4.1 HISTORY
The American Medical Association revolutionized medicine in the United States when its members unanimously adopted the first Code of Medical Ethics in 1847. The AMA’s Code of Medical Ethics has been the authoritative ethics guide for practicing physicians for over 160 years.
The Code contains all the enduring values of medicine to which physicians commit themselves individually and collectively. It defines medicine’s integrity and the source of the profession’s authority to self-regulate. At the same time, the Code of Medical Ethics is a living document that evolves as medicine and the delivery of health change throughout time. The Code links theory and practice, ethical principles and real world dilemmas in the care of patients [1].
Link: http://www.ama-assn.org
Following the promulgation of the American Medical Association Code of Medical Ethics, Jukes Styrap (de Styrap as he was sometimes known) compiled what is considered ’the only important code of medical ethics to be published in Victorian England‘. In 1882 he offered his code to the British Medical Association, hoping it would become the profession’s ethical standard but his offer was not taken up. His publication did however become what was described as “the usually accepted authority on ethics in the BMA” of which he was a member. He published further editions in 1886, 1890, and in 1895 [2].
His initial publication was printed in 1878, but after reviewing the material, further editions were printed in 1886, 1890, and 1895, including fresh material such as sections on consultation with homeopaths, railway medical etiquette, medical detectivism and an appendix on the issue of bulletins from the sickrooms of distinguished patients [2].
Link: http://www.springerlink.com
During the twentieth century, the ethical codes of the medical profession were certainly upgraded in many respects but at the same time, in some areas (especially in America and in Australia) they certainly departed from the altruistic example set by the World Medical Association and were used as an illegal weapon against what was envisaged and promulgated as an opposing healing art.
The framework of modern medical ethical codes was developed following the end of World War II and was based on the ’International Code of Medical Ethics of the World Medical Association – 1949‘ [3]. The World Medical Association (WMA), founded on 17 Sep 1947 is an international organization which represents physicians. The organization’s purpose is to ensure the independence of physicians, and to work for the highest possible standards of ethical behaviour and care at all times. The Association is funded by its members through annual contributions.
The WMA offers a forum where members can discuss and communicate freely, co-operate actively and achieve consensus on medical ethics and professional competence standards [4].
Link: http://www.wma.net
4.2 INTERNATIONAL CODE OF MEDICAL ETHICS OF THE WORLD MEDICAL ASSOCIATION – 1949
Duties of Doctors in General
- A doctor must always maintain the highest standards of professional conduct.
- A doctor must practice his profession uninfluenced by motives of profit.
The following practices are deemed unethical:
- Any self advertisement except such as is expressly authorized by the national code of medical ethics.
- Collaborate in any form of medical service in which the doctor does not have professional independence.
- Receiving any money in connection with services rendered to a patient other than a proper professional fee, even with the knowledge of the patient.
- Any act or advice which could weaken physical or mental resistance of a human being may be used only in his interest.
- A doctor is advised to use great caution in divulging discoveries or new techniques of treatment.
- A doctor should certify or testify only to that which he has personally verified.
Duties of Doctors to the Patients
- A doctor must always bear in mind the obligation of preserving human life from conception. Therapeutic abortion may only be performed if the conscience of the doctors and the national laws permit.
- A doctor owes to his patient complete loyalty and all the resources of his science. Whenever an examination or treatment is beyond his capacity he should summon another doctor who has the necessary ability.
- A doctor shall preserve absolute secrecy on all he knows about his patient because of the confidence entrusted in him.
- A doctor must give emergency care as a humanitarian duty unless he is assured that others are willing and able to give such care.
Duties of Doctors to Each Other
- A doctor ought to behave to his colleagues, as he would have them behave to him.
- A doctor must not entice patients from his colleagues.
- A doctor must observe the principles of The Declaration of Geneva approved by The World Medical Association. [4], [5]
4.3 MEDICAL ETHICS RELATING TO CHIROPRACTIC IN AUSTRALIA
In Australia in 1974 the second edition of the book Medical Ethics and The Law by Arthur W Burton, Medical Secretary of the Victorian Branch of the Australian Medical Association, and Lecturer in Medical Ethics at the University of Melbourne carried the following [6]:
’Chiropractic has been in existence as a healing cult for the past 75 years. During this time have been dramatic advances in knowledge of the pathogenesis of disease. Yet there have been no corresponding changes in the tenets of chiropractors or in their methods of treatment. If the chiropractic concept is accepted, then it must be assumed that the whole basis of scientific medicine, as built up over the past two centuries by a vast amount of research and clinical investigation, is fallacious’. [6]
’Chiropractic schools are not accredited by any recognized educational accrediting body in the United States. They are self-accredited by agencies organized by the national chiropractic associations themselves, and these agencies have not met the standards necessary for recognition by the U.S. Office of Education’. [6]
’The patient has a perfect right to consult anybody he chooses about his own health, including, if he wishes to do so, an unqualified person. A medical practitioner, however, may not have professional dealings of any kind with such a person. The relevant rule of the Victorian Branch of the Australian medical Association is as follows:
‘“Rule 36. – It is unethical for a member of the Victorian Branch of the Australian medical Association to associate professionally with or refer patients to a practitioner of any exclusive dogma, such as homeopathy, osteopathy, chiropractic, hypnotherapy, etc., or any person professing qualifications not acceptable to the Australian medical Association.’ [6]
’On occasion a medical practitioner may be asked by an unqualified person to see one of his ’patients‘ for a condition which the unqualified person feels unable to handle. A patient needing proper medical treatment cannot be turned away, and the best course here is to say that if the patient himself gets in touch with the doctor an appointment will be made. Thereafter there must be no further professional communication with the unqualified person, and the patient must decide by who he is to continue to be treated-he cannot have both.’ [6]
After making references to Chiropractic colleges Burton stated,
“None of these schools provides a course of training which is in any way adequate in quality or in depth to produce graduates properly equipped to diagnose or treat any form of human disease”. [6]
The reference he gave for that statement was to a 1966 background paper written by himself as Medical Secretary of the AMA. As Willis has pointed out, ’It drew mainly on American material to evaluate chiropractic, in particular that provided by the American Medical Association’s Department of Investigation, though it did also utilize a pseudo-patient. The report found there were powerful forces working towards registration in Victoria. These included increasingly militant occupational associations able to mobilize considerable patient support, as well as support some minor political parties. Chiropractic in other words was drawing on its clinical legitimacy (i.e. with patients) to press for politico-legal legitimacy‘. [7]
’In 1966 the AMA was invited by the state government to investigate chiropractic and report on the advisability of statutory registration. A science subcommittee was set up and its report of 1967, accepted by the AMA, not surprisingly advised against registration. However it did set down minimum criteria under which registration should be considered. These included accreditation of chiropractic training schools by a recognized educational or academic institution, with registration restricted to graduates of those schools only, and educational training nothing less than what is required of other paramedical bodies‘ [7].
’The intention of the committee and the AMA was clear, as professor Rod Andrew, a member of the committee recalls, ‘The AMA committee at the time thought they’d built enough walls and dug a deep enough ditch and filled that with Enough bullshit to make it impossible for any chiropractic group ever to fulfill all those conditions‘. (Andrew 1979, 2) (Professor Rod Andrew who was dean of medicine of Monash University made this statement at the graduation ceremony of Phillip Institute of Technology). [7]
’The AMA communicated their report to the state government but apparently not to the chiropractors themselves who eventually learnt of the minimum criteria three and a half years later, when they requested discussions with the AMA in 1971 in an attempt to establish better relations. The ACA responded with an analysis of the AMA paper given to the state Minister of Health in which they challenged some statements of fact but basically agreed with the criteria set out, claiming training in the areas the AMA specified (ACA, 1971). Since there was little disagreement the ACA argued legislation could proceed‘.[7]
As will be seen, the American Medical Association had been very influential in bringing mis-information relating to the practice of chiropractic and the education of Chiropractors to its’ Australian counterpart over a considerable period of time.
Action has been taken by the Chiropractic profession in Australia relating to provisions of the Trade Practices Act which also come within the preview of the Australian Competition and Consumer Commission. The following extracts from a letter to the profession are relevant. [8]
In December 1992, it was held the first informal meeting of the Chiropractors’ Association of Australia (CAA) with the Australian Competition and Consumer Commission (ACCC). Since that date, there had been several meetings and teleconferences involving officials from the CAA and the ACCC. A significant change was made in the application of the Trade Practices Act (TPA) and as a result of this the following article was written, ’The AMA and Chiropractic: a Trade Practices Viewpoint‘ (Aug. 1998 issue of ACCC Journal), authored by Alan Ducret, ACCC regional director, Brisbane.
The ACCC had to be convinced at the beginning of the possible anticompetitive aspect of the policies and activities of the medical profession in Australia toward the chiropractic profession. The approach chosen was to inform the ACCC of the details of the Wilk case in the U.S.A. Then a comparison to the actions of the Australian Medical Association was made. Wilk v AMA confirmed briefly that the American Medical Association had labelled chiropractic as an unscientific cult. The purpose of this boycott was to eliminate chiropractic as a health care alternative in the U.S. health care system.
The ACCC thought that the AMA’s 1977 policy stating that ’the Australian Medical Association does not recognise any exclusive dogma such as homeopathy, osteopathy, chiropractic and naturopathy. It is unethical for doctors to associate professionally with practitioners of such dogmas.’ was effectively boycotting chiropractors and others. In 1981, the AMA Federal Assembly modified this policy removing the overt boycott as follows: ’The Australian Medical Association does not recognise any exclusive dogma such as homeopathy, osteopathy, chiropractic and naturopathy or any other practices which are not based on sound scientific principles.’
In spite of this change, the rules of the Victorian branch in 1982 still noted that it was unethical for a member to work professionally with a chiropractor. As recently as1997, it was still deemed unethical to refer to a chiropractor by an AMA member.
As professional bodies were essentially exempt from the TPA, the minor policy changes of the AMA did not hold much meaning to the ACCC. However this situation changed with the passage of the State and Territory Competition Policy Reform Acts of 1995, which applied the competitive conduct rules to the Australian professions, including the medical profession. With these changes came a commitment from the ACCC to assess the AMA position to determine if it was in breach of the TPA.
At present members of the AMA are allowed to work professionally with a chiropractor if they choose to.. The AMA retains the right to market its member services and to question all forms of health care and remains a staunch opponent of health services believed to be unsafe or ineffective [8].
4.4 MEDICAL ETHICS RELATING TO CHIROPRACTIC IN THE UNITED STATES OF AMERICA
In 1987, a verdict was passed against the American Medical Association (AMA) which found them guilty of efforts to ’contain and eliminate‘ the profession of chiropractic through a planned and long waged boycott of chiropractors.
At that time, it was stated that ‘this historic decision has opened a door that many believe will usher in a new era of interprofessional cooperation and openness which will ultimately benefit you, the health care consumer‘. That prediction has certainly been fulfilled in the USA and around the world in many countries where the practice of chiropractic is recognized under statute law.
To discuss in more detail; On August 27, 1987, following an eight week trial the AMA was found guilty of breaching anti-trust laws by conspiring to restrict chiropractic access to medical facilities such as hospitals and education institutes. Judge Susan Getzendanner set out a 101 page opinion which showed that the AMA had engaged in ’lawless’ behaviour”.
The AMA appealed Judge Getzandanner’s decision several times and on February 7, 1990, the appeals court confirmed the defeat of AMA.
Finally, in November 1990 the U.S.Supreme Court refused to review the case and the AMA was deemed guilty. [9]
Link: http://www.dynamicchiropractic.com/
Further Background to the Case and Consequences for the Defendants:
Dr Chester Wilk, DC and four chiropractors filed a suit against the AMA and numerous other medical groups in October 1976. The suit claimed that the defendants had participated for years in an illegal conspiracy to destroy chiropractic. In 1987 after 11 years of legal action, the court ruled that the AMA had engaged in an unlawful boycott designed to restrict cooperation between MDs and chiropractors with the purpose of eliminating chiropractic as a health care alternative in the United States health care system.
During the proceedings it was shown that the AMA attempted to:
- Undermine Chiropractic schools
- Undercut insurance programs for Chiropractic patients
- Conceal evidence of the effectiveness of Chiropractic care
- Subvert government inquires into the effectiveness of Chiropractic
- Promote other activities that would control the monopoly that the AMA had on health care (This was upheld by the 7th United States Circuit Court of Appeals.)
The AMA offered a patient care defense. However, data from Workmen’s Compensation Bureau studies served to validate chiropractic care.
AMA and its members were instructed to cease its efforts to restrict the professional association of chiropractors and AMA members. A growing number of medical doctors, hospitals and health care organizations in the United States have begun including the services of chiropractors after the findings and conclusions of the court were released.
Numerous research studies and various government inquiries have resulted in increasingly widespread recognition of chiropractic and generally support the efficacy of chiropractic treatment. Some studies comparing chiropractic care to care provided by a medical physician have been presented showing that chiropractors were ’twice as effective as medical physicians, for comparable injuries, in returning injured workers to work at every level of injury severity‘ [10], [11], [12].
Link: http://www.chiro.org/Wilk/
http://www.chiro.org/wordpress/
Code of Ethics of the American Chiropractic Association
The American Chiropractic Association Code of Ethics is typical of ethical codes utilized by chiropractic associations and the other health care profession worldwide [3].
Codes of ethics articulate principles and guidelines shared among members of a group, and it ideally expresses a shared commitment to respect and accomplish certain ethical standards and principles, and could also serve as a guide in specific situations.
The American Chiropractic Association preamble outlines the clear intent of their document.
Link: http://ethics.iit.edu/
State Association Code of Ethics
Organization: Colorado Chiropractic Association
Code of Ethics
Preamble – the basis of the Code
This code of Ethics is based upon the fundamental principle that the ‘greatest for the patient’ should be the objective and ultimate end of the professional services and effort of every chiropractor. [2]
Link: http://www.coloradochiropractic.org/
New Zealand Chiropractic Board Code of Ethics and Standards of Practice
These New Zealand documents are quite comprehensive and are well supported by the New Zealand Chiropractors’ Association and its members. These documents are of course reviewed from time to time. The Standards of Practice are rigorously upheld and any contraventions reported are, without delay, thoroughly investigated. [3]
Code of Ethics and Standards of Practice
This Code of Ethics and these Standards of Practice comprise a guide to the rules governing the professional conduct of all registered Chiropractors and governing the duties and obligations of Chiropractors to patients, the public, their colleagues and their profession. [13]
Link: http://www.chiropracticboard.org.nz/
Note: A full copy of the New Zealand Chiropractic Board Code of Ethics is presented as reference material.
References
- American Medical Association [Online]. 2009 [cited 2009 Nov]; Available from: http://www.ama-assn.org
- An Introduction to Jukes Styrap’s a code of medical ethics (1878) [Online]. 2009 [cited 2010 Sep]; Available from: URL: http://www.springerlink.com
- Hunt RG. Explanatory notes; November 2009.
- World Medical Association [Online]. 2009 [cited 2009 Nov]; Available from: URL: http://www.wma.net
- Third general assembly of the world medical association at London. World Medical Association Bulletin; October 1949. p.109, 111.vol 1,
- Arthur W. Burton. Medical ethics and the law. Sydney: Australasian Medical Publishing Company Limited N.S.W. Australia; 1974.
- Evan Willis. Medical Dominance. Revised edition. Sydney London Boston: Allen & Unwin; 1989. p. 181-182
- Simpson JK, Dynamic chiropractic; Australian AMA Update. March 8 1999. Vol 17. issue 06. [Online]. 2010 [cited 2010 Sep]; Available from: URL: http://www.dynamicchiropractic.com
- Editorial Staff,, Dynamic Chiropractic; Adjustment Pix. April 26, 1991. Vol 09 Issue 09 [Online] 2011 [cited 2011 Nov; Available from: URL: http://www.dynamicchiropractic.com
- Tyler R, Grumling L. Chiropractic: the right choice all along. Huntington Beach California: Motion Palpation Institute; 1991.p.4.
- The Chiropractic Resource Organization [Online]. 2009 [cited 2009 Nov]; Available from: URL:http://www.chiro.org
- ChiroOrg Blog (The Chiropractic Resource Organization…news, research, commentary) [Online]. 2009 [cited 2009 Nov]; Available from: URL:http://www.chiro.org
- Effective November 2004 Chiropractic Board of New Zealand [Online]. 2009 [cited 2009 Nov]; Available from: URL: http://www.chiropracticboard.org.nz
