Over the years there has been this belief among chiropractors that if you tell a patient they need x-rays and they refuse then you can just have them sign an "x-ray waiver" and adjust them without the x-rays. The false belief is that this somehow absolves you of any guilt should something happen and the future reveals that x-rays should have been taken after all.

Unfortunately there is no "Get Out of Jail Free Card" on this issue.

The issue of whether to take x-rays on a patient or not has been a heated issue within the profession for decades. Within the past several years it has reached a boiling point as those who control the profession push harder to stop the practice of managing vertebral subluxation.

The strategy is to remove the ability for chiropractors to objectively measure and document the components of vertebral subluxation and it is the culmination of a long drawn out effort to marginalize chiropractors who practice this way.

Their goal is to frame chiropractic as the management of pain syndromes using spinal manipulative therapy absent any measures of the biomechancial or neurological components of subluxation. They believe this will bring the profession the cultural authority they crave. Sadly it will not.

These issues really heated up recently with the decision in Canada to ban x-rays for subluxation analysis and the recent debacle involving the Federation of Chiropractic Licensing Boards (FCLB) which claims, without providing any evidence, that there are so called "material risks" that must be disclosed to your patients prior to taking any films. Its proponents defend the action as a political compromise on policy, however the "material risks" language was another horrible compromise made that only further advances the agenda of those who wish to get rid of the ability to identify the biomechanical component of subluxation on x-rays.

Numerous state organizations, the Foundation for Vertebral Subluxation and ChiroFutures Malpractice Program have rejected the FCLB claims related to material risks and related consent requirements.

When you are confronted with a patient who in your clinical judgement needs radiographs for whatever the reason in order for you to provide care and that patients does not want or refuses the films - that is the right of the patient to do so. It is also your obligation not to manage a patient without all the information you need to do so safely and effectively. If radiographs are necessary to do that - then they are necessary.

Problems arise when the doctor has told the patient that radiographs are necessary, the patient refuses and the doctor goes ahead and manages the patient anyway without the films. Films he just told the patient were necessary and suddenly they really aren't.

This will make things worse from two perspectives:

1. You already told the patient the X-rays are necessary. But when they refuse you agree to see them anyway. To the patient that means the X-rays weren’t necessary to begin with. What does that tell a patient about your ethics and what does it tell them about any other recommendations you make? Now when you tell them you need to see them 3 times a week perhaps they will question if that's really necessary too and decide to come once a week instead.

2. There is no get out of jail free card on this. If you tell them they needed them and then had them sign a form attempting to absolve yourself of blame if there was something ominous there you have simply memorialized your guilt. This is an admission of guilt for 12 people who couldn’t get out of jury duty that they were necessary but you went ahead without them.

We find that chiropractors generally make this decision because they truly want to help the patient and will attempt to do that even without the films they feel are necessary to provide better care and/or they don't want to lose the patient. These are not good motivators for decision making.

Your obligation is to provide the best care possible. If that means x-rays, then explain the benefits of the films, address their concerns in regards to costs, radiation exposure etc. If they refuse - then explain with love and compassion that you cannot put them or yourself at risk and remain open to them if they want care in the future.

This honors their personal autonomy and yours at the same time, it reduces risk to their health and reduces risk to your practice.

As always we look forward to your feedback, comments and questions.