Ethics in Modern Practice of Traditional Chinese Medicine (TCM)
There are numerous matters that fall under the category of medical ethics, and I have selected three of them in order to illustrate an approach to pursuing a higher ethical standard for the modern practice of TCM. The three categories are:
Educational Responsibilities of TCM Practitioners
Scope of Responsible Practice for TCM
Claims for Success and Efficacy
These three areas are intimately connected. Well-educated practitioners are more likely to keep to the scope of practice for which they are licensed, while poorly educated practitioners are more likely to fall prey to a variety of kinds of alternative practices that are (or should be) outside their scope of training and licensure. Well-educated practitioners who work within their scope of practice are less likely to make claims that are unsubstantiated and misleading, while less educated practitioners who journey outside their scope of practice are more likely to make proclamations of capability and success that are not based on any objective assessment. Patients’ health and well-being, as well as their wallets, are affected by weak ethical standards, and the entire profession can be tainted by failing to adhere to high standards.
While there exists, within all professions, a risk of unethical practices by individuals who lack a strong sense of right and wrong, what is to be addressed here are areas of susceptibility within the structure of the modern TCM community that may encourage practitioners to pursue methods not of suitable ethical standard, and, more importantly, that give no indication that anything is awry.
Too often, these ethical issues become couched in terms that dissuade challenges: there is a purported clash in “paradigms.” The matter is eventually described in terms of power: how—and by whom—does a determination get made as to what is valid, true, or acceptable? Objections are raised to those who are perceived as being closed minded about what goes on in TCM practices. But, there is a difference between having a critical mind, one that challenges appropriately and demands some accountability, and having a closed mind that is not able to consider an alternate viewpoint. In this presentation, I will offer some judgments on activities that have taken place in this field, and hope that these are seen as tackling the problem of invasive movements rather than raising barriers to valid approaches.
One of the ways to address the matter with some fairness is to turn to ethical principles that are espoused in the community of Chinese medicine practitioners in China, such as presented in the book Medical Ethics in Imperial China, and to supplement that with the ethical considerations that belong to a western culture, such as associated with the scientific community. There are two towering figures—Sun Simiao in China and Hippocrates in the west—that provide beacons to guide us. In the end, some will agree and others disagree with the selection of issues and determinations as made here. Yet, it is hoped that the points raised will serve as a basis for further work in this area that might lead to a consensus, at least amongst those who are in a leadership role. The particular concerns addressed in my essay are about practitioners of Chinese medicine who were trained in the west, especially in the U.S.
The subject to ethics in Chinese society was first dealt with in a formal manner by Confucius (Kong Fuzi; his life usually dated 551-479 B.C.). He did not address medical ethics, but, instead, focused on relations within society: its governments, communities, and families. In a summarization of Confucian ethics, the terms ren; yi versus li and li (different character) together with xiao form the basis:
Rén: The fundamental virtue of Confucianism; it refers to benevolence, charity, humanity, love, and kindness. Confucius defines the principle Aì rén: to love others. Yì; involves right conduct, morality, duty to one’s neighbor, and righteousness, whereas Lì, involves profit, gain, and advantage, which are not proper motivation for actions affecting others. It is put this way: “The gentleman (junzi) understands yì; the small man (xiaoren) understands lì.” Yì may be broken down into two components: zhōng, doing one’s best, conscientiousness, and loyalty; and shù, reciprocity, altruism, and consideration for others. There is also the general manner of living within a family, it includes Lĭ (an entirely different word than Lìabove) meaning propriety, good manners, politeness, ceremony and worship; and another important principle which is Xiào, to honor one’s parents, known as filial piety.
While some forms of medicine were present since the most ancient times, the system we become familiar with was organized during the Han Dynasty period, with preliminary work done during the Eastern Han and the formation of essential texts, like the Nei Jing and Shang Han Lun, during the Western Han period (25-220 A.D.), mainly during the last half of that period. Chinese medical historians recognize that a period of disorganization of the medical field occurred from time to time, and Sun Simiao played a big part in the revitalization of Chinese medicine that took place after China had gone through a time of great divisiveness and war, with reunification occurring in the Sui Dynasty (589-618), and China flourishing during the Tang Dynasty (618-907).
The website ChinaCulture.org presented information on Sun Simiao, emphasizing his contribution to ethics. Here is a portion of their presentation (1):
Sun Simiao (581-682) was a great medical scientist of China in the Tang Dynasty (618-907)….Sun Simiao's viewpoint on medical ethics was very important in the history of Chinese medicine. In his Qianjin Yaofang (Essential Prescriptions Worth a Thousand Pieces of Gold), he put forward the notion of “good faith of a great doctor” for the first time, offering an all-round argumentation on the guiding rules of medical ethics a doctor must hold to. “Human life is of paramount importance, more precious than a thousand pieces of gold; to save it with one prescription is to show your great virtue.” His book was just a manifestation of such a noble moral character. He gathered and studied the medical data before the Tang Dynasty, with reference to his own clinical experience of several decades, wrote Beiji Qianjin Yaofang (Essential Prescriptions Worth a Thousand Pieces of Gold for Emergencies) and Qianjin Yifang (Additions to the Prescriptions Worth a Thousand Pieces of Gold), which have 30 volumes each....Sun Simiao paid great attention to women and children's care and wrote The Prescriptions for Women in three volumes and the Prescriptions for Children and Infants in two volumes….Sun Simiao’s study on health care was very profound. He advocated putting prevention of diseases at the first place, stressed the importance of “restraining the desires [in order] to cultivate mental poise”, “caution in speech,” and “moderate in eating.”
Among the things to note in this presentation is that he took care of those in great need, including saving the lives of those who were too weak or ill to be cared for by their own families, giving attention to the needs of women and children (who were in a secondary position of the society), and paying attention to moderate behavior as a means of both preventing disease and maintaining a healthy community. His dedication, displayed by the lengthy studies and tireless writings, offers guidance for others who wish to contribute to a high standard of medical ethics.
In the West, we have the basis for medical ethics established by Hippocrates a thousand years before Sun Simiao. He summarized his ethical views in his famous “oath,” for which many people know it by name, but are not familiar with its content (2):
I SWEAR by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation- to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!
We may note here the emphasis on education, including the honor to one’s teacher and passing on of what has been learned; the protection of the patient and, as one example, not stepping outside the scope of practice but leaving certain actions to those who are specialists; and abstaining from mischief and that which is mischievous, which would include giving information that is misleading, such as comments about health and disease and claims of success that are not substantiated
Part I. Educational Responsibilities of TCM Practitioners
Principle: It is vital that persons who offer professional services in the field of TCM maintain adequate knowledge of all the relevant subjects in order to give a level of service consistent with the current state of the art.
Problem: There are a number of deficiencies in education related to TCM, especially to its application in the modern setting, that need to be rectified. Examples of these deficiencies include the following four areas.
a) In China until recent years, persons who provided Chinese medical services grew up in a culture in which basic philosophical concepts, such as yin/yang, five elements, and jing-qi-shen (essence, qi, and spirit), had a broad meaning that could be learned through education and daily experiences. By contrast, Western practitioners of TCM are usually introduced to these concepts later in life, in a didactic manner, and with a minimum of exposure to their historical and cultural significance, as well as limited description of their meaning and relevance in the medical system. Additionally, students of TCM are often given scant exposure to the ancient texts that are required reading for practitioners in Asia, and rarely presented with biographies of model medical men and scholars that can inspire deep study of the field. As a result, the fundamental concepts and original ideas that form the basis of TCM are often improperly used by today’s practitioners to the detriment of the field and, potentially, as a barrier to effective utilization of TCM.
b) Today, modern medicine, which is the standard and orthodox form of treatment, and modern science (including, but not limited to: clinical trials, laboratory studies, and the theoretical frameworks of biology and physiology) are the means of presentation of concepts and information that are expected by most patients. Insufficient training in the sciences and modern medicine, and outright prejudice against these aspects of our knowledge base expressed by some educators (particularly writers of articles and books) can lead practitioners to provide incorrect, misleading, and potentially harmful information and recommendations, as well as suboptimal treatments.
c) Teaching of TCM often focuses on conveying the ancient dogma and the assignment of properties and effects for acupuncture points and herbs without adequate attention to essential details of their practical applications. As a result, those who are licensed to practice Chinese medicine frequently do not have adequate training in key matters affecting outcomes such as frequency of acupuncture therapy and the recommended techniques of maintaining stimulus; herbal dosage and duration of therapy; issues of herbal safety (including the meaning of contraindications); and true TCM concepts of how life style influences healing. As a result, practitioners may offer therapies that have reduced value even though these are provided at great expense to patients (both in terms of cost and time).
d) The method of self-learning and in-depth pursuit of knowledge following the initial TCM training is often ignored; practitioners are not encouraged to vigorously gain deeper understanding. To undertake such additional learning, graduating students must be taught to distinguish between valuable resources and those that are deceptive and useless. There is an unfortunate abundance of intellectual dishonesty in the broad field of “alternative medicine,” a field to which TCM, as practiced in the West, often attaches itself. To quote a useful definition (3): “Intellectual dishonesty is the creation of misleading impressions through the use of rhetoric, logical fallacy, fraud, or misrepresented evidence. It may stem from an ulterior motive, haste, sloppiness, or external pressure to reach a certain conclusion. The unwary reader [or hearer] may be deceived as a result.” TCM practitioners may be led into beliefs that have little relevance to either TCM or modern medicine, and which have little or no basis anywhere, giving patients a false sense of hope and contributing to their confusion about health matters.
Resolution: It is first necessary that members of the profession become aware of these deficiencies and to recognize that the deficits are widespread and to some extent affect all TCM practitioners today to varying degrees (indeed, all people face related challenges in their various professions).
Once the deficits are acknowledged, educational institutions—their directors and faculty—must together find ways to address the problem. Practitioners, informed of the need from the outset of their training, must be willing to put aside a certain amount of time towards study and contemplation that will narrow the knowledge gap. This is accomplished through active and ongoing critical study by the practitioner, and not limited to symposia that are utilized for continuing education credits or for attaining additional techniques or certifications. Critical study is a never ending process, because the subjects involved have a great depth and the medical situation is ever changing.
A process of examining sources of information and ideas with good judgment must be established. The relevant materials must be accessed, studied, and then given consideration as to how they might apply to actual situations. In China, there is a concept of “cultivating” oneself, one’s moral and ethical principles, and one’s qi. This is accomplished by a three-fold process of study, living a life style that is consistent with the underlying principles, and putting the fruits of study and daily experience into practice. This ideal of self-cultivation serves as a model for the TCM practitioner.
Much of Chinese medical practice originates with Taoist philosophy. I would like to quote briefly from a statement on ethics provided by the Taoism Culture and Information Center (4):
Taoism [Daoism] considers ethical education and practice as its fundamental task. On the one hand, Taoism tries to publicize its theory and doctrine in society, leading people to be good in the hope of creating an ethical society. This is Taoism’s ethical education. On the other hand, Taoism encourages ethical practice, which is to lead human beings to good behavior. Ethical practice aims at accomplishing one's duties and accumulating merits, which is to bring forth one’s spiritual release, instead of seeking to win compliments.
I think most people will see that these principles exist with similar form in the Judeo-Christian tradition, in Buddhism, and, in fact, all religious and spiritual traditions. Taoism is an especially useful reference point because of its close relation to the development of TCM.
In an article I wrote on the essentials of Taoism and the Taoist influence on medical literature (5), I included this quotation from Xu Dachun (6), writing about 250 years ago, on the need for physicians to continually study:
Today’s physicians possess no skills. They do not read a single book. Hence those who merely browse through the medical literature [become prevalent]....Those browsers believe themselves to be increasingly right after some time. [Yet], in the beginning they harm other people through mistaken treatments; then they harm their relatives through their mistaken treatments; in the end, they harm themselves through mistaken treatments.
Physicians whose training is insufficient may still avoid harming people as long as they are able to follow proper principles. And if they are able to remain modest, and if they attach great importance to studying, their knowledge will progress every day, and each of their therapies will result in a cure. Hence their fame and reputation will increase and many people will seek their help as a consequence-with riches following them. If one searches for nothing but riches, one will miss both fame and riches. Why do the physicians increase their own problems by neglecting one [studying] and going for the other [seeking rewards]?
Gong Xin (ca 1600 A.D.) had written about the proper approach used by enlightened physicians and what is too often the actual case—the methods of common physicians—as relayed in the book on medical ethics in Imperial China (7):
The enlightened physicians of today cultivate humaneness and righteousness in their attitude. Their study is extensive and embraces all of the writings in their entirety. For this reason, they are well versed in theoretical medicine and its practical use. They know yin and yang, and understand the macrocosmic phases [yün] and the types of climate [qi]….They ponder over their best procedures, are flexible in their treatments, and do not cling mechanically to any formulas….Today’s common physicians brag about the unusual and the strange. They do not study the classic writings, neither do they understand the meaning of the words. They praise themselves into the forefront in order to deceive the world around them….they being a confused treatment without having searched for the origin of the disease....”
In quoting these writers from centuries ago, I am demonstrating that the problems of today were the problems of all times. We have a somewhat organized system of college education of practitioners, so we should be getting past these problems rather than passing them on. In quoting these writings, I do not wish to put too much emphasis on the need to know yin and yang, yün and qi, or even the classical writings; there is just as much, if not more, need to know the relevant aspects of modern medicine, the modern understanding of herbs, and other parts of the knowledge base that were unknown in their times. I also wish to point to the Gong’s caution about the “unusual and strange.” It is unfortunately common today for many practitioners to adopt devices and techniques that are, in relation to both TCM and modern medicine, truly “unusual and strange.”
In China, students of TCM are presented with biographies of numerous famous physicians; these biographies are not so much accurate portrayals of their lives as stories to encourage the students towards great things. In every biography, there is mention of the intensive study of the classics and the great efforts to pursue knowledge of medicine. As an example, Hua Tuo (which many practitioners know for the acupuncture points named after him) has this story, which I summarized from various Chinese sources and relayed in my article about him (8):
Hua Tuo studied and mastered various classics, especially those related to medical and health measures, but also astronomy, geography, literature, history, and agriculture, when he was young. He was stimulated to pursue a career in medicine after seeing so many people die of epidemics, famines, and injuries from wars. His father had died when Hua Tuo was seven. His family lived in poverty and his mother wanted him to pursue a career. So, he walked hundreds of kilometers to Xuzhou to access all the medical classics retained there and learned from a famous physician named Cai. He studied tirelessly while practicing medicine, and became expert in several fields, including acupuncture, gynecology, pediatrics, and surgery.
Studying tirelessly is often the only way to catch-up on the needs of patients, especially when the training in TCM is so limited. Ethically, it is a requirement. One could say, also, that this intensive study “keeps one out of trouble,” that is, from straying too far from the area of expertise.
Part II. Scope of Responsible Practice for TCM
Principle: It is essential that practitioners maintain and actively promote the integrity of Chinese medicine and be scrupulous in evaluating any diagnostic or therapeutic approach which is not an authentic part of TCM that might be incorporated into a TCM practice.
Problem: Many practitioners in the West have quickly added to their TCM practice both diagnostic and therapeutic methods that have these characteristics: they have no basis in TCM; they have no support in modern medicine (the accepted medical system in the Western culture); and they can taint the field of TCM for all practitioners.
a) One of the primary attractions of TCM is that it has a long history of use, that it has been and continues to be extensively used in its country of origin, and that its component parts are unified by a relatively consistent dogma. Patients going to practitioners of Chinese medicine have a reasonable expectation of being provided authentic TCM services, reflecting the best and safest practices from China (or, under the heading Oriental medicine, from Japan, Korea, and other countries that adopted Chinese medical concepts and practices). Chinese medicine is recognized as being a system that, like other health care systems, is liable to be adversely affected by deception, quackery, practice by untrained people, and similar problems whereby patients might be exploited by practitioners either wilfully or without realizing it (even with best of intentions). Traditional Chinese medicine literature refers to many instances where these problems arose in China. Patients going to practitioners who are licensed by their respective State governments have a reasonable expectation that such fraudulent and non-authentic or amateur practices have been weeded out via the required educational process, the testing and licensing processes, and monitoring of practitioners once they have set up their medical business. However, there are defects in the current system that allow practitioners to ignore their scope of practice and incorporate techniques not consistent with authentic TCM and not consistent with the high standards of education and monitoring that are expected.
b) Patients can reasonably expect that practitioners of TCM have undergone rigorous, prolonged training and appropriate internship in order to understand their field of expertise and carry out its techniques with adequate knowledge and skill. Practitioners usually graduate from accredited schools, work (while being students) in professionally supervised clinics, and meet requirements for competence and understanding that are to be maintained and expanded through approved continuing education, as established by state and national organizations. Unfortunately, when adding other techniques to the practice of TCM, a practitioner might receive little training and the training might be provided by a person who would not meet qualifications consistent with accreditation of schools; the techniques may be ones that are not acceptable within the approved programs or in accordance with their standards, or the board responsible for monitoring and approving such courses may fail to do its important duty of careful oversight. Practitioners and their patients will not have a means for evaluating the training that is received nor the level of competence gained in use of these methods.
c) TCM is regarded, by most practitioners and educators in the field, as a system of great depth, one which requires years of effort to master, far beyond the basics learned in a college program. By adopting non-TCM approaches into the clinical work, the practitioner may be diverted from further investigation of his/her field of expertise and licensing, particularly if the adopted methods are proclaimed (usually without proof) to resolve difficulties of practice that would otherwise require much study and effort. The problem is compounded when practitioners adopt non-TCM methods soon after completing their basic training, before getting a depth of knowledge and experience from working with TCM; because of limited experience, they may not be able to distinguish between authentic TCM and other methods that are popular fads.
That these basic issues are not new and not unique to the Western situation can be illustrated by quoting from Qing Dynasty authors. Huai Yuan wrote a warning to physicians of his day, in a book dating from 1808 (7):
In medical practice one cannot act at one’s own discretion. Patients entrust physicians with the decision over their life and their death….[the physician] searches for the causes and considers the consequences. He knows the normal and understands the changes….A physician plans in detail and thinks comprehensively. He observes a disease and takes precautions against it to avoid a second. He is glad over a success and yet he is aware that one cannot repose on this…Those, however, who surrender to fashionable trends do not carry out their practice conscientiously. They place themselves in the greatest light and make use of the need of others in order to appropriate their material goods to themselves….A physician has to love and respect himself; only then will he, when he faces a grave disease, possess enough trust in himself. I have studied at great length and in any diagnosis of a disease, I proceed with exactitude and conscientiousness; how could I carelessly acquit myself of that which others have entrusted to me and which I have promised to them?....Every patient has to consider the practicing physician a trustworthy person. A physician may examine the respectable [methods] without any further consideration. Yet, if he meets with the disreputable, he is first to assure himself of all the details related to it before making a decision.
Xu Dachun, (writing 50 years earlier, in 1757), also warned physicians about the ease of deceiving patients with wrong ideas (6):
The fact is that patients are people who do not know anything about medicine….When the patients meet someone who knows a little about medical principles, and [who] offers clear-cut discourse and discussion, they will believe what they hear, especially if he displays extraordinary concern and if emotions and face are involved. Who knows that this talk is based on superficial reading and stands for nothing but gossip? Before the people offering [these things] have considered what will happen to the patients following their advice, the patients will have already followed them…..As a result, they recklessly treat people’s illnesses and if these illnesses heal, they consider this their own achievement. If the patient dies, they have done no wrong. They cling only more strongly to their one-sided views….they go on and write books and establish doctrines of their own, and thusly bequeath harm even to later generations. There are so many such people—one cannot count them.
Although Xu mentions the extreme case of a person dying, which is usually not the situation in modern times, he gives a good analysis; it is easy for a person to claim credit for any improvements that a patient has, and to disregard failures: in the modern situation, a patient doesn’t die but simply decides not to come back for another treatment; the practitioner doesn’t see a failure because of keeping awareness only of those who come back again and again.
Huai, Xu, and other Chinese commentators were aware that many practitioners of TCM could easily be distracted from their medicine by promulgators of disreputable techniques and from hearing presentations by charismatic speakers. They worried about people doing superficial investigations and introducing methods that were based on gossip and emotion-based claims. The same can and does happen in the modern world. Practitioners of TCM in the West are particularly susceptible because they are working within a culture that is not inherently supportive of their efforts, where the medicine they are licensed to practice is already considered an alternative to what is widely accepted. As a result, the ethical barrier to invasive, superficial, and distracting ideas, a valuable barrier that should exist, is sometimes left too porous or removed altogether. The requirement for an ethical barrier is not a matter of having a closed mind, but rather a matter of maintaining appropriate and necessary ethical restrictions under difficult circumstances.
In the following presentation of examples in the current setting, I rely primarily on talks I have had with practitioners of TCM during the past two decades for information about how techniques are entering into TCM practices. I have written extensively about the problems with incorporating such techniques and about the importance of challenging claims made for them. For purposes of discussion, I will give as examples the “diagnostic” technique of applied kinesiology (muscle testing) and the “therapeutic” technique of NAET (allergy-clearing therapy).
Applied kinesiology has been widely introduced into Western TCM practices; it is unproven (and easily disproved by using blinded samples); it has no basis in or consistency with TCM (it was devised by a chiropractor who had no TCM experience); and may divert practitioners from study of their field. Learning the technique may require only a few hours (if that) and it can be taught by anyone who is a self-proclaimed expert. For those not familiar with this practice, a common method of application is for the patient to hold some material (e.g., a bottle of herb pills) to their naval, and then hold out one arm parallel to the ground or hold their thumb and first finger together in a circle; the practitioner then presses down on the outstretched arm while the patient resists, or pulls on the two fingers held together with the patient resisting; if the muscles seem to give way easily, the remedy is deemed wrong, while if the muscles seem to resist well, the remedy is deemed correct. For the average educated person, this technique—used for medical purposes rather than entertainment—may seem silly in the extreme; for practitioners who adopt it, this is a serious method based on the concept that the body does not lie, and that the body will accurately reflect the relative value of the remedy as detected through its “energy field” which then influences the strength of the tested muscles. The role of the practitioner is to apply the counter-pressure to the patient’s applied muscular tension; the result seems equally obvious to the patient and the practitioner, so there is no expertise required.
In speaking with and challenging practitioners who use the technique, defences for its use in a TCM practice include keeping its use restricted (e.g., to cases where it is difficult to decide between two herbal formulations that might seem equally suitable); not relying solely on its use (e.g., using it only as a final “check” for decisions made on the basis of TCM); or claiming that it evidently helps the practitioner get good results, so its application is justified (e.g., “my practice is much more effective with it”). In all three instances, there is no established basis for determining that applied kinesiology is of benefit whether it is widely applied or only for limited cases; in the last instance, the claim of benefit is made without considering the generally accepted means of making such judgments (that is, established methods of modern science, which has its foundation in evaluating the veracity of claimed outcomes). In a few cases, practitioners are swept into working with an entire theoretical framework of “body energetics” in which applied kinesiology plays a substantial role, and the practitioner no longer presents what he or she is doing in standard TCM terminology. As an example, one chiropractor-acupuncturist lists on his website the services he offers, saying that the therapeutic approach involves “acupuncture together with other methods” and includes homeopathy (another non-TCM practice, which is also not part of chiropractic), described this way: “the use of homeopathic remedies to enhance the body's ability to heal itself. We stock highly effective European homeopathics. Bach Flower Remedies are dispensed according to applied kinesiological testing to assure effectiveness.” An especially notable example of offering TCM and then “other” techniques, is a clinic of three acupuncturists who describe how their work “evolved” (Three Rivers Clinic, accessed June 2006):
“The medical philosophy of Three Rivers Clinic is based on Traditional Chinese Medicine (TCM) with acupuncture as the cornerstone of that philosophy…..As Three Rivers Clinic has evolved, our practitioners have embraced new forms of energetic healing. BioSET Allergy Elimination treatments and the Jaffe-Mellor Technique are two examples of this new energetic healing. Both use acupuncture and Traditional Chinese Medicine concepts, yet they bring them to a new level of assessment and treatment by implementing the modern discovery of muscle resistance testing (or applied kinesiology) as a way to obtain information directly from the body. These exciting new techniques have offered us new and powerful tools to help us reach our goal of healing the body, mind, and spirit!”
Practitioners who embrace the self-proclaimed higher level techniques often become involved further with non-TCM methods, using various electromagnetic testing devices, pursuing the angle that the body’s field can be measured to determine a treatment. The possible divergences from TCM practice are endless; applied kinesiology may be described as a first step onto the “slippery slope.”
A retort by some of those who use applied kinesiology is to challenge the TCM system this way: ‘if kinesiology is questioned, then why not question pulse diagnosis as well?’ Although a diversion from the true question, this point of potential dispute is raised because pulse diagnosis presents certain difficulties: it is claimed that by touching the body (mainly the wrist) in certain ways (i.e., holding three fingers at the radial artery and placing differing amounts of pressure), one can determine imbalances of the internal organ systems. This seems an incredible claim, and somewhat like the claim for kinesiology. In fact, pulse diagnosis is an unproven method. However, it differs from applied kinesiology in significant ways; in regard to the ethical question at hand, it is a different situation because it is an authentic aspect of TCM. A practitioner may decide not to rely heavily on pulse diagnosis or not to use it at all if he or she questions its value in the modern setting. However, the practitioner who utilizes it in a manner consistent with its use in TCM is relying on a part of the official training that is given for the original medical system. Using traditional medicine systems does not require that each component of the system be proven valid or effective, because traditional medicine is a cultural construct that is being retained; however, introducing a non-traditional technique places an ethical burden on the one introducing it, especially if that person claims that, in fact, “it works.” Not only is patient care at stake, but also the reputation of the entire profession.
A related problem is introduction of therapeutics (in contrast to diagnostics) that have little or no connection to TCM. Mentioned briefly above was homeopathics (and one of the recent derivatives called Bach Flower Remedies). A particularly insidious example affecting the TCM profession is NAET, which became popular a few years ago, though it is now waning (thankfully). Initially, it was claimed that this technique applied to allergy patients could cure allergies permanently within 24 hours. The therapy was developed by a young practitioner of chiropractic who was studying acupuncture. She incorporated the concepts of NLP (neurolinguistic programming), a bizarre system that was developed in California about thirty years ago, which has been widely adopted by chiropractors, the same group that initiated and has extensively used applied kinesiology (NLP has also been used in some other areas, such as popularized negotiating strategies, because it involves trying to change people’s ideas, attitudes, and behaviours). Naturally, NAET failed to meet the initial claim, but it did attract many practitioners to offer prolonged, expensive treatment regimens to patients; the financial rewards has been cited by practitioners who still offer NAET as one of the reasons for retaining it. The practitioners would, in many instances, even claim to cure an allergy that they themselves diagnosed, through methods such as applied kinesiology, thus making an internally self-satisfying system. Spin-offs of this technique (such as BioSET and Jaffe-Mellor Technique (JMT), mentioned by Three Rivers Clinic) were then promulgated to offer cures not only of allergies, but of autoimmune diseases and numerous other recalcitrant health problems. Although use of acupuncture needles is a usual component of the therapy, no in-depth knowledge of TCM is required to apply NAET, BioSET, or JMT. Thus, these methods could give the external appearance of being authentic TCM, while actually being an unrelated practice. Claims of its effectiveness were arrived at easily by interpreting patient responses and case histories in unusual and limited ways.
There are no reputable studies demonstrating the effectiveness of either applied kinesiology or NAET that might be relied upon to help justify a need for them to be incorporated into a TCM practice. The explanations of how these techniques “work”—as given by proponents—is based on descriptions of the body that are not consistent with what has been established through modern investigations; though they might remotely sound like explanations of TCM, they are, in fact, only superficially of any similarity. While the lack of studies or the non-standard explanation by themselves does not rule out the possible reality and effectiveness of the techniques, neither do the claims for them have any basis on which one could ethically introduce them into a licensed TCM practice. As with comparisons of applied kinesiology with pulse diagnosis, the theories behind NAET might be compared with certain concepts of the flow of qi and the concept of unblocking qi to resolve diseases. As before, the proper description of qi circulation falls within the realm of authentic TCM, and practitioners can minimize or avoid the use of this description if they question its suitability in the modern context (for example, acupuncture effects can be described in terms of manipulations of the nervous system, circulatory system, and various signalling substances in the blood). Thus, comparisons to somewhat esoteric TCM concepts do not excuse the unchallenged introduction of a non-TCM technique that lacks both authenticity and valid proof of efficacy.
Practitioners who have used these techniques will no doubt find some patients who believe that it is these techniques that have helped them (rather than other, equally logical explanations for changes that they experienced). However, a closer examination will show a more complex story.
In their enthusiasm for offering these new techniques, practitioners may not realize that they are providing a certain deception. Patients may be attracted by the statements like these: “Acupuncture is a 5,000 year old medical science that is used worldwide; I am a licensed acupuncturist and studied 3 years [or more] at [name of college], an accredited institution.” Their action, however, may actually be this (if defined honestly): “I am going to offer you a technique that is not anywhere near 5,000 years old, nor 500 years old, but less than 50 years old, for which I am not licensed by the State and which was not taught at an accredited college.”
There are some instances where a non-TCM approach might be incorporated into a practice. The example I usually give is this: if a practitioner has a good grasp of TCM dietetics and modern nutritional knowledge as well as expertise in Chinese herbs and corresponding understanding of herbal constituents, it may be reasonable to recommend nutritional supplements to patients in the TCM setting. This is because certain selections of TCM dietary and herb formula ingredients and dosage levels are made in such a way that they actually provide high levels of substances found in these supplements, which may then serve as substitutes for unavailable or difficult to use original ingredients. The possible addition of such “prescribing” is dependent on the knowledge base and the connection of the activity to a TCM fundamental approach.
Resolution: It is essential that practitioners of Chinese medicine give serious consideration to the introduction of non-TCM techniques into their practice before including them. Schools of Chinese medicine and teachers in the field need to explicitly define what constitutes TCM and emphasize that it has characteristics which patients expect to encounter, including authenticity of the technique as part of TCM, training of the practitioner in the techniques they apply within the accredited courses, and reasonable interpretation of the scope of practice. The method for evaluating claims of effectiveness and evaluating patient responses to treatments need to become part of the TCM curriculum.
Part III. Claims of efficacy and safety
Principle: Educators, researchers, and practitioners must relay honest, carefully considered, educated assessments of efficacy and safety when describing the services and treatments in a setting where TCM is offered.
Problem: Frequently, claims of success are made on the basis of cursory observations and by relaying information from sources that have not been properly scrutinized. Assurances of safety are sometimes given on a theoretical basis rather than from consulting the evidence. As a result, potential and existing users of TCM services may be misled, with impact on their financial expenditures and time commitments. It is not in the interest of patients to rely on uninformed or inadequately informed decision-making for determining their health care priorities.
a) As a traditional medicine system, TCM developed over the centuries under the influences of the culture and historical experiences of China. Prior to the 20th century, no systematic method of determining therapeutic efficacy and safety existed. Highly acclaimed texts of Chinese medicine typically described which therapies were indicated for certain disease conditions, but did not give information about their efficacy. Sometimes, suggestions were made for a next step in the therapeutic process if the treatment failed or if an adverse consequence occurred. During the first half of the 20th century, laboratory research was conducted on active components of Chinese herbs, and some evidence was gained to indicate that pharmacological activity of the herb or one or more components correlated with traditional therapeutic claims. However, the large gap between laboratory work and detailed study of human clinical applications was not bridged. During the second half of the 20th century, thousands of studies were carried out in China, examining the full array of TCM modalities, including acupuncture, massage, moxibustion, qi gong, and herbal formulae (orally consumed, topical, injection, and other routes). It has been demonstrated by careful evaluation of the published reports, that virtually all such studies were conducted with inadequate techniques and that the stated results were not reliable. Therefore, few of the conclusions of efficacy derived from the vast collection of Chinese medical reports during this period can be utilized to make statements about Chinese medicine. At the beginning of the 21st century, efforts are being made to correct this situation, but success in this area has been limited. Thus, reliable information about efficacy is still difficult to obtain.
b) Patients have the need to make rational decisions about their health care. Health care costs are spiralling upward, including for various natural, alternative, and complementary health care methods. Expenditures for even minimal TCM intervention, such as an initial office visit and a few follow-up visits plus cost of herbs can involve hundreds of dollars. Time commitments for TCM therapies (including transportation to and from a practitioner office) can involve several hours per month. Sometimes decisions must be made by patients, such as whether to schedule undesirable therapies, such as surgery, or to initiate a drug therapy which would otherwise be avoided, that will depend on the potential for success of TCM methods. In order to make rational decisions, patients must have a reasonable estimate of costs, time, therapeutic efficacy, and risks involved with TCM.
c) The field of TCM is still in its infancy in the West, leaving it vulnerable to negative impressions. For example, in the U.S., there was little access to TCM just 30 years ago; not all states in the country have provision for licensing practitioners; and the total number of licensed practitioners is relatively small; there are about 40 medical doctors for every licensed acupuncturist in the U.S. Similar conditions prevail in Europe and other regions where TCM was introduced in the 20th Century. Therefore, the reputation of TCM is still uncertain. False claims of efficacy and safety, even when made by a relatively small number of practitioners, can impose a heavy burden on the profession by conveying a negative impression.
While all false or exaggerated claims are potentially harmful, the ones that are especially damaging are those for which it is claimed that a disease which is not known to be curable can be cured, perhaps even easily cured. This has been done, for example, with cases of cancer, autoimmune diseases, and neurodegenerative diseases. There are a number of reasons why a person makes such a claim and the basis for such actions today runs parallel to causes that have been the basis of cautionary advice in the past. Huai Yuan, a Qing Dynasty medical ethicist, wrote a warning to physicians of his day, in a book dating from 1808 (7), addressing this issue under the heading “decisions.” Although he talks about accepting or rejecting the patient who can not be cured, the discussion can be adapted to the current situation. He makes the clear point about the necessity for an honest assessment:
If I am faced with the case of a disease which cannot be cured under any circumstances, and I attempt to save the patient in spite of this fact, I must have accumulated knowledge in regard to the “middle” [that is, the affairs of men] and experience with similar cases in the past. Yet, when I examine the results of my attempts at saving, I will come to the conclusion that it does not correspond to my expectations. There was, in fact, no other possibility. Is it not better to decide immediately in such hopeless cases to give up the case? Two reasons are responsible for such decisions not being made. For one thing, the emotional ties with relatives play a part. Because one can not bear their loss, one thinks up a hundred plans to protect them, in the hope that ultimately one will fortunately lead to success. Yet, thereby the physician merely causes the patient to become angry. The second reason for reluctance quickly to reject the treatment of an incurable case lies in the hope of great profit. In such cases magnanimous words are to cover everything, until chance will perhaps bring about a success. Yet, thereby, a physician attracts only slander. Therefore, if in a situation of danger the physician has clearly recognized the course of the phenomena, he should preferably make the decision early not to treat, and not worry about profits and emotional ties.
This statement is quite rich in teachings about ethical behaviour, so it will be analyzed further here. It should not be taken from this passage that a person who can not be cured of their disease or whose life can not be saved by the practitioner should simply be turned away; instead, it is important not to entice the patient or falsely proclaim to the patient that the offered services will yield results that can not properly be promised. It is clear from Yuan’s discourse that making the claim that one can cure this person is unethical. The guidelines for accepting a patient with such an incurable condition are given: the first is to have accumulated knowledge—and this would imply also wisdom, spiritual discipline, intensive study, and dedication to practice—that prepares one to guide the person through this difficult medical situation in an entirely open and honest manner. And, one has to have sufficient experience with cases of similar nature to be able to understand and explain the process, without deception. In the absence of such qualities, the patient should either be referred to someone who possesses them or should be offered only the limited palliative care that can be reasonably claimed and provided at an expense that is appropriately restricted.
There are situations where practitioners may make claims that are not within these bounds because they are relying upon a rather cursory analysis of their own experiences. Thus, there are many instances where a patient with an incurable disease will come for treatment and express gratitude for the offering and describe a certain alleviation of symptoms. This may be interpreted as success in treatment of the disease by the practitioner (and it represents a type of success, no doubt). But, if the patient stops coming for treatment because the benefits have not been sufficient or because they become too debilitated, and then their disease progresses and/or they succumb to it, any claims of success must be greatly tempered. If the practitioner does not take time to learn about this end result, and consider it in the prognosis to be given to the next patient, then any positive rendition of the treatment is dishonest by virtue of the failure to examine the case fully. Indeed, when people have claimed to cure cancer with various natural and alternative remedies, those who sought to actually follow-up the results find the patients were not cured. In some instances, a patient may be “diagnosed” with the cancer by an alternative method that is not recognized anywhere else as being valid, and then similarly proclaim a “cure,” but such self-contained situations are not of value in evaluating the outcomes.
It is essential that practitioners learn to detect unsupported claims in the literature and how to avoid making such claims themselves. As an example of bizarre methods of interpreting cases that have been utilized, I was contacted by a practitioner who claimed to have cured a patient of cancer, and in response I pressed for details. It turned out that the patient had undergone standard medical therapies, including chemotherapy, as well as pursuing the alternative treatment. When asked why this practitioner determined that the therapy he had provided was the successful one and not the medical treatment that produced the “success,” I was told [paraphrasing]: “Chemotherapy never works; cancer can only be cured by natural means.” By refusing to look at the entire picture, practitioners can become convinced that they do have experience of successful treatment. Only when a patient is given an honest assessment, such as: “symptoms may be alleviated for a period of time, but that there is not evidence for a cure,” will the patient be in a good position to make a judgement about how to proceed.
Huai Yuan gives two reasons that practitioners end up deceiving the patients. One is the emotional response to the plight of the patient and, especially, the patient’s relatives who are desperately seeking to save their loved one. Out of sympathy for them, one shrinks away from the bad prognosis and instead wishes to offer hope. However, false hope is not what they seek, and the failure to gain ultimate success can lead to anger, by the patient, and by the relatives; at other times, they may feel sorry for the practitioner who seems to be a victim of the failure as well. At risk, though, is the fact that the practitioner, who had been viewed as a saviour, may now be seen instead as a fraud, and the field of medicine he/she practices may be deemed a sham even if it has legitimate applications. The other reason for making untenable claims is the simple self-serving desire to gain patients, retain patients, and hope to have a success that will bring more fame. The services are rendered, the money is collected, but the result is that the practitioner and the profession become open to slander. One need not quash all hopes of benefits in order to give a reasonable description that includes the expected limitations of treatment.
Unfortunately, a too common response to this ethical issue is for practitioners to speak only among themselves and discuss the closed-mindedness of those who question their claims, actions, and motives, while bolstering one another’s impression of competence and assuredness in success. This approach is contrary to that recommended by the majority of practitioners, which is to work in conjunction with the modern medical profession and bring the standards of TCM research and practice to acceptable levels. Making valid claims should be the goal of all.
Chen Keji, one of the leading international proponents of TCM and its integration with modern medicine observed: “the evaluation of efficacy [for TCM] should seek truth from facts, should stand up to current international criteria” (9). He also notes that with all its benefits, “TCM fails to provide cure from many diseases” (10). These views, expressed by a spokesperson for this field, are consistent with the need for an honest assessment, as opposed to claims that lack a firm basis. By acknowledging the limitations in prior studies and the limitations of TCM for certain diseases, he is not withdrawing support for TCM; rather, he is calling for a strengthening of this traditional medical system and for its integration with the rapidly developing modern medical system.
Learning from prior examples
In an attempt to demonstrate how claims that turn out to be unjustified develop and persist, I had written about the example of a purported cancer cure known as laetrile. It is worth mentioning this failed therapy in this context of discussing Chinese medicine for a couple of reasons. First, when Chinese medicine was becoming popularized in the U.S. several proponents of laetrile treatment contacted me with the hope of confirming their story through examples of traditional use in China. Laetrile (amygdalin) is an apricot seed derivative, and apricot seed (kuxingren) has been used in China for 2,000 years. It turned out that Chinese historical use of the herb was mainly focused on treatment of cough (e.g., in asthma, bronchitis, influenza) and secondarily for constipation (as a source of lubricating oil), but there was no mention of treatment of cancer. Second, I was provided with information that was part of a recent flurry of interest over the proclaimed anticancer activity of artemisinin and artesunate, a modified active component from a Chinese herb used for malaria: qinghao. The pattern of development of the claims is similar to that which occurred with Laetrile, even the proposed mode of action is parallel. This story of this remedy has spread among some practitioners of Chinese medicine without apparent concern for the veracity of the testing and claims. Yet, when I attempted to pin down the claims being made, many of which were difficult to believe, I was given no further details by the practitioners spreading them. The University of Washington (Seattle) where two workers in the bioengineering department had done some of the initial work and had not hesitated to make provocative claims, has found it necessary to make a disclaimer, such as this one they posted on their web site (2006 University of Washington):
“IMPORTANT NOTE: The Department of Bioengineering and University of Washington do not advocate the use of artemisinin to treat cancer. The US Food and Drug Administration does not currently approve the use of artemisinin for the treatment of any disease. Research on artemisinin and cancer is still in very early stages. Human use of artemisinin should be considered experimental and taking artemisinin or any other drug should be approached with extreme caution and responsibility.”
Another case that I wrote about was the claimed successful therapy for prostate cancer, PC-SPES, which was described as a combination of traditional Chinese herbs. Just days before PC-SPES was pulled from the market—because it was found to have a number of drugs in it—a medical doctor in New York City proclaimed in a national news interview that this was a successful natural treatment for prostate cancer. The mechanism of action of this formulation turned out to be a reliance on an estrogen analogue to temporarily shrink the prostate cancer (which also lowers the PSA marker), while utilizing a small does of warfarin to prevent clots due to estrogen therapy. Hormone therapy for prostate cancer is already widely used for limited benefits in modern medicine. A number of other cancer-related scams have come from China, including one based on a soy bean extract sold (sometimes by TCM practitioners) to unsuspecting patients for a very high cost.
The promulgation of false medical claims often follows from lack of critical thinking. Too often, proponents of natural therapies will immediately, and without question, disseminate information and hearsay about a therapy when a study is supportive, but will demand and pursue intensive investigation and debunking of any study that gives a negative result. For a negative study on herbs, questions about botanical identification, dosage, controls, statistical analysis, and interpretation of results are raised to help assure that the study is rejected; while for a positive study the benefits are merely explained and even elaborated with projections of broader usage. I have written about the problem of lack of critical thinking, which is a fault that must be laid primarily at the doorstep of the colleges that train practitioners and researchers. While a large effort is given to teaching the acupuncture points and indications, herbs and their uses, little time is given to analyzing the information that is to be utilized, its source, and whether any claim is verified.
The other side
What has been discussed thus far is the problem of implying, confirming, or assuring efficacy of treatments when, in fact, the treatment may lack adequate evidence to support those statements. There is the other side of the ethical issue that is also quite important. If one does, in fact, have an efficacious remedy, a treatment that does not merely alleviate a minor problem but, for example, cures a disease thought to be incurable or difficult to cure, then there are responsibilities that fall to the person who has encountered or invented such a wonderful gift for humanity. A practitioner who has actually accomplished a medical feat, particularly something that is reproducible (that is, not just involving one extremely rare case), has the obligation of making a concerted effort to have the results verified and disseminated so that others suffering from the disease condition can benefit. It is not sufficient to simply say: “come to my clinic, and I will cure you,” restricting such a great potential benefit to a small group of those privileged to learn about and be able to access such a therapy or, worse, prolonging a false claim for personal aggrandizement.
During the Qing Dynasty, Xu Dachun wrote about this very issue, under the heading “On prescriptions that are kept secret,” saying (6):
“The virtue of heaven and earth lies in their appreciation of life. The mind of the Sages is characterized by their devotion to the interests of the public. When the latter established prescriptions to cure an illness, they saw to it that these prescriptions became known to everyone throughout the world. To spread their knowledge has been the utmost desire of heaven and earth and of the Sages….Dishonest persons, who have nothing but profit in mind, falsely claim to possess secret prescriptions. They cheat the world and delude the masses.”
Once a person claims to be able to cure a disease that is normally incurable, or that is normally only curable by the most difficult and risky means, it becomes a duty to proceed to a next step. Today, that means something far more technical than merely making a simple disclosure and spreading it widely. Rather, the claim must be subjected to full scrutiny. There are patents and other means of protecting a reasonable financial interest in such discoveries, but there is no ethical basis to restrict access through keeping a therapy secret even from scientific scrutiny.
In this presentation, I have stuck to the discussion of the efficacy of treatment. However, the same concerns to issues of treatment safety, where unsupported claims of safety can be detrimental. A further discussion about safety of treatment is planned for a future article.
Resolution: It is essential that educators, practitioners, and proponents of Chinese medicine make the effort to critically challenge claims that are made—or that they wish to declare—about TCM efficacy and safety so that potential and current patients can be given accurate information and reasonable prognosis in order make decisions about their health care. It is essential that claims be subjected to rational evaluation and scientific scrutiny so that those treatments claimed and then proven effective can be spread widely to benefit mankind.