I have been struggling recently to find ways to rehash my post on scientific authority without causing NPG any further distress. This evening, on the train journey home, I think I finally found a way because I read one of the most remarkable scientific papers I have ever come across.
The paper, by Keating et al., brings us directly back to the ongoing saga of the British Chiropractic Association’s libel suit against Simon Singh. It was published in 2005 in the open access journal Chiropractic & Osteopathy and at least three of the six authors have affiliations with Chiropractic colleges. To all six authors I would like to say:
Gentlemen, I salute you.
The title of the paper, Subluxations: Dogma or Science?, is quite telling. Inside the authors fearlessly examine the status of the subluxation syndrome, a founding concept in chiropractic since the introduction of this method of treatment in the 1890s. I have struggled a little to find a definition of subluxations. As quoted in the paper, the Association of Chiropractic Colleges states:
A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.
You see what I mean? If I understand correctly, the idea is that problems with the spine can propagate to the rest of the body via neural pathways. But I am not the only one wrestling with this concept. The whole substance of the paper is a discussion of how the idea of subluxations has come to pervade chiropractic without any experimental verification. It’s a pretty rigorous treatment. The summary is worth quoting in full (I am taking full advantage of the open access!):
Hypothetical constructs involve tentative assertions about physical reality. They serve as essential tools in the development of science, and permit the empirical testing of the non-obvious. However, when the speculative nature of an hypothesis or hypothetical construct is not made obvious, an otherwise acceptable proposition becomes a dogmatic claim. Such is the history of subluxation in chiropractic.
This brief review of the role of subluxation dogma in clinical practice, in marketing, in the legal and political arenas, as a basis for professional identity, and in the rhetoric of leading chiropractic organizations and agencies, is not a statement about subluxation’s validity or lack thereof. Only focused clinical research will enable us to determine whether the traditional chiropractic lesion merits clinicians’ attention. We don’t know whether subluxation is meaningful or not.
The dogma of subluxation is perhaps the greatest single barrier to professional development for chiropractors. It skews the practice of the art in directions that bring ridicule from the scientific community and uncertainty among the public. Failure to challenge subluxation dogma perpetuates a marketing tradition that inevitably prompts charges of quackery. Subluxation dogma leads to legal and political strategies that may amount to a house of cards and warp the profession’s sense of self and of mission. Commitment to this dogma undermines the motivation for scientific investigation of subluxation as hypothesis, and so perpetuates the cycle.
The simple expedient of amending dogmatic assertions to note their tentative, hypothetical character could do much to improve the image of the profession, to re-orient it to the challenge of testing its cherished hypotheses and to establishing the cultural authority of chiropractors in our unique realm of health care. The task of reorienting the profession to a credible science and art belongs to all who understand the scourge of dogma, and who seek a brighter future for the chiropractic profession and its patients.
If that has whet your appetite, I can recommend the rest of the paper. It was certainly a revelation to me who, in common with many others, I suspect, knew very little about chiropractic until a short while ago. The authors’ candour in squaring up to a fundamental problem within their own field is refreshingly scientific.
What a contrast this makes to the rather feeble pronouncements that have come from the BCA in recent weeks in response to the mounting campaign in support of Simon Singh. Their main complaint is that the libel case “has been re-characterised by his supporters as a freedom of speech issue”. Writing in New Scientist today, Richard Brown (chiropractor and vice-president of the BCA) avowed “To stifle scientific debate would clearly be wrong.”
I think they are terribly confused about the necessary connection between free speech and scientific debate.
If Keating and colleagues are correct, the chiropractic profession has spent the past century not engaging in scientific debate. An earlier press release from the BCA mentioned “27 different publicly-available research papers” that Singh should have consulted before writing his contentious article but I haven’t been able to find out which papers they are referring to. Since they are already in the public domain, why can they not be listed, so that a proper scientific debate can commence?
In science we know — from hard-won experience — that the culture of vigorous and ruthless examination is our best prospect for learning about the workings of the world, including the processes of health and disease. It’s how we figure out what authorative statements can be made about the nature of reality. The process isn’t always pretty or efficient. Brilliant ideas are conceived and nurtured but they’re not always right and when the error is found, the idea is eventually discarded and left to die. No-one likes to be proved wrong – we are all human, after all. But as scientists we accept that only through the detection of error can progress be made. Hypotheses are made to be falsified. Science flourishes because it has the freedom to err.
That is why the stifling of scientific criticism through the law courts is so lamentable. The BCA claims it is only defending its reputation but the implications of its actions have spread far wider than that.
Let me leave you with what was for me the most interesting paragraph from the Keating paper:
Chiropractors’ insistence upon defining the profession in terms of a hypothetical (and largely untested) construct is foolish at best: subluxation may or may not be a meaningful notion. This commitment also augurs against the conduct of clinical research to confirm or refute the utility of the subluxation construct, firstly because the presumption of validity undermines the motivation to investigate, and secondly because such research has the potential of undermining this proposed identity (i.e., subluxation doctor). The erosion of reimbursement for chiropractic services is also a possibility if subluxation research fails to measure up to expectations.
I have no further comment, but would welcome your comments and criticism!
Keating, J., Charlton, K., Grod, J., Perle, S., Sikorski, D., & Winterstein, J. (2005). Subluxation: dogma or science? Chiropractic & Osteopathy, 13 (1) DOI: 10.1186/1746-1340-13-17