Jun 17 2008

Chiropractic Lawsuit

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Sandra Nette suffered a stroke following a neck manipulation by an Edmonton chiropractor. She alleges that the manipulation caused the stroke and she is therefore suing the chiropractor and the provincial government that allowed him to practice for $500 million dollars. This is an interesting development and how this case plays out is likely to have a dramatic effect on not only chiropractic but the regulation of non-science-based medical practitioners.

Chiropractic Neck Manipulation and Stroke

At present there is no evidence-based indication for chiropractic neck manipulation. There are many claims made for this procedure, that it can cure migraine or other headaches being the most common, but the evidence does not support such claims. Straight chiropractors – those who believe in the ideology that a magical life energy they call “innate intelligence” is necessary for health, and that most or all disease is caused by the blockage of innate intelligence. They manipulate the spine, including the neck, in order to relieve imagined subluxations and free the flow in innate intelligence. This form of chiropractic is pure pseudoscience.

But even those who partly or completely reject this ideology may still not live up to the ideas of science-based medicine. Since there is no indication for which there is adequate evidence to conclude that neck manipulation is an effective treatment, any risk to the procedure will be risk without benefit. Assessing the risk/benefit ratio of every intervention is one of the cornerstones of scientific medicine. Zero benefit means no measurable risk is justified.

The risks of neck manipulation are not trivial. The primary risk is that aggressive neck manipulation may cause a tear (called a dissection) in one of the four arteries that feed the brain – two carotidsto the front of the brain and two vertebrals to the back. If a tear forms in one of these arteries then a clot (called a thrombus) can form around that tear, blocking off flow through the artery and causing a stroke. It is also possible that the thrombus may break lose and flow downstream and then lodge in and completely block off an artery – when a clot moves it is called an embolus.

This is apparently what happened to Sandra Nette. She had a dissection in one of her vertebral arteries causing a stroke in her brainstem. This resulted in what is called a “locked in” syndrome – probably the worst outcome possible of a stroke. People who are locked in can move their eyes but nothing more (depending upon how complete it is). They may or may not be able to breathe on their own, but they cannot speak or move any of their limbs. They are locked into a living death.

Malpractice Suits

Even though I am a practicing physician, I believe in the necessity of malpractice suits. I have even given expert testimony for both plaintiffs and defendants.  It is not a perfect system – but it is necessary that genuine malpractice can be redressed through the courts. It is a needed “back end” method of regulating quality control – if a practitioner falls too far below the standard of care of harms patients, they should have to give compensation and perhaps even have their ability to practice restricted. Without such a system in place quacks would flourish.

Of course the system can be abused as well, and in this country the system could benefit from some reforms – but that is a topic for another blog

It is interesting that so-called alternative practitioners seem to be much less liable for malpractice suits. There is far greater variability in practice, and far less logic and evidence behind the practices, and yet they do not get sued as often as physicians. Part of the problem is that malpractice is based upon the standard of care – if there is no standard of care, because the practices are not based upon evidence, then how can you prove that what someone did was substandard. In other words – if a “healing profession” is entirely based upon pseudoscience, then pretty much everything they do is magic and quackery  – so what is there to sue for?

As regulations are progressively eased on these practitioners the situation becomes worse. Increasingly practices that are not medicine are allowed to be labeled as medicine. For example, Minnesota just gave permission to naturopaths to call themselves “doctor.”  Invariably, when a profession like naturopathy or chiropractic is recognized by the government they are generally given the ability to regulate themselves. Therefore unscientific practitioners can decide what their standard of care is by any methods they choose. They can decide that utter quackery is accepted practice, and the government signs off on it.

Law suits generally only happen when direct harm is caused – as is alleged in this case. I think this lawsuit is a good thing, and I hope it is successful and spawns more. If an MD performed a procedure that was not supported by scientific evidence and it directly caused a young patient to have a horrible stroke – you better believe they would be sued blind. If chiropractors won’t regulate themselves and the various governments let them get away with it – the courts are the last line of defense for the public against this dangerous quackery.

The very interesting twist in this case is that Sandra Nette is also suing the government for allowing this practice to continue. Good for her. If insurance companies and governments are going to be involved in deciding what care can be delivered, they have to share the liability. I have no idea about the legality of this case, especially in Canada – I don’t know if it is even possible to sue a provincial government. I would not be surprised if that part of the case were thrown out for technical legal reasons.

But I think this case should be a wake up call. The government cannot continue to license nonsense and call it medicine.  The public deserves better. I also think that public awareness about the risks of neck manipulation needs to be raised, and more importantly this practice needs to simply stop.

Watch how the government and chiropractors respond to this law suit. It will be very telling.

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