Chiropractic Referral Fees & Conflict of Interest

Sometimes, when consumers need two different, but related, goods or services, they rely on the advice of the provider of one product to select a provider of the second. That often makes sense, because providers in related businesses often have specialized knowledge that lets them give good advice (e.g., the guy who sells you your carpet likely knows who would be good at cleaning that carpet.) In such a case, people in related businesses can be a good source of expert, independent advice.

That is, if the advice is truly independent. And the most obvious way to eliminate independence is to inject a financial interest into the scenario. If the person you’re relying on for advice is financially beholden to the person he or she is recommending, you have every reason to doubt that advice.

And if that advice you’re after isn’t about something mundane, like carpets (something about which a great many non-experts know quite a lot) but is instead about your health, you have every reason to worry — especially when one of the service providers involved is taking active steps to put the person you’re relying on for advice into a Conflict of Interest.

Here’s an article (in which I’m quoted) about just such a situation. It’s by Yoni Freedhoff, MD, writing for the Canadian Medical Association Journal, Chiropractic clinic offered referral kickbacks

A chiropractic clinic with locations in Ontario, Nova Scotia and Manitoba offered lucrative kickbacks to physicians for referring clients to its five outlets until the College of Physicians and Surgeons of Ontario (CPSO) apparently stepped in to scuttle the payments as a result of CMAJ inquiries.

The offer of kickbacks, which were in the form of financial compensation, arising out of referrals from doctors, came to light as a result of a CMAJ request for a “doctor’s information kit” in accordance with instructions from an advertisement placed in the journal by the Low Back Clinic.

The kit included a document detailing appropriate patient referral criteria, which was followed by the proclamation: “In compliance with the C.P.S.O. standards, a $300 documentations fee will be provided once the patient completes care….”

Summary of problems:

  • The payments put referring physicians into a conflict of interest;
  • The payments, which are based on completion of a course of care, induce physicians to encourage patients to complete a course of care independent of whether that’s in the patient’s best interests;
  • The payments risk jeopardizing patients’ trust in their physicians;
  • The payments risk the professional reputation of the medical profession quite generally;
  • Referring to the payments as being “In compliance with the C.P.S.O. standards” falsely implies that the payments are required by the C.P.S.O.

All in all, this scheme was a pretty bad idea. Perhaps the clinic offering the fee could be excused for not knowing that doing so was contrary to regulation. But health professionals certainly ought to know enough about conflict of interest to recognize that such a scheme is seriously ethically problematic.

4 comments so far

  1. JonA on

    The behaviour of the chiropractors and doctors here is despicable. What is also despicable is the fact that many chiropractors offer unproven treatments to clients.

    Don’t medical practitioners have an ethical duty to test their treatments before offering them, or at least inform patients that there’s scant evidence in favour of the treatments?

  2. Rachel on

    So this will also refer to every single doctor who has ever prescribed a pharmaceutical drug and has gotten a kick back from the pharmaceutical company?

    • Chris MacDonald on


      Yes, of course it does. Would you think otherwise?


  3. […] of interest inherent in such arrangements, see this post  from Chris MacDonald’s excellent Business Ethics Blog : “If the person you’re relying on for advice is financially beholden to the person he or she […]

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