This perceptive report discussed why the licensing of chiropractors did not protect the public from their dangerous practices.
Medical cultism involves the practice of purported “healing” through methods or according to theories which do not have a scientifically accepted foundation. Although chiropractic is not the only existing cult, it is the only one which still constitutes a significant hazard to the public. Osteopathy, which in its origins was similar to chiropractic, has progressively incorporated the rigors of medical science and is currently being integrated with scientific medicine. Homeopathy has also been transformed and merged into legitimate allopathic medicine. Naturopathy and naprapathy are rapidly disappearing by attrition. On the other hand, recent estimates place the number of chiropractors practicing in the United States between 14,360 and 35,000, and the number of patients treated by chiropractors as high as 3 million a year.
1. The Cult of Chiropractic
Chiropractic had its origin in an alleged cure of deafness by a back-cracking performed in 1895 by D.D. Palmer, an Iowa grocer and “magnetic healer.” Subsequent growth of the cult’s dogma and practice has been narrated so often that it need only be summarized here.
Chiropractic is represented by its adherents as a complete and independent healing art which can prevent and cure all human disease. The basic tenet of chiropractic is that diseases are caused by a dislocation or “subluxation” of the vertebra in the spine. This subluxation, it is alleged, is accompanied by a narrowing of the apertures between the vertebra, which exerts pressure upon the nerve branches issuing from the spinal cord, and supposedly results in disease in parts of the body activated by the pinched nerves. Chiropractic treatment is to reduce the subluxation, thereby relieving pressure on the nerves, aiding the return of “nerve force,” and purportedly curing the patient’s illness.
Medical authorities unanimously agree that chiropractic has no validity. The cult’s theories have never been supported by objective evidence, and they have been thoroughly refuted by medical science. Besides considerable economic consequences, the dangers inherent in this healing cult are twofold. First, chiropractic treatment frequently delays proper and effective medical care until it is too late. Second, chiropractic treatment often produces actual physical damage to patients. Ideally, therefore, the statutes should be repealed to remove the cult’s shield of legitimacy. Realistically, however, since repeal is unlikely in light of the power of the chiropractic lobby, suggestions are made here for improvements in statutory formulation and enforcement. But it should be recognized that no matter how high they are set, no matter how strictly they are enforced, licensure standards cannot redeem the scientific invalidity of chiropractic. Moreover, increased official attention to licensure provisions can only lend credence to public misconception regarding chiropractors.
In light of these facts, the only legal issue regarding chiropractic is how best to protect the public from its dangers. The goal of licensure laws for health professions and occupations, as previously noted, is to permit only those who are properly qualified by their education, training, and ethics to provide particular kinds of health care. Mandatory medical licensure laws have significantly contributed to the elimination of cultism, quackery, and inferior medical education. However, there is one paradoxical exception to this accomplishment — the licensing of chiropractors.
2. The Legal Status of Chiropractic
Among the many triumphs of chiropractic, none is more remarkable than its achievement of licensure status in all but three States . . . The first licensing act was passed by Kansas in 1913. By 1915, five States had such laws; by 1925, 32. . . . Legislators in most of the remaining States, caught between the clear fact of the falsity of chiropractic practice and belief and the equally clear fact that chiropractors enjoyed licensure in more than half of the States, threw up their hands in embarrassed confusion. Most decided that the lesser evil was to license the cult and thus at least bring it under regulation.
The rationale for mandatory licensure of chiropractors — in all States except Louisiana and Mississippi — is to limit chiropractors’ functions to a sphere in which they are supposedly qualified, to assure that they meet specified educational requirements, and otherwise to control their activities. The following review of selected features of licensure statutes demonstrates that these goals have not been realized.
(1) Definitions, Scope, and Effect — Mandatory licensure statutes provide varying definitions of the practice of chiropractic.’ Several statutes describe the peculiar theories of chiropractic, but most define its practice in terms of the particular methods used by chiropractors. Although these definitions differ considerably in specific details, all are generally designed to confine chiropractors to manual manipulation or mechanical adjustment of the spinal column and to exclude them from the prescription of drugs, the performance of surgery, or the administration of other medical therapy. Some statutes, however, either define or allow chiropractors to practice chiropractic “as taught in chiropractic schools or colleges” or “in accordance with the method, thought, and practice of chiropractors.” The latter phrases, unless restrictively interpreted by licensing boards or by the courts, may open the door to the full practice of medicine except for major surgery. For chiropractors have proclaimed their opposition to definitional constraints upon their practice:
There is no special merit in having any single definition of chiropractic, for any such would tend to straightjacket [sic] the educational process . . . I would urge avoiding any narrow limiting of the scope and definition of practice which can only tend to prevent growth and understanding. At work is the pragmatic factor . . . where the scope of practice is determined by practitioners in their offices.
Because of this tendency of practicing chiropractors to expand the actual scope of their functions, a special burden is placed upon State legislatures to specify prohibited activities, and upon State licensing agencies to enforce such proscriptions.
In most jurisdictions where they are licensed, chiropractors are permitted to use the titles of “doctor” or “physician.” Some statutes, however, limit licensees to the title “doctor” or the prefix “Dr.,” which must be accompanied by the words “chiropractor” or “chiropractic” or by the letters “D.C.” These titles only increase the possibilities of public confusion created by chiropractic licensure. More particularly, designations of chiropractors as having achieved doctorate degrees seem to misrepresent the nature of chiropractic education.
(2) Educational Qualifications. — Chiropractic education and training are appallingly inadequate, as has been well documented by both independent and chiropractic studies. There are currently 12 schools of chiropractic recognized by the two chiropractic associations, but none is accredited by any agency recognized by the National Commission on Accrediting or the U.S. Office of Education, and no school has full accreditation even by the American Chiropractic Association or the International Chiropractic Association. The faculties of these schools are poorly qualified, and the ratio of faculty to students is extremely low. Admission requirements, although also low, are dubiously enforced. A study of actual admission applications showed that chiropractic schools do not observe their own admission rules, and admit students with less than high school educations and questionable credentials.
Licensure statutes which specify educational attainments prior to admission to chiropractic schools are about evenly divided between requirements of high school graduation or its equivalent and requirements of 2 years of college. For chiropractors, however, perhaps the most significant licensure requirement is passage of basic science examinations in jurisdictions where they are required. In those States in which the same examinations are given to medical and chiropractic students, and the examinations are uniformly graded by the same board, an average of 81.4 percent of all physicians pass their first examination, whereas an average of 84.5 percent of chiropractors fail. Chiropractic students show improved performance on examinations separately administered and graded by boards of chiropractors, so that, nationally, about a third of them pass this test of nonclinical scientific knowledge. However, basic science requirements, like other licensure standards, may be subvested through licensure by interstate reciprocity between “tough” and “easy” jurisdictions. Similarly, since chiropractic licensure is entirely a 20th-century creation, a substantial number of chiropractors are insulated from such standards by “grandfather” clauses which exempt chiropractors already (and usually illegally) in practice when licensure statutes were passed.
(3) Alternate Licensure — The experience of the last half century with attempts to control chiropractic through licensure laws leads to the conclusion that more effective safeguards are needed. The Louisiana Medical Practice Act may well serve as a model. Basically, the Louisiana licensure statute prohibits the practice of chiropractic unless the practitioner is also a medical doctor. This requirement provides a more effective safeguard than licensure of chiropractors because it assures that the practitioner will possess the education and training necessary to understand his diagnosis and prescribed therapy in terms of medical principles as well as those of chiropractic. Medical education and training should be required of adherents to chiropractic because:
There should be no such thing as limited education and training when one is dealing with human illness. You cannot limit the extent to which a disease process or an ailment will affect the human body. The person who assumes the responsibility for treating human beings must be prepared to treat the whole person. He must be qualified to provide the care of the whole person. He cannot restrict himself to just one system of treatment; he must employ all techniques that will be of benefit to the patient.
b. Other Regulation and Recognition
With similar reasoning, a few courts have held chiropractors to medical standards of performance in cases of civil criminal negligence:
If a person undertakes to cure those who search for health and who are because of their plight, more or less susceptible of following the advice of anyone who claims the knowledge and means to heal, he cannot escape the consequences of his gross ignorance of accepted and established treatment of diseases . . .
Chiropractors may also be subject to the same State and municipal public health regulations which apply to physicians. Most chiropractic licensure statutes so provide, and require or permit licensed chiropractors to execute various health reports and certificates. These provisions usually include death certificates and four States specifically include birth certificates. On the other hand, chiropractors are prohibited by statute from signing any reports or certificates in New Jersey, birth or death certificates in Maryland, and birth certificates in Tennessee. Although most statutes do not deal with hospital privileges, the North Carolina statute gives licensed chiropractors access to public hospitals, and in North Dakota these licensees may practice in any public or private hospital or other institution . . . when requested so to do by any patient or the guardian of any patient.
Chiropractic has achieved an impressive array of other legal and official recognitions. For example, Federal funds are available to chiropractic students and practitioners under programs established by the Social Security Act (but no Medicare or Medicaid), the U.S. Employee’s Compensation Act, and the GI bills of rights. In addition, the U.S. Bureau of the Budget classifies chiropractic as one of the four major healing professions; the U.S. Immigration Service admits foreign chiropractic students outside of quotas; the Selective Service Act has permitted the deferment of chiropractic students; and the Internal Revenue Service permits income tax deductions for chiropractic fees.”‘ Chiropractic services qualify for indemnification under most State workmen’s compensation acts, and under a great many insurance policies. These official recognitions of chiropractic tend to promote chiropractic rather than limit its scope and effect, which is the premise of licensure. The basic assumption of licensure of chiropractors — that licensure facilitates regulation — should be reexamined.
Summary and Conclusions
Licensure laws clearly affect the delivery of medical care by physicians. By setting minimal qualifications for entering into and remaining in the medical profession these laws affect educational curriculums, approval of educational institutions and programs of graduate education, delegation of responsibilities to allied and auxiliary personnel, geographic mobility, and substantive and procedural rules governing actions for violation of these minimal standards.
This study of licensure laws affecting physicians, osteopaths, and chiropractors indicates, among other things, that:
- Current statutory provisions impose constraints on medical school curricular innovations;
- Specific statutory requirements restrain needed developments in graduate medical education, such as elimination of the internship as a separate entity and substitution therefore of appropriate programs of graduate medical education integrated with undergraduate medical education;
- Initial licensure examination requirements of the States do not measure many of the qualities relevant to fitness to practice and are not necessarily relevant to current goals of undergraduate medical education;
- Legal requirements for programs in continuing medical education to prevent educational obsolescence are absent;
- Incomplete interstate recognition of medical licenses results in barriers to geographic mobility of physicians;
- Licensure requirements for foreign medical graduates are not generally geared specifically to fitness to practice high quality American medicine;
- Delegation of tasks to allied and auxiliary personnel is governed by statutes which may be restrictive, ambiguous, or unrelated to accepted custom and usage;
- Statutory interpretations relevant to delegations of tasks by physicians to allied and auxiliary personnel are not always based on the realities of the delivery of modern medical care;
- Osteopaths cannot, under present laws, be integrated fully into the practice of medicine so as to permit their addition to the pool of physician manpower; and
- Attempts to control unscientific schools of practice or cultism by licensure cannot give unscientific practices a scientific basis but can endanger the public by giving unscientific schools, such as chiropractic, protection through the sanction of law.
Resolution of these problems will require legislative, rather than judicial action. Judicial action permits resolution of problems only on a case-by-case basis, with decisions limited to the facts and circumstances of each case. Since licensure laws are quasi-criminal in nature, judicial decisions in these cases are unlikely to result in the establishment of broad principles which would transcend the immediate facts before the courts.
The legislative process, however, can establish broad principles. It can consider facts, evidence, and social policy without the procedural limitations of the judicial process. Moreover, it can delegate many interpretative functions to the administrative process in which the tribunals have both expertise and flexibility.
Among the many problems presented by the medical licensure laws, without question, the issue of delegation of tasks is a highly significant, if not the most significant, problem requiring resolution. It involves not only the medical profession, but also nursing and other allied and auxiliary professions and occupations. Resolution of the problem of delegation will require consideration of the legal regulation and scope of functions of all the professions and occupations comprising the manpower matrix rendering personal health care. If the legal authority affecting the functions of physicians and other health professions and occupations is amended, the composition of the official licensing agency and its relation to other agencies of government must be reconsidered. Careful study, analysis, and consultation among the health professions will be necessary to develop guidelines for legislative resolution of the issue of delegation and other problems in licensure.
This article was posted on May 27, 2002.