Letter from...Chicago. Matters of turf.

The prevailing economic doctrine of the day holds that the public always stands to gain from increased competition in the market place. Under this doctrine, enthusiastically embraced by the Federal Trade Commission, sick "consumers" will get well quicker, cheaper, and more conveniently if all kinds of people are allowed to set up shop and start playing doctor.' As a result optometrists compete with ophthalmologists, exercise physiologists substitute for cardiologists, respiratory physiologists offer to treat emphysema, and colonic irrigators obviate the need for gastroenterologists. Nutritionists are setting up independent cholesterol lowering practices; nurse practitioners see patients on their own, charging $25 for a house call; and dental hygienists are happy to be rid of the dentist as they polish their clients' teeth for that wonderful bright smile. Psychologists set up fashionable Jungian or Freudian consulting practices in affluent neighbourhoods without bothering about psychiatrists; chiropodists reach towards the knee or even above, though facing competition from the podiatrists; and even "our long term allies the pharmacists" are clamouring for a piece of the action. ' Another group, the chiropractors, though never in danger of being our allies, are also benefiting from competition economics. They have indeed come a long way in the 100 years since their visionary founder renounced mesmerism and phrenology in order to massage and manipulate backs.2 Yet they had repeatedly been denounced as ineffective, dangerous, and unscientific by their more advanced "allopathic" brethren who had long ago discovered leeching, cupping venesection, and later moved on to colectomy for focal sepsis, gastric freezing for ulcers, and hyperalimentation for everything else. Ethics were invoked, under which a doctor could no more associate with a chiropractor than a high caste shastri with an untouchable. Yet over the years chiropractic steadily gained ground, abetted by a lobby of grateful patients and some excellent lawyers. In 1979, under an agreement reached with the American Medical Association, the chiropractors moved up a notch, so that physicians could now associate with them without risking contamination.2 But even this was not enough for an upward moving caste. For almost a decade legal skirmishes continued; and again the 30 000 strong chiropractic profession won out over their powerful rivals. In September a federal judge ruled that the American Medical Association had indeed violated antitrust laws and caused an "unreasonable restraint of trade" by "orchestrating a campaign to eliminate the chiropractic profession" through boycotts, denials of reimbursement or hospital privileges, and rules forbidding doctors to refer patients to chiropractors or work with them. The judge then ordered the American Medical Association to inform its members within 30 days, as well as publishing in its journal, that doctors were free to associate with chiropractors if this seemed to be in the best interests of the patient. While the lawyers for the chiropractors hailed all this as a major breakthrough the American Medical Association announced that it would appeal against the decision.