To the Editor:
The narrative review by Lehman et al1 that posed questions for the chiropractic profession to consider, relating to informed consent, is to be applauded. We disagree, though, with your premise that the “informed consent doctrine” is not promulgated as the standard of care. The prevailing view in the profession, in our opinion, is that this “process” is a part of the standard of care but is not routinely implemented.
The National Board of Chiropractic Examiners Job Analysis of Chiropractic found that the chiropractors who responded to this survey reported counseling patients about informed consent “sometimes” but get written informed consent “frequently.” Because informed consent must include counseling, it appears that those responding to the survey do not have a good comprehension of the process of informed consent and thus have not implemented it in a routine way in their practices.2
Informed consent is not explicitly mentioned in the “new” American Chiropractic Association (ACA) Code of Ethics (revised and ratified September 2007, http://www.acatoday.org/content_css.cfm?CID=719), but it is implied by the following provision of the code:
V. Doctors of chiropractic should use their best good faith efforts to provide information and facilitate understanding to enable the patient to make an informed choice in regard to proposed chiropractic treatment. The patient should make his or her own determination on such treatment.
The ACA House of Delegates expanded upon the Code of Ethics and implied requirement for providing patients with informed consent within their updated informed consent policy ratified on September 19, 2008 (http://www.acatoday.org/level2_css.cfm?T1ID=10&T2ID=117#51).
“Since the American Chiropractic Association (ACA) recognizes that there are varying legal standards for informed consent among different jurisdictions, it is recommended that Doctors of Chiropractic consult with their personal attorney, malpractice carrier, licensing board, state statutes, case law and CMS (Medicare) to determine the range and detail of the information required locally in an appropriate informed consent process.”
The Council on Chiropractic Education3 mandates that students demonstrate an ability to “appreciate the need to obtain the patient's informed consent, cooperation and compliance with care and/or referral recommendations” (x) and “understand the appropriateness of obtaining informed consent from the patient prior to initiating clinical care” (y).
Some chiropractic examining boards, such as Oregon, have affirmatively addressed informed consent.
811-015-0070 Scope of Practice Regarding Examinations, Tests, Substances, Devices and Procedures
(3) … In determining risk, the Board may use the following criteria:
(c) For moderate risk procedures, defined as those which when properly performed on the general public have a significant chance of mild injury and a mild chance of moderate injury, when improperly performed on the general population have a slight chance of severe injury, and when properly performed in select populations have a slight chance of serious injury.
(A) Written informed consent is required;
Some are reluctant to create specific rules regarding informed consent, especially written (www.chiroweb.com/mpacms/dc/article.php?id=36273).
Thus, although it appears that chiropractic professionals do not appropriately implement the informed consent process with most of their patients, the profession through its associations has acknowledged that informed consent is a part of the standard of care.