Doctors, chiropractors and a secret agreement: Manitoba lawsuit suggests a troubling code of silence

Chiropractors are suing doctors. Or, rather, the Manitoba Chiropractors Association has just launched another lawsuit against the College of Physicians and Surgeons of Manitoba.

Having sued the doctors previously for defamation, in 1997 and 1998, the association is now suing the college for allegedly violating a secret agreement the two groups signed in 2003.

This lawsuit raises troubling ethical questions. But to come to grips with these questions requires some background information. 

First, underlying this imbroglio is a debate about scientific evidence. The association acknowledges that close to 99 per cent of Manitoba chiropractors practise spinal manipulations on a daily basis. They describe spinal manipulations as "a key component of chiropractic practice."

However, the college of physicians and surgeons has serious scientific reservations about the validity of the procedure, according to their submission in a 2017 report to an advisory council to the health minister.

Collegiality with allied health-care professions is a desirable goal.… But surely the goal of protecting public health should trump such considerations.

The doctors point to research showing that spinal manipulations are associated with such serious adverse events such as fractured vertebrae, spinal cord injury and strokes. They also point to lesser adverse effects such as fatigue, nausea and tinnitus.

In response, the chiropractors cite four articles in the 2017 advisory council report which, they contend, support their claim about the benefits of spinal adjustment for targeting neck pain and headaches. The doctors aren't persuaded and regard the scientific evidence cited by the chiropractors as weak.

Hence, the earlier lawsuits filed by the chiropractors against the doctors for defamation.

Agreement to 'refrain from criticisms'

According to the association's latest lawsuit, in March 2003, the two groups — the Manitoba Chiropractors Association and the College of Physicians and Surgeons of Manitoba — signed a secret agreement in which the doctors agreed to accept the legitimacy of the practice of chiropractic.

The association's lawsuit says the agreement itself is confidential, but also says the groups agreed "to refrain from criticisms by each institution of the other."

If the college did indeed sign such a secret agreement, then it is guilty of violating the fundamental principle of medical ethics. Every doctor takes an oath to place the life and health of patients above all other considerations.

If the professional regulatory body of physicians and surgeons believes that spinal manipulations, as practised by chiropractors, pose unwarranted risks to the life and health of patients then how could they commit themselves to remain silent about these risks? Collegiality with allied health-care professions is a desirable goal, as is avoiding costly litigation.

But surely the goal of protecting public health should trump such considerations.

Was the confidentiality clause in the purported agreement an implicit acknowledgement that what they were agreeing to do … was a shameful derogation from their commitment to protect public health?

A similar criticism can be made against the Manitoba Chiropractors Association. They are licensed health-care professionals. They are committed to put the life and health of patients above all other considerations.

So how could they, in conscience, agree in a blanket manner to refrain from criticizing the medical profession? If chiropractors have good evidence to support the view that some medical procedures are unsafe and ineffective, then surely they have a professional obligation to warn the public.

Moreover, one has to wonder why these two professional organizations, having allegedly decided to sign a non-aggression pact, further decided to keep that pact secret. Was the confidentiality clause in the purported agreement an implicit acknowledgement that what they were agreeing to do, presumably for reasons of mutual self-interest, was a shameful derogation from their commitment to protect public health?

Concerns raised in private letter

Notwithstanding the agreement it's alleged to have made, the College of Physicians and Surgeons of Manitoba did eventually voice its concerns in a 2016 letter. Not to warn the general public, mind you, but in a private letter to the minister of health's advisory council on the regulation of Manitoba's health professions.

Two years later, when the chiropractors association got wind of this private letter, they took legal action.

There are other bones of contention between the parties. One of these concerns informed consent. Do Manitoba chiropractors adequately explain the various risks of spinal manipulation to their patients? If they exaggerate the likelihood of benefit or brush lightly over the risks of harm, then they are not obtaining genuinely informed consent. 

The chiropractors could respond with what philosophers call the tu quoque argument: aren't physicians and surgeons also guilty of failing (sometimes, often) to adequately inform their patients of the various risks associated with prescription drugs and surgical procedures?

Of the poor quality of the evidence supporting many medical treatments? What cannot be doubted is that patients are entitled to give or withhold informed consent to any recommended medical procedure. Failure by any health care professional to provide patients with adequate information would be a serious violation of patient rights. 

I am not a lawyer. Hence, I'm not qualified to offer an expert opinion on whether the chiropractors association will succeed in its legal efforts to force the college to comply with the terms of the secret agreement and to pay financial damages.

But the purported secret agreement is so clearly contrary to the public's interest in health protection that it would be shocking if the Manitoba Court of Queen's Bench were to allow it to be enforced.

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