Alan Breen in praise of chiropractic and democracy

We were pleased to see a call from Prof Alan Breen (at the Anglo-European College of Chiropractic, and on two GCC committees) for a move beyond or supplement to evidence-based medicine in order to achieve a “more democratic and inclusive…age” in “musculoskeletal practice”. However, it is unfortunate that Breen fails to follow through on the implications of his demand.

In a Journal of Health Services Research & Policy article “In Praise of Chiropractic” (alongside an article by Prof Ernst in the same issue) Breen takes an interesting stance. Breen takes a strong stance against certain (perceived) criticisms and critics of chiropractic, arguing that

The suggestion that chiropractic does harm is specious. Allegations are sometimes based on the fact that manipulation (as well as exercise) can result in a temporary (and usually mild) increase in pain. The evidence is that if this happens it does not last and does not influence long-term outcomes.

Breen goes on to argue that

It is devastating enough to have to witness a stroke let alone to be falsely accused of causing it. Yet this is one of the arguments used repeatedly to denigrate chiropractic.

To portray only part of the relevant information in a critique is itself pseudoscience, yet strong ontological commitment to only part of the knowledge base seems often to be the stance taken to contest the scientific basis of chiropractic.

There is an odd logic in play in Breen’s article. On the one hand, he is arguing for more democracy and inclusivity – and I would certainly agree with him that there is a need for evidence-based medicine to remain open to the experiences of patients and practitioners. On the other hand, though, Breen is actively excluding the experiences of many patients. For example:

• Some people do feel that they have suffered strokes resulting from chiropractic manipulation: see for example Action for Victims of Chiropractic. On what grounds does Breen believe that it is appropriate to exclude their experiences and their suffering from the discussion?
• A substantial number of those who undergo chiropractic manipulation will suffer from muscle soreness. Although this is, generally, comparatively minor discomfort, this is not a good enough reason to exclude such experiences from consideration and analysis.
• Breen dismisses critics of chiropractic as ‘pseudoscientists’. Surely in a more democratic, inclusive approach to musculoskeletal practice, the views of these critics should be given due consideration – rather than dismissed with sweeping claims based on limited evidence – even where they go against the chiropractic orthodoxy? After all, a full and detailed consideration of the evidence regarding chiropractic is important, and researchers such as Ernst have a great deal to contribute here.

We were also surprised that – given the the British Chiropractic Association is currently pursuing a libel case against the science journalist Simon Singh – Breen did not speak up for Singh’s right to speak freely. After all, surely a democratic and inclusive approach to muskuloskeletal practice must keep open the possibility of robust criticism – and robust examinations of the empirical and theoretical bases for chiropractic.

Regrettably, it appears that what Breen is moving towards is not democracy and inclusivity. As Sackett et al argue, evidence-based medicine aims to

integrat[e] individual clinical expertise with the best available external clinical evidence from systematic research.

Evidence-based medicine therefore draws on the experiences of patients, clinicians and patients. In contrast, Breen seems to be moving towards a privileging of the experiences of a small subset of medical professionals – chiropractors and associated practitioners – and he seems to be advocating this privileging at the expense of numerous other stakeholders: from patients to researchers.

Evidence-based medicine is certainly not perfect – and there are important areas in which it should be improved, supplemented or superseded. However, compared to Breen’s approach – an odd kind of chiropractic-centric obligarchy – evidence-based medicine is a much more promising approach.