Informed Consent: A Potential Dilemma for Complementary Medicine

What an interesting commentary by Professor Ernst.1 In it he quotes his own systematic review of chiropractic for neck pain and states that this is the most up-to-date review. Unfortunately, he does not say that this review has been thoroughly and ably criticized by Peloso and Gross.2 In fact, they have done such a skilled job at criticizing Ernst's review that I would refer all your readers to their article in the Journal of Pain [October 2003; 6 (8)]. This critique of Ernst's work is so detailed and solid that it is a lengthy article, although still worth reading.

However, one can summarize the shortcomings of Ernst's review as follows:

The shortcomings of this study are so critical that the value of the review is sadly very low. In complete fairness to Ernst, he does mention that the others have come to “more positive conclusions,” but he fails in his commentary to mention what those conclusions are. On the other side of the equation, the potential for vertebral dissection is a possibility that chiropractors have dealt with for many years, and yet still, there is no definitive data on occurrence levels. The Danish retrospective study suggested less than 1 in 1000000.3 Haldeman4 in his study suggests 1 in 5800000. Chiropractors should indeed tell patients about this risk, but contrary to Ernst's idea, this is not an off-putting thing to a patient who is informed about the risks involved in all treatment methods and especially in those who have already tried exercise therapy alone. In fact, patients appreciate the honesty of being informed. The unfortunate thing about Ernst's constant concerns for patients with neck pain is that he has never at any stage published any criticism of informed consent for the use of nonsteroidal anti-inflammatory drugs in the care of neck pain. Present estimates of mortality rates vary, but not far from 1:12000.5 We have yet to hear Professor Ernst suggest that allopathic physicians should tell patients with neck pain that chiropractic is safer treatment than using nonsteroidal anti-inflammatory drugs.

The truth is that patients are entitled to the honest opinion of their treating physician. That will no doubt always be a bias interpretation of the currently available scientific data. In our clinic, we inform patients of the estimated risks and respect their opinions during treatment, but most patients including the medical doctors that we treat are happy to undergo our recommended care.

Ernst should, in my view, relook at this issue while taking account of the valid criticism his previous papers have attracted.