically possible and historically demonstrated that things once lauded as pseudoscience can turn out to be correct. It is what occurs after they are found to be so and better yet, how they come to be so that is so important. One could capture it in this pithy remark: broken clocks are right twice a day. I don’t know about you, but I want a reliable clock even if it happens to not be set to the correct time. Put much more eloquently by philosopher of science Karl Popper, the aim of a project tackling the demarcation problem is,
“…to distinguish between science and pseudo-science; knowing very well that science often errs, and that pseudoscience may happen to stumble on the truth.”
This begs the following question: what would it take for a pseudoscientific research program to usher a field into an era of scientific progress? In other words, how could a community rife with pseudoscience transform itself into something deemed scientific? Is that possible? Would there need to be a breakaway faction with new epistemic and non-epistemic values? I’ve already given away that, like Massimo Pigliucci, I think the demarcation problem is far from finished; it is in need of an academic and cultural reification.
A brief word must be said about the differences between the demarcation problem in philosophy of science and in philosophy of medicine. Previous discussions of the demarcation problem sometimes discuss science and medicine as if they are a cohesive whole. Such an assumption may not be justified. Whereas science can be said to seek after an understanding of the natural world, medicine seeks to intervene into it. Certainly a goal of medicine is to understand disease, but the usefulness of that knowledge is to perform the acts of diagnosis, prognosis, treatment, and/or palliation. In other words, it is not to simply know what the natural world is composed of, but rather, such knowledge must be translated into a benefiting the human being(s) in your care. Thus, you can have a particular form of scientific medicine which is not practiced scientifically. There may be other forms which span the spectrum of non-science to pseudoscience. It is an active form of using science rather than science itself. If we allow this premise, it follows that the demarcation of scientific medicine is unique from the demarcation of science itself. A helpful analogy might be that scientific medicine can give me a pharmaceutical designed for a specific disease, but only an astute and expert-level diagnosis can apply this pharmaceutical scientifically.
This expresses the hope that medicine is not simply based on treatments developed through science but that it is scientific in and of itself. This is the major sticking point of the evidenced-based medicine (EBM) movement, to make a science of clinical care. Here’s where it gets interesting. If one thinks that demarcating between a scientific medicine and anything else is important, then it seems that EBM may indeed be sufficient for that purpose. After all, pharmaceutical greed can create products which are formed through science, but if they are applied to the treatment and amerilation of disease in a biased manner than such an entity may not be a bonafide scientific medicine. An interesting dilemma may also arise, sometimes practices that are filled with quackery may turn out to have something correct. Maybe we can form a hypothesis, integrate it into scientific theory, and continue testing it. The ultimate question you should ask yourself, if you are attempting to make a pseudoscientific finding into a scientific one, I would argue, is something like, “how can I test this and generate usable information both inside and outside of my community?” After all, you aren’t generating this research knowledge for your community alone. The outside communities deemed “scientific” will need to integrate it into current theory and then see if it generalizes.
In this essay, I hope to introduce the reader to how this very problem is currently being debated in an EBM-like movement in chiropractic. I hope to introduce the reader to this movement for modern evidence-based practice (EBP) in chiropractic, a guiding epistemology of medical evidence that I will hereafter refer to as evidenced-based chiropractic (EBC). Chiropractic, a profession imbued with pseudoscientific thinking from the start, seems to at least have a faction which seeks to mirror the EBM movement in allopathic medicine. As such, I will consider EBC as the copycat of EBM, with the former struggling to gain ground for one simple reason: the chiropractic community, much unlike the allopathic medical community in years past, has certain historical events, social values, and political aims that prevent EBC philosophy from taking hold. This essay will serve as the first part in a multi-part series on EBC’s views on chiropractic for non-musculoskeletal conditions. I’ve chosen to focus on these conditions because chiropractic has shown efficacy for certain musculoskeletal conditions, something often touted by chiropractors as evidence of the incredibly pseudoscientific subluxations. It’s hard to seriously consider that such a field may have warrant from an allopathic perspective. I would contend that it is a modality of care which remains, as one author posits “full of science, antiscience, and pseudoscience.” That is an argument for another day.
I will first discuss how viewing EBM & EBC as social movements within their respective professions is justified. The view we often have of science is what we are left with from grade school. A rigid, objective, and sometimes boring search for what in the actual f*** is out there by a group of super nerds who are quite bland. Zoom out a bit and you will see that it is quite messy and full of ironies. For example, many Nobel prize winning scientists hold one or more “fringe” beliefs, a term affectionately called nobelitis. This phenomenon is a direct result of the fact that science is social, it begins in groups of people who establish ways of knowing, what we may refer to as methods, alongside the set of results that those give. For instance, a scientific community comes to the conclusion that using a certain method or path is the correct/right/best way to secure the thing we call “knowledge.” This is important because social movements, especially scientific movements, don’t start in vacuums. As I stated in an earlier piece titled, “Archie Cochrane and the Early Days of Evidence-Based Medicine…” EBM can, and many argue should, be viewed as a social movement [3].
As EBM has risen in allopathic medicine, it has established the bounds by which “scientific” medicine is judged. Now, whether that is correct is besides the point. What we are concerned with here is how this prevents other groups from joining medicine without meeting its epistemic standards. In their quest for legitimacy, professions such as chiropractic have been forced to professionalize or die. If EBM-like principles are the way to professionalize, then those standards must be observed. After all, if allopathic medicine claims scientific legitimacy and brands you as “quacks” your customer base drops quickly. This is, after all, one of the main drivers of pseudoscience, namely the quest for societal legitimacy, the key to professionalization and profit. It became obvious to chiropractic, somewhere around the mid-20th Century, that they needed research programs to confer this legitimacy. First, let’s explore its infancy and path to professionalization. Brevity is needed here as this could fill a library with nonsense I don’t have time for.
From its beginning in the late 1800s to its modernization in the 20th century chiropractic set itself in opposition to “orthodox” or allopathic practice. In a story that one could easily consider legend, D.D. Palmer “adjusted” a partially deaf janitor in Davenport, Iowa, returning his hearing. Later, Palmer reported good outcomes in a man with heart disease [1]. Palmer would start the field of chiropractic, claiming that he heard about it from the spirit of a deceased physician. He truly thought these “subluxations” were the cause of disease, minimizing the importance of mainstream medicine, a sentiment which led to jail time as he made his way across the Midwest. It is important that we understand this history, as modern-day chiropractic tends to focus on musculoskeletal conditions, the majority of their practice. In its infancy, chiropractic sought to treat mainly non-musculoskeletal conditions. Thus, it is an entirely modern phenomenon for chiropractic to be largely confined to musculoskeletal conditions.
Fast forward to 1990 and the landmark Wilk v. AMA case, and you will see chiropractic vying for power in the modern landscape of healthcare. Soon after the rise of D.D. Palmer, chiropractic would become a sort of pseudo-religion, with overt oppression from mainstream medicine. As we enter the 20th century, modern/mainstream/allopathic medicine (I will use these terms interchangeably) did not take kindly to chiropractors claiming that 95% of disease was caused by “subluxations,” the chiropractic term for misaligned vertebrae that cause disease. It was a time of science, industrialization, and culture expansion above and beyond the knowledge of “bonesetters.”
In Wilk v. AMA, chiropractic earned the right to receive referrals from other professions. In the years prior, it was shown that the AMA had staged a deliberate public campaign to disparage chiropractors in the public’s eye. This is even as chiropractic was undergoing considerable criticism internally. The tension between chiropractic and allopathic medicine led, as one might predict, to denials of a history laden with quackery.
Even today, leading chiropractic professional bodies and research organizations act as if calling chiropractic “quackery” is inaccurate, rewriting history. In a 1991 reply to a letter in Dynamic Chiropractic, Joseph C. Keating Jr. states [2]:
“The so-called ‘quackery myth about chiropractic’ is no myth … the kernels of quackery (i.e., unsubstantiated and untested health remedies offered as “proven”) are ubiquitous in this profession. I dare say that health misinformation (if not quackery) can be found in just about any issue of any chiropractic trade publication (and some of our research journals) and much of the promotional materials chiropractors disseminate to patients. The recent unsubstantiated claims of the ACA are exemplary [examples provided] … It escapes me entirely how Dr. Downing, the ACA, MPI, and Dynamic Chiropractic can suggest that there is no quackery in chiropractic. Either these groups and individuals do not read the chiropractic literature or have no crap-detectors. I urge a reconsideration of advertising and promotion policies in chiropractic”
As I will show in subsequent parts of this series, such internal conflicts have resulted in barriers to the widespread adoption of EBC. Though leaders in the movement are eager to copy the allopathic EBMers, it is extraordinarily difficult to transpose it into a profession with a past such as chiropractic.
Nevertheless, similarities do exist. For instance, EBM first arose in allopathic medicine as an anti-authoritarian movement trying to wakeup mainstream medicine. As such, it was an internal critique of allopathic medicine and a reformative social movement. Likewise, EBC has arisen to reform a profession from its pseudoscientific past, conferring legitimacy. At the time of EBM’s rise, mainstream medicine was grounded in the positivistic scientific enterprise where bench science was given significant weight. Hypothesize, measure, observe….generalize to the bedside. The concern that David Sackett and the founding fathers of EBM had was that this last step, generalization, was too big of a leap. We needed evidence at the bedside to tell if treatments lacked generalizability to whole human organisms in populations. In other words, if one of the aims of medicine is to ameliorate disease in patients who reside in populations of individuals like them, then that’s where the best evidence to determine treatments/diagnosis/prognosis lies. Thus, EBM could be seen as trying to develop a “science of clinical care.” Unsystematic clinical observation, pathophysiological rationale, and “clinical expertise” would no longer be the primary evidence used by clinicians. Rather, systematic evidence was to be gathered, assessed for its transferability to the patient in front of the clinician, and used to guide treatment decisions. Later, the movement would appear to catch itself, admitting that clinical expertise was to be used in the application of treatment, integrating it with the patient’s values and goals of care. [5]
As all social movements arise within a predominant culture, “base,” or “medium,” one can’t simply export a particular social movement across domains without changing the movement’s goals and purposes. Whereas EBM arose as a “anti-authoritarian movement” which elevated the common practitioner within allopathic medicine, the mirror of this may look different in another profession, especially one vying for political and ideological stability in the landscape of modern healthcare. In other words, EBM arose as a redemptive/restorative faction of an already established (i.e. mainstream) profession. In contrast, an EBC would have to reform a profession marked by competition with the mainstream. Along with reforming the profession you now have to meet significant external critiques from allopathic medicine. A daunting task indeed.
Allopathic medicine was and is the holder of power within healthcare. What is the main reason for this? Years of claiming and often backing up that its treatments lie in the institution of science, bolstered by its reliance on biomedicine (i.e., bench science dealing with biology, specifically human biology and physiology). Chiropractic, at least currently, has minimal evidence that can integrate with science. Instead, the path forward for those in support of EBC is to copy EBM. Why? Because it’s been very successful in allopathic medicine, despite its critiques.
While ongoing debates rage regarding EBM, it has obviously succeeded as a social movement in at least one regard — it has advocated for the place of the RCT design within pharmaceutical regulation, clinical practice guidelines, and in the minds of individual clinicians. Though there continue to be debates as to the proper role of the RCT; the movement itself, regardless of what one thinks about its philosophy, was successful. I have often been inspired by the writings of “EBMers”, feeling a sense of rapture at the thought of rebelling against tradition-based clinicians and demonstrating what we really ought to be doing in clinical practice. It is no wonder that fields once looked down upon by society at large (i.e. chiropractic) want to assert almost the same thing: our profession is broken and in need of repair, we need better evidence. The only difference is that one has a firm scientific past, mostly removing itself from quackery. The other can’t seem to separate itself from that past, as evidenced by the frank misinformation in COVID-19.
This all is profoundly interesting to me, mainly because it’s a perfect example of the difficulties and idiosyncrasies of the demarcation problem. The next part in this series will reference two main papers: the “Global Summit on Chiropractic for Non-musculoskeletal Conditions” and a breakaway article referring to it as an “over-extrapolation and amalgamation of evidence.” The debate which has ensued from these papers highlights the challenges that EBC faces, especially in light of recent criticisms of EBM in allopathic medicine. I will be detailing these criticisms in the next part of this series.
[1] DeVocht JW. History and overview of theories and methods of chiropractic: A counterpoint. Clin Orthop Relat Res. 2006;444(444):243–249. doi:10.1097/01.blo.0000203460.89887.8d
[2] https://www.dynamicchiropractic.com/mpacms/dc/article.php?id=44130
[3] Daly J. Evidence-Based Medicine and the Search for the Science of Clinical Care.; 2005.
[4] Janati, Ali et al. “An Evidence-Based Framework for Evidence-Based Management in Healthcare Organizations: A Delphi Study.” Ethiopian journal of health sciences vol. 28,3 (2018): 305–314. doi:10.4314/ejhs.v28i3.8
[5] Miettinen, Olli S. “Feinstein and study design.” Journal of clinical epidemiology vol. 55,12 (2002): 1167–72. doi:10.1016/s0895–4356(02)00542–5
[6] Evidence-Based Medicine Working Group. Evidence-based medicine: a new approach to teaching the practice of medicine. JAMA. 1992;268(17):2420–24251404801
