COMMISSION OF INQUIRY INTO CHIROPRACTIC

FINAL SUBMISSION ON BEHALF OF

THE NEW ZEALAND MEDICAL ASSOCIATION

AND ASSOCIATED BODIES

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COMMISSION OF INQUIRY INTO CHIROPRACTIC

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FINAL SUBMISSIONS ON BEHALF OF THE NEW ZEALAND I-1EDICAL ASSOCIATION AND ASSOCIATED BODIES

The case presented by orthodox medicine

It has been convenient throughout these hearings to refer to

the party which Dr Boyd-Wilson, Mr Webb and I have represented

as the Medical Association. But it is important to bear in

mind that both in fact and in form we speak for orthodox

medicine in New Zealand as a whole. We again set out the bodies

we represent:

The New Zealand Medical Association

The Roy~l Australasian College of Physicians

The Royal Australasian College of Surgeons

The Royal Australasian College of Obstetricians and Gynaecologists

The New Zealand College of General Practitioners

The Royal College of Pathologists of Australia

New Zealand Branch of The Royal Australasian College of Radiologists

Paediatric Society of New Zealand

The New Zealand Branch of the Australian and New Zealand College of Psychiatrists

Medical Superintendants' Association of New Zeala~d

New Zealand Medical Women's Association

The Neurological Association

The New Zealand Branc~ 1?f the New Zealand Society of Occupational Medicine

h N ' J d O h a· A ' ' {l) Te ew Zea_an rt opae ic ssoc1at1on

(1) We take the opportunity to add these two whose names were omitted earlier.

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It is important to emphasise also that the support which the

various bodies listed have given to the presentation of this

case is more than a verbal formality. Those bodies gave their

assent to be joined with the NZMA case, they gave their approval

to the approach. taken by the NZMA as indicated in its principal

paper, and there have appeared before you as witnesses Fellows

of a number of those Royal Colleges.

Next the point needs to be made that this situation is by no

means unique to this Commission of Inquiry or to New Zealand;

quite the reverse. Just as science knows no international

boundqries - scientists share a common language and the bond of

scientific truth - so opposition to chiropractic is and has been

universal, not only on the part of the medical profession but by

the scientific community in gener ~. Opposition on the part of

the medical profession, as apparent before this Commission, is

therefore cohesive, consistent and has the full support not only

of the medical community within New Zealand, but the international

medical community and the scientific community as a whole. -

What then is the basis of this opposition and why is it an

international commodity? Chiropractors disparage it as based

on self interest and on the innate conservatism of a profession.

Is that an adequate or a fair explanation of this continued

strenuous cohesive and international opposition?

'J.'he Commission can take it for granted that an exercise conducted

at the length and in the depth of the Medical Association's part

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in this Inquiry, with the attendant expense not only in

money terms but in the way of personal involvement and

sacrifice on the part of so many people, has occasioned a

good deal of soul searching as to the medical profession's

attitudes. It would be an insensitive profession indeed

that failed to realise that there was much food for thought

in material which had been presented before this Commission,

material affecting the welfare of the patient, and matters

cf professional attitudes and the best conduct of practice.

Yet nothing has occurred to cause the medical profession to

think tha.t the basic spirit of opposition with which we

entered this-Inquiry and the note on which we opened our

case last September, should be modified in any way at this

stage.

What does the medical profession oppose and why?

As in opening, it is necessary to emphasise that the opposition

of the medical profession is not to chiropractors as individuals,

as persons, but to chiropractic as a philosophy. Notwithstanding

the many disagreements which we have had we are still willing to

say that the majority of chiropractors are sincere and dedicated

people who believe in their vocation and follow it in good faith.

Unfortunately, when it comes to advancement of what they regard

as their cause, as distinct from their caring for their patients,

their zeal sometimes outdistances their discretion.

That it is

opposes is

difficulty

chiropractic as a ~oncept which medicine so strongly

a distinction which chiropractors seem to have

in graspi~g, and partly for this reason, I believe

respond .Ath personal attacks upon the opponents of chiropractic

in the mistaken belief that by discrediting some individual

opponent you thereby somehow advance your own case.

This last point deserves a moment's discussion. It was and

remains the wish of the medical profession to debate the issues

before this Commission on a scientific basis and in a spirit

of objectivity. It was with a degree of dismay that we came

to appreciate that the hard realities were different. Seen

through chiropractic eyes the realities were that this was a

contest to be won and that the tactics to be used were those

appropriate to attaining that objective. We found that from the

opening day of the Commission there would be attacks on the

profession as a whole and personal a~tacks on medical wjtnesses,

and that any information which seemed useful in discrediting

medical presentation or medical individuals would be used.

Statements were made about the medical profession in opening and

in the course of the initial NZCA presentation which were

completely without foundation, and of which in some cases nothing

more has been heard, though phrases like "medical retribution 11

may have been useful in obtaining headlines. This is no place

to attempt a catalogue, but the Commission will recall that the

campaign descended to unfounded unsubstantiated hurtful allegations

such as that one of the NZMA witnesses had been convicted of

perjury, or that its principal medical adviser had in some way

manipulated an inaccurate press report. If as time went by -

some of our own presentation became aggressive and unfriendly I

hope that you accept that it was not the note upon which we

wished to conduct this Inquiry or the spirit in which we set out

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to do so. I wish to add that neither in the comments just made,

nor in those to follow, is it our intention to make any reflection

on counsel as distinct from those instructing them.

Chiropractic lobbying

Although it is tempting to spend time on this theme, I do not

think that it will be helpful to the Commission in reaching its

decisions or writing its report. There is one aspect in this

vein however which, in my submission, is very relevant to the

Commission's deliberations and that is the eleven thousand letters

from patients. Long before that episode ever occurred Dr Boyd­

Wilson in the course of preparing his submission had written a

section on the chiropractic mail-box. Those readers who were

making their first acquaintance with chiropr~~tic no doubt

regarded this as a touch of Americanism to be treated with

tolerant amusement. It couldn't happen here. But happen it did.

In retrospect it may be seen as the single most effective, most

decisive blow struck for the chiropractic cause. What other party

to any inquiry or litigation has ever been sufficiently bold,

daring or imaginative to flood the Tribunal with thousands of

testimonials to its cause immediately before the hearing was due

to commence? By a method so simple yet so subtle? So open yet

so deceitful. In a way there is little point in complaining

because no words will undo the effect, namely subconsciously to

implant the thought that .something which has obviously done so

much for so many must deserve consideration.

One may .ask how any Tribunal would feel if for days and weeks

prior to the opening of an important hearing they had been

telephoned by individuals connected with one side of the cause

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.,, which they were to hear and bombarded with laudatory r:-.essages.

Yet what occurred is no different in principle. So sir:-.ple a

concept, yet a brilliant one, and devastating in its execution

and one might add, traditionally chiropractic. The Cor:-.::1ission,

with respect, will never be able to de~ide objectively the

extent to which it was influenced by this episode, for the reason

that its influence was subconscious, subliminal, pervasive and

insidious.

But there is one aspect about which the Corrunission may be crystal

clear. This was no spontaneous outburst of letter writing by

grateful patients. It was a carefully calculated exercise. The

"Notice to Patients 11 <2 > went out in April 1978 and stated that

the Commission would comm:!nce hearings in June. Obviously it was

timed so that the responses would be flowing in at or about the

time that the Commission commenced its public sittings.

These points gain emphasis from the attempts which it was thought

necessary to make to keep from the Commission the manner in which

the exercise had been carried out and its purpose. The Commission

will well recall the ingenuous attempts made to disarm the

Commission when on one of the earliest sitting days the Corri.mission

itself raised the topic of the letters with a degree of

displeasure. In reply reference was made to openness and

directness, yet the Commission will well recall the attempts

later made to keep from t.he Medical Association and the Co:-r.mission

page 2 of the NZCA newsletterf 3 )After many public and private

requests the page was eventualJy made available after Mr Pallister

(2) Exhibit CA26

(3) Exhibit CA54

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had left the witness box. 'I'he Commission will recall· the statement

made to justify its exclusion. It contained privileged material -

statements which allegedly contained advice by Counsel which was

being passed on to members. Of course when at last the document

was seen this turned out to be sheer sophistry. The page

contained details of what was called a telephone tree - stark

evidence of how the spontaneous outburst of letterwriting was

manipulated.

I submit to the Commission that it should do its utmost - not to

put the eleven thousand letters out of its mind, for that is

impossible - but its utmost to realise and make allowance for

the gigantic manipulation to which it was subjected, and to

endeavour to appreciate the extent to which its thinking p,ay

have been preconditioned by this exercise. Indeed, whatever

other impression one may have obtained of the skills of chiro­

practors during the hearings, one has to admit to a new respect

for their skills in the ability to manipulate opinion as well as

backs.

Many unsatisfactory episodes, great and small, occurred during

the hearings. In a sense it exaggerates their importance to

mention them, but some assist in understanding of the reason why

chiropractic has been so rigorously excluded by the medical and

scientific communities everywhere. Behind that friendly

humanistic egalitarian charm which the Commission probably saw

as characteristic of most of the chiropractors with which it came

into contact, there lurked a hard headed creature of a different

kind. What you were shown so often, I am afraid, were the

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Emperor'J clothes, and that particular fairytale was far from

being the only fable which was paraded before the Commission,

but often with much greater subtlety.

"The Listener" article( 4 )was another example of the lobbying

technique. It appeared in the same month as the setting up of

the Commission was announced. Those who were following the matter

on behalf of the NZCA would have been well aware of the timing.

The Commission will have some understanding of the time and effort

required to arrange the publication of a lengthy article,

accompanied by photographs, in a publication of that kind. The

explanation preferred, that the article had been submitted for

publication before the appointment of the Commission had been

announced (which no doubt was true) will in no way divert the

Commission from the criticism t . ..: be made of this kind of tactic.

The NZCA must regard those- present at this Inquiry as very naive

if it expects credence to be given to explanations of the kind

which it offered when its attempts to influence opinion were

challenged. In this and many other respects chiropractic here

moves exactly the same way as it does overseas, and it will be

quite apparent that attempts to influence opinion rather than

prove its case in a scientific way is as much a part of

chiropractic technique as is the white coat, the stethoscope,

the x-ray film and the dynamic thrust.

In these respects as in so many others one cannot but detect

the tremendous underlying pragmatism of chiropractic - the ability

to do, to say, to bend to, what is necessary to achieve the

objective of the moment.

·(4) N.Z. Listener, January 28, 1978

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The reference material ,,

Without wishing to spend too much time on a matter which was fully

explored during the hearing, this episode in our submission sheds

some light on chiropractic attitudes, and lends support to some of

our broad contentions.

The Commission has already announced that where the original

reference material was not produced, it would take no notice of

those references. That stance must of course be entirely proper.

There is in our submission·a deeper significance. If the. Commission

refers again to the cross examination of Mr Blackbourn and to the

lists which were put to him, {S) it becomes a ryarent that at the

time of writing the paper the authors had actually read the orig­

inals of no more than a handful of the 88 footnotes. To forestall

challenge on matters of arithmetic I add that if one excluded

the Chiropra.ctors Act, ·the Concise Oxford Dictionary, the ibids

and the supras, there were left on my count 62 distinct papers

or works. The first batch of material submitted by the NZCA in

July accounted for eight of the 88; of those eight, three came

from a single work, namely the La Croix Report which in fact had

been filed by the Medical Association, while two others were f:?:"om

one source.

Furthermore, and it is a matter or regret that attention has

to be drawn to this, the authors·were prepared to resort to a

degree of deception in order to disguise the facts from the

(5) Exhibits CASS and 56

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Commission. No fm•-1er th.:m 15 of the ori9inal references had

been taken second hand from what I decribed in cross-examination

as a tract, and there seems no reason to modify that description.

Yet there was no hint in the original paper that this was the

source; the references were quoted as if they were from reputable

medical and other journals. When the first list of chiropractic

reference material was submitted, although the Weiant tract was

in the possession of the authors, it was not mentionea! 6 ) It

is with a degree of regret that one makes this submission, but

there seems no escape from the proposition that those responsible

held back disclosurE.~ of the Weiant tract in the hope that the

original material could be found in the meantime, in which case it

would have been presented as if it had been that material which

had been available to the authors at the out~et.

•rhe vice of using second hand references hardly needs emphasis.

A snippet from a long work may be used to support some broad

proposition, such as that in some parts of the world doctors

allegedly have come to appreciate the advantages of chiropractic.

One cannot possibly rely on one sentence from a long article to

support such a proposition unless on consideration the article

as a whole fairly reflects that view. Without that one can

obtain no picture of the context in which the remark may have

been made, the reservations which the author may hold, or the .

exceptions which may appear from other sources of the article.

(6) Transcript pages 2991 ond 3003

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By comparison, the Medical Association, on its own initiative

without any prompting by the Commission, much less the NZCA,

filed with the Commission, weeks before the hearings conmenced,

all its reference material, carefully indexed. Except in the case

of common medical journals freely available in the library system

of this country, the original journals and monographs were filed.

Many of these papers were chiropractic publications and had been

obtained from North America only with the greatest difficulty;

the Commission may imagine that the efforts required to obtain

much of this chiropractic literature constitute a separate saga.

Not only was the Commission provided with the original reference

material but also with xerox copies of the sections of those

papers showing the context in which passages had been quoted in

the principal Medical Association submission. By way of co~trast

the Commission may be reminded that at this time NZCP. mernbe:rs were

busily engaged in obtaining references of a less scientific kind;

they were culling their patient records by way of groundwork for

the eleven thousand letters.

Another aspect of the reference material was that many were from

German publications. Two comments should be made about that.

There is a good deal of evidence before the Cormnission to suggest

that the German brand of chiropractic is built on a different

philosophical base. Further, so far as the FAC is concerned,

it is apparent.that a full medical diagnosis is a pre-requisite

to manipulative treatment, and that members of the FAC are all

medically qualified.

Some reservations must be held about the accuracy of the translation,

of German material. If as was the case with one particular I iJ . .:

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article (Biedermann) (?)the translation originated from Davenport,

Iowa, then one cannot entirely clear one's mind of the thought

that a translator's emotional involvement with a cause could lead

him in good faith to see a point of view in an article which

might elude a more objective reader.

Finally, we must comment on the extraordinary way in which the

principal NZCA paper was conceived and presented. Mr Mudgway,

the NZCA's principal and, as they hoped, only witness, wrote

little of the paper. If he had so much to contribute (and this

was the reason given for his selection) why was he not asked to

play an important role in its writing? The answer, it must be

submitted, is that it was thought that he was the person most

likely to disarm the Commission. The writing was left to '-hose

who were regarded as more experienced in chiropractic politicking.

For 60 days or so they flitted about, shadowy figures at the

rear of this room. It was only through the Commission's inter­

vention that some eventually had to face the witness box, and the

Commission may not have been so impressed with what it saw then.

The Commission will weigh carefully .whether the NZCA submission

set out the simple facts of chiropractic life in New Zealand, or

whether it was a document carefully calculated to tell the

Commission what it was thought the Com.~ission should be allowed

to hear.

This section of the final address has given counsel and those

assisting them a good deal of anxiety. The Commission must

(7) Exhibit CAGO

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realise that the decision to attack the probity of the

authors has not been made lightly. We submit however that

this is another instance where the desire of the chiropractor

to attain a goal has exceeded considerations of scientific

truth and objectivity.

Other reports

One other preliminary matter is that of reports of similar Inquiries

in various other countries and jurisdictions. What I now

submit echoes remarks of the Chairman at the opening session.

While undoubtedly it will have been of value for the Commission

to have made reference to such reports, I submit that at

this fina+ stage the weight which the Commiss::i...,n should give

to their conclusions is strictly limited. I do not say this

because 0£ reliance on any supposed peculiarity of New

Zealand conditions. Indeed, it is our contention that in

those relatively few countries where chiropractic flourishes

the relevant characteristics are much the same as those

which the Commission has to consider. My reason for saying

that the Commission should make its decisions simply on the

basis of its own considerations, is that it is doubtful

whether any previous Inquiry has been conducted with the

thoroughness or has had the benefit of so much research and

information as the present one has had. One has only to

compare the met.hods by which the Australian Committee of

Inquiry was conducted. If the Commission's views on certain

aspects are confirmed by similar conclusions reached before

the Inquiries, no doubt this Commission may feel its views

strengthened accordingly, but I urge you to feel completely

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untrammelled by the findings of previous Inquiries which

must necessarily have been shaped by their own mode of

presentation, by the question whether cross-examination was

permitted or not, and by the efforts or otherwise with which

the opponents of chiropractic responded in the case of the

particular Inquiry.

The basis of medicine's opposition

I return to the question, why does medicine oppose chiropractic?

we·see no need to alter the short proposition we put forward in

opening: it is that the basis of chiropractic is a theory of the

cause of disease which is unproven and unprovable, and in

the minds of many thoughtful medical scientists absurd; not

only that but the theory is shackled to a single modality of

treatment which is also unproven.

What is a chiropractor?

When one turns to consider these matters in greater detail,

one is led immediately to the question what is chiropractic?

What is a chiropractor? And here one encounters a problem of

definition which if one turns to recognised professions is

unique. One does not have to ask what is a doctor, what is a

lawyer, an engineer, a dentist. Each may practise his profession

in any one of a number of different ways, but it is taken for

granted that in whichever setting he practises - whether the

lawyer is in private practice,· works for a corporation, or is a

civil servant~ whether the doctor is a general practitioner, a

specialist or employed in a hospital - one can take it for

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granted that he believes in the same sys.tern of law and the same

concepts of what law is, or in the same basis of scientific

medicine.

Not so with the chiropractor. No profession allows such elastic

individual notions as to the boundaries of his usefulness. No

profession has the.situation that depending on what college you

attended, and when, the teachings as to the purposes and scope

of your own profession may be so different. No profession has a

· spectacle equivalent to that of the liberal and conservative

wings of chiropractic in USA, each proclaiming that it represents

the only true viewpoint and is prepared to go to litigation to

prove it.

Of course as happens when any group is facing a common threat

the best was done to keep these differences from the view of the

Commission. But every now and then, mainly by virtue of

chiropractic's own writings, the curtain was drawn aside

sufficiently for the Commission to obtain some insight to these

matters. The.Commission will not be drawn into the pretence

that these differences do not exist, or if they do exist that

they are irrelevant to New Zealand. It is plain enough that they

are already present in Australia.

By now it is I think clear that there is no single answer to the

question what is a chiropractor. There is no model or mean. 'l'here

is no average. One ca.n see now so clearly why the NZCA endeavoured

for so long to get away with putting forward a single witness

and presenting him as typical. The more chiropractors the·

Commission heard, the more. it became apparent that apart from

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-~· being bound together by an iron determination to progress, and

to make that progress by lobbying, by canvassing, by advocacy,

by presentation, by everything in brief short of actually proving

the soundness of the theory or the efficacy of their treatment;

apart from this common bond, th~y are a series of individuals

on the Jarvis continuum. Perhaps nothing illustrates this better

than the notes on which we started and finished the subject of

the subluxation. Mr Mudgway in a memorable answer to a memorable

question by Professor Penfold said that the whole practice of

chiropractic depended on the validity of the concept of the

subluxation. Many months later Dr Haldeman maintained that it

was the opponents of chiropractic who endeavoured to tie them

to the concept of the subluxation.

In our submission one must see chiropractors as a continuum and

the Commission must approach any one of its recommendations on

the basis and against the background that what it decides must

be appropriate to, and hold good for, any point of the continuum

and not just some part of it which is claimed to be representative.

These differences are important in two respects. First, the

Commission is asked to keep in mind the relatively restricted

view it has been allowed to obtain of what constitutes the New

Zealand chiropractor. The Palmerian influence has dominated.

Secondly, it is important to consider the next 100 New Zealand

chiropractors. Many are still likely to be USA graduates. All,

as we shall submit in more detail later, will be affected by

the USA influence.

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Mr Mudgway learnt his chiropractic some thirty years ago. Since

then, like so many of his brethren, he has practised in isolation.

In his case the extreme isolation of being one of two practitioners

in a somewhat remote area.

Members of the recognised professions of course practise in such

areas too. But they have the advantage of daily exchanges with

their colleagues elsewhere by letter and telephone. They meet

and converse with their fellow practitioners, and see their

peers at ·work in hospitals, offices or courts. There is not

the slightest basis for regarding Mr Mudg·way as the average

New Zealand chiropractor, nor as typical of the young chiropractor

emerging from American coJleges now, nor of those likely to emerge

from an Australian college in the future. Th~ undoubted fact

is that Mr Mudgway was a conservative old school Palmer graduate,

well to the left of Professor Jarvis's continuum and an entirely

different species from the modern semi medical American chiro­

practic graduate from CCE Colleges at the right hand end of the

continm:un.

Indeed, although we heard frequent mention of the CCE, the

Commission may doubt that it has really been put in any position

to judge what type of practitioner is being produced by the CCE

oriented colleges. The two who appeared before you were scarcely

typi~al, Mr Ross with his unique physiotherapist 1 s background,

and Mr Yochum, a roentgenologist rather than a chiropractor.

Significant too, was Mr Mudgway's concession(B) that quite possibly

many New Zealand chiropractors would be prepared to treat some

(8) Transcript page 194

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conditions which he as an older standing practitioner would not

be prepared to undertake.

For the assistance of the.Commission the following is a·

table of the chi_ropractors who gave evidence showing their

origins:

Name 'l'ranscrip'l:_ College

L.C. Mudgway 149 Palmer

P.V. Rose 2129 Bournemouth

J.J. Richardson (non NZCA) 2163 Palmer

B.J. Lewis 2218 Palmer

C.M. Ross 2251 Los Angeles

s. Pallister 2524 CMCC

L.C. Blackbourn 2980 Palmer

P.D. Wells 3119 Palmer

T.R. Yochum 3172 National

A.M. Kleynhans 3198 Palmer

s. Haldeman 3285 Palmer

In examining the question, "what is a chiropra.ctor? 11 , it is

· important to keep in mind whether one is referring to what one

believes a chiropractor really does, or whether one is relying

on what he says he does. I do not wish that remark to be taken

as entirely an unkind one. It would be fair to say that most

persons daily engaged in the hurly burly of the practical aspects

of their profession do not spend too much time rationalising

what they are doing as a matter of theory, and I submit that not

too much can be taken out of the results when they do.

A number of chiropractors were asked rather solemn questions

requiring definition of their belief or philosophy. At the time

it may have seemed a worthwhile exercise, but now that we are at

the end I seriously question what one can take out of it. I

suggest that one is left with the strongest impression that few

ordinary practising chiropractors, certainly not the less

sophisticated, have spent a great deal of time in recent years

thinking about the basis of what they do. It is more important

simply to do it. Indeed one wonders whether but for the prodding

of its opponents, and the insistence on occasions such as this

that a scientific base is necessary, chiropractors would be

content to say as little as possible about the theoretical base

for their therapy. How else does one explain the constantly

shifting stances, the number of possible explanations advanced?

The essential pragmatism of chiropractors is never better illus­

trated than when considering what they say as compared with what

they do. How well and how prophetically Dr Boyd-Wilson captured

this - as he said, in an eternal sunbeam - when referring( 9 )to

the oft-quoted dialogue before the Royal Commission on Social

Security when Sir Thaddeus McCarthy remarked concerning the

evidence of Mr Reader, the chiropractor and NZCA office bearer:

" ••. it seems the doctor was getting into an area which was so

different from the impression you gave from your description

of what your activities were ••. "

From time to time those representing the. Medical Association

before you have been made very aware of your disapproval on

(9) Submission No. 26, page 8

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various aspects of its case, and no doubt this will apply to

a good deal of what is said today; but I ask the Commission to

reflect on the impression it would have received of the New

Zealand chiropractor had the NZCA succeeded in its original

plan of calling a single chiropractic witness, or if he had

been cross examined relatively briefly. In this regard I must

tell you that the Medical Association representatives are

entirely unrepentent about the length of the cross examination,

much of which was directed to matters not even mentioned in the

NZCA submission, and as to which the Commission otherwise would

have been left in ignorance.

The Young Palmer Graduate

Sensing that the Mudgways and the Richardsons possibly represented

an earlier generation, and an apj?roach now somewhat fossilised, we

waited eagerly for. "the young Palmer graduate".

were presented with Mr Lewis.

In due course we

If we expected that the old factory was now turning out a

significantly different new model, we were disappointed. In

general approach, in chiropractic theory, one did not detect

any noticeable change. One is forced to the conclusion that

in matters of general approach and chiropractic theory, Palmer

remains Palmer.

Mr Lewis, a recent graduate, centred everything around the

sublu~ation~lO)Yet another ex~mple that Dr Haldernan's view is

(10) Transcript page 2230

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unfounded on fact. Nothing he was taught at Palmer was irrelevan-:.

to the New Zealand setting.

This current Palmerian had a broad outlook towards visceral

disorders. He had never yet found a new patient sans subluxa-t.:i~J~)

He could not be certain whether the subluxation had a bearing

on the disorder< 12 >so in general he would proceed to adjust

the subluxation but with no certainty that there would be a

favourable result. He would proceed on a wait and see basis~l 3 )

If after a number of treatments he had corrected the subluxation,

and in the meantime the condition had cleared up, he would assume

that the treatment was responsible. "These things tend to

snowball. Someone says you can help bedwetters, the next

thing you have eight of them 11 <14 > 11That is how one builds up

a practice 11 515 ) Given the opportunity he would adjust for

schizophrenia. (lG)

On this kind of evidence it is clear, in our submission, that

however close the right hand end of the Jarvis continuum may

' now be to medicine, Palmer firmly holds its place, well away

to the left. The philosophy remains that the removal of the

vertebral subluxation restores normal function, just as an

older practitioner in J.J. Richardson said it was in his time. (l?)

In these matters Mr Lewis was little different from another modern

young chiropractor in Mr Rose. The latter found that 98% of

(11) Transcript page 2230 (12) Transcript page 2235

(13) Transcript page 2236 (14) Transcript page 2220

(15) Transcript page 2243 (16) Transcript page 2249

(17) Transcript page 2163

.. :>· r.

i •·

- 22 - ·

. . . bl f l . · ( l 8) presenting patients were suita· e :or c11ropract1c treatment.

Generally he was prepared to proceed on a "wait and see" basis.

Willing to treat patients who had a fair range of visceral

disorders, he "neither encouraged nor discouraged people to

think that his treatment played a part 11 fl 9 )

In one respect Mr Lewis certainly differed from the older

generation. There was a complete lack of perception of any limits

to his abilities or knowledge, one might say a complete lack of

humility. Here was a practitioner who on any view was less than

fully qualified medically. In fact as a chiropractor he had

been qualified for three years only. The Conunission will be

aware of the comparative rarity with which chiropractors come

into contact with juvenile rheumatoid arthritis. Encountering

such a case, Mr Lewis did ~ot have the slightest difficulty or

hesitation in differing as to the best course to follow from

a specialist who, as it happened, is not merely well qualified

by New Zealand standards, but is recognised as a world authority

in this field. Surely this must give the Commission pause in

regard to any recommendation which confers greater recognition

upon chiropractic tban it enjoys at the moment.

The Commission may find it useful to be reminded of the

chiropractor Ross who had previously been a physiotherapist.

Like many bthers his starting point was to identify a subluxation,

but if there was no "other condition" present, he would not

treat it. <2o)Thus he leaves an uncorrected subluxation

(18) Transcript page 2153

(20) Transcript page 2274

(19) Transcript page 2137

- 23 - ·

present and shows a lack of faith in chiropractic theory.

Others said that if they found a subluxation they would

treat it; rather the approach of the explorer who wishes to

climb the mountain because it's there. Mr Ross illustrated

graphically the ultimate confusion to which chiropractors

are brought when medical background conflicts with chiropractic

dogma.

Mr Ross, who trained in Los Angeles, followed the concept that

he looked for the subluxation and adjusted it! 21 )

Again, one may contrast this with the standpoint of Dr Haldeman,

that this approach is a figment dreamed up by chiropractic's

opponents.

One other respect in which Mr Ro~s was of special interest was his

attitude towards referrals. Here he followed generally what

medicine would regard as an orthodox and acceptable approach. He

was one of the few chiropractic wit_nesses to do so. It is

interesting to reflect that his attitude in this respect no doubt

had been moulded by his experier.ce in working with medical

practitioners while practising as a physiotherapist.

Scott Haldeman: the demise of the subluxation

Any discussion of the chiropractic spectrum must conclude, as did

the chiropractors' case, with Scott Haldeman. The main question

raised by his evidence I submit is, whence chiropractic? For when

(21) Transcript page 2253

- 24 -

one analyses his place in the spectrwn, there is little doubt that

he is as far right on Professor Jarvis's continuum as it is

possible to get. Indeed, at the risk of being thought a shade

irreverent it is tempting to say that he has fallen off the encl. of

the continuum and into the medical bin.

By the time he gave evidence perhaps our minds may all have bE:cn

a litt.le dulled by the sheer volume of material which had already

been placed before the Commission. On analysis Dr Haldeman

deposed to things which, if stated at an earlier stage, would

have been regarded as startling revelations.

This thoughtful, well qualified exponent of chiropractic, for

many years believed in the chiropractic subluxation, calling it

by that name. He published long articles dissecting the

subluxation and rehearsing the theories in relation to it.

Yet today he criticises some of the stances which not only

have been the very cornerstone of chiropractic for so long,

but which plainly are still in the lifeblood of the New

Zealand chiropractor. One may admire the way in which Dr

Haldeman disposed of these problems. Overclaiming, a significant

and dangerous feature of chiropractic, becomes a mere weapon

in the hands of the opponents. Chiropractic in turn is seen

as no more than spinal manipulative therapy. The "single

theo~y" is blandly described as a contrivance of.the opponents

of chiropractic; it is defined as the nerve compression

theory, and of course the point is made that this is long

out of date. No answer is made to the point that by -v.-hatever

- 25 -

name the rose is called, however much lip service there is

to multifactoriality, the single theory continues to flourish.

So far as we can judge from the few who gave evidence, the

New Zealand chiropractor calls it the subluxation. When

pressed for theoretical justification they cling to it

through thick and thin.

It must have shaken the Commission somewhat to hear Dr Haldeman

say< 22 )that the evidence given repeatedly, and given rather

righteously, that the chiropractor identified and corrected the

subluxation, he did not treat any conditions or disease, was a

defence mechanism. On reflection that may be no more than a

euphemism for saying that it was thought to be the right attitude

to take before a formal Inquiry of this kind.

It is fair to concedo= that by the time Dr Haldeman had been

here for some days, had been reexamined and had concluded

his evidence, the difference between his point of view and

that of the New Zealand chiropractic witnesses was no longer

so easy to discern, and_I make no further comment on that,

but Dr Haldeman's unease at and lack of empathy with the

stance taken by the New Zealand witnesses is plain enough to

see when one reads his evidence at pages 3350 and 3351 of

the transcript.

Where in the end does Dr Haldeman stand? Clearly he secs the

desirability of getting away from the old terminology. So he

(22) Transcript page 3351

I

I

I I I ,. ~

26 -

refers to the manipulatable lesion. But is this anything

more than semantics? Does the change of terminology lead us

any closer to discovering what the lesion is? Or is it

simply a recognition by a thoughtful and upright man that

past theories are discredited, that no scientifically proven

theory exists - whatever the standard of proof - and that as

a defensive move it is prudent to discard the terminology

associated with outmoded unproven and discredited theories?

The Commission may think that as an exercise in chiropractic

politics that is sound, from the point of view of honesty it is

unobjectionable, but that from the point of view of progress in

a scientific sense it should be seen for what it is - a nullity.

Indeed when asked about a phrase he had used in his paper

"Specific short lever dynar,1ic thrust manipulation" and he

was asked "specific to what?" his answer is worth repeating:

"Doing whatever it does at that point - whatever that particular

clinician feels - whatever theory he has. 11 <23 >

The extent to which Dr Haldeman has moved along the continuum

towards medicine is best illustrated by his assimilation of

chiropractic with spinal manipulative therapy. As he saw it the

differences between chiropractic spinal manipulative ther&py

and SMT carried out by a doctor or a physiotherapist lay solely

in the degree of skill involved. Evidently differences in philos-

(23) Transcript page 3311

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- I. I -

oplly, in his view, had disappeared or did not matter. Chiropractic,

he said, was merely the trappings of the profession practised by

chiropractors. A person with full medical training could within

a year acquire all the skills and expertise of a chiropractor. He

did not share the viev! of the importance of the 11why 11 of

chiropractic taken by others - to the extent of differing from the

views of that oft-quoted chiropractic academic Dr Harper. <24 >

Dr Haldeman summarised his views in this area in a succinct way

d · · ( 25 ) · · ' h · . d h l un er cross examination. He is certain in is nun t at w 1en.

following chiropractic manipulation the condition, whatever it is,

clears up, there have been cause and effect, but he is less certai~

what the cause and effects are, and the further one gets away

from the immediate effects the less he knows as to what is going

on. Further, there will be differences as to the reasons to which

individual chiropractors ascribe '1:he success of their treatment.

There are some other matters I .need to deal with to conclude the

topic of the chiropactic continuum, but it would be convenient. at

this stage briefly to state the import.ant points \'ihich I sub,:ii t tl:e

Commission should take out of this discussion.

First, the obvious cormnon bond of chiropractors lies in theix- singl:

modality of treatment, the manipulation. Secondly, the reasoning

behind their treatment, the ''why" varies over a wide spectrum.

On the left is belief in the Innate with strong theosophical over­

tones; more towards the centre but still on the left of it lies the

(24) Transcript page 3314 (25) Transcript page 3340

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- 28 -

Palmer graduate. Thereafter as we go to the right we move furthe~

towards medicine until the two merge uneasily in the person of

Dr Halcleman.

When one looks at the table of the chiropractic witnesses who have

appeared before the Com.111.ission it is easy enough to see why by now

one may believe that one has some impression of a "typical"

chiropractor. It is simply because so many have come from the sa.mc

Palmer stable. The impression I suggest is misleading. When

one recalls the breadth and scope of the chiropractic pamphlets,

of the chiropractic literature, of the chiropractic magazines and

writings which have passed before this Commission, ·there is no

such thing as a typical chiropractor.

The importanc~ which we place upon this aspect is that the

individual chiropractor's views as to the "why" must strongly

influence his opin~on of the proper scope and functions of his

practice - as to whether he should treat the patient with

particular symptoms, whether medical investigation is desirable

first, how long he can continue on a "wait and see" basis before

_admitting that chiropractic will not help in the particular case.

It is impossible to predicate what chiropractors will or will not

do without considering the whole spectrum. It is impossible to

restrict them, to construct rules that will adequately protect the

patients and deal with the risks, because the background, the

philosophy, the rationale, the views &s to the scope of practice

of X may be so utterly different from those of Y who comes from

the other end of the continuum.

- t:.':J -

Reverting to Dr Haldeman, his view point can be summed up in two

short propositions.

In relation to type O disorders, the efficacy of SMT has been

neither proved nor disproved. Much research is still needed.

Generally, manipulation is unlikely to do any harm, and if it

may do some good, why not try it, even if the resul t.s are no

better than can be accounted for by the placebo effect. But

administration of the placebo effect as a sole modality of

therapy is no basis for what we contend is an alternative health

care system.

The second proposition relates to type M. Here, Dr Haldeman

believes that cause and effect have been established. He

considers that the precise mechanism remains uncertain:

many theories have been advanced, and chiropractic is in a

state of confusion. Again, this is a dubious foundation for

a system of health care, and none at all for a State subsidy.

Chiropragmatism

Dr Haldeman's evidence underlines the incredible pragmatism of

chiropractic, to which I have referred before. Science and truth

are secondary to the attainment of objectives. And indeed one

should not express too much surprise, because without pragmatism

chiropractic could not exist. The medical doctor may truthfully

say that he can't diagnose the exact nature of the complaint,

but clearly it is not serious! and it will go away in a few days

if the patient rests and takes aspirin. Whereas the chiroprc:1.ctor

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will say wit:i. absolute conviction that the root of the trouble 1.s

a subluxation at C4/5, will adjust it, and will look his usual

cheerful, charming and confident self when after a few days the

trouble duly remits, for which he will modestly accept the

patient's grateful thanks, and his commendation of chiropractor

and chiropractic to family and friends.

The truth of the matter is that even in the case of type M

disorders, the chiropractor does not know what he is doing,

he merely knows (or believes) that what he does is beneficial.

No doubt it will be suggested again, as it has been before,

that in the case of some medical treatments, the doctor does

not know cause and effect either, or that the causation of

some common ailments remains unknown. The essential difference

is that in the case of chiropractic, the whole basis, the

whole foundation of their existence, remains unproven. Dr

Haldeman's evidence in effect amounted to saying that it did

not matter, so long as in the practit~oner's mind, it worked,

and this only echoes an attitude wh~ch has been apparent

many times during the hearings. When I suggested to Dr

Haldeman that it would help if the chiropractor knew what he

was doing, he gave his charming boyish laugh.

Finally, I return through Dr Haldeman's evidence to the

heading of this section of this address, what is chiropractic?

"The trappings of a profession". In other words, there is

no such thing as an overall or coh8rent theory of chiropractic.

One well remembers passages of cross examination 1 some of

them arid and unproductive, and sometimes, with respect,

- 31 -

unsympathetically received. Such as when it was suggested

to chiropracto.rs that the concept of subluxation was notional,

that it was in the mind of the chiropractor transferred to

the mind of the patient. Such as the earnest replies given

to questions by the Commission of individual chiropra~tors,

as to their concept of chiropractic. One well remembers

high sounding answers - "that theory and practice which

mobilises the inherent recuperative powers of the body ••• "

And one thinks too of the heavy theosophical overtones in

some of the definitions from overseas. After Haldeman, what

is left of this? Dare one call it window dressing for the

benefit of those who the speakers think will be impressed?

The truth, by Dr Haldeman, is that there is no chiropractic

theory. There is nothing specially chiropractic. Chiropractic

is but a skill~d form of spinal manipulative therapy. So

much for "separate and distinct."

I come next to a series of topics which, although relevant to

the points which I have just summarised to you, can conveniently

be grouped together and dealt with under their own subheading.

Chiropractic as a calling

I deliberately say calling and not profession, because the

theme of this next part of my address is that chiropractic

falls short i:1 a munber of significant respects of the

conduct and the standards which the public is entitled to

find in a profession. That in the submission of the Medical

Association is a further reason against State subsidy.

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(,

- 32 -

Salesmanship

One must commence with the indisputable fact that chiropractic finds

it necessary to sell itself to an extent and in ways simply not

found in the professions. The instincts of professions have

generally been against advertising. Any recent relaxation in

that outlook has resulted from consumer pressures rather than from

any changes within the professions themselves.

I have already referred to the singularly chiropractic techniques

of lobbying by political means, the use of the mailbox and other

devices. It is not that these are unknown in other walks of

life. But I say with confidence that they are not of the daily

armoury of the professions.

Then there is the emphasis of practice building. I hope that the

Commission has found time to read the Parker Manual. I refer to

Parker of Fort Worth. Some chiropractic witnesses indicated

distaste for this type of approach, a sentiment which may be

echoed by the Commission. I hope that this will not disarm the

Commission into ignoring it. It has been said that 10,000 people

have attended his seminars. Although this includes aides,

receptionists, and so on, when compared with the total number of

chiropractors in the United States of some 15,000( 26 )it is a

formidable number. I do not overlook that much of the material

in Dr Parker's book is unexceptionable. But there is clearly

another element which to say the least is unprofessional; that is

the systematic endeavour to convert patients to belief in

chiropractic philosophy. No doubt it suits the NZCA t~ brush

(26) Submission No. 26, page 62

- 33 -

Dr Parker aside, but the part which he has played over the years

in moulding chiropractic attitudes should not be underestimated.

I will say a little more on this topic under the heading of the

American influence.

The Commission must ask itself, in my submission, why chiropractic

should find it necessary to sell itself with this constant and

almost blind determination. Again, it is an attitude, of course,

without parallel in the professions. As with so many other facets,

one cannot help but feel that it is the hallmark of a cult,

a sign of basic insecurity, of a lack of quiet faith in the

soundness of one's beliefs.

Sc;,t•.'.'\ chiropractic witnesses, as I have reminded you, tended to

pass Parker off as an aberration. This attitude I regret is

in itself symptomatic of another characteristic of chiropractors -

what I may call the "it's not us" syndrome. The attempted

impre.:.,sion that Dr Parker was not really approved. That

those who made claims for cures for all sorts of ailments

were the fringe practitioners. That wild claims were made

in some countries but not in our country. That the infamous

nerve chart does not have official sanction. That such

pamphlets would never be used in New Zealand. That they

were used once but had been stamped out.

Whereas we find that Dr Parker's seminars have been attended by

thousands, including New Zealand chiropractors, and that he

has held seminars both in New Zealand and Australia. That the

vast majority of practitioners of whom one heard made cl4ims in

relation to visceral disorders. 'l'hat a chiropractor of most

conservative appearance and habits had administered the same

manipulation t.o the same patient twice weekly for three years, and

t . th .t d . th b f · f · ( 2 7 ) no wi s -an ing - e c1 sencc o · any sign o improvement. rrhat

the same techniques of cultivating a pseudo medical image - the

white coat,.the stethoscope, the examination of the child's ch.est -

were being used in Australia as had been used in USA, even down to·

the same photographs. That the nerve chart kept popping up.

That pamphlets of an objectionable kind were currently being used

by an NZCA member of apparent good standing. That a member of the

NZCA executive was using a card with the slogan nchiropractic

prolongs life" but did not regard this as advertising or practice

building. <2B)That the petition, signed by so many persons, was not

a spontaneous outburst, but that the signatures has been

obtained from 80 chiropractors' offices. That the nerve

chart is still currently i.1 use at Palmer College. That the

reaction of the NZCA to the proposed Consumer article, rather than

endeavour to answer the six pertinent questions to the best of its

ability, was to endeavour to stifle £he publication.

We do not put these points forward just to denigrate chiropractic

or chiropractors. We have no doubt that there are many whose

personal ethics are just as high as those in any other

calling, nor would anyone attempt to dispute that all callings

have their share of black sheep. Several points, however,

arise from the foregoing which we have to place very plainly

and firmly before the Co~nission.

(27) Transcript page 2106

(28) Transcript pages 2130 and 2196

The first is that the eagerness of chiropractors to obtain

objectives and t.o advance the standing of their calling sometimes

outruns the pursuit of truth, science and ethics. We repeat very

strongly that the Conunission should make its assessment of the

likely future course and conduct of chiropractic in New Zealand

on the basis of evidence of acts and facts rather than on

statements of intention and opinion, however honestly or

hopefully these may be thought to be made. The Commission

must consider and contrast the fact of chiropractic as

practised by the Wades, the Brauns, the Cheynes, the Lewises,

the Kellys, as distinct from the more idealistic forms

spoken of by the Haldemans and the Moddes.

Each of the members of the Commission is very familiar with the

concepts and tenets of a profession. Each of you is steeped in

your own profe."ion, indeed in the Chairman's case in two. And

your professional and personal lives necessarily have brought you

into contact with and have led you to some degree of familiarity

with the concepts of other professionals as well. Many of us who

have attended thes3 hearings are in that position. In all honesty,

can any of us say that there is another calling, another profession

quite like this? I refer to the practice building, the deliberate

cultivation of patient dependency !29 ) the will\ingness to espouse

concepts such as "the greatest untapped practice building gold

mine yet", ( 30}the advertising, the pamphlets, the "yet" disease,

all the hocus pocus about x-rays, the unwillingness to make

examination papers or journals available, the inability to

(29) Transcript page 2598 "(30) Transcript page 2196

'~·

- 36 -

distinguish a profession from a business, the devising of a code

of ethics just in time for the commencement of the hearings,

the background of mysticism and cultism.

I have conceded that all professions have their fringe, but

here we are not talking about that. I am afraid we are

talking about things that are part and parcel of the lifeblood

of the chiropractor.

A shortcoming perhaps more significant than any of those

mentioned is the absence of chiropractic scientific

literature. The reasons are plain. Clearly there are

limits to the extent that anyone can write about a concept

as nebulous as the vertebral subluxation. It has been

suggested that it is incapable of proof or disproof. In

our subDission the chiropractic subluxation lies in the

mind of the chiropractor 1 its diagnosis wholly subjective.

In his heart of hearts the thoughtful chiropractor may

uneasily feel that this is so, and the Commission will

not readily forget the bridling, as the Chairman aptly

called it, which occurred when a trial of a basic nature

was proposed to test whether chiropractors would diagnose

the same subluxations in the same patients.

Putting subluxation aside, the only other broad topics that

are likely to attract the chiropractic author are the

description of ~anipulative techniques, and controlled

studies. The extent to which one can go on writing about

the former must be circumscribed, while in the case of the

I i )

I j

I I

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latter, controlled studies dealing with the efficacy of

manipulative therapy in O type and M type disorders have

generally been avoided by chiropractic to date.

Chiropractic exists in something of a scientific vacuum.

There is nothing original or novel in the studies dealing

with nerve compression carried out by Dr Haldeman in his

formative period, and their end result appears to have

been to disillusion Dr Haldeman as to his original beliefs

in chiropractic hypotheses.

There is the aspect too, and one which from the point of

view of public interest, of public health, must give the

Commission concern, that one cannot help but notice the

constant endeavours of chiropractic· to expand its

buundaries. Not, it will be noted, on the basis of

scientific advances, of new discoveries, of a broad~1ing

of knowledge, but rather of expanding the scope of the

calling as in commerce a business might be expanded.

These are considerations too that must weigh with the

Commission when it has regard to the question of the

granting of benefits and the expansion of demand which it

seems-inevitably goes with that.

The last is a theme to which I will return, but at the

moment I wish to say a few concluding words on the subject

of self discipline. One of the strengths or weaknesses

of a calling lies in its ability to regulate its members.

One cannot but have the gravest doubts as to the ability of

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·"'' chiropractic to do so a<lequateJ.y. There are practices in the

field of advertising and pamphleteering which the governing

body deprecates, yet only once have disciplinary proceedings

even been considered, and on that occasion they failed at

the threshhold owing to some legal difficulty. One would

have to have reservations whether there was any real desire

to exercise discipline, or, with respect to the persons concerned,

whether the non-·chiropractor members of the Board had ever really

been brought to grips with problems of the kind which I have been

discussing.

A facet of the problem is what the Commission may see as a

disturbing inconsistency or unpredictability. For example

Mr Mudgway, a conserva.tive if ever there was one, did not think

that the meric chart had the effect of inviting patients to

respond for treatment for an improperly wide range of disorders. ( 3 l)

He thought that it was a matter to be left to the good sense of

the chiropractor. Mr Mudgway of course is one of the chiropractic

members of the Board; if he does not regard the use of the meric

chart as unprofessional, what chance is there that more recent

graduates will do so? Again, Sherman College, one of the new

"straight" schools, has been approved by the same Board, on what

evidence or information, one can only wonder. In this respect,

Mr Mudgway provided another illustration of the inconsistency

to which I have been referring. He was very much in sympathy

with the new definition of straight chiropractic< 32 >yet at the

same time appeared to feel that the new Coll0.ges represented

a minority cult.

(31) Transcript page 590 (32) Transcript pages 622-623

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One may find evidence of this curious lack of consistency

even in Scott Haldeman. He did not regard the Woodbridge

appendix 1.0, submitt.E:d to the Parliamentary hearing, as over

1 · · ( 33 ) h .. 1 N CA "t th th h d c aiming. Te principa Z, w1 ness on e o- er an

readily disowned it~ 34 )

'l'he situation is compounded by a peculiar reluctance on

the part of patients to complain. This is a factor

·which makes it difficult to get to the bottom of the

question of the risk of chiropractic. One of the effects

of the chiropractic technique is to create strong bonds

between patient and practitioner. How this process begins

is graphically described in Cowie & Roebuck's book, "The

Ethnography of a Chiropractic Clinic." They call it "dipping"

the patient, a graphic description. The Commission may think

that this pro-:: ss and the bonds which it creates are an

important and genuine part of the healing process, and for

our part we do not by any means underestimate its benefits.

On the other hand the existence of these bonds tends to

obscure other aspects. The patient may develop a blind

faith which may react to his disadvantage when he overlooks

the need for proper medical care for himself and his family.

The situation is well described by the phrase "the silent

conspiracy".

(33} Transcript page 3317 (34) Transcript page 507

- 40 -

'l1he bond .:_,3 also an important f uctor 111 preventing

complaints. 'l1hese days, in the case of some professions,

patients have little hesitation in lodging complaints

to the professional bodies concerned. In the case of a

practitioner in whom they have developed an almost

irrational faith, it is much less likely that they would

be moved to complain if something has gone wrong, or worse,

even to recognise that something has gone wrong and where

the fault lies.

Chiropractic pamphlets

It was perhaps unfortunate that these had to be produced

at a stage of the Inquiry when their significance may

not have been as apparent as it became in the light of

later evidence.

There can be no doubting the importance of pamphlet.eer~ng·

in chiropractic's endeavours to widen its boundaries,

to magnify its importance, and to build member's practices.

The extent to which pamphlets are used in USA, and the

absurd, exaggerated and dangerous lengths to which the

claims extend, can hardly be disputed in light of the

material put before you. One could regard many of them

with amusement, were it not for the fact that there is

no subject upon which people are so credulous, arc so

susceptible to influence, as matters affecting their health . .

Probably the only rival that merits consideration arc appeals

for funds for investment, and our laws show a stringent regulatory

concern in that field.

It is clear that one major source of such advertising material

in USA is Palmer College itself, the alma mater of three out

of four New Zealand chiropractors, the College of choice of seven

of the eleven chiropractic witnesses who appeared before you.

It is not surprising that when overseas trained, and particularly

Palmer trained chiropractors, return to New Zealand to practise,

they should have the same views about the virtues of such

advertising as are held in the United States. Notwithstanding

the NZCA statements of efforts to keep such advertising within

limits, evidence of use of New Zealand pamphlets in simil,n:· st.yle

came before the Commission, as well as examples of excessive

advertising, and of group patient "dipping" sessions. :Most

patients who were asked said that pamphlets were available. Is

it to be taken for granted that they were confined to NZCA­

approved material? The Commission must seriously question, as

we urge in another part of our submissions,.whether the steps

taken against advertising reflect a genuine desire to stamp it

out, or whether they are mere window dressing. Even if the former,

compared with the disciplinary procedures of the established

professions, the chiropractors' attempts at discipline can only

be described as pitifully inadequate, and any measures taken at

Association level of course do not reach the 25% who are not members

of the NZCA.

- 42 ·-

The USA influence

However, v1hetber any ef fect.i ve edict prohibiting the use

of such material in New Zealand is issued or not - and

I recall the Chairraan's remark that. members of the Commiss.ion

could not help but see a certain amount of material of this

kind i~ waiting rooms - the important point in our submission

is that the pc1mphlets make it only too clear how an influential

section of the chiropractic scene in USA thinks. It is an

import&nt enough segment in USA itself, but it is of crucial

importance to New Zealand where the majority of chiropractors

have had their education at Palmer.

If a chiropractor thinks this way, if his relationship with

his patients is that explicitly or by implication he makes

claims of the kinds contained in the pamphlets to them, for

them to pass on to their family and friends, it is of

relatively minor significance that he is prohibited fr.om

circulating such claims in a material form. The real vice

is the unsound philosophy, the unfounded belief that the

chiropractor is fit to function as a complete primary health

care physician, that it is in order for him to encourage

patients to come to him in the first instance "no matter what

your complaint may be" as one of Mr Wade's current circulars

urged. That is what is proved by these pamphlets, that is

why we attach such importance to them.

' ,: ..

i-' f,

. I ' \

- •.t.;> - .

We can understand that when they were first produced the

American scene may have seemed rather remote. After all,

the witness in the box hailed from Whangarei. For reasons

already discussed I submit that the American scene has

long been of vital importance to an understanding of

chiropractic in New Zealand. But whether one accepts that

view or not, the American scene came dramatically close to

home with the advent of the Preston College and the

appearance of Mr Kleynhans. The Preston brochures< 35 >

brought the USA influence to New Zealand in a tangible form.

The identical syllabus, the very same pictures depicting

the doctor-like chiropractor,.white coat and stethoscope,

tending to little children. It became apparent too that

more than the mere idea of pamphleteering had been borrowed

from North America, in some cases the very documents were

unashamedly used word for word.

Any recommendation which this Commission makes and whic_h

is carried into effect, will affect the present practitioners

as well..as those yet to qualify. The present situation

where.the majority of New Zealand chiropractors are Palmer

graduates will continue for many years. In this period

the importance of the American influence is clear. But even

in the more remote future, America being the home of chiropractic,

American chiropractic thinking will continue to ex<:~rt a

dominant influence in New Zealand. Teaching at Preston is

based on North l.\mcrican models. ( 3G) It will continue to be

American-oriented for the foreseeable future. Mr Kleynhans

(35) Exhibits CA 68 and 69

(36) Transcript page 3249

- 44 -

was given every opportunity to state whether there were any

areas of American teaching, in regard to chiropractic I philosophy or otherwise, which he thought would be inappropriate I to the Preston course. He referred only to physiological 1 therapeutics. Whatever the facets of American chiropractic

teaching may be that make chiropractic in USA what it is today,

we are assured of having those influences reproduced at

Preston.

The "it's not us 11 syndrome is rampant in this area. That,

and "it can't happen here" are the only defences to what

the NZCA recognises as an aspect damaging to its causes.

It has been said on its behalf that professional attitudes

in USA generally are different from our own, but this ignores

the fact that our doctors and lawyers do not habitually receive

their undergraduate training in USA. In this respect, so far

as chiropractic is·concerned, the USA scene has a unique influence.

The traits under discussion are inherent in chiropractic and as

old as chiropractic itself. One might say they constitute one

of the few respects in which chiropractic can be said to be

separate and distinct. The NZCA can only hope and pray that

the Commission should fail to grasp and recognise the importance

of the subject.

An interim summary

We draw this portion of our submissions.to a close in the

following terms.

The aspec..:s discussed so far concern solely the outlook of

chiropractors, their philosophy of practice, and their

qualification to be regarded as a profession. On these counts

alone, and without going into the much larger problems of

whether chiropractic works, and, if it does, how, it is firmly

submitted that the grounds so far discussed alone justify the

conclusion that no steps should be taken which would extend

the present boundaries of chiropractic in New Zealand. We

submit that the alternative propositions put forward by

Dr Boyd-Hilson< 37 )should be seen as a high truth, namely that

the chiropractor must choose between -

1. being a m~nipulative therapist and adopting the

ethic of referral, or

2. adopting the professiL al tenets, the scientific base,

of orthodox medicine, and training as a comprehensive

primary health care practitioner.

No intermediate position is possible.

Since this proposition was first put forward, nothing has

occurred before the Commission to alter its validity, and

Dr Haldeman's stance supports it.

The frame of mind that regardless of philosophy, irrespective

of outlook, chiropractic seems to work and therefore should be

harnessed, is fraught with danger. The weaknesses and dangers

are such, in our submission, that it is impossible to harness

(37) Transcript page 1773

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the strengths until the weaknesses have been eradicated.

I turn now to the central issue of the efficacy of chiropract.ic.

Th~ Efficacy of Chiropractic

To recapitulate, the stance of the medical profession is

that it opposes the support of chiropractic through public

funding for two distinct reasons. First, chiropractic is a

theory of disease which it is submitted is unproven and unpj:ovable

Second, that theory is grafted on to a particular form of

manipulative therapy, the efficacy of which is also unproven.

We acknowledge at the outset that the avail.ability of a proven

explanation for the manner in which a therapy work~ is not a

precondition for the clinical application of that therapy and

by the same token is not a precondition for public funding. If

a therapy has been demonstrated by the scientific method to be

effective and safe, then it is entirely proper that that the~apy

should be employed by suitably qualified persons while resenrch

proceeds to establish "the reason why"_.

Professor J.B. McKinlay defined( 3B)effectiveness in this

context as the ability to beneficially alter the natural

course of a clearly defined condition or set of conditions. Jie

then set the following qualifications:

(a) It is particularly impor.ti:mt to demonstrate a benefit over

and above any possible placebo effect;

{38) Addendum to Submission No. 41, page 3

- '¾I -

(b) The ~emonstration of benefit must be as free as possible

(c)

(d)

from important sources of bias;

In general the demonstration must involve some comparison.

The proposed intervention must be demonstrably better than

existing procedures or services (if any) designed for the

sarr.e purpose, and this improvement must. be real, not a

placebo effect;

In determining any benefit, due account must be taken of

any accompa.nying negative side effects or added risks;

(e) The benefit should be applicable to as wide a section of

the population subject to the condition as possible. This

requires that the demonstration be carried out on as

representative a group as is feasible.

In our submission, this is an unimpeachable approach t_o any

proposal for the introduction of a new health benefit. There is

no realistic alternative.

As Professcr Jarvis has said~ 39 )"the-only safe and rational course

to follow is one where a defensible criterion is established based

upon proof of safety and effectiveness via the scientific method,

and let the burden of proof shift to the applicant who wishes to

be included."

I turn now to examine the claims made by chiropractic that the

effectiveness of the service offered by chiropractors hils been

(39) Submission No. 58, page 14

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- 48 -·

demonstrated. It is . ( 40) said - that the growth of the chiropractic

profession in New Zealand is itself evidence of the efficacy

of the treatment it offers. There is no doubt that m_any

people attend chiropractors for treatment and during the

course of tr.eat.mcnt obtain relief of their symptoms. The

Commission has heard testimony from chiropractic patients to

this effect and has received written statements from a very

much larger number.

Professor McKinlay has categorised this anecdotal evidence

as worthless as any kind of evidence of the effectiveness of

h . . ( 4 l) . . 1 . d h c 1.ropr,;1ct1.c. It is simp. y evi ence t at a number of people

are satisfied with what has happened to them. His objections

to this form of evidence are that it is biased and self­

selected. To that could be added the criticism that to rely

upon evidence of this nature is to reascm post hoc propter

hoc: 'I was treated my condition improved during the

course of treatment - the treatment was the cause of my

improvement.' This patient testimony tells us many things

about chiropractic in New Zealand, but nothing about its

effectiveness as a therapy.

An immediate difficulty with which we are faced is, of course, to

know precisely what the therapy is, and the mechanism by which it

is said to have its effect. We are told that the therapy is

"the manual correction of subluxations for the removal of intor-

ference to nerve transmission and expression as a cause of dis-­

ability and disease. This corrective procedure, known as

(40) NZCA Submission Part 1 page 75, para. 30.l

(41) Transcript page 450

i

chiropractic adjustment, is a well calcul~tcd planned specific

thrust applied to the subluxated vertebrae of the spinal colr:rnn

or pelvis. 11<42 >

The chiropractic subluxation is the foundation on which the

entire practice of chiropractic is erected. It is a concept

which is unique and which ensures to chiropractic its distinctive-·

ness from orthodox medicine. Mr Mudgway t.he principal

witness for the NZCA, was in no doubt that the whole practice

of chiropractic depends on the validity of the subluxation

( 43) thec~y.

h·e have heard a host of descd.ptions of the chi:roprac'..:ic

subluxaticn fron chiropractic witnesses. Yet no-one at any

stage in this Inquiry has been able to demonstrate that the

subl~xation exists. ~e have been told that its essential

characteristic is abnormal function. It will generally be

. ~ b . l' f b l · ( 44 ) acco:-,·.paniea y misa ignment o a verte ra, :1ut not necessa:ctly. -

It is a deviation from the norm which may be so rnillimstric -

Hr Yochum's word( 45 2. that the very act of palpating to

locate it may of its~lf correct it. ( 4 G)

I -'- .,_ b f. 1 ( 4 7 ) t . . d. h ~ canno~ e seen on x-ray 1 m, no w1.thstan.1ng t .e stance

of the p'3.rticipants in the Hou;e,ton Conference, a stance wh:i_ ch

enabled the1n to produce the "Rndiological Manifestations of

Spinal Slibl~xation. 11 (4 B)I invite the Comnission to reflect

(42) ~-JZCA Submission Part I I page 27, para. 11.1 (c)

( 4 3) Transcript page 1346 (44) Transcript page 339

( 4 5) Tra;:is:..'ri pt page 3191 (46) •rru.111.:;cript pag .. ~ 3064

(.17i . . Transcript page 1316 ( 4 8) Subrnir;sion No. 26, pages 47-50

on the PL'agma tisrn disr)layed by that Conference--. Acr•ept a c·.., 1· 11 '-' ( :JU.

when it is offered, even if it requires the use of~ procedure

which conflicts with your beliefs. What other calling woul<l

act in i:.his v.12..y? 'rhe scruples of accepting benefits on such a

basis evidently do not trouble the: adherent~=~ of chiropractic

at all.

Notwi thst;c-~nd.ing its subtle quality, the chircpractic subluxa t:ion

appears to be a condition possessed by almost every new

chiropractic pa.t.ient. Mr Mudgv.1ay described hir.:; inability to

find a subluxation in the case of a patient with back pain

a.s a relatively rare event! 49 )Mr Ross had a • ' 1 ~,]•_,c,_r,,1. ( 5 0) SJ.Hll a.r , ~

Mr Lewis went fuythcr. He had never in three years of

( ::; , ) practice seen a new patient who did not have a subluxati.on. ~~

The cletc.ction of the subl'- .. :ab.on is a skill possessed only

by the chiropr2.ctor. He wj 11 palpate the spinal colm,m in

order to detect areas of tenderness, abnormal function, or

spinal deviation. But palpation alone will not deter~ine

the presence of a subluxation: C52 >The chiropractor will

also evaluate the posture of the patient and take a case

history. He will take an x-ray, not for the purpose of

diagnosing the subluxation(~ 3~ut in order to exclude pathologies

. . . . 1 . ( 54) . }. . t. and contra-1ndicat1.ons to man1pu ation. It 1s a com~ina-1.on

of t~ese factors which enables the chiropractor to say that

a s·c.bl.'J.xa tion is present.

( 4 9) 'I:ranscr:Lpt page 7.40 ( 5 0) Transcript page 225(.!

( 51) T:rz-.. nsc:r i pt r;c~g(.:! 2235 (52) Transcript page 555

( 5 3) Tran sc:J::-.i.pt pc:1ge 338 (54) 'J'ranscr.i.pt paqe 3181

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."'.. I -I have deliberately left aside from this summary of the

chiropra6tic diagnostic procedure, the use of the device known

as the neurocalometer or neurocalograph, or any of its variants.

It is apparently something which is used by many but not all

New Zealand chiropractors. 'J~he Commission has had an opportunity

to inspect a North American model which was produced by one of

the Medical Association witnesses.

The neurocalograph is a heat measuring instrument. Its part in

the detection of the subluxation can only be guessed at. The

United States Dcpartlnent of Health, Education and ·welfare appears

to have formed the view that the instrument is of no value. (SS)

The chiropractor's diagnosis will be revealed to the patient

at an early consultation. It would appear that the word

"subluxation' Ls rarely used - as witness to fact that almost

all of the patients who appeared before the Commission had not:

heard of it. How then does the chiropractor depict what he

has found? Patients have spoken of "bones that did not seem

to line up" f5 G) "vertebrae ••. which were quite clearly to one side" f57

"an S-bend in the spine"; (SS)"neck bones all jammed down into one

another; 11 <59 >of "rotated vertebrae". (GO)

We could multiply these examples, but one thing is clear: the

chiropractor has successfully conveyed the notion that there is

some tangible condition, some defect of the spinal column, somethinq

undetected by the medical profession, which the chiropractor with

his special skills has revealed.

(55) Exhibit M.04 (56) Transcript page 797

(57) 'l'ranscript pacre ., 866 (58) Transcript. page 1033

(59) 'l'ranscJ~ipt page 111 (GO) 'l'r ans er .ini-. n;.1cr0 c; ~ 7

1

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_,..

It is the use by the chiropractor of x-ray films which is the major

element in the establishment of the patient's belief. New Zealand

chiropractors x-ray the vast majority of their new patients. In

due course, the patient is shown the x-ray film. Almost without

exception patients have testified that the chiropractor then

pointed out to them on the film the apparent cause of their problem.

Mariy times the patient could see himself "with a little

encouragement II that something 1,o.,1as wrong. It may be that the

spine was not perfectly regular. Perhaps there were signs of

some degeneration. To assist the patient to recognise the

unfortunate condi ti.oi1 of his spine, lines rn.iqht be drawn on

the film at right m:gles to show the degree of bone dispJ.c:1c2inent

fro~ dead centre. (Gl) To heighten the effect, the patient

rnig~-:t be shoh'n an x-ray film or an illustration of a "perfect

The powerful effect of these revelations was all too plain to see,

yet the principa.l ·witness for the NZCA claimed that: tr,e x-ray

film is put in ~he viewing box for the benefit of the chiropractor.

He said that often it is the patient who asks to see his problem,

who initiates the discussion. (G3) Dr Parker of Fort Worth on

the other hand is quite blunt as to the importance of using x-rays

to demonstrate the patient's condition. He leaves nothing to the

im-:=.sination. He suggests that the chiropractor - "point out

pathological conditions, curvatures, etc. connecting to a spinal

cause (use magnifying glass) - show the worst conditions firsL -

poi rlt 01.:,t r:1:i. ~~o l J.~;rn:1r2nts, suhluxations; prcssu:r:e points; kinks,

'Dr::,, C'S '' ( 6 ('. ) ~i- •••

(61) Transcript p3ge 830

( Ci 3) Tr.1.nscript pa•Je> 5 7 3

(G2) Transcript pages 940 and 1007

( 6 4) Parker Mar.1.1c1l page 181

- JJ

I remind the Commission that the vast majority of spinos show

l 1 . 1 f'l (GS) some misalignments no matter 10w s 1.g1t on x-ray 1 rn. There

is almost invariably something for the chiropractor to show the

patient. The- conclusion is irresistible that the x-ray film is

used to implant the notion of the subluxation. The patient is

then ready to be convinced that it is the chiropractic

subluxation which may be the cause of his symptoms because of

its pervasive influence on the nervous system. The suggestion is

at the same time both simple and attractive. It is the first

and most important step in the operation of the chiropractic

placebo, an essential element (perhaps the only element) of the

efficacy of chiropractic.

Having located the subluxation, the chiropractor will ~roceed

to deliver his adjustment

Mr Mudg1·my saw the therapy as possessing a singularly chiropractic

flavour: (66 )

"Chiropractors use this movement of vertebrae by hand but it is

used in a very specific manner in a specific direction - most of

all reasons - for a specific purpose .

. . . We believe that in executing the adjustment, we are endei:wour:i.ng

to restore this ·✓crtcbral unit to its normal functioning ability,

at the same time restoring any neurological insult at that a1:c-1."

. (65) Transcript page 579 (66) Transcr.ipt page 656

Yet as th{s Inquiry has proceeded, I suggest it has become plain

that the chiropractic 'corrective procedure' - the chiropractic

adjustment - is of itself no more than the application of

spinal manipulative techniques Well known to the medical and

physiotherapy pro:fe::;sions. Dr Haldeinan certainly left no

doubt as to his views. He would draw no distinction between

spinal manipulative therapy as administered by a chiropractor

on the one hand or by a skilled medical practitioner or

physiotherv.pist on the other"

The crux of the matter in my submission is that it is the

J?_\!rpose for which the therapy is applied which is the distinc:ti ,_.·;:;

feature of ·chiropractic, that purpose being (so it is claimed)

the removal of interference to nerve transmission and exp£essio~.

So it transpired that the Jarvis dichotomy of Type t-1 cbir.op:::.::,,ctic

(treatment of musculoskel.et. ·11 disorders) and Type O chiropract:ic

(treatment of visceral disorders) does not, as one rrd.ght

think, suggest that the therapy is in either case different

in some way from the other. The difference lies simply in

the chiropractor's perception of the purpose of his trcatme~t.

The "straight" to the left side of centre in Professor

Jarvis's continuum re<Jards himself simply as treating the

subluxation, a condition of the musculoskeletal system. He

cannot conceive of a Type O chiropractor. The "chiropragmatist 11

at the right hand side of the continuum aims to treat the

patient's back pain or asthma. He does so by manipulating

the 'manipulatable lesion'.

I pause· at this stage to refer to the NZCA surveys. The

NZCA presented to the Co11Lmission two surveys conducted by

it: a survey of new chiropractic patients during a three

month period and a profile of New Zealand chiropractors. In

the case of the new patient survey, onl.y members of the NZCA

took part. The profile on the other hand was circulated to

both ~ZCA and non-NZCA practitioners. It is important then

at the outset to note a feature of both surveys. The surveys

were not structured so as to obtain responses only from a

proportion of the members of each class. By this I mean

that the proportion was not defined in advance. The consequence

is that it is impossible to estimate the effects of the non··­

respcnses to the requests for participation. We do not know

whet~er those chiropractors who responded are a typical

cros3-sectio~ of the profession in New Zealand. We do not

kno,,; whsther L~e patients of the responders or the non­

resp~nd=r~ are in any way different. There was apparently no

atte~pt to follow up the non-responders to discover the

explanation. It is not so much the number of non-responders

that is important as the fact that they represent an unknown

and unknowable bias in the data.

Non2theless, the surveys did throw up some useful information.

I have already referred to the apparent probability that a

chiropractic subluxation will be found on examination of a

-l--~,::, -l-(67) i? a'-_,. ._n '- • This peculi~rity of chi~opractic practice

was 2xe::~plif ied by the :responses of chiropractors to a

{67) Transcript p~ge 586.

·I

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question ~~lling for a chiropractic analysis of each new patient.

Of 4,609 patients, 4,222 were found on initial examination

to have one subluxation. 1,077 were found to have two

subluxations and 438 patients were found to have more than

{68) I . . 1 . two. t is not entJ.re y a fruJ.tful task to endeavour to

correlate statistics, but it is of interest to note that

while 387 new patients were appnrently free of subluxations,

yet at that first consultation the decision was made that

the patient would be referred in only 18 cases. (G9 )

The new patient survey also served to exemplify the difficulty

of relying upon statements from chiropractic sources as to

the nature of the conditions which they treat. The questionaire

included a question(?O)which required the chiropractor to

state the 11 nat.ure of patient's cornplaint 11 • The completed

survey did not include an analysis of the answers to that

question. Instead, we were told that the only useful conclusion

that could be drawn was a general one to the effect that the

preponderance of complaints related to head, neck and lmver

back. (7l) The answers to that question entered on the questionaires

were in fact the patients' descriptions of their complaints. <72 )

When those answers were encoded, however, they were interpreted

by Mr Pallister and labelled by him in relation to the

anatomical reg ion of the body where the s:ymptoms were

described. (?J) A patient complaining of migraine headache

then would he described as having a hend complaint. A

(74' patient with asthma would be within the category of tho):ax. 1

( 6 8) •rranscript pc1gc 2316 (69) Subm:i.s:,~ion Pc1rt. II page ] J_ (i

(70) Question I ( 71) Submission Part II page 100, para. 49. 3.

{72) 'l'ranscr ipt page 2298 ( 7 3) '.l.'ranscript Pi:ltJC 2299

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I do not attribute any improper motive to Mr Pallister. 'l'hc

fact remains, however, that the tunnel vision of a chiropractor

leads· him to view many many complaints (some of which may be

purely visceral) as referrable to the spine, neck and head.

Of course we will never know what in fact the questionaires

disclosed as the answers to Question I. A request was made by

the NZMA that the answers in their original form be provided.

The ruling of the Commission was that the Commission itself

would see what could be done. It would appear that that task

too fell to be performed by Dr Thompson of the DSIR. Unfortunatelyr

the DSIR's reanalysis does not do any more than repeat what we

know to be Mr Pallister's interpretation of the patients'

responses. Needless to say, it is now too late for us to

pursue the matter further, though it is cause for regret that

.. :1e re-analysis was not received by Counsel until 9 April thi _

year notwithstanding that the document itself appears to be dated

on 12 December 1978.

It is the invariable practice of New Zealand chiropractors to xr~y

the spinal column of each new patient. The patient survey

demonstrated that 94.2% of all new patients seen were given a'.'.1

xray as part of the diagnostic procedure: <75 > a total of 4247 x-ray~

during the three month period 1 March to 31 May 1978. Participants

in the profile of chiropractors produced a mean .number of x-ray

examinations of both new and current patients of 1.0.4 per ,.,eek. ( 7G)

(75).Submission Part II, page 115 (76) Op. cit., page 139

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The purpose of these xrays is said to be to check for pathologies,

to ensure the structures arc suitable for manipulation, and to

assist in evaluation of posture. <77 )

The question must be asked as to the necessity for this volume of

radiological exposure. If many chiropractic patients would

respond by the application of tho.re.pies other t.han chiropractic,

then correspondingly a substantial reduction in the number of

xrays taken could be expected. It is simply the fact that these

patients are to be manipulated which justifies xray screening.

No doubt it will be argued that were chiropractors granted

access to medical diagnostic facilities, particularly radiological

facilities, there would be no need for them to use x-rays to

the same extent; but if a chiropractic radiological benefit were

gr~nted there would be the temptation, based on economic groundb,

for chiropractors to do what they do now, x-ray virtually

all their patients as a routine. One cannot imagine chiropractors

utilising medical diagnostic facilities to any significant extent

if there were a chiropractic radiological benefit. In any case,

the Commission is reminded that on 8th July 1977, the Council

of the Royal Australasian College of Radiologists resolved that

Radiologists should not accept paitents referred from chiropract­

ors. (?a)

I return nO'w to the subject of the beliefs of chiropractic

as to the reasons why chiropractic is said to work.

(77) Transcript page 3182 (78) Transcript page 1775

-- .. JJ

There are a variety of theories offered to explain the results

of chiropractic manipulation in the relief of back pain.

Dr Haldeman has acknowledged however that the influence of

. . h . f t. . 1 t · ( 79 ) any specific mcc anism o- ac-ion remains specu a-ion.

The significance of chiropractic theory concerning the relief of

visceral disorders is even more obscure. Dr Haldeman outlined

to the Corr.mission in considerable detail his theories of

neuroplasmic flow and somato-sympathetic relaxes. ( 80) There: is

nothing unique or novel in these hypotheses. Dr Eyre agreed

that disordered neuroplasmic flow can result from nerve

. ( 81) compres-sJ_on. 'l'here is however no evidence that the chirc,practic

subluxation, undetectable as it is by x-ray, would be sufficient

to produce this interference with axoplasmic flow. Nor in

D E , · ( 8 2 ) f th tl h . f r yre s view can one go -ur .er 1an t.o say tat 1- an

impedance were to occur there is the possibility of visceral

effects.

The somato-s:ympathetic reflexes present similar difficulties

of precision. The reflexes exist, but wh~t is the connection

with the chiropractic subluxation? Dr Eyre has reminded us

that the hypothesis relies upon an assumption that the

chiropractic subluxation (if it exists} has some special

significance (which has not been demonstrated) over other

causes of altered sensory input. <33 ) He has also posed for

(79) Submission No. 131, pages 33-38, para. 3.G

(80) Submission No. 131, page 38, para. 3. '/

(81} Supplementary Paper, page 3, para. 12

(82) Transcript page 3588

(83) Supplerr.cntary Paper, page 6, para. 24.

..

.,.1

- bU -

us the improbability that tho body's homeostatic mechanisms

could be overwhelmed by sensory insult from such an intangible

source as Dr Haldeman's manipulatable lesion. <84 )

There are of course a number of additional explanations for the

apparent benefits of chiropractic manipulation. Dr Haldeman has

listed five alternatives: <95 )

1. Misdiagnosis: The patient may not have had the disease

in the first place.

2. Self-limitation: The disease may have gone throush a

natural course of: recovery and would have improved in

the absence of any treatment.

3. Spontaneou8 remission: The disease may have gone

through a natural course of remis~ion and exacerb~tion

and was proceeding to the remission phase during the

period of trea~ment.

4. Concurrent therapy: The patient may have been receiving

rr.ore than one therapy at the same time.

5. Placebo effect: The patient may have felt subjectively

better simply by being under the care of a physician

who gives trc.'0.t1~·:'2nt ~-md is syn::pathc.tic to the patient's

probJ?m. Professor Hubbard has suggested that the

(84) Trar1script pag2 3591. (85) Exhibit HL8

I

I I ! I

, placebo effect could in turn be associated with the

production of endorphins and enkephalins. (BG)

I have already referred to the use of x-ray films by chiropractors

to implant in the mind of the patient the notion of the chiropractic

subluxation: the first step in the operation of the chiropractic

placebo. Dr Jim Parker explains the message clearly enough -

seeing is not believing ... believing is seeing. While Dr Parker

may never use the term "placebo", this is precisely the product

he so successfully markets.

In the final analysis, there can be one means only whereby the

efficacy of chiropractic (if there be such) over and beyond the

placebo can be demonstrated. That is by the use of properly

controlled trials. Many research studies have been referred to

in the course of these hearings. Almost without exception,

there has been·objection by one side or the other to either

the methodology of those studies, the suggested bias of the

researchers or the participants, or the correct interp~etation

of the reported results. If that state of affairs tells us

anything, it is that clinical research into the efficacy of

chiropractic therapy is in its infancy.

One would have thought that the starting point of chiropractic

research would have been to deroonstrate the existence of the

chiropractic subluxation. It is, after all, the existence

and the implications of that subluxation with which this

(86) l\.ddendum to Submission No. 90

. t

I

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Commission is largely concerned. We can echo then with

astonishment the observation of Dr Haldeman(B?)when he said:

" ••• there are at least two majo:c research projects underway which

are attempting to find more accurate ways of measuring a subluxation

in the absence of any solid data that the subluxation is worth

measuring."

To this one could add - and in the absence of any evidence

that the subluxation exists.

Many of the studies have been no more than uncontrolled

clinical trials at the first level of research. They are in

effect reports of successful treatment outcome without any

attempt to introduce a comparison with alternative forms of

treatment. It is SU::Jgested that these studies do not advance

matters one way or the other. They remain subject to the

criticism that they cannot_exclude the alternative explanations

for a successful outcome which may be unconnected with the

treatment.

We will pass instead to the relatively small number of trials which

have introduced a comparative control. All except one have been

trials of low back pain. None of them has emanated from a

chiropractic source and indeed only one (the Utah trial) is

concerned with chiropractic as opposed to medical therapy.

(87) Exhibit BIA

An attempt at evaluating the effectiveness of chiropractic

, treatment was made at the University of Utah College of Medicine

by comparing the Workmen's Compensation records of patients with

spinal disorders treated by a chiropractor, on the one hand, or

a physician, on the other. This study showed no essential

difference in the outcome of either form of therapy; patients

., .

of chiropractors, however, were more satisfied with the degree to

which they were made to feel welcome.

The authors(SS) admit several limitations to their study:

1. The design being retrospective relied on the patient's

recall of his functional status at several points in time

over the previous year;

2. Because ~hiropractors utilise a diagnostic nornenclatm:-e

different fro1:11 physicians, comparability of case material

was impossible; and

3. The number of patients examined was small.

DoraJ1 and Newell ( 89 ) described a multi centre trial undertaken by

the British Association of Rheumatology and Rehabilitation in

which 456 selected patients with low back pain were randomly

allocated to one of four treatments - manipulation, physiotherapy,

corset, or placebo (analgesic tablets). The authors concluded

that none of the methods of treatment showed any great superiority.

(88) Produced by Dr J.S. Boyd-Wilson as Reference 72

( 89) Doran, m-1L and Newell, DJ: "Manipulation in Treatment of Low Back Pain: A Mt..lti-centre Study", British Medical Journal 2: 161-164, 1975

f !

I I I

Dr Haldeman has called into question the skill of the manipulators

involved in this trial( 90) and criticised the fact that no attempt

was made to 'blind' eJ:ther the p~·ti'ent or the c • h c' ·- ( 91) ~ - · a~sessing p y~ici~n.

It should be noted that manipulators from several 'schools'

participated, including an osteopathic physician: <92 >

the technique used was at the discretion of the manipulator and

could include procedures such as mobilisation.

The trial showed, beyond doubt, in no less than 456•selected

patients, that spinal manipulation carried out by an experienced

manipulator confers little more benefit than the administration of

a placebo. Neither of Haldeman's criticisms can be sustained:

a spectrum of experienced manipulators was employed; the lack

of blinding would have produced a more favourable result in the c~se

of those pati~·1ts treated by manipulation as opposed to those

given the analgesic tablets (placebo).

In a simple cross-over trial of two three-week periods involving

32 patients with chronic low back pain, Evans et a1< 93 > 'blinded'

the observer only - a single blind trial. Manipulation was given

by an experienced medically qualified manipulator .. Patients

were randomly allocated into two groups. In the first

group, manipulation was given on days O, 7 and 14 with

'rescue' analgesia allowed; treatment during the second

three-week phase was with analgesics only - the 'control'

(90) Submission No. 131, page 19, para. 315

(91) Exhibit HL8

{92) British Medical J·ournal 2: 158, 1975

(93) Exhibit PKG

phase. In the second group, the phases were reversed. The

first week of manipulative treatment was more painful than

the corresponding week in the control group, but in the

second and third weeks there was less pain in the manipulated

group. Pain scores were reduced to a significant degree

within four weeks of start_ing treatment only in the group

manipulated in the first treatment period.

It is submitted that crossover trials are far from ideal in

studies where manipulation is involved; as admitted by the

authors, the active treatment can exert a delayed effect which

can carry-over to the control period and create problems of

interpretation.

A controlled prospective study of low back pain was carried out

LJ Bergquist-Ullman and Larsson. <94 ) Patients treated with

combined physical therapy (by physiotherapists specially trained

in manual therapy) showed a mean value of the time between first

treatment and recovery of 15.8 days compared with 28.7 days for

a group of patients given placebo treatment, and 14. 8 days for tlLc

Back School group.

But the placebo used (short-waves of the lowest possible intensity)

which at the most might "increase the local blood-flow of the

subcutaneous tissues 11 <95 >di<l not remotely measure up the

standards set by Dr Haldeman( 35 ) of " ... a similar but ineffectual

therapy (applied to) the second group in such a manner that

(94) Exhibit HL7

(95) Exhibit HL7, page 37

"

t I

I

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the patie~t is unaware of the type of therapy he is receiving."

According to the authors "the personality of the patient and

of the therapist and the time spent with the therapist are

probably important factors when one is trying to assess the

placebo effect. The significant effect of the Back School

in relation to the 'placebo' group might to some extent be

explained by the fact that the patients spend more time with

the therapist in the Back School ... Physiotherapy as defined

in this study is to a great extent directed towards manual

contact with the patient. This might also contribute to a

further placebo effect."( 9G)

The trial at the University of California at Irvine supervised by

Drs Buerger and Tobis <97 > is concerned with a trial of manipula·i:ion

of the lumbar spine. It appears that some success has been

achieved in blinding the ooserver and. the patient to the

type of manipulation given. The control group in this

instance received soft tissue.massage, but even so doubts

remain as to the capacity of this technique to eliminate the

possibility of a placebo effect. (9 a)

The Commission has been privileged to have presented to it details

of the first prospective trial of chiropractic therapy to be

conducted anywhere in the world, a trial commissioned by the:!

Australian Government Committee of Inquiry into Chiropractic,

Osteopathy, Homoeopathy and Naturopathy, and conducted by

G.B. Parker, H. Tupling and D.S. Pryor. <99 >

(96) Exhibit IIL7, pages 92-93

(97) Submission No. 131, page 20, para. 3.5

(98} Transcript page 3323

Migraine was chosen as the subject of the trial at the insistence

of the Australian Committee of Inquiry, and against the advice

of those who would conduct the trial. Migraine was perhaps an

unfortunate choice: its diagnosis presents difficulties not

only because it may be confused with tension headache. Its

relationship with cervical spondylosis (degenerative disease

of the cervical spine) is, to say the least, tenuous, so that

migraine cannot be categorised as either an O type or M type

disorder. Not only that, but emotional factors are often

involved in cases of migraine with the need for psychological

management.

It is of interest that members of the Australian Chiropractors'

Association, American-trained in the main, and the count.eJ:9art of

the New Zealand Chiropractors' Association, refused repeated

invitations ot the authors and thEi Cormni ttee of Inquiry to take

part in the trial; four Australian-trained mero.bers of the U!1i ted

Chiropractors' Association were nominated by that Association and

did take part.

The trial was conducted to evaluate the efficacy of manipulation

of the cervical spine in the treatment of migraine. There were

three treatment groups: spinal manipulation by a chiropractor,

spinal manipulation by a medical practitioner or physiotherapist,

and spinal mobilisation by a medical practitioner or physio­

therapist. Mobilisation was used as the control in that

patients in this gJ:-oup would be given comparu.ble therapist

contact but in the sense that mob.:i.lisation involves small

oscillatory movements to a joint within its normal range of

"

, ' l l

!

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, movement, it could not conceivably produce a mechanical

effect such as might be produced by manipulation (defined as

movement of a joint beyond its normal range of movement).

The trial was designed to test four hypotheses:

(a} That all treatments would lead t6 a reduction in migraine

symptoms.

. (b) That cervical reanipulation (whether performed by a

chiropractor, medical practitioner or physiotherapist) would

be more effective than the control treatment of cervical

mobilisation.

(c) That chiropractic treatment would be more effective than

the other two treatments considered together.

(d} That chiropractic trea.tment would be more effective than

cervical mobilisation alone.

The first hypothesis was supported by the results. There was

no support for the second hypothesis that cervical manipulation

would be more effective than cervical mobilisation. The third

hypothesis was supported on one variate only, the intensity of

pain, but was no more effective than the other two treatments i.n

reducing frequency, duration or induced disability of migraine

attacks. The fourth hypothesis was not confirmed.

- t)~ -

It is perhaps significani that during his cross-examination,

Dr Haldeman took the view that mobilisation was simply another

form of manipulation; he said he could have predicted that it

would produce a beneficial effect. So it did: a placebo effect.

The treatment of migraine by spinal manipulation carries a real

risk; it should be abandoned in favour of equally effective

methods of treatment which carry no risk.

We have seen criticism of Dr Parker's data by Dr Thompson of the

D.S. I. R. The re·worked data did not however produce any change

in the absence of support for those hypotheses as to the

superiority of chiropractic manipulation.

In passing we must express some unease at the way in which

Dr Thompson's involvement with this aspect of the Inquiry has

developed. \'?e can fully appreciate the Commission's initial

desire to have assistance in understanding the langua~e

and method of statisticians. However, once it became apparent

that Dr Thompson was strongly critical of certain of the

statistical bases on which he had proceeded, in retrospect

it might have been better if like any other critic involved

in this matter Dr Thompson could have been subjected to cross

examination. We say this particularly because the criticisms

most recently made by him (the "Summary Report 11 ) which are

undated but were received by counsel only on 30 March 1979,

are in places couched in the lDnguage of an advocate of a cause

rather than that of a detached scientific observer. We ha,~

,.

!

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- 70 -

to add that comments already received from Dr Parker state that

the statistician engaged by him, Dr Dird, strongly challenge

the validity of Dr Thompson's comments except to the extent that

they relate to punching or arithmetical .errors. We are hoping

to receive a written response from Dr Bird which will deal with

these aspects.

In concluding this review of the controlled trials, we are

left to echo the conclusion of Dr M. Goldstein in the NINOS

monograph: (lOO)

" .•. specific conclusions cannot be derived from the scienti:i:ic

literature for or against either the efficacy of spinal manipulative

therapy or the pathophysiologic foundations from which it is derived."

The absence of any valid demonstration of the efficacy of

chiropractic does not of course deter the practitioner, who

believes that proof of the value of his technique will

follow in the fullness of time. He is likely to discover a

chiropractic subluxation in almost every new patient who

consults him. (lOl) 'l'he patient may also be suffering from a

visceral condition. As a result of his philosophy, the

chiropractor believes that the reduction of the subluxation

may assist the visceral condition.

We touch at this point upon a continuum of chiropractic

practice. Those to the left of centre will proceed to deliver

(100)

(101)

Produced by Dr J.S. Boyd-Wilson as Reference No. 50

Transcrip~ page 2235

treatment'on a 'wait and see' basis. If after a number of

treatments the condition does not seem to be improving, then

no doubt the patient will be sent to a ·medical practitioner. (l0 2 )

Those to the right of centre (perhaps as a result of a greater

understanding of orthodox medicine) will probably distinguish

those cases in which the visceral condition might deteriorate

in the absence of medical care.

While prepared to give chiropractic care, they will nonetheless

insist that the patient should also obtain concurrent medical

treatment.

Dr Haldeman would put it to the patient this way:

" 1 You are u,-:..-.ler good medical care. I want you to see

your medical doctor •. I am willing to give you a trial

of treatment, or so many treatments', and specify

so many treatments, 'with no guarantee that it will have

any benefit at all, but if you wish to do it, I am willing

to co-operate.'" (103)

Now wha_t is the patient to think of all this? As far as he is

.concerned, the chiropractor is offering to treat his visceral

condition. The subtleties of the chiropractic subluxation will be

lost on him. The chiropractor has offered an alternative and

additional treatment to that he is receiving from his medical

(102)

(103)

Transcript page 2236

Transcript page 3408

practitioner; a treatment moreover which is apparently

unavailable within orthodox medicine. Certainly the chiropractor

has offered no guarantees of success, but on the other hand Lhe

chiropractor must believe the treatment may be beneficial. Wby

else would he suggest it?

I call this procedure 'the two-headed penny'. The chiropractor

has it both ways. If the condition does not improve, then of

course the chiropractor has promised nothing. If on the other

hand there is an improvement, the chiropractor will modestly

claim the result as a demonstration of the healing power of

chiropractic.

It is my submission that not only is such a form of practice

unscientific and confusing to the patient, but it must also carry

a risk of de~ ying proper medical care. Without clinical

hospital experience to guide him as to the course of many visceral

conditions and reluctant as he must be to admit the failure of his

treatment, the risk must exist that the chiropractor will delay

too long in calling a halt to his 'trial."

The ambivalence of the chiropractor's sta.nce is heightened by

the increasing se of the prefix "doctor" by chiropractors. I

say 11increasing 11 because it was not always so in this country;

indeed some of the older, more conservative chiropractors such

as Richardson(l0 4 )in Christchurch still prefer the title "Mr".

In many respects, chiropractic consciously imitates orthodox

medicine - for example, in terms used to describe facets of its

( 10 tl) Transcript page 2177

- 73 -

educational system. The use of the prefix "tloctor" comes into

this category: it is used both in the privacy of the consulting

room and in publications such as "Healthways" designed for the

"tasteful delivery of public information". (l0 5 )

Many overseas studies of chiropractic have drawn attention to

the unsatisfactory nature of this practice, and to the confusion

which must ensue. There should be no need to remind the

Commission that for the uninitiated patient the illusion is

completed by the white coat the chiropractor wears together

with his stethoscope.

The broader issue is, of course, not simply whether or not

the patient should be exposed to a harmless, albeit probably

~~effective, therapy. It is an unfortunate fact that there

is the risk of damag8 to the patient as a result of spinal,

particularly cervical, manipulation. The Commission has seen

a communication(lOG)from Mr G.M. Macdonald, a neurosurgical

specialist, concerning three cases of brain stem infarction

following cervical manipulation by a physiotherapist, a

chiropractor, and a medical practitioner. There is of

course some risk attendant upon many forms of therapy. The

risk may be clearly outweighed by the demonstrated benefit

of the therapy. But the risk cannot be regarded as acceptable

if the efficacy of the therapy remains unproven. As was

said by Dr Boyd-Wilson: (l0 7 )

(105) Submission No. 26, page 80

(106) Supplement to Submission No. 26.

(107) Transcript page 1785.

- 74 -

"It is better to have one thousand patients in this

country putting up with their migraine without going

through the process of cervical manipulation - rather

than have one patient paraplegic, or close to it, as

a result of a poorly performed and ill-advised

manipulation of the cervical spine."

The attitude of the NZ.MA then to spinal manipulative therapy

is simply this: that spinal manipulative therapy, if it has

a place at all, has a very small place for a limited number

of musculo-skeletal disorders. Even in that limited area,

its efficacy has yet to be proven.

I should also repeat that the chief issue for the Commission

is in our submission not che availability of manipulative

services, but the philosophy of chiropractic. Manipulative

services are available within the orthodox health team to

deal with that very limited class of cases for whom it may

be considered appropriate. There is common acceptance within

the medical profession that manipulation is a technique

which can properly be employed as one of a number of available

modalities within the entire concept of the health team,.in

contrast to the use of manipulation as a sole modality by

chiropractors operating in a primary position.

Interprofessional Relationships

It is of course the differences in philosophy, and the lack

of <1 cor.unon scientific base, which are -the root cause of the

inability'of the medical profession to accept cooperative

treatment of patients with chiropractors. An essential

requirement for successful interprofessional referral is that

there is acceptance both by the referring doctor on the one

hand and the practitioner to whom the patient is referred on

the other of the same professional tenets, the same philosophy,

the same scientific infra-structure upon which to base their

forms of practice~lOS) It must be clear beyond any doubt that

in the case of chiropractic and orthodox medicine in New

Zealand there is no such compatible philosophical base.

There may well be medical practitioners who for one reason

or another have chosen from time to time to refer patients

to chiropractors for treatment. No doubt they have done so

because of a sincerely held belief that their patients would

benefit from hiropractic manipulation, but without a:;:1y real

understanding of the true nature of chiropractic. By so

doing, they have acted contrary to the considered vie'l.·l of

their profession: a view which finds expression in the

ruling of the NZ~L~ that it is unethical for a doctor to

refer a patient to a chiropractor for treatment. (l0 9 )

That ethical ruling ha.s been the subject of much discussion

throughout these hearings. It has been castigated as being a •

barrier to patients receiving the demonstrable benefits of

chiropractic: as the expression of a bigotted establishment,

seeking to prevent doctors acting in accordance with their

(108)

(109)

Submission No. 109, page 5, para. 5.1

Exhibit M4

- 76 -

better judgment. The critics for their part would claim that it

should be a matter for the individual judgment of each doctor

whether he should refer his patients to chiropractic. But I

submit that on close scrutiny there has been found to be no

support for that view at all.

I will examine briefly the factors which influence the medica.l

profession in its stance against referral of patients to

chiropractors. First and foremost is that chiropractors adhere

to the belief that their treatment is directed towards the

reduction of the chiropractic vertebral subluxation, a conditicin

the existence of which has not been demonstrated by the scientific

met.hod. It follows from the absence of any belief by the doctor

in the chiropractic subJ.uxation that he cannot direct the treatment

which the ch:: ·opru.c'cor will deliver. Were he to attempt to do

so, the chiropractor would not in any event feel himself restricted.

He would regard himself as free to conduct his own diagnosis and

to reach his own conclusions as to the appropriate form of

treatment. The chiropractor wishes t.o undertake responsibility

for what he regards as the patient's spinal condition while at

the same time viewing the patient as primarily the patient of the

d . l . . (J.10) me ica practitioner.

Next is the requirement that the efficacy of chiropractic be

adequately demonstrated. In this regard, it would plainly be

insufficient for the doctor to form his own judgment based on

., t 1 t f f J · t t 011e '·.7ould J.ook for anecao-a repor~s o~ success·u. ~rea men·. ~

(110) Transcript page 2074

efficacy to be demonstrated in properly controlled randomised

trials. That evidence does not exist.

The chiropractor is, of course, for his part prepared to accept

a patient on referral from a medical practitioner and to treat

that patient if, in his opinion, chiropractic treatment is

indicated!lll) Although he is prepared to accept patients off the

street, and also upon referral claiming the right to a health

benefit whether he operates in a primary or secondary position,

the chiropractor will not accept a benefit which is conditional

upon referral. His unwillingness would appear to rest upon the

view that medical practitioners are not qualified to know when

a patient will benefit from chiropractic treatment and that

accordingly it would be unworkable for chiropractors to rely-upon

such referrals. Yet it is this very lack of belief by medical

p, .. :actitioners in chiropractic which is a major factor in the

prohibition of referral.

The ethical rule does not require a doctor to refuse to

accept a patient simply because the patient has come to him

through the medium of a chiropractor. Indeed it would be improper

for him to do. so.

At the same time, any doctor would be perfectly entitled to refuse

to be a party to concurrent medical and chiropractic therapy.

The concept is naturally one which is attractive to the

(111) Communication to the Commission from the Secretary of the New Zealand Chiropractors Association Inc. dated 20 November 1978

chiropractic profession. The chiropractor will deliver his

therapy in the hope that the patient may improve, while

simultaneously the doctor is expected to take ultimate

responsibility for the patient, prescribing essential drugs

or getting up in the middle of the night to deliver the

baby. Were such a situation to occur under a scheme for the

subsidy of chiropractic, then in addition to delivering

concurrent therapy the chiropractor would be claiming a

concurrent primary health benefit as well as a concurrent

radiological benefit.

To lend point to these abstract considerations, to exe,nplify

the real difficulties which exist in everyday practice, it may

be helpful to remind the Commission of the case of Adam Pugh.

Let me say at once that the following facts are taken from th~

public record - but they -'~monstrat.e the utter impor;sibiJ.ity of

concurrent primary therapy and the grave difficulties in the

way of any kind of academic association between medical

practitioners and chiropractors.

Adam Pugh was four years old and suffered from juvenile rheumatoid

arthritis, diagnosed and treated as such at the Waikato Hospital,

and later at the QE Hospital in Rotorua. It may be stated that

the QE Hospital is a special unit which cares for chronic

rheumatic conditions and because of Dr Isdale's interest in

juvenile rhemnatoid arthritis, the unit has an international

reputation in the care of such cases. All this is public

knowledge.

- 79 ·-

, \\7hile under the care of QE Hospital, Adam Pugh's case was

referred by an organisation known as Janacia Child Care to

Barry Le\-1is, a chiropractor of Tauranga, who examined Adam

Pugh on 17 January 1978 and diagnosed (radiologically) "severe

anterior subluxation of C3 on 4". Lewis was described as

"particularly good with children so that Adam happily responded

to adjustrr:.ents as a playing game". From the first adjustment

Adar.1 1 s condition appeared to improve. Under the care of Janacia

Adam was given 11 ••• a diet as close as possible to that for a.

rheu..-uatoid arthritis patient bearing in mind that we only had

him with us for a period of two weeks. Gentle oiling massage

to sti~ulate and much encouragement, to which he delightfully

responded."

It is co;.-a.:-non 0round that the diagnosis of juvenile rheumato.id

arthritis was known to the chiropractor(ll 2 )and to Janacia

Child Care; the representative of the latter organisation could

see no difficulty in having the child subject to different

progra~mes of treatment at the same time. (ll 3 ) But the

chiropractor's treatment was directed toward correcting the

subluxation(ll 4 ) whereas in my submission the Hospital treatrr.ent

·would have been directed toward controlling the inflammation

and at the sarr,e time preserving joint function with appropriate

physical therapy.

It must be obvious to any.thinking person that it is not possible

to have t·wo different practitioners primarily responsible for the

(112) 'l'ranscript pages 282 and 291

(113) Transcript page 284

(114) Transcript page 295

~

t t ?' fl'-.'

- 80 -

care of a given patient at the one time, even if those practitio~~rs

share a common scientific training: when their training differs

in crucial respects, when there is no common scientific base, the

situation becomes doubly impossible.

The Commission has nonetheless quite rightly in my submission

explored with the .NZCA the views of that Association as to mccUcal

referral. I suggest that the results of that enquiry confirm

the conclusion of the medical profession that so long as

chiropractors occupy a primary position vis-a-vis their patients

then chiropractic will operate as an alternative system of health

care.

Thus it is the view of the NZCA that were a patient to be referred

to a chiroprr1ctor for treatment of condition A then if at a later

date the patient were to approact the chiropractor direct for

treatment for condition B there would be no ethical bar to the

chiropractor treating the patient. without communication with the

d . l . . (111) me 1.ca practi tJ_oner.

Referral to a chiropractor thus becomes the crack in the door

through which the chiropractor wishes to walk. Let us assume

that a doctor refers a patient to a chiropractor for treatment of

low back pain. Six months later the patient consults the

chiropractor direct and asks for treatment of his asthma.

It seemed something of an afterthought when Mr Blackbourn ( 11 •; I -~,-----, SC.l\...,.,

that in this situation there would be no obligation upon him to do

so, the chiropractor would probably in that event contact

(115) Transcript page 3089

the doctc .;.: . There was no suggestion that the chiropractor

would decline to treat the patient. He would simply inform

the doctor so that the doctor might have an opportunity to

explain any relevant facts which the patient had not mentioned.

Were the doctor to object to chiropractic.treatment on the

ground that he dj..d not believe that asthma could be beneficially

affected by manipulation of the spine, we can only assume

that the chiropractor would politely disagree and proceed

to treat.

In summary, the effect of the evidence is that the chiropractors

wish to preserve the best of all worlds. They will carry out

the directions of the medical practitioners as long as it suits

them, but reserve the right to go their own way if they do not

agree. Consider the variety of the propositions which were put

.c0n·:2rd at various times under various headings.

1 A h . t . h 1th t · t · ( 116 ) . c_ iroprac or is a primary ea care prac i ioner.

2.

3.

4.

(116)

(117)

(118)

This is an international stance.

It is proper for a chiropractor to treat a patient

without prior medical screening.

It is proper for a chiropractor to treat on a "wait

and see" basis. (ll?)

A chiropractor is a specialist in the field of spinal

health. (lla)

N2CA Submission Part I page 5, para 4.1

Transcript page 2537

Transcript page GOO

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5. A be1~fit would not be acceptable if conditional on

medical referral. (ll 9 )

6. Chiropractors are however pleased to receive patients

on referral from medical practitioners. (lJ. 9 )

7. If the treatment prescribed by the medical practitioner

on a referral is treatment with which the chiropractor

agrees, he will "follow the medical practitioner's

direction". (l 2 0)

8. If however the chiropractor does not think that the treatment

is appropriate he is free to disagree. Mr Blackbourn

maintained in re-examination that if agreement could

not be reached he would not. carry out any treatment at

all. <121 > In view of other answers and stances one

would doubt that that was a generally held view, and

one would suspect that the chiropractor would proceed

to administer the treatment that he thought proper.

After all, is he not the "specialist"?

In this regard, there clearly was little understanding by

the chiropractors as to what a specialist really is, or as

to his relationship with a general practitioner who refers

a patient to him; nor indeed on the ethic of referral

( ~! until it had been explained in detail by the medic~l witnesses.

{119} NZCA Submission Part I page 91, para. 45.3

(120) Transcript page 3073

(121} Transcript page 3088

9. Once the treatment has been completed it is ethical for

the chiropractor to accept the patient at a later date

· 1 · (l 22 ) b h . h' h b t with another con~ aint - e aviour w 1c as e ween

doctor and doctor would plainly be a gross breach of

professional ethics.

As the referral ethic stands in the way of what chiropractic

would regard as an avenue to expand its activities, it is

not surprising that it has been vigorously attacked by chiropractic

organisations, particularly in the United States of America

under anti-trust legislation peculiar to that country. The

ethical rules of the American Medical Association provide

that a physician should not use unscientific methods of

treatment nor should he voluntarily associate professionally

with anyone who does. ~['hat rule is regarded by the AiV:-tA. as

precluding a physician from referring a patient to a chiropractor

for treatment. During the last two years a number.of legal

actions have been commenced by chiropractic groups against

the American Medical Association and.hospital authorities.

The primary purpose of the litigation appears to have been to

challenge what is claimed to be a restraint of trade and to

require the withdrawal of the ethical prohibitions.

It is our understanding that the AMA has agreed to the settlement

of what is known as the Slavek-North Penn Suit on terms which

amount to a recog-rrition that physicians may choose either to

accept or to decline patients sent to them by chiropractors.

appears that the prohibition on referral by physicians to

(122) Transcript page 2075

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chiropractors remains. Challenges have in turn been mounted

to that settlement by the American College of Physicians,

the An~erican College of Surgeons, the American College of

Radiology and tbe American Academy of Orthopaedic Surgeons.

The whole situation of course arises out of peculiarly American

legislation, the anti-trust laws, but the weight of the

opposition within the AMA's own membership to this move must

be appreciated.

The British Medical Association appears to regard it as ethical

for a doctor to refer a patient to a practitioner skilled in

manipulation l. -r-.L the doctor is satisfied that that per.r.;on is

capable of safely performing the manipulation. The General

Medical Council Statement on professional conduct and discipline

requires that the doctor should at all times retain ultimate

respcnsibili t 21 for the management of his patients. It was the

view of Sir Randal-Elliott(J. 23 >that the general medical

practitioner who refers a case to a chiropractor does not

have control if the chiropractor is treat~ng the patient for

a subluxation. He concluded that the British ethical rule

would debar a medical practitioner from referring a patient

to a chiropractor who practises in the manner of New Zealand

chircpractors.

The position of the Australian Medical Association in unequivocal.

Its policy is that it is unethical for doctors to associate

professionally with chiropractors. <124 >

( 123)

(124)

Transcript page 1957

E;.:hibit Ml2

Of perhaps equal importance is the referral to the chiropractor

of one patient by another patient. The Parker Manual devotes

a whole section to this topic entitled "How to Stimulate

Referrals". <125 ) Points to remember in building a referral

practice include 11 the suggestion and desire to refer sick

acquaintances to the doctor can be successfully implanted in

the mind of each responding patient 11 • "By using some of the

following ideas, the doctor may artfully suggest to his

patients that they refer others: 1. Place tract racks with

literature on various diseases in the reception room, dressing

rooms, and other conspicuous areas. 11 Dr Parker lists 37

other artful ideas.

It is easy to see why the refusal of doctors to refer patients

to chiropractors can be misconstrued by patients as reflecting

nothing more than deep-·r, ,ted antagonism to chiropractic.

One of the more striking features of chiropr~ctic is its

ability to produce a strong sense of loyalty amongst its

patients. Many chiropractic patients see little or no

limitation to the conditionb which chiropractic can treat.

If the family doctor dismisses as unthinkable the suggestion

that a referral should be made to a chiropractor for treatment

(and particularly will this be so if the condition is within

the scope of Accident Compensation) then he may well be

regarded as hostile and motivated by commercial considerations.

( 12 5) Parker .Manual page 241

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'I'hE' cl11· t · £ · f · · ~ .roprac·ic pro·ession ·or its part 1s fond of labelling the

medical prof cssion as seeking every opporturii ty to confront

chiropractic, so that co-operation between the professions is

being delayed largely, if not solely, by the attitude of official

d . . d . 'l] . (]26) me 1.cine an J_ ts anci .. an.es. · · 'l'he truth is that in th:Ls

country as in North Z.:.,rnerica, the record shov1s that the ini ti.:i.ti vc

has always been taken by the chiropractic lobby. From the tirr.e

of the enactment of the Chiropractors' Association Act 1955,

there has been a relentless procession of petitions and other

parliamentary activity, culminating in the 1975 petition of

R.A. Houston and others. The actions of the medical profes$:i.on

have been simply in response.

We have already indicated in our opening address that the one area

in which we see some scope in the future for greater co-opera~ian

between the professions i .. : in the promotion of reseo.:r:c:h into the

value of spinal manipulative therapy. Leaving aside the

question of how such research should be promoted and as to

priorities of time and money, there is a willingness on the part

of the medical profession to see such research undertaken. At

the same time, it is an unfortunate fact that the record of

joint medical/chiropractic research does not engender a sense

of confidence that future research can be pursued on fully

co-operative lines.

I pass now to deal with another aspect of the relationship

between the two professions. It has appeared, with respecL, that

the Commission has been troubled by the inabi 1.ity of chiroprc1.ctors

(126) Submission No. 19, paras 2.2 and·2.4

to obtain rclinical training in hospitals while at the same time

the medical profession has criticised the lack of clinical

experience of chiropractors and consequently their diagnostic

skills. The explanation of this paradox is simply the

failure of chiroprc:.ctic to subscribe to a common scientific

base. It is the view of Professor D.S. Cole that teaching

staff would be unwilling to tench clinical subjects involving

the use of patients to students who did not share the same

basic beliefs as to causation of disease, physiological

mechanisms and the accepted pharmacological background for

therapy. <127 ) We thus return time and time again in this

inquiry to the incompatability of chiropractic beliefs with

those of orthodox medicine and the resultant barrier to

understanding and closer relationships between the two

groups.

I make no apology for repeating that the 1nedica_l profession secs

inter-professional co-operation as feasible only if chiropractors

accept one of two alternative courses. -Either they train as

manipulative therapists, pure and simple, and accept the ethic

of referral, or they adopt the tenets of orthodox medicine and train

as comprehensive primary health-care practitioners.

Chiropractic Education

A good dGal of time throughout these hearings h~s been devoted

to the subject of chiropractic education: quite rightly so

because, claiming as he does to be a prima.ry health care

(127) Supplementary Submission page 10, para. 5.6

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practi tio~-~r, the chiropractor must expect his training t.o be

judged and compared with that of the medical practitioner. It

is also that training which shapes the attitw1es of the

chiropractor towards the functions and limitations of his

clinical practice.

Chiropractic will brook no unfavourable comparison of its

educational institutions v-.ri th those of orthodox medicine.

Certainly there have been deficiencies in the past, but it

is claimed that these are being cured with time. It is said

that the standard of students, faculty, and facilities is

t 1 . . (128) cons ant y irnprovJ_ng.

There is of course much in chiropractic education which is

imitative of orthodox medicine. The modern CCE-apprcved

colleges hav 0 curricula, which, at least in terms of the pre-

clinical subjects, are almost identical with those of ruedical

·schools. Even pharmacology is taught, disguised as something

else, perhaps toxicology. <129 ) But grafted on are the clinical

subjects, in which the student is taught of the chiropractic

subluxation, a condition which may be causative of an almost:

limitless range of disorders. ~he existence of the subluxation

and its significance (if any) have yet to be demonstrated by

the scientific method. In our submission the theoretical base

for chiropractic education is false and the quality of that

education therefore largely irrelevant.

(128)

(129)

Transcript page 3247

Transcript page 3376

We do not find it necessary to say a great deal about the new

'straight' colleges, but at the same time we do not wish to be

taken as inviting the Cooonission to ignore them. It is more that

their place has been quite distinctly defined by the evidence.

'I'heir importc1.nce in the New Zealand scene is that the majority

of New Zealand chiropractors are 'straight' by philosophy and

upbringing. When taxed with some of the wilder aberrations of the

new colleges all the New Zealand chiropractors who appeared before

the Commission tended to dismiss them as fringe manifest.ations,

nevertheless their basic outlook was closely in sympathy. Not.

only that, but the founding of the 'straight' colleges provides

firm evidence of the new orientation of the CCE-approved colleges.

Any consideration of the chiropractic educational process must

inevitably lead to the question - a pertinent question - of

chiropractic diagnosis. 'i'wo procedures must ,tt once be

differentiated: chiropractic analysis, on the one hand, and

medical diagnosis on the other.

The method by which the chiropractor makes his 'separate and

distinct' analysis is known only to him. Certainly he takes

a history and makes some kind of physical examination,

principally directed toward the spinal column. The diagnosis

of vertebral subluxation depends, we are now told, not on

its radiological manifestations as depicted at IIoust.on, but

on the sensitivity of the chiropractor's fingertips: the

chiropractic version of· subluxation cc:m be palpated. Of coun-;e,

the neurocalometcr helps, particularly (i.t mc1y be thought.) to

impress the patient. Often chiropractic analyr;;is does not

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present any great difficulty as in the case of Derek Luke

when the chiropractor concerned simply ran his fingers down

the baby's spine under the singlet. (lJO}

Medical diagnosis is a different matter, one area in which

chiropractic is unable to imitate medicine. Not taught as a

separate subject in medical schools, diagnosis is the essential

skill of the physician acquired by undergraduate and post­

graduate studies, his years of clinical experience, and

continuing post-graduate education. In the sense that this

clinical experience cannot be matched by the chiropractic

profession, chiropractors are forced to teach differential

diagnosis as·though it were a separate subject. Chiropractors,

therefore, are simply unable to acquire a level of diagnostic

skill uhich is appropriate to their primary position.

There is at the same time a most profound danger in the teaching

to chiropractic students of a wide range of medical conditions:

the febrile disorders of childhood, gastrointestinal disorders,

genitourinary disorders, and eye, ear, nose and throat disorders,

to mention some. The danger is that the teaching includes

the hypothesis that the chiropractic subluxation may be

. f f 1 d . ' ( l J l ) S ' ' t ld causative o any o- t1ese con itions. ince i wou

appear that thQ chiropractor is also taught that the only

way of judging the applicability of chiropractic care is to

treat the patient. and then to wait and see whether the

( 130)

(131)

Tr~nscript page 170G

Transcript page 3213

condition'improves, the chiropractor is conditioned to a

trial of his therapy. He is unable in any objective sense

to weigh the needs of the patient and to refer him accordingly.

It is against this background that we can understand the

insistence of the chiropractor that he be seen as a primary health

care practitioner. He believes that he is trained sufficiently

to know when to refer his patient and when to treat. He is

therefore happy to encourage the patient, as did Hr Wade, to

"always consult your Doctor of Chiropractic first".

The State and Chiropractic

The Commission then is 1:equired to deal with a situation in which

North American-trained chiropractors believe thert!selvcs to b2

competent to ict as primary health care practitioners and pr~ctise

as sucho The task. of the Commission is to consider the

desirability of providing for the patients of those chiropractors

health benefits and medical and related benefits in respect

of the performance of their chiropractic services. It is

the strong submission of those I represent that the payment

of such benefits cannot be justified.

I remind the Commission of the criteria laid down by Professor

J.B. McKinlay to determine whether or not a service should be

publicly funded. He said that the service should be effective,

cost efficient.:. and socially acceptable. Eu.ch criterion is

suggested to be a necessary but not sufficient conditio11 for

the inclusion of the next criterion. The effectiveness or

. . otherwise of chiropractic treatment remains after 83 years a

moot point. It has not been demonstrated that the therapy

has an effectiveness which is attributable to the therapy

itself rather than to factors extrinsic to the therapy.

The cost of the service must be compared wi.th the cost of exi~ting

subsidised procedures. Particularly in the case of visceral

disorders, chiropractors are willing to deliver their therapy

concurrently with the treatment of the same visceral disorder

by a medical practitioner. Under the NZCA proposals, the

chiropractor would claim a primary health benefit for that

treatment. He would also claim a secondary benefit in

respect of his xrays. Unlike the chiropractor, the medical

practitioner will arrange for his patient to be x-rayed in·

only a small-proportion of cases. The result then of concurrent

therapy wi.l_ be that two primary benefits (one medical and

one chiropractic) and one secondary benefit (for chiropractic

x-rays) will be paid in respect of that patient. The cost

of the treatment of the patient's medical condition is

increased by the addition of a second subsidised primary

practitioner who is treating the same condition.

Social acceptability means more than simply that people are

satisfied with the service. It involves the requirement that

the service should be generally available to those people who

wo-....ld be assisted by the treatment. The number of practising

chiropractors in New Zealand is 96. In many areas of the country

(particularly in the South Island) access to these practitioners

must be extremely difficult for many people, if not out of

the question.

The payment of benefits for chiropractic services would ulso be

incompatible with the present dual system of public and subsidised

· h ltl · As· w~s poi"nted ou·t in ~he main submission private ea - 1 services. ~ ~

f ) th (132) of the Department o Hea. :

" ..• in the existing dual system, there is not a single exrunple of a

health benefit or subsidy being available in the private secto:c for

services not avz..ilable in the public sector. 'l'o introduce such a

subsidy or benefit would be invidious and quite contrary to the

essential philosophy of the health service."

Chiropractic services are not at present available to the

patient within the hospital system in this country. Even assuming

that this situation were to change, it is doubtful whether

chiropractic services would be effective in a hospital setting.

A key ingredient in chL practic treatment is the development

of an emotional bond between the chiropractor and his patient.

The bond is created in the chiropractor's waiting room with its

pamphlets and notice boards, and reinforced by his encouragement

and enthusiasm during treatment. The hospital atmosphere does

not lend itself to the creation of this type of rapport.

Looming over us in any consideration of the payment of chiropractic

benefits is the presence of large numbers of people ·who consider

that they have obtained satisfaction from chiropractic. Many

of these people say they l1ave received treatment from the medical

profession which has not relieved their conditions. Yet following

(132) Submission No. 39, page 26, para. 14

.. - ~'-¼ -

a period of chiropractic treatment, they appear to have

obtained relief. Some have spoken of 'miracle' cures, of

relief from painful and sometirnes disabling conditions.

They have paid for their treatment from their own resources,

and no doubt in a great number of cases it has-been a hardship

to do so. I pause to note that the payment of the fee by

the patient may be part of the explanation for the results.

The service that is paid for is rnore appreciated than the

service which is subsidised by the State - or as put more

directly by Dr Parker of Fort Worth:

. (133) "Patients who pay cash get better results."

These patients then ~2:now that they have benefited from th2ir

treatment and why then should that treatment not be subsidi2ed?

So long as people are achieving relief, what does it matter

how that relief has been brought about?

I have already discussed the difficulties with this type of

evidence. I do not belittle these people or seek to brush thorn

aside. The fact remains however that in the context of a decision

whether or not to establish Government funding of chiropru.ct.ic

services, we must require something more. In my submission, the

Conuni.ssion must require evidence by way of properly conclucted

comparative trials; evidence that the service does more than

simply satisfy patients, but is effective in improving their

health. If, notwi thstandh1g the absence of such evidence, tLe

( 13 3) Transcript page 1826

Co:nmission is of a min<.1 to recommend the payment of benefits tor

chiropractic services, we trust that the Report will reflect in

the clearest terms that the recommendation is not basc~cl on any

scientific evidence. It is however inconceivable to those I

represent th2:.t this Commission could make such a recommendation

without having been brought to a belief in the validity and

effectiveness of chiropractic treatment over and beyond the

demands of.patients, compelling though these may be.

I want to examine briefly the consequences of the granting of

subsidy for chiropractic services in the present state of

things. First and foremost, it would constitute an acceptance

by Government of the value of chiropractic as a legitimate

and alternative health care system. At that point there is

no turning b~ck from further demands for full equality with

the orthodox rnedical sy:;;tem: in this regard North A.rnerican

experience as to the growth of demands may be salutary. The

consequent inevitability of two funded health care systems

operating in parallel and providing in many cases concurrent

treatment for the same patients is apparent.

At the same time, the impetus for chiropractic to demonstrate

its effectiveness by the scientific method would be substantially

weakened. If acceptance for Government funding can be achieved

without the demonstration of an adequate scientific base, then

it is an unfortunate conclusion that a profession of clinicians

is likely to see J.i tl:.J.e point in bringing together research

. (134) proJects.

(134) TrJnscript page 1347

Faced with' these dif f icul tics, it is incvi tab.le that the co1m1i.i.ssio~1

should be drmvn to consider various alternative bases of funding.

It may be thought that subsidy could be restricted to the treatment

of musculo-skeletal disorders alone, an area in which chiropructic

claims its greatest successes. Even in these cases, however, we

can find no adequate evidence that chiropractic is any more

effective than could be accounted for by a placebo.

The difficulties of restricting the range of conditions for wl1ich

subsidy would be priid in any event appear insuperable. After all

the evidence presented to the Commission at these hearings, it. is

clear that the scope of chiropractic is virtually unlimited.

Perhaps the most singular demonstration of the wide scope of

chiropractic practice in this country was to be found in the

testimony of patients.

But not only is the scope of chiropractic all-encompassing,

yet it is seemingly indivisible. The chiropractor is after all

simply looking for and treating the subluxation, not the patient 1 s

diabetes or asthma. Almost any disorder of the human body is

capable of being linked by his philosophy to the spinal column.

In any event, a restriction of subsidy to treatment of musculo·­

skeletal disorders is unlikely to be welcome to chiropractors.

·a<l35) As Dr Haldeman has sai :

"I think as a clinician, I want the right to cir::ply trcatmeut I

think rr.u.y benefit my patient... I would not Li.kc co[.;t to the

patient to be a consideration af; to whether I would b0 wiJJ.j ng to

/l')C::\ fT1 ,- - ,. ' ~- - .,._ ~ ._..,,. .J... ... .... -. ...... - ""'I JI ~ A

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apply a potentially beneficial trca1:ment. 'l'haL vmuld be the car;e,

because a poor patient could not afford it and he would not receive

a trial for that form of treatment."

What Dr Haldeman is saying is that chiropractic treatment of

patients suffering from visceral disorders should be funded

because it is possible that the patient might respond to a

trial of chiropractic treatment. We are asked then to envisage

subsidy of chiropractic treatment not. upon the grounds that

it is effective, but upon the grounds that it may be effective.

And that effectiveness is to be assessed by the clinical judg~ent

of each individual practitioner. If that is to be the crit2rion

for subsidy, then there is really no criterion at all.

This is perhaps a convenient point to mention the subject of

children and chiropractic. It is the propen~ity of chiropractor3

to treat young children, even babes in arms to encourctgc

patients to bring in their children. It is a theme which has

emerged repeatedly from patient testimony. The risks a:re

obvious, as is the fact that unlike his adult counterpart, the

child chiropractic patient has no choice. ~e do not see that

any restriction is practicable if one believes in the chiropractic

subluxation. One cannot very well suggest that infants'

subluxations should be put in cold storagr..: until some minimum

age is attained. One can only see the wh0le subject of children

and chiropractic as an ndditionitl ground ~cighing against Eny

State subsidy for chiropractic.

In the final analysis, the Commission is :aced with two ~ltorn~tivc

courses: ej.thcr no subsidy for chiropra~~ic services, or

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subsidy for treatn1t':nt of any condition which i.n the jud 0n1ont

of the chi.ropractor might be assisted by it. As Mr Mudgw~y

t . t ( 13 6 ) tl l · · pu l - , - ·1e on. y restriction can be on the therapy that

is used, and not on the conditions which might be treated.

The choice is to be seen against a background of subsidised

primary health-care based on the general medical practitioner,

and in turn upon teaching within the University system.

As medica.1 science evolves, and infective diseases such -3.s small­

pox, typhoid, tuberculosis, poliomyelitis, pneurnm1ia, plague,

malaria, chulera, and typhus - the great killers of the past - are

co:-:trollccl if !1ot eradicated, their place is taken by dcgencra.tive

disorders, both mental and physical, which in turn limit man's

qualitative and quantitative life-ex~ectancy.

. ·' d t· a· ~ Prominent among ~nesc egenera-ive isoraers is spondylosis,

degenerative spinal disease. Ultimately, of course, there is

no answer to this problem: as life expectancy is increa.!3ed by

medical science, so the statistical risk of suffering from such

degenerative disorders increases. This is Nature's homeostatic

mechanism.

It is perhaps natural, almost Darwinian, that chiropractic should

tend to flourish within the spectrum of disorders which are ill-

def inoc., vihich i:l:Ce chronic.:, 1•1hich are not irnmcdi.a tcly lif (;--

threaten.in;, w:nich tend to come ;::i_nd go, o.nd where c.::..u~,•~ and

(136) Transcript page 585

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effect are often blurred. Into this category comes degenerative

spinal disease, the rudiological manifestations of which were

admirably documented at Houston and which (on their own) would

provide chiropractors with a livelihood. It is in this grey

area of medicine that chiropractic flourishes.

But it is illogical for the State to accept into this area a

small group of self-styled primary health-care practi~ioners

whose training, far from being centred in the New Zealand University

system, is carried out in institutions of doubtful quality.

Nowhere in the world is there a chiropractic teaching institution

with University affiliation indeed, there are those within

the chiropractic profession who feel such affiliation would

jeopardise chiropractic autonomy; in the academic sense, chiro--

practic is literally 'separate and distinct'. It is to the

University, above all, that the Sta~· must look for the ult.imate

scientific truth, and as a corollary of that truth, in the field

of medicine, look to rational scientific practice.

Using a single modality of unproven treatment for a range of

disorders only limited by the imagination or conscience of its

practitioners, it would be little short of an absurdity for

chiropractic to be recognised by the State as a valid form of

healing art, let alone subsidised by taxpaying citizens.

Sumrnary

The opposition of the medical and scientific communities which

is universal and international is to chiropractic as a philos6phy

not to chiropractors as individuals (pp. 1-4}.

The Commission should see the 11,000 letters from patients as

a calculated exercise of the well known chiropractic mailbox

lobbying technique; likewise the "Listener" article (pp. 5-8}.

In a nu.i7lber of respects the preparation and presentation of the

main chiropractic paper is open to serious criticisrn (pp. 9-12).

The Comr:1ission should give full weight to its own crn1cl1:isim1s,

untrarn.i~1ellec. by the viewB of other Inquiries which m.::.y not hcrve

been ccnc1ucted ,·:i tL the same thoroughness (pp. 13-14) .

The basis of the opposition of medicine remains that the basis

of chiropractic is an unproven theor~ shackled to a single

modality of treatment, the efficacy of which is also unproven

(p. 14).

Individual chiropractors differ significantly in their philosophy.

A..>1y recom.1;1cndations of the Commission should hold good at all

points of the continuum. One should distinguish between what

. . t ~niror>rac ~or:: say and what they do. (pp. 15-19).

i·:hatever ch;::;.n~Jcs may be ·c:!.tt:d.butc<J to the CCE, the gr<1duates

of Palmer College continue to base the5.J: outlook on locriting

and treating the subluxation. (pp. 20-23). nut. Scott llaJ.du11,m

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recognises that neither this nor any other theoretical basis has

been proven, and that the repeated references to treating the

subluxation arc a defence mechanism (pp. 20-27). The reason

whv the treatment is administered or is thought to work varies ....

greatly. In the end the backbone of chiropractic is pragmatism

(P":J. 29-30). Chiropractic is simply what chiropractors do.

Turning to the characteristics of chiropractic as a calling, in

its outlook, standards, ethi.cs and ability for self-discipline,

chiropractic falls short of the standards of the professions

{pp. 31-39).

?~e CSA. influence, with its undesirable implications, will continue

to be felt in New Zealand for the indefinite future (pp. 40-44).

The chiropractor must choose between -

1. being a manipulative therapist and adopting the ethic of

referral, or

2. adopting the profession~l tenets, the scientific base of

orthodox medicine and train as a comprehensive primary

health care practitioner. (p. 45).

?he eemonstration of the efficacy of chiropractic should be

a requirement of any decision to subsidise chiropractic services

(pp. 4 6-- 4 7 ) •

A:-ieccotal evic1c,1•.,c,.,. ~"' v-1]t1eJec:-s ·:l"-" ev1·a,-,1cr. of eff' ~ y ( t.8) - ~ ., •• :, < ••• _·.~ c.c, cl;'- - · :_:J.Cu.C p .. ,, .

t ; • - 102 -

No-one but a chiroprQctor can detect a chiropractic subluxation

(p. 50). Yet. t.hc notion that he has discovered a tan~Jible:

condition of the spine is readily conveyed to the patient,

primarily by the use of x-ray films. (p. 52).

The theoretical base of chiropractic is unproven and unprovabJ.e

(pp. 59-60) .

Controlled trials offer the only scientific method by which the

efficacy of chiropractic (if any) over and beyond the placebo

can be demonstrated (p. 61). Those trials which have been carried

out are inconclusive or negate any superiority of chiropractic

treatment (pp. 62-70).

Chiropractors arc nonetheless prepared to treat on a 'h 1ait an,J

see' basis (p. 71). If the patient improves, then the result

is claimed to be a chiropractic success.

The willingness of the chiropractor to treat patients with a

wide range of medical conditions leads patients to view th~n as

offering an alternative to orthodox medicine (p. 72). There is

a consequent risk that necessary medical care may be delayed.

Chiropractic is not simply a harmless, albeit probably ineffe~tive,

therapy. Spinal manipulation carries the risk (stati~.;tically

slight as it may be) of serious injury to the p~ticnt: (p. 73).

The medical profession opposes the refc~ral of patients to

chiropractors because:

- .L\J.J -

1. A referring doctor could have no control over the nature

of the chiropractor's treatment;

2. The efficacy of chiropractic has not been demonstrated

(pp. 76-77).

The attitude of chiropractors to referral is designed to enable

-~ 1· ~

them to have the best of all worlds. They see themselves as

specialists, but without any control by a referring doctor (pp 81-83)

Chiropractic education is founded on a theoret.ical base which is

false (p. 88). There is at the same time a d,:;_r:.ger in the teachi:1~J

to chiropractic students of a wide range of medical conditions:

the teaching includes the hypothesis that the chiropractic

subluxation may be causative (p. 90).

The payment of ben~fits for chiropractic services cannot be

justified {p. 91). There is no adequate scientific evidence

that chiropractic works (p. 95).

There is no means by which the scope of criropractic can be

restricted (pp. 96-97).

- 104 -

Conclusion

In the course of this address we have dr2:"!.wn attention to

all those aspects which in our submission are of importance

to the Conm1ission in dealing specif icc .. lly with the terms

of reference. There is possibly one exception and that is

the question of 11 separate and distinct". At the time the t.ern1s

of reference were framed it may have seemed important to

crystallise in this way a contention oftRn advanced by

chiropractic in support of claims to inclusion in national

health care schemes. In light of the much more complete

picture which we all now have about chiropractic in general,

it is evident that the question no longer points to any clear

cut answer. To the left of the Jarvis continuum, it is

apparent that in certain senses of:: the phrase c)·,i.ropractic

must be seen as separate and distinct, but not, we submit,

in any way that enhances its claims. I refer to the theosophic2l

component, which is particularly seen on the far left of t.h"-::

continuum, and the belief in the sanctity of the S'.1bluxation 1

which features more widely. These elements certainly separate

chiropractic from orthodox medicine, and lend it a degree of

distinction, or distinctiveness. To the right of the continuum,

on the other hand - and here v.re return to Scott Haldeman ..

chiropractic is simply spinal manipulative therapy under a

different name, spinal manipulative therapy practised by

primary pract.i tioncrs who lack the diagnostic skills which ca1.

be acquired only by a full medical training. 1'here an~ eJ c::rncnt.~~

of separate and distinct at the right hand end of the spectrun

too, but a0ain not in a sense helpful to advancing the c l~nm~_;

,..,.-r-,..1--,; ,·,--.,nr.,-,r+i r- ~ in na:cticular, I 1T,2c:1n the belief that spinal

manipulative therapy is useful in the trcabncnt of a broad

spectrum of disorders. I submit that the issue whether chiro­

practic is separate and distinct cannot he answered in any

more decisive way.

At to the other parts of the terms of reference, those I

represent have throughout been opposed tot.he provision

of any benefits under the Social Security Act for chiropractic

services, or any extension of the provisions made in that

regard under the Accident Compensation Act. We submit that

the proponents of chiropractic have not established a case [or

inclusion. We do not rc~st our position on any mere fa_iJ 1_1rc

to discharge an onus of proof. We maintain that the case of the

opponents has been positively established, but if in the

Commission's viev1 the onus of proof is important., then in that

respect we refer the Commission to the submission contained :i.n

. (137) 1 our opening. . t may be worth repeating one sentence:

is unthinkable that the Commission should make a favourable

recommendation without feeling satisfied in its mind that

chiropractic is soundly based, both as to its theory and in

its practical apFlication.

it

In this regard it is not difficult to discern why it was such

an important part of the NZCA case to attack: the ethical ruling.

To break down that barrier would be a significant step along the

road towards health benefits. Patien-i·.s I demands may then

well bring about the situation where true referrals result.

( 13 7) Transcript page 1731

- 106 -

'£hen one may E~nvi~::age tbe prospect tl1ut health benefit~; are

payable where there is referral. In this way, having st<1rtccl

with mere registriltion, step by step chiropractors may be

enabled to achieve complete recoqni t.ion by political rneasu:cc~s

alone, without the validity of the chiropractic hypothesis eve~

having been put to proof.

Demand should not be confused w.i.t.h need. "rhere will always

be demand for alternatives to the system of medicine. They

appeal to those who want to do their own thing, to the heterodox,

and perhaps most importantly to the inevitable failures of

established medicine. All this is within the normal \·Jide :can~iC:!

of human behaviour, but it does not found any claim to public

funding. The establishment of a national placebo service cou]d

not claim any such priod_ ty.

If contrary to our case the Commission felt satisfied that \·!hat

for brevity may be called the chiropractic hypotheses had been

established, of course it does not automatically follov1 th,~t the~e:

must be a recommendation in favour of the inclusion of chi:coprac-c.i.,;

services in health benefits. There are many health fieJ.ds which do

not attract benefits. Indeed, the Commission v:ill weigh ci.ln~-

fully whether it is not one of the hidden strengths of chiroprc:..cti c

that it stands outside the system of orthodox medicin~.

In all the respects with which I have just. been dealin9 tb.!

attitude of thosG I represent remains exactly as it w~s the day

the Chairman opcnccl these s:i. ttin9.s.

-, ·1 ~. ~ i

That leads me to my final subject. 'l'hc members of the Commission ·1

must be very conscious that those opening remarks were mc1ac as

long ago as 15 March 1978. ~1roughout the protracted sittings

since then, the Commission has extended to those appearing before

it the most exer..plary tolerance, patience,. and attentiveness.

The subject matter of your Inquiry is one which over a long period

of :years has brought two callings into conflict. No Tribunal

faced with such a task can hope entirely to avoid bickering

a:1d bitterness, but the qualj_.ties of the members of the Commission

have been such that these aspects have been kept to a muamum;

and the ~edical Association has asked me particularly to make

reference to the lead given in this respect by the Chairman's

signal courtesy.

Although you have not shown any hint of this in public we are

all conscio~s of the disruption which service on this Crnnmission

re~st have meant to the personal and professional lives of each

o~ you. On behalf of those I represent I wish to express our

appreciation of the matters I have just mentioned, and our thanks

to the Commission for the way in which it has adhered to and gone

about its important and demanding task. We wish also to thank

1'!r Heath and the Commission staff. In t.h.e efficient and, if I

may say sd, invariably pleasant way in which Mr Heath has attende~

to his duties, he has contributed greatly to ease the long

assignrne~t which has faced us all. Finally I express our thanks

and appreciation to the shorthand reporters. To many of us

they are a teilm of old friends from a vnriety of hearin9s over

the years, but one never ceases to admire~ tht:~ir abili t.y and

efficiency.

We concl·~ . .1(~ by \·-d.r;hing the Commission well in its enquiries

overs6as, and we will now awnit with interest the opportunity

to read the final report.