CONCLUSION

Résumé

The practice of joint manipulation has ancient origins, having been a part of medicine for thousands of years. Some who have employed manipulation have been orthodox medical practitioners. Others have not. Bold claims have been made for its effectiveness, but its benefits have also been questioned and concerns about risk have limited its application. Historically, manipulation has been used as a treatment for both musculoskeletal and organic conditions. In the management of musculoskeletal conditions, scientific evidence has emerged to support its use, but for organic conditions the supporting evidence has been more tenuous.

The field of manipulative practice remains a controversial and contested domain, a sphere that has never been under the complete control of a single occupational group. In spite of technological advances in medicine, it has survived. Its development can be understood in terms of the interplay between occupations and in terms of processes of professionalization. The historical assertions of some of its advocates raise questions of justification in respect to claims to knowledge. Consequently, the history of manipulative practice prompts sociological and epistemological enquiry.

One of the strengths of this investigation is the information it provides to support contemporary decision making through enhanced understanding of the history of inter-occupational dynamics in the field of manipulative practice. The study highlights the competitive nature of professional relationships, and therefore, it might be argued, justifies the pursuit of continued offensive and defensive strategies on the part of occupational groups in order to ensure their furtherance. Likewise, it might be argued, it justifies the continued exercise of governmental controls in order to limit the power of elite professions. By contrast, it also draws us to consider the notion of service that is a part of professionalism, particularly service to the patient, and to ask whether in professional affairs group rivalries are inevitable. Professionalism entails a system of both tribal self-interest and concern for the wellbeing of others. This understanding is fundamental.

Final thoughts

At first self-interest might appear to be at odds with concern for others, but the truth is that they are not mutually exclusive as strategies exist for shared advantage. So, for example, in clinical practice the patient in pain benefits from the expertise of the clinician in providing a diagnosis, offering advice, and/or therapy. In return the clinician obtains esteem, satisfaction and financial reward. The result is win-win. Similarly, at the level of the profession, shared benefits can be achieved through statutory regulation. The public is provided with a service that people trust because it is recognized by the state, and through processes of law they are protected from charlatanry. In return for their valued service to society, members of the profession receive status in the social order and protection of job territory. Once again, the outcome is win-win. What is needed is phronesis, or practical wisdom, for the clinician who consistently puts his or her interests before those of patients does them a disservice, and the profession that abuses its power at the expense of its clientele is not worthy of admiration. Co-operation can be better than confrontation. Shared benefit is at the heart of professionalism.

The idea of shared benefit can also be applied to the interactions between occupational groups. Throughout their history chiropractors and osteopaths have been in competition. During the 1920s osteopaths working in Britain initiated processes of political activism with the aim of achieving statutory regulation. Their efforts were opposed by chiropractic purists. Concerned for their existence and advancement, chiropractors organized under the banner of the British Chiropractors’ Association (Wilson, 2013). Rivalries ensued. This was the case even though chiropractors and osteopaths shared much in common. In spite of their similarities, and probably also because of them, they were adversarial towards one another. Osteopaths did not achieve statutory regulation in the 1920s, nor in the 1930s, and it was not until 1993 that the Osteopaths Act was passed (UK Parliament, 1993). Perhaps if the major groups of chiropractors and osteopaths had been more willing to work together they might have achieved more sooner. In other words, if they had focused more on what they shared in common, and less on those things that separated them. Where they are able to, great leaders choose their battles wisely.

Patients often ask what the difference is between an osteopath and a chiropractor. Since working in the north of England, my response has often been to say that they are analogous with rugby league and rugby union. In essence they play the same game, they both use their hands, they have a shared history, but they are opposing traditions. In 2008 I discussed with Lord Walton of Detchant the processes that led to the legal recognition of chiropractic and osteopathy in Britain, processes in which he had been personally involved. He told me that at one time he had thought it might be sensible to put forward a single bill to regulate osteopathy and chiropractic, but it became clear to him that lack of understanding between the two groups would have made that impossible. This raises a question. What is more important, to be a chiropractor, an osteopath, a physiotherapist, or a medical doctor, and to be recognized as such under law, or to provide a worthwhile service to society? To put it another way, should occupational power and prestige be put before the principle of service? My own view, though it is a value judgement, is that they should not. In relations between professions, the state and its people, the people are most important. In health care it is the patient, not the profession, that should be the first priority.

References

Palmer D.D. and Palmer B.J. (1906). The Science of Chiropractic. Palmer School of Chiropractic, Davenport.

UK Parliament (1993). Osteopaths Act. 1993, Chapter 21, Elizabeth 2.

Walton of Detchant (2008). Semi-structured interview with Lord Walton of Detchant. 18th June 2008. Interviewer: F.J.H. Wilson.

Wilson F.J.H. (2013). The origins of the British Chiropractic Association. Contact 27 (2), 10-12.

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