Position Paper on
chiropractic diagnosis and referral

In order to maintain a clear and unique identity for chiropractic, eliminate or reduce the public's confusion as to the role of a D.C. in health care, and protect doctors of chiropractic from malpractice lawsuits, it is critical to establish a common understanding and agreement about the extent of a doctor of chiropractic’s duty to diagnose and refer.

It is the position of the World Chiropractic Alliance that:

1) While training and statute may allow the chiropractor broad diagnostic scope, chiropractors may also elect to limit their practice and diagnostic scope to the detection, characterization and care of vertebral subluxations, and determining the safety and appropriateness of chiropractic care.

2) As stated in the Council on Chiropractic Practice, Clinical Guideline # 1: Vertebral Subluxation in Chiropractic Practice, "In the course of patient assessment and the delivery of chiropractic care, a practitioner may encounter findings which are outside his/her professional and/or legal scope, responsibility, or authority to address. The chiropractor has a responsibility to report such findings to the patient, and record their existence. Additionally, the patient should be advised that it is outside the responsibility and scope of chiropractic to offer advice, assessment or significance, diagnosis, prognosis, or treatment for said findings and that, if the patient chooses, he/she may consult with another provider, while continuing to have his/her chiropractic needs addressed."

3) There exists a wide variety of health care practitioners, systems of health care and cultural overlays that effect how the public utilizes health care services. While every practitioner should be sensitive to this wide variety of cultural and individual practices, it is not possible to dictate a particular class of provider that a patient must see for evaluation of unusual findings. This must be done on a case by case basis and must be a decision the patient is empowered to make.

To arrive at this position, the World Chiropractic Alliance relied on fundamental chiropractic teachings and definitions, the Council on Chiropractic Practice Guidelines, Association of Chiropractic Colleges Position Paper No. 1, literature from the World Health Organization, state scope-of-practice statutes, and numerous legal decisions. The following court cases are of particular importance:

People v. Beno, D.C. (422 Mich. 293. 373 N.W.2d 544, 1985). In this case, the court determined that the "practice of chiropractic" referred to the health care discipline that deals with "the nervous system and its relationship to the spinal column and its interrelationship with other body systems." This included diagnosis, including spinal analysis, to determine the existence of spinal subluxations or misalignments that produce nerve interference, indicating the necessity for chiropractic care. The Supreme Court of Michigan held, "We do not believe the Legislature intended to authorize chiropractors to engage in general diagnostic techniques. Had such a result been intended, it could have been clearly stated."

Kerkman v. Hintz (142 Wis.2d 404, 4178 N.W.2d 795, 1988). This case pointed out the distinct differences between chiropractic and medical practice. The Court very clearly defined the extent of a chiropractor's duty to diagnose: "In summary, we hold that a chiropractor has a duty to (1) determine whether the patient presents a problem which is treatable through chiropractic means; (2) refrain from further chiropractic treatment when a reasonable chiropractor should be aware that the patient's condition will not be responsive to further treatment; and (3) if the ailment presented is outside the scope of chiropractic care, inform the patient that the ailment is not treatable through chiropractic means."

Goldstein v. Janusz (582 N.W.2d 78, 218 Wis.2d 683). The Court of Appeals of Wisconsin relied on Kerkman when it ruled, "Chiropractors have no duty to recognize medical problems." It added that "to do so would require chiropractors to make medical determinations which, under Wisconsin law, they are not licensed to make." The Court further noted, "Although chiropractors may take and analyze x-rays, they only do so for diagnostic or analytical purposes in the practice of chiropractic."

People v. Bovee. D.C. (285 N.W. 2d 53, Mich.Ct.App. 1979). In this case, a D.C. was found guilty of practicing medicine without a license after dispensing non-prescription medicines for colds and other ailments. He also took throat cultures and urine samples and implied to patients that he was diagnosing and treating specific health conditions. The Michigan statute defines chiropractic practice as including "Diagnosis, including spinal analysis, to determine the existence of spinal subluxations or misalignments that produce nerve interference, indicating the necessity for chiropractic care." The judge's ruling made it clear that a chiropractic diagnosis in Michigan involves determining subluxation and nerve interference, not the identification of specific medical diseases or conditions.

Treptau v. Beherens Spa, Inc., (20 N.W.2d 108, 247 Wis.438). A chiropractor examined and treated a patient's foot using bandages and diathermy. The Wisconsin Supreme Court stated, "Plaintiffs do not claim there was malpractice on the part of the defendant while Beherens was engaged in the practice of chiropracty (sic) by chiropractic manipulation or adjustments of the spine. Instead, plaintiffs contend there was malpractice when he and his associates went beyond the practice of chiropracty (sic) and entered into the general field of the practice of medicine...in so far as there was thus an invasion of the general field of that practice, the methods thus used by defendant's employees in diagnosis and treatment were subject to the rules applicable to the practice of medicine and surgery." The court relied on Kuechler v. Volgmann (192 N.W. 1015, 180 Wis. 238, 242-43), which held, "When a chiropractor assumes to diagnose and treat disease he must exercise the care and skill in so doing that is usually exercised by a recognized school of the medical profession."

Spunt v. Fowinkle (572 S.W.2d 259, Tenn.Ct. App., 1978). This case involved a doctor of chiropractic who offered medical procedures such as drawing blood and taking Pap smears. Tennessee statute defines chiropractic as "the science of palpating, analyzing and adjusting the articulations of the human spinal column and adjacent tissues by hand." It also states, "Any person shall be regarded as practicing medicine within the meaning of this chapter who shall treat, or profess to treat, operate on, or prescribe for any physical ailment or physical injury to or deformity of another." The court pointed to the doctor's intent as a critical factor in the case, saying that there was, technically, nothing in the law to prohibit the doctor from doing a Pap smear or drawing blood. If either or both of these procedures had been for the purpose of detecting subluxations or determining a chiropractic program of care for subluxation correction, they would have been acceptable. But since the doctor's purpose was clearly to diagnose disease, he had crossed the line separating chiropractic from medicine.