In response to “The Knowledge of Our Knowledge”: 2 decades and not much has changed

Abstract

The chiropractic profession has struggled with how it is viewed and perceived by those within the profession and the powerful forces outside the profession. This commentary suggests that the vast majority of professional unrest is largely due to lines drawn upon philosophical boundaries and how we perceive what we know. For the profession to advance, it is imperative that unsubstantiated claims are eliminated from our justification for being and that we continue to test theories using scientific methods. Theories espoused must be able to be supported by valid research, and we must be ready to accept the results of these investigations and either build upon that body of research or accept the findings and move in alternative directions that science will take us. In doing so, we will contribute to the philosophy of health and perhaps help to change the health care paradigm from disease focused to wellness, which is based upon evidence and not emotion.

Introduction

It is an honor to review and comment on an article written by my dear friend Jerry McAndrews.¹ One would think that, in more than 20 years, some of the issues of concern that McAndrews addressed should have been resolved or at least ameliorated to some degree. Unfortunately, we have not seen the changes that one would have hoped for. When it comes to discussions about “Chiropractic Philosophy” or should I correctly say “philosophy of chiropractic,”^2,3 there seems to be no limit to the time required for dogma to disappear and credible information to take its place.

It is imperative that we develop a new understanding for how to build the bridge between philosophy and practice. There can be no theory without new data to drive ongoing investigation, as well as no theory without a hypothesis to build upon. Yet when it comes to relating to what constitutes the philosophy of chiropractic, we often believe in things without being able to disprove them. Thus, knowledge transfer to the profession is more difficult than anyone could have possibly realized. McAndrews lamented that the distortion of what constituted philosophy that was being taught and perpetuated would thwart most efforts to truly understand the importance of philosophy and its applicability. The following are my reflections on his article titled “The Knowledge of Our Knowledge,” and I offer suggestions for the chiropractic profession to consider as we continue to look at these issues.

Discussion

No better quote could be proffered to discuss this topic than the words of CO Watkins, DC, who exhorted us to be “BOLD in what we hypothesize, but CAUTIOUS and HUMBLE in what we claim!”² This admonition may be one of the fundamental reasons for how and why the philosophical divide continues to exist. The proponents of the limited approach to patient care (limited to only the detection of subluxation) suggest that, if one understands ”Chiropractic Philosophy,” this understanding negates the need to do research and scientifically investigate these claims. This dogmatic approach results in a means of sidestepping science. Detractors on the other end of the spectrum, those who oppose this limited viewpoint, might go so far as to require scientific evidence and validation a priori for everything done in practice, which is neither reasonable nor realistic. Thus, the division within the profession continues. It would appear that somewhere in the middle lies a position that is valid and achievable.

McAndrews opines in his 1991 article that the meanings of the term philosophy are not well understood by the profession and, thus, this misunderstanding has enabled distortions and improper contexts to contribute to a philosophical divide. The term and its multidefinitions have been polarizing to the profession to a point of creating a paralysis of forward movement. The vitalistic and the mechanistic coalitions fight against each other; and until there is a greater effort to test the testable and untestable components, the battles will likely continue.^2,4

In 2012, the disagreement over what truly constitutes philosophy or ideology is still front and center. The issues regarding educational qualifications, research validity, and professional authority become extremely confusing when many of the issues being debated within the chiropractic community are not “philosophy” per se but are unfortunately linked to, or confused with, philosophy. Emotional tirades fill our publications, with disagreements ranging from opposing or supporting a modernized Council on Chiropractic Education standard of accreditation to whether to oppose or support the use of additional modalities (expanded state statutory authority to use prescription drugs).

Terminology also fuels this philosophical divide. The debate continues over the use of a professional lexicon that has no universal agreement by all participants. For example, mandating the incorporation of, or eliminating, the term subluxation to describe the profession generates a volatile reaction bordering on blasphemy by a segment of the profession. Conversely, defining the chiropractic profession to include primary care physicians or chiropractic physicians brings about an equally intransigent position to another faction. The list of disputed issues and the emotional temperature on both sides of the conflicting debate(s) appear to have no limits, and all exist under the banner of difference of chiropractic “philosophy.”

Chiropractic has always faced a challenging conundrum regarding how it will be perceived by those within the profession and from powerful forces outside the profession. On one hand, there is an increasing body of evidence supporting the contention that health care must focus on health and well-being rather than simply attempting to find a cure in a pill. The metaphysical belief system in and of itself has provided divisiveness by an underlying construct that suggests that these beliefs cannot be scientifically validated. This contention only provides food to fuel the allegation and appearance that cult-like dogma is in play. The very act of holding oneself, or a profession, immune from critique creates the very foundation for ritual and dogma. As Wartfosky stated, “Metaphysics, in introducing the conceptual models as an articulate, explicit object of criticism, represents the way back to a critique of the foundations of understanding.… When a metaphysic holds itself immune from a critique then it degenerates into non metaphysical ritual and dogma.”⁵ Thus, as a profession, we must overcome these urges to “hold ourselves immune” and instead allow ourselves to critique our foundations.

The chiropractic profession has made previous attempts to investigate the principles of chiropractic. In the prior decades, research was focused on double-blind controlled trials, which were perhaps not the most appropriate model for chiropractic research. Moving away from that model was difficult because controlled trials were considered the criterion standard and chiropractic researchers wanted to engage in credible research.⁶ There were not many research projects conducted to test the hypothesis that “subluxations” interfere with the body's ability to maintain health. This research void included both sides of the profession: those supporting the assertion and those repudiating the hypothesis.⁷ In fairness, valid research is expensive; and there was limited access to research funding to engage in trials of the magnitude that would provide meaningful data. However, this does not excuse the lack of focus by the profession in attempting to research these essential questions.

McAndrews bemoans the lack of intellectual challenge. In undergraduate school “claims had to be supported by a footnote reference to its source and hypothesis required challenge by expecting claims to be submitted to refereed journals.”¹ Yet even when attempts are made to potentially test the validity of the “subluxation syndrome,” there is ridicule from scientific communities and confusion within the chiropractic profession.⁸

Unsubstantiated claims that subluxations influence organ systems, and therefore adjustments can effect a cure to these systems, continue to be proclaimed and yet remain largely unsupported by scientific inquiries that test these questions. This is a contentious yet important differentiation between the pragmatic practitioner and the chiropractic scientist. Practitioners witnessing the daily benefits of providing spinal adjustments/manual manipulation to their patients never stop to ask the question that the chiropractic scientist does: “Is the subluxation clinically relevant?” This view is questioned from diametrically polar ends of a spectrum and provides the fertile ground to generate the ongoing seeds of discord because of misunderstanding rather than provide insight and clarity. Subluxation is an unchallenged notion for many in the chiropractic profession and is recognized as such by various chiropractic leaders.⁹

McAndrews rightly viewed the philosophy of the science of chiropractic as referring to the explanation of the science of chiropractic. McAndrews stated that DD Palmer contended that “science is ever developing (and thus changing), so also does the philosophy of chiropractic develop (change) with it. The two not only go hand in hand with each other, they essentially are each other.” Maybe if we can approach science and philosophy in this manner, we would be able to reach beyond our differences.

As we enter the second decade of the 21st century, we are still challenged to understand fully that the fundamental hypothesis of chiropractic has not yet been satisfactorily resolved. The health care environment continues to evolve, and other professions may be moving into areas that we once thought were ours alone. A wave of “New Medicine” theories and advancements has made the distinction between chiropractic and other healing methods more challenging. Pronouncements from biomedicine state that treating the body alone is not enough; the mind can also play a critical role in the healing process. Medical physicians appear to be embracing a more holistic form of health care, seeking to heal the whole person. Treatments once considered fringe, including visualization, meditation, and hypnosis, are being prescribed alongside high-tech Western medicine.⁴

It is interesting to see medicine beginning to embrace many of our chiropractic constructs. No other profession has been so aggressively attacked by medicine than chiropractic, which has always integrated “holistic” approaches to health. Throughout these decades of vicious attacks, the chiropractic profession was the leading alternative health care group to provide an alternative philosophy of health. Chiropractic has developed different concepts of health care: the role of the provider, the role of the healer, and ultimately the health care encounter itself.¹⁰ We must be prepared to build upon our body of research. We have the potential to contribute to the philosophy of health and to change the health care paradigm from disease focused to wellness. However, in doing so, we must profess our knowledge based upon evidence and not emotion.

Conclusion

For the chiropractic profession to advance, it is imperative that unsupported claims be eliminated from our paradigm. Chiropractic and the theories espoused for many decades appear to be gaining credibility and validity.¹¹ However, they must be able to be supported by valid research. We must be ready to accept the results of these investigations and either build upon that body of research or accept the findings and move in alternative directions that science will take us. In doing so, we will contribute to the philosophy of health and perhaps help change a paradigm from disease to wellness based upon evidence and not emotion. Perhaps then the “Knowledge of Our Knowledge” will be understood: McAndrews would be proud.

Funding sources and potential conflicts of interest

No funding sources or conflicts of interest were reported for this study.